A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

Answer is a. Check for neck vein distention.

a. Check for neck vein distention: Correct. Assessing for neck vein distention is an essential intervention for a client receiving IV fluid replacement, especially for dehydration. Neck vein distention can indicate fluid overload, a potential complication of IV fluid therapy. By monitoring for this sign, the nurse can promptly recognize and intervene to prevent fluid overload-related complications such as pulmonary edema and hypertension. Regular assessment of neck vein distention provides valuable information about the client's fluid status and guides adjustments to the IV fluid infusion rate to maintain fluid balance and prevent adverse outcomes.

b. Offer oral fluids every 4 hr: This option is incorrect because offering oral fluids every 4 hours may not be appropriate for a client receiving IV fluid replacement for dehydration. IV fluid replacement is typically indicated when oral rehydration is insufficient or impractical, such as in cases of severe dehydration, altered consciousness, or gastrointestinal disturbances. The frequency and volume of oral fluid intake should be individualized based on the client's condition, fluid requirements, and ability to tolerate oral intake. Therefore, the nurse should prioritize IV fluid therapy and adjust oral fluid intake accordingly based on ongoing assessment of the client's hydration status.

c. Monitor pulse pressure every 6 hr: While monitoring pulse pressure can provide valuable information about fluid status and cardiac function, it may not be as specific or sensitive as other signs such as neck vein distention when assessing for fluid overload in clients receiving IV fluid replacement. Pulse pressure is the difference between the systolic and diastolic blood pressure readings and can be affected by various factors, including cardiac output, vascular resistance, and volume status. However, changes in pulse pressure may not always correlate directly with fluid overload, especially in clients with underlying cardiovascular conditions or receiving vasopressor medications. Therefore, more frequent and comprehensive assessments, including physical examination findings such as neck vein distention, are necessary to evaluate fluid balance accurately.

d. Limit oral fluids prior to bedtime: This option is incorrect because limiting oral fluids prior to bedtime is generally not indicated for dehydrated clients, especially those receiving IV fluid replacement. Restricting fluid intake may exacerbate dehydration and compromise the effectiveness of IV fluid therapy. Instead, the nurse should encourage adequate fluid intake throughout the day and evening to promote hydration and support the client's recovery from dehydration. Individualized fluid management strategies should be based on the client's fluid requirements, renal function, underlying condition, and response to therapy.

In summary, the correct answer is a because checking for neck vein distention is an essential intervention for monitoring fluid status and detecting potential complications such as fluid overload in clients receiving IV fluid replacement for dehydration. This assessment helps ensure safe and effective fluid management and prevents adverse outcomes associated with fluid overload.

The correct answer is choice B, a client who had abdominal surgery 2 days ago and the incision line is separating. This client requires immediate attention as a separating incision can indicate wound dehiscence or evisceration, which are surgical emergencies. Choice A is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention. Choice C is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition. Choice D is incorrect because the client fell 12 hours ago and reports pain as 4 on a scale of 0 to 10, which indicates a low level of pain.

Choice A: A client who has Clostridium difficile and has liquid stools is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention.

Choice C: A client who has a chronic tracheostomy and is intermittently coughing up clear sputum is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition.

Choice D: A client who fell 12 hours ago and reports pain as 4 on a scale of 0 to 10 is incorrect because the level of pain is low and does not require immediate attention.