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 C
Explanation
Choice A reason:
Anxiety may lead to restlessness, but the assumption of a fetal position suggests a pain response, which is a common finding in peritonitis.
Choice B reason:
Fatigue may lead to restlessness, but it does not explain the assumption of a fetal position, which is a pain-coping mechanism.
Choice C reason:
The client assuming a fetal position and exhibiting restlessness are indicative of pain, which is a common symptom in peritonitis.
Choice D reason:
Respiratory distress is not directly related to the findings described in the scenario.
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 the management 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 antibiotic therapy is more critical to address the underlying infection.
Choice C reason:
Initiating intravenous (IV) antibiotic therapy is the highest priority in the management of peritonitis. Prompt administration of antibiotics is essential to treat the bacterial infection and prevent its spread.
Choice D reason:
Encouraging deep breathing and coughing exercises is beneficial for preventing respiratory complications, but it is not the highest priority compared to addressing the infection with antibiotics.
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