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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:

A. Maintain the irrigation solution rate: Pink-tinged urine is expected in the early hours after a TURP due to residual bleeding from the surgical site. The nurse should continue the current irrigation rate to prevent clot formation and maintain catheter patency.

B. Warm the irrigation solution: Warming the solution is not required for bladder irrigation and does not address the normal postoperative finding of pink-tinged urine. It also does not play a role in preventing clot formation.

C. Perform the Credé's maneuver: This technique, involving manual bladder compression, is not appropriate for a client with a continuous bladder irrigation and indwelling catheter in place. It could cause injury or disrupt the surgical site.

D. Replace the indwelling urinary catheter: There is no indication of catheter blockage or malfunction in this scenario. Replacing the catheter unnecessarily increases infection risk and could damage the urethra or surgical area.

A. Refute the client's delusions using logic. B. Give the client one simple direction at a time. C. Allow the client to choose among a variety of activities each day. D. Establish eye contact when communicating with the client. E. Reinforce orientation to time, place, and person.

Correct Answer is ["B","D","E"]

Explanation

A. Refute the client's delusions using logic: Confronting or trying to correct delusions can increase agitation and confusion in clients with dementia. This approach is not therapeutic and should be avoided.

B. Give the client one simple direction at a time: Providing clear, single-step instructions reduces confusion and helps the client successfully complete tasks, supporting independence and minimizing frustration.

C. Allow the client to choose among a variety of activities each day: Offering too many choices can overwhelm a client with dementia, leading to anxiety and agitation. It is more effective to offer a simple choice between two options or to provide a structured routine to reduce decision fatigue.

D. Establish eye contact when communicating with the client: Eye contact enhances attention, conveys respect, and improves comprehension during interactions, which is particularly important for clients with cognitive impairment.

E. Reinforce orientation to time, place, and person: Gentle reminders and reorientation cues help maintain cognitive function, reduce anxiety, and support the client’s awareness of their environment.

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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?

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