A nurse is caring for a client who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider?
Purulent dialysate outflow
Blood-tinged dialysate outflow
Report of fullness with dialysate dwelling
Report of discomfort during dialysate inflow
The Correct Answer is A
Rationale:
A. Purulent dialysate outflow is a sign of infection, specifically peritonitis, which is a serious complication of peritoneal dialysis that requires immediate medical attention.
B. Blood-tinged dialysate can occur, especially if the client is new to dialysis or has had recent abdominal surgery, but it should be monitored rather than immediately reported unless it is excessive.
C. A feeling of fullness during the dialysate dwelling phase is common and usually resolves as the body adjusts to the procedure.
D. Discomfort during dialysate inflow can occur, particularly with fast inflow rates or high dialysate volumes, but it is not immediately life-threatening.
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Correct Answer is C
Explanation
Rationale:
A. Hemoglobin A1C reflects average blood glucose levels over the past 2 to 3 months, not just after meals, so this statement is not fully accurate.
B. A high A1C indicates chronically high blood glucose levels, not low blood sugar levels, so this statement would be misleading.
C. An A1C of 9% indicates that the client's average blood sugar has been high over the past few months, which increases the risk of diabetes-related complications.
D. While a high A1C may suggest variability in blood glucose levels, the more accurate statement is that the average blood glucose is high, which is what the A1C primarily reflects
Correct Answer is D
Explanation
Rationale:
A. Hypertension can be a symptom of many conditions and is not specific to HHS.
B. Fruity breath is typically associated with diabetic ketoacidosis (DKA) due to the presence of acetone, not HHS.
C. Ketosis is a key feature of DKA, not HHS. In HHS, ketosis is usually absent or minimal.
D. A glucose level of 650 mg/dL is indicative of HHS, which is characterized by extremely high blood glucose levels without significant ketosis. HHS often occurs in type 2 diabetes and is marked by severe hyperglycemia, dehydration, and altered mental status.