The nurse is administering peritoneal dialysis to a client with acute renal failure. The nurse notes the presence of a cloudy dialysate return
After notifying the health care provider, which action by the nurse is the most appropriate?
A) Measure abdominal girth.
B) Document the cloudy dialysate.
C) Culture the dialysate return.
D) Increase dialysate instillation.
Answer: C
The return should be clear. The presence of cloudy drainage might indicate peritonitis, and 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 and nursing actions taken would be necessary, but is not the next-priority action. Measurement of abdominal girth is performed prior to the dialysis procedure, and although 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.
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