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
Assisting the adolescent to ambulate 12 hours following surgery is not recommended. Early ambulation is important, but 12 hours post-surgery is too soon and can lead to complications such as increased pain and risk of injury.
Choice B rationale
Ensuring two nurses logroll the adolescent every 2 hours is crucial. Logrolling helps maintain spinal alignment and prevents complications such as pressure ulcers and respiratory issues.
Choice C rationale
Maintaining the head of the bed at a 30° angle is not appropriate immediately post-surgery as it can increase pressure on the surgical site and compromise spinal alignment.
Choice D rationale
Offering sips of water 4 hours following surgery is not recommended. Postoperative patients are usually kept NPO (nothing by mouth) for a certain period to prevent aspiration and other complications.
Correct Answer is B
Explanation
Choice A rationale
Applying a cool pack to the heel prior to the procedure is not recommended as it can constrict blood vessels and make it more difficult to obtain a blood sample.
Choice B rationale
Puncturing the outer aspect of the heel is the correct technique for collecting a capillary blood specimen from an infant. This area has fewer nerve endings and is less likely to cause pain or injury.
Choice C rationale
Using a surgical blade to obtain the specimen is not appropriate for a capillary blood draw. A lancet should be used instead to make a small puncture in the skin.
Choice D rationale
Wiping the site with alcohol after the puncture is not recommended as it can cause irritation and discomfort. The site should be cleaned with alcohol before the puncture and then covered with a sterile gauze pad after the procedure.