Which of the following nursing interventions should be included in the client’s care plan during dialysis therapy?
A. Limit the client’s visitors.
B. Monitor the client’s blood pressure.
C. Pad the side rails of the bed.
D. Keep the client NPO.
Correct Answer: B. Monitor the client’s blood pressure.
Because hypotension is a complication of peritoneal dialysis, the nurse records intake, and output, monitors VS, and observes the client’s behavior. Monitor BP (lying and sitting) and pulse. Note level of jugular pulsation. Decreased BP, postural hypotension, and tachycardia are early signs of hypovolemia
Option A: The nurse also encourages visiting and other diversional activities. Encourage use of relaxation techniques. Redirects attention and promotes a sense of control. Elevate head of bed at intervals. Turn the patient from side to side. Provide back care and tissue massage. Position changes and gentle massage may relieve abdominal and general muscle discomfort.
Option C: A client on PD does not need to be placed in bed with padded side rails. Anchor catheter and tubing with tape. Stress the importance of the patient avoiding pulling or pushing on the catheter. Restrain hands if indicated. Reduces risk of trauma by manipulation of the catheter.
Option D: A client on PD does not need to be kept NPO. Maintain nutritional status. Provide a high-calorie, low-protein, low-sodium, and low-potassium diet, with vitamin supplements to balance nutritional intake.
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