When providing care for a client receiving peritoneal dialysis. While draining the dialysate the nurse notices that the efluent is cloudy. Which intervention is most important for the nurse to carry out at this moment?
Prepare the client for emergency surgery.
Send a specimen for culture and sensitivity.
Clamp the catheter and call the provider.
Irrigate the peritoneal catheter with sterile saline
The Correct Answer is B
Choice A rationale: Cloudy efluent doesn't necessarily indicate a need for emergency surgery unless accompanied by severe symptoms.
Choice B rationale: Cloudy efluent may indicate infection, so obtaining a culture and sensitivity test is crucial for appropriate treatment.
Choice C rationale: This step might be necessary if the efluent suggests infection, but sending a specimen for testing is the immediate priority.
Choice D rationale: This action isn't the first step; investigating the cause of cloudiness through testing is essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: This is a positive Trousseau's sign, which indicates hypocalcemia or tetany. It is not related to meningitis or meningeal irritation.
Choice B rationale: Kernig's sign is indicated when there is resistance and pain with knee extension and hip flexion, suggesting meningeal irritation.
Choice C rationale: This is a positive Homan's sign, which indicates deep vein thrombosis or phlebitis. It is not related to meningitis or meningeal irritation.
Choice D rationale: This is a sign of nuchal rigidity, which indicates meningeal irritation, but it is not specific to Kernig's sign. Nuchal rigidity can also be caused by other conditions such as cervical arthritis or muscle spasm.
Correct Answer is D
Explanation
Choice A rationale: Expressive aphasia is a type of non-fluent aphasia that affects the
ability to produce language. It is caused by damage to the anterior part of the left frontal lobe, which is responsible for motor planning and execution of speech. Patients with expressive aphasia can understand language but have difficulty speaking, writing, or naming objects. They often produce short, halting, and grammatically incorrect sentences with word-finding difficulties.
Choice B rationale: this is another term for expressive aphasia. The patient can
understand language but have difficulty speaking, writing, or naming objects. They often produce short, halting, and grammatically incorrect sentences with word-finding difficulties.
Choice C rationale: Global aphasia is a severe form of aphasia that affects both
comprehension and production of language. It is caused by extensive damage to the left hemisphere of the brain, which is dominant for language functions in most people.
Patients with global aphasia have little or no ability to speak, write, read, or understand language.
Choice D rationale: Wernicke's aphasia is a type of receptive aphasia that affects the
comprehension and production of language. It is caused by damage to the posterior part of the left temporal lobe, which is responsible for processing auditory and visual
information. Patients with Wernicke's aphasia can speak fluently but nonsensically, using words that are irrelevant, invented, or distorted. They also have difficulty understanding spoken or written language and following commands.
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