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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Validation. Validation is a therapeutic technique that involves acknowledging and accepting the feelings and emotions of the person with dementia, even if they are not based on reality. Validation helps to reduce agitation and anxiety and promotes dignity and respect.
The other choices are not correct for the following reasons:
Remotivation is a technique that aims to stimulate the person's interest in the present and future, by providing factual information and encouraging participation in activities. Remotivation may not be appropriate for someone who is agitated and living in the past.
Orientation to reality is a technique that involves correcting the person's misperceptions and confusions, by providing factual information about time, place, and identity. Orientation to reality may increase agitation and frustration and may damage the person's self-esteem.
Guided imagery is a technique that involves using mental images to promote relaxation and well-being. Guided imagery may not be effective for someone who has difficulty with attention, concentration and memory.
Correct Answer is B
Explanation
In clients with obsessive-compulsive disorder (OCD), cleaning and organizing can be a way of decreasing anxiety to a tolerable level. This behavior is a compulsive behavior that is often related to the individual's obsessions. It is not an attempt to manipulate or control others, limit interaction with others, or focus attention on useful tasks.
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