Question: A client with end-stage renal disease is receiving continuous ambulatory peritoneal dialysis. The nurse is monitoring the client for signs of complications associated with peritoneal dialysis. Select all that apply.
1. Pruritus
2. Oliguria
3. Tachycardia
4. Cloudy outflow
5. Abdominal pain
Answer: 3, 4, 5
Rationale: Tachycardia can be caused by peritonitis, a complication of peritoneal dialysis; the heart rate increases to meet the metabolic demands associated with infection. Cloudy or opaque dialysate outflow (effluent) is the earliest sign of peritonitis; it is caused by the constituents associated with an infectious process. Abdominal pain is associated with peritonitis, a complication of peritoneal dialysis; pain results from peritoneal inflammation, abdominal distention, and involuntary muscle spasms. Severe itching (pruritus) is caused by metabolic waste products that are deposited in the skin; dialysis removes metabolic waste products, preventing this adaptation associated with kidney failure. The production of abnormally small amounts of urine (oliguria) is a sign of kidney failure, not a complication of peritoneal dialysis.
Clinical Area: Medical Surgical Nursing
Client Need: Physiological Adaptation
Cognitive Level: Analysis
Nursing Process: Evaluation
This week’s NCLEX exam practice question came from:
Nugent: Mosby's Review Questions for the NCLEX-RN Exam, 7th Edition, Chapter 2, Page 71, Question 802
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