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. It is essential to keep the drainage system below the level of the client's chest to prevent backflow of fluid into the pleural space, which could lead to complications such as a pneumothorax.
B. Clamping the chest tube is generally not recommended during transport because it can lead to a buildup of pressure in the pleural space, increasing the risk of a tension pneumothorax.
C. Disconnecting the chest tube from the drainage system is not advisable, as this could lead to air entering the pleural space, causing a pneumothorax.
D. Emptying the collection chamber is not necessary prior to transport, and it could lead to inaccurate measurement of fluid output. The focus should be on ensuring that the system remains intact and below chest level during transport.
Correct Answer is ["B","E","F"]
Explanation
Rationale:
A. The vital signs are stable and within normal limits. The slight drop in blood pressure post-dialysis is expected and not immediately concerning.
B. The client's weight decreased from 90 kg (198 lb) to 86.4 kg (190 lb) after dialysis. While weight loss is expected due to fluid removal during dialysis, this significant decrease (3.6 kg or approximately 8 lb) may need closer monitoring to ensure the client is not becoming dehydrated or losing more fluid than is safe.
C. The blood glucose levels are within an acceptable range for a client with type 2 diabetes mellitus. The slight decrease from 134 mg/dL to 75 mg/dL is not unusual given the time between measurements and the client's food intake.
D. The presence of a bruit and thrill at the AV fistula site indicates that it is functioning correctly, which is an expected finding.
E. The presence of crackles in the left lower lobe and an unproductive cough on the morning of Day 2 is concerning. These symptoms could indicate fluid overload or early signs of pulmonary edema, which require further evaluation and possible intervention.
F. The AV fistula site is noted to be ecchymotic and warm, with a bruit and thrill still present. While a bruit and thrill are expected findings, the ecchymosis and warmth could indicate a developing infection or trauma at the site, which necessitates further follow-up to prevent complications.