A nurse is assessing a client who is receiving peritoneal dialysis for manifestations of peritonitis. Which of the following findings should the nurse identify as the first indication of peritonitis?
Abdominal pain
Cloudy effluent
Nausea
Fever
The Correct Answer is B
Rationale:
A. Abdominal pain: While abdominal pain can occur with peritonitis, it often develops after the initial changes in the dialysate effluent. Pain may also be related to catheter placement or dialysate temperature, so it is not the earliest definitive indicator.
B. Cloudy effluent: Cloudy dialysate is typically the first and most reliable sign of peritonitis in clients receiving peritoneal dialysis. It indicates the presence of white blood cells and infection in the peritoneal cavity before systemic symptoms appear.
C. Nausea: Nausea may occur later as part of the systemic inflammatory response, but it is nonspecific and can be caused by multiple factors, including the dialysis process itself or other gastrointestinal disturbances.
D. Fever: Fever is a later manifestation of peritonitis, often developing after local signs are present. It indicates systemic involvement and immune activation but is not the earliest detectable change.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Rationale for correct choices:
- Skin turgor: Poor skin turgor indicates dehydration, which can lead to electrolyte imbalances, hypotension, and renal complications. Immediate assessment and fluid management are necessary to prevent further physiological deterioration.
- Heart rate: A heart rate of 120/min is tachycardic. This can be caused by dehydration, stimulant effects of mania, or other underlying medical issues. It requires prompt monitoring and intervention to prevent cardiovascular compromise.
- Sleep pattern: The client has not slept for 2 days, which increases the risk for physical exhaustion, worsening psychiatric symptoms, and impaired judgment. Sleep deprivation in the context of mania requires immediate attention to stabilize the client.
- Hallucinations: The client reports listening to unseen others, indicating auditory hallucinations. This can pose a risk for self-harm or unsafe behaviors, and immediate psychiatric assessment and intervention are warranted.
Rationale for incorrect choice:
- Hygiene: While the client’s hair and clothing are unclean, indicating self-care deficits, this is not an immediate threat to physiological stability. It is important for overall care planning but does not require urgent intervention compared to dehydration, tachycardia, sleep deprivation, or hallucinations.
Correct Answer is ["2.5"]
Explanation
Calculation:
Desired dose = 20 mg.
Available concentration = 40 mg / 5 mL
= 8 mg/mL.
- Calculate the volume to administer in milliliters (mL).
Volume to administer (mL) = Desired dose (mg) / Available concentration (mg/mL)
= 20 mg / 8 mg/mL
= 2.5 mL.
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