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

Blood-tinged dialysate outflow.

Cloudy dialysate outflow.

Dialysate leakage during inflow.

Report of discomfort during dialysate inflow.

Answer and Explanation

The Correct Answer is B

Answer: B. Cloudy dialysate outflow.

Rationale:

A) Blood-tinged dialysate outflow.
While blood-tinged outflow can be concerning, it may not always indicate a severe complication, especially if it is minimal. It should be monitored and documented, but it does not require immediate reporting unless it becomes excessive.

B) Cloudy dialysate outflow.
This finding is significant and warrants immediate reporting to the provider as it may indicate peritonitis, an infection of the peritoneal cavity. Prompt intervention is critical to address potential complications associated with dialysis.

C) Dialysate leakage during inflow.
Dialysate leakage can occur and might be due to improper catheter placement or other issues. While it requires attention, it is not as urgent as cloudy dialysate outflow and can typically be managed without immediate escalation.

D) Report of discomfort during dialysate inflow.
Mild discomfort during inflow can be common, especially in the initial stages of peritoneal dialysis. It should be noted and assessed, but it does not necessarily require immediate reporting unless it is severe or persistent.

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Correct Answer is D

Explanation

"I know you will do well living out in the community.". When a client expresses feelings of gratitude towards a nurse as they are about to be discharged, they are mostly affirming the therapeutic relationship between both parties. The nurse should acknowledge this affirmation clearly, warmly, and humbly, while encouraging the client's progress and independence. Choice D, "I know you will do well living out in the community" acknowledges the client's progress and offers encouragement.

Choice A, "Aren't you excited about being discharged today?" is a closed question that does not encourage the client's progress.

Choice B, "How do you feel about being discharged?" is not the best response because it is too broad.

Choice C, "I will send you a note in a few weeks" does not offer affirmation and encouragement to the client.

A. The client talks constantly about the traumatic experience. B. The client is constantly drowsy and sleeps 11-12 hr daily. C. The client reports satisfying personal relationships with family and close friends. D. The client is easily startled by loud voices.

Correct Answer is D

Explanation

The client is easily startled by loud voices. Clients with posttraumatic stress disorder (PTSD) may exhibit hyperarousal symptoms, including exaggerated startle responses and hypervigilance. The client talking constantly about the traumatic experience is a possible finding in PTSD but not specific. The client is constantly drowsy and sleeping 11-12 hours daily is more associated with depression than PTSD. While the client may have satisfying personal relationships, it does not address the question of what finding to expect with PTSD, making choice C incorrect.

Reasons why the other choices are not answers:

Choice A, the client talking constantly about the traumatic experience, is a possible symptom of PTSD, but it is not specific to the disorder and may also indicate other disorders.

Choice B, the client being constantly drowsy and sleeping 11-12 hours daily, is more indicative of depression than PTSD and also does not address the question of finding expected with PTSD.

Choice C, the client reports satisfying personal relationships with family and close friends, does not address what finding is expected with PTSD, making it an incorrect answer.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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