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 A
Explanation
Rationale:
A. Auscultating for a bruit at the site of an AV graft is the most appropriate method to assess its patency. A bruit is a sound made by turbulent blood flow, indicating that the graft is functioning.
B. Measuring blood pressure in both arms does not specifically assess the patency of the graft and could potentially harm the graft if measured in the affected arm.
C. Auscultating the antecubital fossa using a Doppler is not a standard practice for assessing AV graft patency; instead, a stethoscope is used directly over the graft site.
D. Checking the brachial and radial pulses does not assess the graft directly. Although pulse presence is important, it does not provide information about the graft’s patency.
Correct Answer is C
Explanation
Rationale:
A. Assisting the client to the bathroom might be helpful, but it is not the first action the nurse should take since the client hasn't voided for an extended period.
B. Increasing fluids may be beneficial but does not address the immediate concern of whether there is a problem with urinary retention.
C. Performing a bladder scan is the first action to determine if there is urine retention in the bladder. This information is crucial before deciding on further interventions, such as catheterization.
D. Inserting a straight catheter may be necessary if significant urinary retention is confirmed, but it should not be the first action without knowing the bladder's status.