A nurse is caring for a client on peritoneal dialysis who complains of cloudy drainage from the catheter site. Which of the following actions should the nurse take first?
Administer an antibiotic for potential infection.
Measure the client's vital signs and assess for pain.
Clamp the catheter and notify the healthcare provider.
Obtain a sample of the drainage for culture and sensitivity testing.
The Correct Answer is D
A) This statement is incorrect. While administering an antibiotic may be necessary if peritonitis is confirmed, it should not be done without obtaining a sample for testing first.
B) This statement is incorrect. Measuring vital signs and assessing for pain are essential aspects of client assessment, but they may not provide enough information to determine the cause of the cloudy drainage.
C) This statement is incorrect. Clamping the catheter may be necessary if peritonitis is suspected, but it should not be done without first obtaining a sample of the drainage for testing.
D) This statement is accurate. Cloudy drainage from the catheter site may indicate peritonitis, which is an infection of the peritoneal cavity. Obtaining a sample of the drainage for culture and sensitivity testing can help identify the presence of infection and guide appropriate treatment.
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Related Questions
Correct Answer is C
Explanation
A)This statement is incorrect. Administering an analgesic for the headache may provide temporary relief, but it does not address the underlying issue of fluid overload and elevated blood pressure.
B) This statement is incorrect. Notifying the healthcare provider about the blood pressure changes is important, but assessing for fluid overload and taking appropriate actions should be the nurse's priority.
C) This statement is accurate. Headache and restlessness during hemodialysis, along with elevated blood pressure, may indicate fluid overload. The nurse should assess the client's weight and fluid intake during the dialysis session to determine if there is excessive fluid retention.
D) This statement is incorrect. Increasing the dialysate solution flow rate may not be appropriate without further assessment of the client's fluid status. It could worsen the fluid overload and further increase blood pressure.
Correct Answer is D
Explanation
A) This statement is incorrect. Hypokalemia (low potassium levels) is not an indication for initiating dialysis. In AKI, electrolyte imbalances can occur, but hyperkalemia is more likely due to impaired kidney function.
B) This statement is incorrect. Hyponatremia (low sodium levels) is not a primary indication for initiating dialysis in AKI. It can occur due to fluid shifts, but the primary concern in AKI is the accumulation of waste products like urea, leading to uremia.
C) This statement is incorrect. Hypernatremia (high sodium levels) is not a primary indication for initiating dialysis in AKI. Hypernatremia is rare in AKI and usually occurs when there is a significant loss of free water compared to sodium intake.
D) Uremia, which is characterized by elevated levels of urea and other waste products in the blood, is a critical indication for initiating dialysis in clients with acute kidney injury. Dialysis helps remove these toxic substances from the bloodstream.
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