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:
An elevated WBC count (11,000/mm²) in a client starting treatment for MRSA infection may indicate an inflammatory response, but it is expected in this scenario, and the priority is not as high as other critical lab values.
Choice B rationale:
A serum pH of 7.25 indicates acidosis, which is a potentially life-threatening condition. In type 1 diabetes mellitus, diabetic ketoacidosis (DKA) is a common complication that can lead to metabolic acidosis. This lab result is a priority as it requires immediate attention.
Choice C rationale:
Hematocrit of 26% in a client with sickle cell disease might be low, but it is not the priority over the critically abnormal lab value of serum pH in option B.
Choice D rationale:
A urine specific gravity of 1.032 in a client diagnosed with dehydration is elevated, indicating concentrated urine due to dehydration. While dehydration is concerning, it is not as high-priority as the potentially life-threatening acidosis in option B.
Correct Answer is A
Explanation
The client's daily peak expiratory flow (PEF) measures 85% above personal best.
Choice A rationale:
Salmeterol is a long-acting beta-agonist used to treat asthma. Improvement in the client's daily peak expiratory flow (PEF) of 85% above their personal best indicates effective bronchodilation and better asthma control.
Choice B rationale:
ABGs showing a pH level of 7.32 are not indicative of the effectiveness of salmeterol. ABG values assess the client's acid-base balance and gas exchange, but they do not directly reflect the action of the medication.
Choice C rationale:
A decrease in forced expiratory volume after treatment with medication indicates a lack of response to the therapy, not an effective outcome. It suggests the medication is not adequately controlling the client's asthma symptoms.
Choice D rationale:
Wheezing limited to expiration is not a clear indicator of medication effectiveness. Wheezing can be present in various respiratory conditions and is not solely associated with asthma control. Exhibit. The correct answer is choice B: Increase the rate of the infusion by 160 units/hr.
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