Exhibits

Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.

Choice A reason: Preparing the prescribed dose of rapid-acting insulin from the sliding scale instructions is not appropriate when the client's blood glucose level is low (56 mg/dL). Administering insulin at this point could further lower the blood glucose level, potentially leading to severe hypoglycemia. The priority is to raise the client's blood glucose level to a safe range.

Choice B reason: Giving the client six ounces of non-diet carbonated soda and instructing the client to drink it entirely is the correct first intervention. The client’s blood glucose level is significantly below the normal reference range (hypoglycemia). Administering a fast-acting carbohydrate, such as non-diet soda, helps to quickly increase the blood glucose level to a safer range. This intervention addresses the immediate need to correct the hypoglycemia and prevent potential complications such as confusion, seizures, or loss of consciousness.

Choice C reason: Collecting a blood specimen by venipuncture to send to the laboratory for serum glucose analysis is not the first intervention to implement. While laboratory confirmation of blood glucose levels can be important, the immediate priority is to treat the hypoglycemia. Delaying treatment to collect a laboratory specimen could result in worsening of the client's condition. Immediate administration of a fast-acting carbohydrate should be prioritized.

Choice D reason: Documenting the glucose reading in the electronic medical record (EMR) is important but not the first priority. While accurate documentation is necessary for ongoing care, the immediate intervention should focus on treating the hypoglycemia. Once the client's blood glucose level has been stabilized, the nurse can then document the reading and subsequent interventions in the EMR.

Choice A reason: An exit site infection can occur around the catheter insertion site, leading to redness, tenderness, and drainage. While this is a concerning issue that needs to be addressed, the more significant complication to prevent is peritonitis, which can result from an exit site infection if it spreads.

Choice B reason: Peritonitis is a serious and potentially life-threatening infection of the peritoneal cavity. In clients on peritoneal dialysis, signs such as redness, tenderness, and drainage around the catheter site are alarming indicators that could lead to peritonitis if not promptly treated. Peritonitis can cause severe abdominal pain, fever, and cloudy dialysis fluid, and requires immediate medical intervention to prevent complications.

Choice C reason: Outflow obstruction is a complication where the peritoneal dialysis fluid does not drain properly. This can be caused by a number of issues including catheter malposition or blockages, but it is not directly related to the symptoms of redness, tenderness, and drainage at the catheter site. Outflow obstruction is important to monitor but does not represent the immediate risk that peritonitis does.

Choice D reason: Atelectasis refers to the collapse of a part or all of a lung, often due to blockage of the air passages. This is not related to the symptoms around the peritoneal dialysis catheter site. While respiratory issues must be monitored, the primary concern here is the potential for peritoneal infection.