A nurse is caring for a client who is undergoing peritoneal dialysis. What should the nurse report IMMEDIATELY to the provider?

Clear-colored outflow

Outflow amount exceeds inflow amount

Cloudy opaque colored outflow

Non-purulent outflow

Answer and Explanation

The Correct Answer is C

Choice A reason: Clear-colored outflow is normal and indicates that the dialysis process is functioning correctly.

Choice B reason: Outflow amount exceeding inflow amount may be noted and reported, but it is not an immediate cause for concern unless accompanied by other symptoms.

Choice C reason: Cloudy opaque colored outflow indicates possible peritonitis, an infection of the peritoneum. This is a serious complication that requires immediate medical attention to prevent further complications.

Choice D reason: Non-purulent outflow is not an immediate cause for concern and indicates that there is no infection present.

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Correct Answer is A

Explanation

Choice A reason: Administering an antipyretic to reduce the fever and notifying the primary health care provider are the priority actions. A rapid rise in temperature in a client with multiple myeloma receiving chemotherapy could indicate a serious infection, which requires prompt medical attention.

Choice B reason: Assessing the color and content of the urine specimen for urinalysis is important but is not the immediate priority. The rapid rise in temperature is a more urgent concern.

Choice C reason: Noting the consistency of respiratory secretions and obtaining a specimen for culture is important but not the immediate priority. The primary concern is addressing the fever and notifying the healthcare provider.

Choice D reason: Comparing prior vital signs and continuing to monitor every hour is necessary but not the immediate priority. Immediate action is required to address the fever and potential infection.

A. Polyuria, nausea, headaches B. Polydipsia, translucent skin, obesity C. Profuse sweating, flushing, constipation D. High fever, severe tachycardia, and hypertension

Correct Answer is D

Explanation

Choice A reason: Polyuria, nausea, and headaches are not specific clinical manifestations of thyroid storm. Thyroid storm is characterized by extreme hyperthyroidism, leading to severe symptoms such as high fever and tachycardia. Polyuria and nausea could occur in various conditions but are not hallmark signs of a thyroid storm.

Choice B reason: Polydipsia, translucent skin, and obesity are not typical manifestations of thyroid storm. These symptoms are more associated with other conditions, such as diabetes (polydipsia) and metabolic disorders (obesity). Thyroid storm involves acute and severe symptoms related to excessive thyroid hormone levels.

Choice C reason: Profuse sweating and flushing can occur in thyroid storm, but constipation is not typically observed. In fact, hyperthyroidism generally increases gastrointestinal motility, leading to diarrhea rather than constipation. Thyroid storm involves symptoms reflecting severe metabolic overactivity.

Choice D reason: High fever, severe tachycardia, and hypertension are classic clinical manifestations of thyroid storm. The condition involves a rapid and life-threatening escalation of hyperthyroid symptoms, requiring immediate medical attention to prevent complications.

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A nurse is caring for a client who is undergoing peritoneal dialysis. What should the nurse report IMMEDIATELY to the provider?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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