A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings?

Outflow obstruction.

Exit site infection.

Atelectasis

Peritonitis.

Answer and Explanation

The Correct Answer is B

B. Redness, tenderness, and drainage around the catheter site are classic signs of an exit site infection in peritoneal dialysis. Exit site infections are a common complication of peritoneal dialysis and can lead to more serious complications, such as peritonitis, if not promptly treated. Preventing exit site infections through proper catheter care and hygiene is essential in peritoneal dialysis management.
A. While outflow obstruction can occur in peritoneal dialysis, it typically presents with symptoms such as poor drainage of dialysate fluid, abdominal discomfort, and a decrease in dialysis efficiency. The described findings of redness, tenderness, and drainage around the catheter site are more indicative of a localized issue rather than outflow obstruction.
C. Atelectasis refers to the collapse of a part or the entire lung. While it can occur in hospitalized patients, especially those with underlying respiratory conditions, the described findings are not indicative of atelectasis. Atelectasis typically presents with symptoms such as dyspnea, cough, and decreased breath sounds on auscultation.
D. Peritonitis is a severe complication of peritoneal dialysis characterized by inflammation and infection of the peritoneal lining. While redness, tenderness, and drainage around the catheter site may precede peritonitis, the focus of concern in this scenario is primarily on preventing exit site infection, which, if left untreated, can progress to peritonitis.

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Correct Answer is ["A","C","E"]

Explanation

A. Standard precautions should always be followed when caring for any patient to prevent the transmission of infectious agents. Additionally, wearing a mask can provide further protection, especially if there is a risk of respiratory droplet transmission.
C. Culturing the wound drainage allows for the identification of the specific bacteria causing the infection, including whether it is methicillin-resistant Staphylococcus aureus (MRSA). Sensitivity testing helps determine which antibiotics are effective against the bacteria, guiding appropriate antibiotic therapy.
E. Contact precautions are necessary for preventing the transmission of MRSA to other patients, staff, and visitors. This includes wearing gloves and gowns when providing care, as well as ensuring proper hand hygiene practices. Visitors may also need to follow specific precautions to prevent the spread of infection.
B. While monitoring the client's white blood cell count may be important for assessing the body's response to infection, it is not specific to MRSA infection. MRSA infection is typically diagnosed based on clinical presentation and confirmed through laboratory tests such as wound cultures.
D. A low bacteria diet is not typically indicated for MRSA infection. MRSA is primarily treated with antibiotics, and dietary modifications are not a standard part of its management.

A. Teach the client about phantom pain symptoms. B. Perform a complete mental status exam. C. Determine if the client has had a shingles vaccination. D. Complete an assessment of the client's pain.

Correct Answer is D

Explanation

D. Persistent pain following the resolution of herpes zoster, known as postherpetic neuralgia (PHN), is a common complication, especially in older adults. PHN can cause significant discomfort and affect the client's quality of life. Therefore, it is essential for the nurse to conduct a comprehensive assessment of the client's pain to better understand its characteristics, severity, duration, aggravating or alleviating factors, and impact on daily activities.
A. Patient education should follow a complete assessment of the pain to ascertain the diagnosis.
B. Performing a complete mental status exam is not indicated solely based on the client's report of persistent pain from herpes zoster.
C. Determining if the client has had a shingles vaccination is important for preventive healthcare, but it is not the priority action in addressing the client's current pain concern related to PHN. The focus should be on assessing and managing the client's pain to improve their comfort and well-being.

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A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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