A nurse is changing the dressing for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
Place a mask on the client during the procedure
Cleanse the catheter site using a side-to-side motion.
Tape down the corners of the dressing
Secure an occlusive dressing over the gauze pads.
The Correct Answer is A
A. Place a mask on the client during the procedure: A mask should be placed on the client to reduce the risk of infection during the dressing change. Peritoneal dialysis involves accessing the peritoneal cavity, and maintaining a sterile environment is crucial to prevent contamination.
B. Cleanse the catheter site using a side-to-side motion: The catheter site should be cleansed using a circular motion starting from the site of insertion and moving outward. This helps avoid introducing bacteria into the insertion site. Side-to-side motion may push bacteria into the area.
C. Tape down the corners of the dressing: While securing the dressing is important, taping the corners may not provide the optimal seal and could risk introducing contaminants. The dressing should be secured properly, but not necessarily with just tape at the corners.
D. Secure an occlusive dressing over the gauze pads: An occlusive dressing over gauze pads is not ideal for peritoneal dialysis catheters. A sterile, breathable dressing is recommended to allow for proper airflow and prevent moisture accumulation, which can promote infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administer digoxin by IV bolus: Digoxin slows conduction through the AV node and can worsen a complete heart block. It is contraindicated in this condition and may lead to further bradycardia or cardiac arrest.
B. Prepare the client for temporary pacing:Third-degree (complete) heart block results in electrical dissociation between atria and ventricles, leading to dangerously low heart rates and inadequate perfusion. The definitive treatment is temporary pacing to stabilize the cardiac rhythm until permanent pacing can be arranged.
C. Instruct the client to perform the Valsalva maneuver: This maneuver is used to terminate supraventricular tachycardias by stimulating the vagus nerve. It is not indicated in bradyarrhythmias like third-degree heart block and could further lower the heart rate.
D. Perform carotid sinus massage: This is another vagal maneuver used to treat tachycardias, not bradycardias. Performing it in a client with third-degree heart block could dangerously reduce the heart rate further and is therefore inappropriate.
Correct Answer is A
Explanation
A. Frothy sputum: Frothy sputum, particularly pink or blood-tinged, is a classic sign of pulmonary edema, which is common in left-sided heart failure. The left side of the heart cannot pump blood effectively, leading to fluid accumulation in the lungs and causing this symptom.
B. Bradycardia: In left-sided heart failure, tachycardia (elevated heart rate) is more commonly seen as the heart tries to compensate for decreased cardiac output, not bradycardia (slow heart rate).
C. Warm skin: In left-sided heart failure, the skin may feel cool and clammy due to poor circulation and reduced cardiac output. Warm skin is not a typical finding in this condition.
D. Jugular vein distention: Jugular vein distention is more indicative of right-sided heart failure, where there is a backup of blood in the venous system. Left-sided heart failure primarily causes symptoms related to pulmonary congestion.
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