A nurse is teaching a client about self-administering peritoneal dialysis. Which of the following statements by the client indicates a need for further teaching?
"The microwave in my kitchen can warm the solution before I use it."
"The catheter can become infected even with sterile precautions."
"The volume of the output solution should be greater than the input solution."
"The fluid from my abdomen will be clear or slightly yellow."
The Correct Answer is A
Choice A reason:Using a microwave to warm the solution is not recommended as it can lead to uneven heating and potentially damage the solution or harm the patient.
Choice B reason: The statement about the catheter becoming infected despite sterile precautions is accurate and reflects an understanding of the risks associated with peritoneal dialysis.
Choice C reason:Expecting the volume of the output solution to be greater than the input solution is incorrect; typically, the volumes should be equal to ensure proper fluid removal.
Choice D reason: The fluid from the abdomen being clear or slightly yellow is a normal finding and does not indicate a need for further teaching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A heart murmur is not a common finding in right-sided heart failure unless there is an associated valvular heart disease.
Choice B reason: Dependent edema is a classic sign of right-sided heart failure due to the accumulation of fluid in the tissues, particularly in the lower extremities.
Choice C reason: Chest pain is more commonly associated with left-sided heart failure or other cardiac conditions such as angina.
Choice D reason: Crackles in the lungs are typically found in left-sided heart failure due to pulmonary congestion, not right-sided heart failure.
Correct Answer is A
Explanation
Choice A reason: A distended bladder is a common cause of autonomic dysreflexia. It can trigger an exaggerated response from the autonomic nervous system, leading to a rapid increase in blood pressure. This is because the full bladder sends signals to the spinal cord, which then attempts to send signals to the brain. However, due to the injury, these signals cannot pass through, resulting in a reflex that increases blood pressure.
Choice B reason: While a severe headache is a symptom of autonomic dysreflexia, it is not a cause. The headache results from the body's response to a triggering stimulus, such as a distended bladder, which leads to the high blood pressure characteristic of autonomic dysreflexia.
Choice C reason: Nasal congestion is not typically a cause of autonomic dysreflexia. The condition is usually triggered by a noxious stimulus below the level of the spinal cord injury, such as a full bladder or bowel, skin irritation, or other types of physical discomfort.
Choice D reason: Elevated blood pressure is a symptom, not a cause, of autonomic dysreflexia. The condition itself causes a sudden spike in blood pressure due to an uncontrolled reflex sympathetic discharge in response to a triggering stimulus below the level of the injury.
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