A nurse is developing a plan of care for a client who is to begin receiving peritoneal dialysis. Which of the following interventions should the nurse implement to ensure proper dialysate exchange?
Maintain the client in a left lateral position during dialysis.
Monitor vital signs every 2 hours during the procedure.
Warm the dialysate solution prior to instillation.
Place the drainage bag above the level of the client's abdomen.
The Correct Answer is C
Choice A reason: Maintaining the client in a left lateral position is not specifically required for peritoneal dialysis. Positioning may vary based on the individual's comfort and specific medical needs.
Choice B reason: While monitoring vital signs is important during any medical procedure, it is not an intervention that directly ensures proper dialysate exchange in peritoneal dialysis.
Choice C reason: Warming the dialysate solution prior to instillation is a standard practice in peritoneal dialysis. It helps to promote patient comfort and more efficient exchange of wastes and fluids.
Choice D reason: Placing the drainage bag above the level of the client's abdomen would impede gravity drainage, which is necessary for proper dialysate exchange. The drainage bag should be placed below the level of the client's abdomen.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: Ensuring the client's urine output is at least 1 mL/kg/hour is important before administering potassium to prevent hyperkalemia, especially in clients with renal impairment.
Choice B reason: While educating the client about high-potassium food sources is important, it is not directly related to the administration of intravenous potassium.
Choice C reason: Cardiac monitoring during infusion is crucial due to the risk of arrhythmias associated with rapid
changes in potassium levels.
Choice D reason: Repeating blood serum potassium is necessary to monitor the effectiveness of the supplementation and avoid hyperkalemia.
Choice E reason: Potassium should not be prepared with 5% dextrose solution as it may cause a trans-cellular shift of potassium into cells, which is not recommended.
Correct Answer is D
Explanation
The correct answer is D. Urine output 75 mL in 1 hr.
Adequate urine output (at least 30 mL/hr) indicates effective hydration, showing that the kidneys are functioning properly and fluid balance is improving. A urine output of 75 mL in 1 hour suggests sufficient fluid replacement.
Here’s why the other options are incorrect:
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A. Urine specific gravity 1.005 to 1.030 – This range covers both normal and abnormal values. In dehydration, urine specific gravity is usually high (>1.030) due to concentrated urine. Effective treatment should lead to lower urine specific gravity, but the full range does not confirm improvement.
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B. Decreased pulse pressure – Pulse pressure is the difference between systolic and diastolic blood pressure. Dehydration typically causes a narrowed pulse pressure, so improvement should lead to a normal or increased pulse pressure rather than a decrease.
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C. Lightheadedness – Dizziness and lightheadedness are signs of dehydration-related hypotension. Effective hydration should resolve these symptoms, not maintain them.
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