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: Often results from direct trauma to the skull, but not typically associated with CSF leakage or raccoon eyes.
Choice B rationale: Basilar skull fractures, particularly involving the anterior or middle fossa, can lead to CSF leakage from the nose (rhinorrhea) and periorbital ecchymosis (raccoon eyes).
Choice C rationale: A simple fracture line without displacement, less likely to cause CSF leakage and raccoon eyes.
Choice D rationale: Less commonly associated with CSF leakage and periorbital ecchymosis compared to basilar skull fractures.
Correct Answer is C
Explanation
Choice A rationale: Performing active range of motion exercises may not be safe or appropriate immediately following a hemorrhagic stroke.
Choice B rationale: Maintaining the head of bed flat or at a 30-degree position might be used for ischemic strokes but not necessarily for hemorrhagic strokes.
Choice C rationale: Teaching measures to avoid the Valsalva maneuver (straining during activities like defecation) helps prevent sudden increases in intracranial pressure, which can be detrimental after a hemorrhagic stroke.
Choice D rationale: Monitoring for Battle's sign (bruising behind the ears associated with basilar skull fracture) is not relevant in the care of a hemorrhagic stroke.
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