A nurse is caring for a client who is receiving peritoneal dialysis. When caring for the client's dialysis catheter, which of the following actions should the nurse plan to take?

Apply clean gloves when removing the old dressing from the catheter site.

Cleanse the area by using a circular motion beginning at the catheter site and moving outward.

Use warm water to cleanse the catheter site.

Place an occlusive dressing over the catheter site after cleaning.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Applying clean gloves when removing the old dressing from the catheter site is essential to prevent infection and maintain an aseptic technique during peritoneal dialysis catheter care. Gloves protect both the nurse and the patient from potential contamination.
Choice B rationale:
Cleansing the area by using a circular motion beginning at the catheter site and moving outward is not the correct technique. When caring for a dialysis catheter, the nurse should cleanse the site using an outward, circular motion starting from the insertion site to minimize the risk of contamination.
Choice C rationale:
Using warm water to cleanse the catheter site is not recommended. The peritoneal dialysis catheter site should be cleaned with an appropriate antiseptic solution or disinfectant, as warm water alone may not effectively remove bacteria or prevent infections.
Choice D rationale:
Placing an occlusive dressing over the catheter site after cleaning is not the standard practice for peritoneal dialysis catheter care. Typically, a clean, dry dressing is applied to the catheter site after cleaning to keep it clean and dry, but it should not be occlusive.

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Correct Answer is A

Explanation

"I changed the floor plan of our home to accommodate my father's wheelchair.”.

Choice A rationale:

This statement indicates acceptance of the role change as a caregiver for the aging parents. Making changes to the home to accommodate the father's wheelchair demonstrates the client's willingness to adapt and provide a suitable environment for caregiving.

Choice B rationale:

Feeling stressed out and overwhelmed does not necessarily indicate acceptance of the role change. It may reflect the challenges and emotional burden that come with caregiving but does not necessarily signify acceptance.

Choice C rationale:

Expressing frustration with caregiving does not necessarily indicate acceptance of the role change. It is normal to feel frustrated at times, especially when dealing with chronic illnesses, but acceptance involves embracing the responsibilities that come with the role.

Choice D rationale:

While the statement shows a willingness to learn and adapt to caregiving, it does not explicitly indicate acceptance of the role change. Acceptance involves acknowledging and embracing the new responsibilities and challenges fully.

A. Papilledema. B. Halo sign. C. Racoon's eyes. D. Elevated WBCs.

Correct Answer is B

Explanation

Choice A rationale:
Papilledema refers to swelling of the optic disc in the eye, which can occur due to increased intracranial pressure. While it may be present in cases of basilar skull fracture, it is not a reliable finding for determining the discharge of cerebrospinal fluid (CSF).
Choice B rationale:
The halo sign is a reliable finding for determining that the nasal discharge is cerebrospinal fluid. The halo sign is characterized by a ring of blood surrounded by a clear or yellowish fluid (CSF) on a dressing or tissue. This occurs because blood from the fracture mixes with the clear CSF, creating a distinct appearance.
Choice C rationale:
Racoon's eyes, also known as periorbital ecchymosis, is a term used to describe bruising around the eyes. While it can be seen in basilar skull fractures, it is not specific to cerebrospinal fluid leakage and, therefore, not reliable for identifying the nasal discharge as CSF.
Choice D rationale:
Elevated white blood cells (WBCs) in the nasal discharge can indicate infection, inflammation, or an immune response. However, it does not provide direct evidence that the discharge is cerebrospinal fluid, so this is not a reliable finding for determining the nature of the nasal discharge in this context.

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A nurse is caring for a client who is receiving peritoneal dialysis. When caring for the client's dialysis catheter, which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?

Correct Answer is A

Explanation

A nurse in an emergency department is assessing a client who has a basilar skull fracture and serosanguineous nasal discharge following a motor vehicle crash. Which of the following findings should the nurse identify as reliable for determining that the discharge is cerebrospinal fluid?

Correct Answer is B

Explanation

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