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: Cerebral motor cortex primarily controls voluntary movements, not autonomic functions like respiration, heart rate, and blood pressure.
Choice B rationale: The brain stem controls vital functions like respiration, heart rate, and blood pressure, so damage to this area can lead to difficulties in these functions.
Choice C rationale: Broca's area is responsible for speech production and is not directly involved in autonomic functions.
Choice D rationale: The occipital lobe is primarily associated with visual processing and perception, not autonomic functions like respiration or heart rate.
Correct Answer is C
Explanation
Choice A rationale: Irregular respirations, bradycardia, and widened pulse pressure might indicate increased intracranial pressure.
Choice B rationale: This set of symptoms is often seen in cardiac tamponade and is referred to as the Beck’s triad and not Cushing's triad.
Choice C rationale: Cushing's triad is a set of clinical signs associated with increased intracranial pressure (ICP) and typically includes bradycardia (slow heart rate),
hypertension (elevated blood pressure), and irregular breathing patterns. Fixed pupils can also be present in some cases, but it's important to note that this triad is not always consistently present and may vary from person to person.
Choice D rationale: This set of symptoms describes symptoms of shock, not specifically Cushing's triad.
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