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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason: Renal failure is typically associated with abnormal creatinine and BUN levels, which are not

indicated in the given lab values.

Choice B reason: A low-protein diet is not directly indicated by the lab values provided and does not typically result in

collapse after exertion.

Choice C reason: Dehydration is consistent with the client's history of collapsing after playing football on a hot day

and is supported by the elevated sodium level.

Choice D reason: SIADH usually presents with low sodium levels due to dilution, which is not the case here.

A. The client who had general anesthesia for back surgery 4 hours ago. B. The client who has a history of liver failure. C. The client who reported eating a diet high in calcium oxalate. D. The client who was treated with antibiotics for Staphylococcus aureus infection of the skin 2 weeks ago.

Correct Answer is A

Explanation

Choice A reason: General anesthesia can cause urinary retention due to its effects on the nervous system, which may temporarily impair the normal re?exes that control urination. This is particularly relevant in the immediate postoperative period.

Choice B reason: While liver failure can have many systemic effects, it is not directly associated with an increased risk of urinary retention. Urinary retention is more commonly related to factors affecting the urinary tract or nervous system.

Choice C reason: A diet high in calcium oxalate can contribute to kidney stones, but it does not directly increase the risk of urinary retention. Urinary retention typically involves an obstruction or nerve dysfunction.

Choice D reason: Antibiotic treatment for a skin infection, even one caused by Staphylococcus aureus, would not typically result in urinary retention. Urinary retention is usually related to urinary tract obstructions, medications, or nerve issues.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

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