Exhibits

The nurse performs an initial focused assessment of the client. Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of a disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.

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.

Choice A reason: Activity intolerance related to ischemia is a common concern for clients with AMI, but it is not the primary nursing problem when the client is receiving thrombolytic therapy. The focus should be on monitoring for complications related to the therapy itself.

Choice B reason: Risk for injury related to effects of thrombolytics is the priority nursing problem for a client receiving thrombolytic therapy. Thrombolytics can cause serious bleeding complications, including internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or intracranial bleeding. The nurse must closely monitor the client for signs and symptoms of bleeding, such as sudden onset or worsening of headache, changes in level of consciousness, hematuria, melena, ecchymosis, or hematoma formation.

Choice C reason: Ineffective breathing pattern related to adverse drug effects can occur following thrombolytic therapy, but it is not the primary concern. The risk of bleeding complications takes precedence as the priority nursing problem for this client.

Choice D reason: Deficient knowledge related to a new medication regimen is important for client understanding and adherence, but it is not the priority nursing problem in the immediate post-thrombolytic therapy period. Ensuring the client's safety by monitoring for bleeding complications is the primary focus.