The nurse is administering peritoneal dialysis to a client with a diagnosis of chronic kidney disease (CKD). The nurse notes the presence of a cloudy dialysate return. After notifying the healthcare provider, which action by the nurse is the most appropriate and of highest priority?
A)Measure the client's abdominal girth.
B)Document the cloudy dialysate.
C)Culture the dialysate return.
D)Increase dialysate instillation.

Question

Quizplus · Accepted Answer

A)The client's dialysate return should be clear. The presence of cloudy drainage might indicate peritonitis, so the nurse should culture the return in order to help identify the presence and type of organism that could be causing the infection. Documenting the cloudy dialysate would be a necessary nursing action, but is not the next-priority action. Measurement of abdominal girth is performed prior to the dialysis procedure, and even though increased girth could indicate peritonitis, culturing the return is more important. The instillation part of the procedure is completed prior to the collection of the dialysate return, and the rate of the instillation has no relationship to the development of an infection.
B)The client's dialysate return should be clear. The presence of cloudy drainage might indicate peritonitis, so the nurse should culture the return in order to help identify the presence and type of organism that could be causing the infection. Documenting the cloudy dialysate would be a necessary nursing action, but is not the next-priority action. Measurement of abdominal girth is performed prior to the dialysis procedure, and even though increased girth could indicate peritonitis, culturing the return is more important. The instillation part of the procedure is completed prior to the collection of the dialysate return, and the rate of the instillation has no relationship to the development of an infection.
C)The client's dialysate return should be clear. The presence of cloudy drainage might indicate peritonitis, so the nurse should culture the return in order to help identify the presence and type of organism that could be causing the infection. Documenting the cloudy dialysate would be a necessary nursing action, but is not the next-priority action. Measurement of abdominal girth is performed prior to the dialysis procedure, and even though increased girth could indicate peritonitis, culturing the return is more important. The instillation part of the procedure is completed prior to the collection of the dialysate return, and the rate of the instillation has no relationship to the development of an infection.
D)The client's dialysate return should be clear. The presence of cloudy drainage might indicate peritonitis, so the nurse should culture the return in order to help identify the presence and type of organism that could be causing the infection. Documenting the cloudy dialysate would be a necessary nursing action, but is not the next-priority action. Measurement of abdominal girth is performed prior to the dialysis procedure, and even though increased girth could indicate peritonitis, culturing the return is more important. The instillation part of the procedure is completed prior to the collection of the dialysate return, and the rate of the instillation has no relationship to the development of an infection.

The Nurse Is Administering Peritoneal Dialysis to a Client with a Diagnosis