A nurse is providing teaching to a client and their partner about performing peritoneal dialysis at home.
When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?
Cloudy effluent.
Increased heart rate.
Generalized abdominal pain.
Fever.
Fever.
The Correct Answer is A
The earliest indication of peritonitis in a patient undergoing peritoneal dialysis is often cloudy dialysis fluid when drained from the body.
Choice B is incorrect because an increased heart rate is not the earliest indication of peritonitis.
Choice C is incorrect because generalized abdominal pain is not the earliest indication of peritonitis.
Choice D is incorrect because fever is not the earliest indication of peritonitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should consult the client before approaching the dog.
Service dogs are working animals and it is important to respect their role and the handler’s wishes.
Choice A is wrong because petting the dog briefly to demonstrate acceptance could distract the dog from its duties.
Choice C is wrong because offering the dog a bowl of water without consulting the client first could interfere with the dog’s training or schedule.
Choice D is wrong because commanding the dog to sit while talking with the client could confuse the dog and disrupt its training.
Correct Answer is B
Explanation
The correct answer is choice B: Insert an NG tube.
Choice A rationale: Inserting an indwelling urinary catheter may be necessary for monitoring urine output in some cases, but in this situation, the priority is to insert an NG tube. This will help prevent aspiration during surgery due to the client's high blood alcohol level, which increases the risk of vomiting.
Choice B rationale: Inserting an NG tube is the priority action for the nurse because a high blood alcohol level increases the risk of vomiting and aspiration during surgery. An NG tube can help reduce this risk by keeping the stomach empty and minimizing the chance of aspiration.
Choice C rationale: Obtaining consent for surgery is important, but in emergency situations, consent may be implied, or a designated surrogate decision-maker may provide consent. It is not the priority action for the nurse in this scenario.
Choice D rationale: Applying antiembolic stockings is a preventive measure for deep vein thrombosis, but it is not the priority action in this case. Ensuring the client's safety during surgery, specifically by preventing aspiration, takes precedence due to the client's high blood alcohol level.
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