A nurse is teaching a client and his 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?
Increased heart rate
Generalized abdominal pain
Cloudy effluent
Fever
The Correct Answer is C
This is because peritonitis is an infection of the peritoneal cavity that can occur as a complication of peritoneal dialysis. Peritonitis can cause inflammation and irritation of the peritoneum, which can lead to cloudy or milky appearance of the dialysate fluid that drains out of the abdomen (also known as effluent). Cloudy effluent is often the first and most reliable sign of peritonitis in peritoneal dialysis patients. Other signs and symptoms of peritonitis may include increased heart rate, generalized abdominal pain, fever, nausea, vomiting, loss of appetite, and malaise.
The nurse should instruct the client and his partner to inspect the effluent for clarity every time they perform an exchange and to report any changes to their health care provider immediately. The nurse should also teach them how to prevent peritonitis by following strict aseptic technique when handling catheters and supplies, washing hands before and after each exchange, wearing a mask during exchanges, and storing supplies in a clean and dry place.
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Related Questions
Correct Answer is C
Explanation
The first action that the nurse should take is to collect information about the irritant that caused the injury, as this will help determine the appropriate treatment and duration of irrigation. Ocular irrigation is the process of flushing the eye with sterile fluid to remove foreign substances or chemicals.
Different types of chemicals may have different effects on the eye, such as acid burns, alkali burns, or organic solvents. Therefore, it is essential to identify the type and concentration of the chemical, as well as the time and duration of the exposure, before proceeding with the irrigation.
Correct Answer is A
Explanation
The nurse's priority is to ensure that the client has given informed consent for the surgery, which requires that the client is competent and understands the risks and benefits of the procedure. A client with a high blood alcohol level may not have the mental capacity to consent and may need a legal representative or a court order to proceed with the surgery.
The other actions are important but not as urgent as obtaining consent.
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