A nurse is caring for a client who is undergoing initial peritoneal dialysis. Which of the following should the nurse
report immediately to the provider?

Choice A reason: Blood-tinged dialysate outflow can occur initially due to the surgical procedure and is not typically a cause for immediate concern unless it persists or is accompanied by other symptoms.

Choice B reason: Dialysate leakage during inflow might indicate a problem with the catheter placement or integrity but is not usually an emergency. It should be monitored and reported if it continues.

Choice C reason: Discomfort during dialysate inflow is common, especially in new patients, as they adjust to the sensation of fluid being infused. It should be reported if the discomfort is severe or persistent.

Choice D reason: Purulent dialysate outflow indicates an infection, such as peritonitis, which is a serious complication

of peritoneal dialysis. This requires immediate atention and intervention by the healthcare provider.

The correct answer is Choice A

Choice A rationale: Headache and restlessness can be signs of a seizure or neurological disturbance, which phenytoin is used to treat. Phenytoin is an anticonvulsant medication that helps control seizures by stabilizing neuronal membranes and reducing excitability.

Choice B rationale: Decreased blood pressure and rapid pulse are not indications for phenytoin administration. These symptoms may suggest hypotension or cardiovascular issues, which require different interventions such as fluid resuscitation or vasopressors.

Choice C rationale: Muscle cramps and chest heaviness are not treated with phenytoin. These symptoms could indicate electrolyte imbalances or cardiac issues, which need specific treatments like electrolyte replacement or cardiac monitoring.

Choice D rationale: Pain and tingling at the access site are not indications for phenytoin administration. These symptoms may suggest local irritation or infection at the dialysis access site, requiring appropriate wound care or antibiotics.