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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Taking 3,000 mg of vitamin C daily is not recommended as it may increase the risk of calcium oxalate stones due to possible conversion of vitamin C to oxalate.
Choice B reason: Drinking 3 L of fluid every day is advised to prevent kidney stones by diluting the urine and reducing the concentration of stone-forming substances.
Choice C reason: Eating 12 oz of animal protein daily is excessive and can increase the risk of kidney stones due to higher excretion of calcium and oxalate.
Choice D reason: Restricting calcium intake to one serving per day is not recommended as a normal calcium intake is necessary to bind oxalate in the gut and reduce oxalate absorption.
Correct Answer is C
Explanation
Choice A reason: Decreasing the IV fluid infusion rate and limiting oral fluid intake may not be appropriate without further assessment, as the client's BUN level is elevated, which could indicate dehydration or renal impairment. The normal range for BUN is typically 7-20 mg/dL.
Choice B reason: Collecting a urine specimen for culture and sensitivity may be necessary if there is a suspicion of infection, but there is no indication of infection based solely on the provided lab values.
Choice C reason: Evaluating urine for amount and specific gravity can help assess the client's hydration status and kidney function, which is pertinent given the elevated BUN level and ongoing nausea and vomiting.
Choice D reason: Continuing routine care may not be appropriate because the BUN level is above the normal range, indicating that further assessment and intervention may be necessary.
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