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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A capillary refill of less than 1 second is a normal finding and indicates adequate peripheral perfusion. It is not a cause for concern in this postoperative client.
Choice B rationale:
The presence of a pulse deficit should be reported to the provider because it suggests a discrepancy between the apical and radial pulses, indicating potential cardiovascular compromise or inadequate arterial perfusion.
Choice C rationale:
A systolic blood pressure 10 points lower than before surgery can be a normal response to anesthesia or surgery and may not necessarily require immediate reporting unless accompanied by other concerning symptoms or vital sign abnormalities.
Choice D rationale:
Pulse oximetry at 96% is within the normal range for oxygen saturation and does not warrant immediate reporting. However, if the client is experiencing respiratory distress or other concerning symptoms, it should be addressed promptly.
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not cross the client's legs when sitting in the recliner following a total left hip arthroplasty. Crossing the legs can put strain on the operative hip and may increase the risk of dislocation or other complications.
Choice B rationale:
Providing a heating pad to the operative hip is not recommended. Heat can increase blood flow to the area and may lead to increased swelling and potential complications in the postoperative period.
Choice C rationale:
Placing a pillow between the legs when turning the client to their side is the correct action. This technique is known as the "abduction pillow”. or "wedge pillow.”. It helps maintain proper hip alignment and prevents the operated leg from crossing the midline, reducing the risk of dislocation and promoting healing.
Choice D rationale:
Having the client lean forward when assisting them out of the bed is not appropriate after a total left hip arthroplasty. Leaning forward can put strain on the hip joint and increase the risk of injury.
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