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 D
Explanation
Choice A rationale
An adolescent with a urinary tract infection (UTI) is not at high risk for insufficient vascular perfusion. UTIs primarily affect the urinary system and do not typically impact vascular perfusion.
Choice B rationale
A toddler receiving intravenous fluids is not at high risk for insufficient vascular perfusion. IV fluids help maintain hydration and vascular volume, supporting adequate perfusion.
Choice C rationale
A preschooler with otitis media (ear infection) is not at high risk for insufficient vascular perfusion. Otitis media affects the middle ear and does not typically impact vascular perfusion.
Choice D rationale
A school-age child in a spica cast is at high risk for insufficient vascular perfusion. The cast can restrict blood flow, leading to complications such as compartment syndrome, which requires immediate medical attention.
Correct Answer is D
Explanation
Choice A rationale
While explaining the procedure to the adolescent and their guardian is important, it is not the nurse’s primary responsibility to provide detailed explanations of the procedure. This should be done by the provider performing the procedure.
Choice B rationale
Witnessing the adolescent’s signature on the informed consent form is part of the nurse’s role, but it does not address the guardian’s lack of understanding about the procedure.
Choice C rationale
Requesting assistance from the anesthesiologist to clarify the misunderstanding is not appropriate, as the anesthesiologist may not be the best person to explain the procedure. The provider performing the procedure should be the one to provide clarification.
Choice D rationale
Notifying the provider who is scheduled to perform the procedure is the correct action. The provider is responsible for ensuring that the patient and their guardian fully understand the procedure and its risks and benefits before obtaining informed consent.