To prevent the most common serious complication of peritoneal dialysis, it is important for the nurse to:

Reposition the patient frequently and promote deep breathing.

Infuse the dialysate slowly.

Use strict aseptic technique in the dialysis procedures.

Have the patient empty the bowel before the inflow phase.

Answer and Explanation

The Correct Answer is C

Choice A reason: Repositioning the patient frequently and promoting deep breathing are important interventions for various conditions, particularly for preventing atelectasis and respiratory complications. However, they are not directly related to preventing the most common serious complication of peritoneal dialysis, which is peritonitis.

Choice B reason: Infusing the dialysate slowly can help manage discomfort and ensure proper fluid exchange during peritoneal dialysis. However, it does not address the most serious complication, which is infection.

Choice C reason: Using strict aseptic technique in dialysis procedures is crucial in preventing peritonitis, the most serious and common complication of peritoneal dialysis. Peritonitis is an infection of the peritoneal cavity and can lead to severe complications if not prevented. Adhering to aseptic techniques during catheter insertion, connection, disconnection, and any other procedure involving the dialysis system is essential to reduce the risk of infection.

Choice D reason: Having the patient empty the bowel before the inflow phase can help ensure adequate space in the peritoneal cavity for the dialysate and prevent discomfort. However, this action does not directly prevent the serious complication of peritonitis.

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Correct Answer is C

Explanation

Choice A reason: Rechecking all of the patient's vital signs is a good practice, but it is not the priority action in this scenario. The patient's symptoms indicate a potential case of autonomic dysreflexia, a life-threatening condition that requires immediate action to reduce blood pressure and address the cause. Rechecking vital signs alone will not resolve the underlying issue.

Choice B reason: Elevating the patient's knees and lowering the head of the bed is not an appropriate action in this situation. This position could potentially increase intracranial pressure and exacerbate the patient's condition. The focus should be on measures that will help lower the blood pressure and alleviate the symptoms of autonomic dysreflexia.

Choice C reason: The priority action is to elevate the head of the bed immediately and notify the provider. Elevating the head of the bed helps to decrease blood pressure and improve venous return. Promptly notifying the provider ensures that the patient receives timely medical intervention to address the underlying cause of autonomic dysreflexia, which is critical for preventing further complications.

Choice D reason: Administering PRN Tylenol for the patient's headache is not the priority in this situation. While pain management is important, the patient's symptoms suggest a more severe condition (autonomic dysreflexia) that requires immediate attention to lower blood pressure and address the root cause. Pain medication alone will not resolve the underlying issue and could delay necessary interventions.

A. Maintain NPO status. B. Soft, bland diet. C. Regular diet. D. Low-fat, high-fiber diet.

Correct Answer is A

Explanation

Choice A reason: Maintaining NPO (nothing by mouth) status is essential for patients with acute pancreatitis. This allows the pancreas to rest and decreases the secretion of pancreatic enzymes, reducing inflammation and promoting healing. NPO status is typically maintained until the patient's symptoms improve and the inflammation subsides.

Choice B reason: A soft, bland diet is not appropriate for the initial management of acute pancreatitis. Introducing food too early can stimulate pancreatic enzyme production and worsen inflammation. Once the patient stabilizes, dietary recommendations may include a gradual reintroduction of low-fat, bland foods.

Choice C reason: A regular diet is not suitable for patients with acute pancreatitis. Consuming a regular diet can exacerbate symptoms and inflammation by stimulating pancreatic enzyme secretion. Patients need to follow a more controlled dietary plan to manage their condition effectively.

Choice D reason: A low-fat, high-fiber diet is beneficial for general health but not for the initial management of acute pancreatitis. Once the patient's condition stabilizes and they are no longer NPO, a low-fat diet may be introduced gradually to avoid stimulating pancreatic enzyme production.

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