Nokea
A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse?
- A. Warm the dialysis solution in a microwave before instillation
- B. Take a sample of the effluent and send to the laboratory
- C. Flush the tubing with normal saline to maintain patency of the catheter
- D. Check the catheter for obstruction
Correct Answer: B
Rationale: An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse.
You may also like to solve these questions
A nurse reviews these laboratory values of a client who returned from kidney transplantation 12 hours ago. What is the priority assessment?
- A. Assess blood pressure for hypotension
- B. Assess skin turgor for dehydration
- C. Auscultate lung sounds for crackles
- D. Monitor daily weight for fluid retention
Correct Answer: A
Rationale: By taking blood pressure, the nurse is assessing for hypotension that could compromise perfusion to the new kidney. The nurse then should notify the provider immediately. Skin turgor, lung sounds, and weight could give information about the fluid status of the client, but they are not the priority assessment.
A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse?
- A. Use the catheter for the next laboratory blood draw
- B. Monitor the central venous pressure through this line
- C. Access the line for the next intravenous medication
- D. Place a heparin or heparin/saline dwell after hemodialysis
Correct Answer: D
Rationale: The central line should have a heparin or heparin/saline dwell after hemodialysis treatment to prevent clotting. The central line catheter used for dialysis should not be used for blood sampling, monitoring central venous pressures, or giving drugs or fluids.
A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema?
- A. Maintaining oxygen saturation of 88%
- B. Minimal crackles in the lungs and lung sounds
- C. Maintaining a balanced intake and output
- D. Limited shortness of breath upon exertion
Correct Answer: C
Rationale: With an optimal fluid balance, the client will be more able to eject blood from the left ventricle without increased pressure in the left ventricle and pulmonary vessels. Maintaining a balanced intake and output is the most direct goal to prevent fluid overload and reduce the risk of pulmonary edema.
A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse?
- A. Discuss what the treatment regimen means to him
- B. Refer the client to a mental health nurse practitioner
- C. Reschedule the appointments to another date and time
- D. Discuss the option of peritoneal dialysis
Correct Answer: A
Rationale: The initial action for the nurse is to assess anxiety, coping styles, and the client's acceptance of the required treatment for CKD. The client may be in denial of the diagnosis. While rescheduling hemodialysis appointments may help, and referral to a mental health practitioner and the possibility of peritoneal dialysis are all options to assess the client, the client's acceptance of the treatment should come first.
A client has a serum potassium level of 6.5 mEq/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL per 24 hours. What is the priority action by the nurse?
- A. Place the client on a cardiac monitor immediately
- B. Place the client on a low-potassium diet
- C. Continue to monitor the client's intake and output
- D. Ask to have the laboratory redraw the blood specimen
Correct Answer: A
Rationale: The priority action by the nurse should be to check the cardiac status with a monitor. High potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.