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 B
Explanation
Rationale:
A. Popping sounds, also known as crackles, are typically associated with fluid in the alveoli, often seen in conditions like pneumonia or heart failure, not pleurisy.
B. Loud, grating sounds, known as pleural friction rub, are characteristic of pleurisy. This sound is produced by the inflamed pleural surfaces rubbing together during respiration.
C. Snoring sounds, or rhonchi, are usually heard in conditions involving airway obstruction by mucus, such as bronchitis, rather than pleurisy.
D. Squeaky, musical sounds, or wheezing, are associated with airway narrowing, such as in asthma or chronic obstructive pulmonary disease (COPD), and are not typically heard in pleurisy.
Correct Answer is A
Explanation
Rationale:
A. Slow, steady bubbling in the suction control chamber indicates that the system is functioning correctly. The nurse should continue to monitor the client's respiratory status and the drainage system.
B. Clamping the chest tube is not indicated unless instructed by the healthcare provider, as it could lead to a dangerous buildup of pressure in the pleural space.
C. Checking the suction control outlet on the wall is not necessary if the suction control chamber is already bubbling steadily.
D. Checking the tubing connections for leaks is unnecessary if the bubbling is slow and steady, as this indicates the system is working properly.