A nurse is providing peritoneal dialysis to a child and observes there is minimal dialysate outflow at the end of the outflow time. Which of the following actions should the nurse take?
Increase the dwell time during the next dialysis infusion.
Instruct the child to change position.
Increase oral fluid intake.
Assess for a bruit at the site of the peritoneal catheter.
The Correct Answer is B
Choice A rationale
Increasing the dwell time during the next dialysis infusion is not appropriate. The issue is with the outflow, not the dwell time. Increasing the dwell time could exacerbate the problem.
Choice B rationale
Instructing the child to change position is correct. Changing position can help facilitate the drainage of dialysate by allowing gravity to assist in the outflow process.
Choice C rationale
Increasing oral fluid intake is not relevant to the issue of minimal dialysate outflow. The problem lies with the mechanical process of dialysis, not fluid intake.
Choice D rationale
Assessing for a bruit at the site of the peritoneal catheter is not directly related to resolving minimal dialysate outflow. A bruit indicates blood flow through a vascular access, not the peritoneal catheter.
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Correct Answer is B
Explanation
Choice A rationale
Reinforcing the dressing may be necessary, but controlling bleeding is the immediate priority. Applying pressure just above the insertion site is the first step to control bleeding and prevent further blood loss.
Choice B rationale
Applying pressure just above the insertion site is the first step to control bleeding and prevent further blood loss. This action helps to stop the bleeding and stabilize the patient.
Choice C rationale
Obtaining vital signs is important, but it can wait momentarily until the bleeding is under control. The immediate priority is to stop the bleeding.
Choice D rationale
Monitoring the pulse distal to the insertion site is important, but controlling bleeding takes precedence. Once the bleeding is controlled, the nurse can then monitor the pulse
Correct Answer is D
Explanation
Choice A rationale
Asking the child’s parent to leave the room during the procedure may increase the child’s anxiety and make the procedure more traumatic. Parental presence can provide comfort and reduce anxiety.
Choice B rationale
Performing the procedure in the unit’s playroom may not provide the necessary equipment and sterile environment required for a venipuncture. It is important to perform the procedure in a controlled and sterile environment.
Choice C rationale
Explaining the procedure in detail to the child 3 hours prior to the procedure may increase anxiety and anticipation, making the procedure more traumatic. It is better to explain the procedure closer to the time of the procedure.
Choice D rationale
Applying a topical anesthetic cream 1 hour prior to the procedure helps reduce pain and discomfort during the venipuncture, promoting atraumatic care. This approach minimizes the child’s pain and anxiety.