A nurse is preparing a care plan for a client with peritonitis. Which nursing intervention is essential to include in the plan to address potential complications of this condition?
Assessing for peripheral edema daily
Monitoring blood glucose levels regularly
Encouraging fluid intake to 3 liters per day
Implementing fall precautions during ambulation
The Correct Answer is B
Choice A reason:
Assessing for peripheral edema is important for clients with various conditions, but it is not directly related to the potential complications of peritonitis.
Choice B reason:
Monitoring blood glucose levels regularly is essential in clients with peritonitis, as hyperglycemia can be a complication of the inflammatory response and stress associated with the condition.
Choice C reason:
Encouraging fluid intake is essential for clients with peritonitis, but the specific recommendation of 3 liters per day is not universally applicable and may vary based on individual client needs and medical status.
Choice D reason:
Implementing fall precautions is important for clients at risk of falls, but it is not directly related to potential complications of peritonitis.
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Correct Answer is C
Explanation
Choice A reason:
Administering pain medication is important for the client's comfort, but it is not the highest priority in managing sepsis, a life-threatening complication of peritonitis. Addressing the underlying infection with antibiotics takes precedence.
Choice B reason:
Monitoring vital signs is essential for assessing the client's condition, but initiating broad-spectrum antibiotic therapy is more critical in managing sepsis.
Choice C reason:
Initiating broad-spectrum antibiotic therapy is the highest priority in managing sepsis. Prompt administration of antibiotics is crucial to treat the bacterial infection and prevent its spread.
Choice D reason:
Providing deep breathing exercises is important for preventing respiratory complications, but it is not the highest priority compared to addressing sepsis with antibiotics.
Correct Answer is C
Explanation
Choice A reason:
An electrocardiogram (ECG) is used to assess the electrical activity of the heart, not the abdomen.
Choice B reason:
An abdominal X-ray provides a basic overview of the abdomen but may not offer detailed images of the peritoneal organs and structures.
Choice C reason:
Magnetic resonance imaging (MRI) can provide high-resolution images of the abdominal organs and structures, including the peritoneum, making it a valuable diagnostic tool for suspected peritonitis.
Choice D reason:
Ultrasonography can provide images of the abdominal organs, but it may not offer the level of detail provided by MRI in assessing peritonitis.
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