A nurse is providing care to a client who has peritonitis. Which of the following conditions is the highest priority for
the nurse to monitor?

Heart atack

Diabetes

Respiratory failure

Sepsis

Answer and Explanation

The Correct Answer is D

Choice A reason: While a heart atack is a serious condition, it is not directly related to peritonitis. Peritonitis can lead to systemic infection, which may indirectly affect the heart, but it is not the primary concern in the immediate care of peritonitis.

Choice B reason: Diabetes is a chronic condition that requires ongoing management. However, it is not the most immediate threat when a client is diagnosed with peritonitis. The nurse should continue to monitor blood glucose levels as part of routine care.

Choice C reason: Respiratory failure can be a complication of peritonitis if the infection spreads and affects other systems. However, the primary concern with peritonitis is the potential for the infection to lead to sepsis.

Choice D reason: Sepsis is a life-threatening condition that can occur as a complication of peritonitis. It happens when the body's response to infection causes injury to its own tissues and organs. Monitoring for signs of sepsis is crucial because early intervention can be lifesaving.

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Correct Answer is C

Explanation

Choice A reason: The output solution is typically the same or slightly less than the input solution due to fluid removal during dialysis.

Choice B reason: The fluid from the abdomen should be clear or slightly yellow; any other color may indicate infection or bleeding.

Choice C reason: Using a microwave to warm the solution is not recommended as it can unevenly heat the solution and damage its composition.

Choice D reason: While sterile precautions are taken, there is still a risk of infection with any catheter.

A. Dribbling of urine B. Color of the urine C. Voiding patern D. Proteinuria E. Bladder distension

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Dribbling of urine can indicate urinary retention, as it may suggest that the bladder is not emptying

completely during voiding.

Choice B reason: While the color of the urine can provide information about hydration status and other health issues, it is not a direct indicator of urinary retention.

Choice C reason: The voiding patern is an important assessment for urinary retention. Infrequent voiding or small amounts despite a full bladder can be signs of this condition.

Choice D reason: Proteinuria is not typically used as an assessment for urinary retention. It can indicate kidney damage or disease but does not directly relate to the bladder's ability to empty.

Choice E reason: Bladder distension can be observed and palpated in cases of urinary retention, as the bladder may become enlarged due to the accumulation of urine.

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A nurse is providing care to a client who has peritonitis. Which of the following conditions is the highest priority for the nurse to monitor?

Nursing Test Bank

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A nurse is providing care to a client who has peritonitis. Which of the following conditions is the highest priority for
the nurse to monitor?