A nurse is caring for a client who is scheduled to receive intermittent peritoneal dialysis. Which of the following actions should the nurse take?

Weigh the client before and after each dialysis treatment.

Apply clean gloves when handling the bags of dialysate fluid.

Refrigerate the bags of dialysate fluid until ready for instillation.

Check peripheral circulation of the client's arms prior to treatment.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct action, because weighing the client before and after each dialysis treatment can help monitor the fluid balance and the effectiveness of the dialysis.

Choice B reason: This is an incorrect action, because the nurse should apply sterile gloves when handling the bags of dialysate fluid to prevent infection.

Choice C reason: This is an incorrect action, because the bags of dialysate fluid should be warmed to body temperature before instillation to prevent hypothermia and abdominal cramps.

Choice D reason: This is an irrelevant action, because checking peripheral circulation of the client's arms has no relation to peritoneal dialysis, which involves the insertion of a catheter into the abdominal cavity.

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Correct Answer is B

Explanation

Choice A reason: This is a nonspecific finding, because a report of a severe headache can be caused by many factors, such as concussion, migraine, or tension. A headache alone is not an indication of a skull fracture.

Choice B reason: This is a specific finding, because clear fluid coming from the nares can indicate a cerebrospinal fluid (CSF) leak, which is a sign of a basilar skull fracture. CSF is the fluid that surrounds and protects the brain and spinal cord, and can leak through the nose or ears if the skull is fractured.

Choice C reason: This is a nonspecific finding, because a brief change in level of consciousness can be caused by many factors, such as hypoxia, hypoglycemia, or seizure. A change in level of consciousness alone is not an indication of a skull fracture.

Choice D reason: This is a nonspecific finding, because bleeding from the top of the scalp can be caused by many factors, such as laceration, abrasion, or contusion. Bleeding from the scalp alone is not an indication of a skull fracture.

A. Elevated blood pressure B. Involuntary muscle spasms C. Cold intolerance D. Weight loss

Correct Answer is B

Explanation

Choice A reason: This is an incorrect finding, because elevated blood pressure is not a sign of hypoparathyroidism, which is a condition that occurs when the parathyroid glands produce insufficient parathyroid hormone (PTH). PTH regulates the calcium and phosphorus levels in the blood and bones. Elevated blood pressure can be a sign of hyperparathyroidism, which is the opposite condition.

Choice B reason: This is the correct finding, because involuntary muscle spasms are a sign of hypoparathyroidism, which causes hypocalcemia, or low blood calcium levels. Hypocalcemia can cause neuromuscular irritability and tetany, which are manifested by muscle spasms, twitching, cramps, or seizures.

Choice C reason: This is an incorrect finding, because cold intolerance is not a sign of hypoparathyroidism, but a sign of hypothyroidism, which is a condition that occurs when the thyroid gland produces insufficient thyroid hormone. Thyroid hormone regulates the metabolism and body temperature. Cold intolerance can also be a sign of Hashimoto's thyroiditis, which is an autoimmune disease that causes inflammation and destruction of the thyroid gland.

Choice D reason: This is an incorrect finding, because weight loss is not a sign of hypoparathyroidism, but a sign of hyperthyroidism, which is a condition that occurs when the thyroid gland produces excessive thyroid hormone. Thyroid hormone increases the metabolism and energy expenditure. Weight loss can also be a sign of Graves' disease, which is an autoimmune disease that causes overstimulation and enlargement of the thyroid gland.

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A nurse is caring for a client who is scheduled to receive intermittent peritoneal dialysis. Which of the following actions should the nurse take?

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