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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Preventing aspiration pneumonia is one of the benefits of an NG tube, but the primary purpose in peritonitis is to relieve abdominal distension caused by fluid and gas accumulation.
Choice B reason:
Relieving abdominal distension is the primary purpose of an NG tube in clients with peritonitis, as it helps remove fluid and gas from the stomach and intestines, reducing pressure on the peritoneum.
Choice C reason:
Monitoring gastric pH levels may be done with an NG tube in certain situations, but it is not the primary purpose in the context of peritonitis.
Choice D reason:
Administering enteral nutrition may be a secondary purpose of an NG tube in some cases, but it is not the primary goal in clients with peritonitis.
Correct Answer is C
Explanation
Choice A reason:
Chest pain is not a typical symptom of peritonitis, as the condition primarily affects the abdomen.
Choice B reason:
A severe headache is not a characteristic symptom of peritonitis.
Choice C reason:
Abdominal pain and tenderness are hallmark symptoms of peritonitis, resulting from inflammation of the peritoneum lining the abdominal cavity.
Choice D reason:
Shortness of breath is not a common symptom of peritonitis unless there is an associated respiratory complication.
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