Medical Surgical Dialysis #1

Question

The nurse assesses a client with renal failure who receives peritoneal dialysis. The nurse observes cloudy drainage fluid. Which is the nurse’s priority action following observation of the cloudy dialysate drainage?

Answers

  1. Give 250 mL bolus of normal saline to help flush kidneys.
    • Rationale:

      This answer is not correct because adding more fluid to the client will be harmful; therefore, this action is not appropriate. Having cloudy dialysate drainage is not normal. The nurse should contact the health provider immediately as cloudy dialysate drainage may indicate peritonitis and infection.

  2. Do nothing but monitor as cloudy dialysate drainage is normal.
    • Rationale:

      This answer is not correct because cloudy dialysate is not a normal finding; therefore, this nursing action is not appropriate. The nurse should contact the health provider immediately as cloudy dialysate drainage may indicate peritonitis and infection.

  3. Remove the peritoneal tubing and change the entire set-up with sterile technique.
    • Rationale:

      This answer is not correct because although the healthcare provider may want to culture the tubing and bag, this action is not the priority nursing intervention after observing the cloudy drainage. The nurse must contact the health care provider.

  4. Contact the health care provider and continue monitoring for further signs of infection.
    • Rationale:

      This answer is correct because cloudy dialysate is often indicative of a compilation of PD, usually infection. The priority action by the nurse is to notify the healthcare provider and continue to monitor the client for additional manifestations that may be indicative of infection.

Overview

Peritoneal dialysis (PD) is a treatment for kidney failure that uses the lining of the client’s abdomen to filter the blood inside the body. Having cloudy dialysate drainage is not normal. The nurse should contact the health provider immediately as cloudy dialysate drainage may indicate peritonitis and infection

Explanation

Learning Outcomes

Having cloudy dialysate drainage is not normal. The nurse should contact the health provider immediately as cloudy dialysate drainage may indicate peritonitis and infection; therefore, continued monitoring for further signs of infection is also warranted. Other symptoms of peritonitis may include unusual abdominal pain, fever, and chills.

Test Taking Tip

Priority indicates that while more than one choice may be appropriate, only one should be done first.

Video Rationale