ch27: renal disorders
A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? Activity intolerance Impaired urinary elimination Risk for infection Toileting self-care deficit
Risk for infection The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection.
A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for: thrush and circumoral pallor. nausea and vomiting. dyspnea and cyanosis. fatigue and weakness.
fatigue and weakness. RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue and weakness. Nausea and vomiting may occur in CRF but don't result from faulty RBC production. Dyspnea and cyanosis are associated with fluid excess, not CRF. Thrush, which signals fungal infection, and circumoral pallor, which reflects decreased oxygenation, aren't signs of CRF.
A client requires hemodialysis. Which type of drug should be withheld before this procedure? Antibiotics Insulin Cardiac glycosides Phosphate binders
Cardiac glycosides Cardiac glycosides such as digoxin (Lanoxin) should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digoxin toxicity. Phosphate binders and insulin can be administered because they aren't removed from the blood by dialysis. Some antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects. The nurse should check a formulary to determine whether a particular antibiotic should be administered before or after dialysis.
The nurse is reviewing a patient's laboratory results. What findings does the nurse assess that are consistent with acute glomerulonephritis? Select all that apply. Polyuria White blood cell casts in the urine Red blood cells in the urine Proteinuria Hemoglobin of 12.8 g/dL
Red blood cells in the urine Proteinuria The primary presenting features of an acute glomerular inflammation are hematuria, edema, azotemia (an abnormal concentration of nitrogenous wastes in the blood), and proteinuria (excess protein in the urine). The urine may appear cola colored because of red blood cells (RBCs) and protein plugs or casts; RBC casts may be present, indicating glomerular injury. Acute glomerulonephritis does not present with white blood cell (WBC) casts.
The nurse is caring for a patient in the oliguric phase of acute kidney injury (AKI). What does the nurse know would be the daily urine output? 1.5 L Less than 400 mL 1.0 L Less than 50 mL
Less than 400 mL The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The minimum amount of urine needed to rid the body of normal metabolic waste products is 400 mL. In this phase, uremic symptoms first appear and life-threatening conditions such as hyperkalemia develop.
A patient has acute kidney injury (AKI) with a negative nitrogen balance. How much weight does the nurse expect the patient to lose? 0.5 kg/day 1.0 kg/day 1.5 kg/day 2.0 kg/day
0.5 kg/day AKI causes severe nutritional imbalances (because nausea and vomiting contribute to inadequate dietary intake), impaired glucose use and protein synthesis, and increased tissue catabolism. The patient is weighed daily and loses 0.2 to 0.5 kg (0.5 to 1 lb) daily if the nitrogen balance is negative (i.e., caloric intake falls below caloric requirements).
A community health nurse is well-aware that the incidence and prevalence of chronic renal failure (CRF) has increased significantly in recent years. In a recent strategic planning meeting, the nurse has proposed health promotion activities to address this problem. Which of the following health promotion campaigns addresses the most common cause of CRF? Encouraging adults to know their family history of CRF Promoting smoking cessation Screening for CRF among adults age 70 and older Teaching individuals with diabetes to manage their disease
Teaching individuals with diabetes to manage their disease Diabetes is the most common cause of CRF; vigilant glycemic control reduces diabetics' risks of developing CRF. Family history and advanced age are also significant risk factors, but less so than diabetes. Smoking is not closely associated with CRF.
A client has undergone a renal transplant and returns to the health care agency for a follow-up evaluation. Which finding would lead to the suspicion that the client is experiencing rejection? Weight loss Tenderness over transplant site Hypotension Polyuria
Tenderness over transplant site Signs and symptoms of transplant rejection include abdominal pain, hypertension, weight gain, oliguria, edema, fever, increased serum creatinine levels, and swelling or tenderness over the transplanted kidney site.
A nursing educator is speaking with a group of new graduates about a patient who has acute glomerulonephritis. The educator should tell the nurses that the patient may exhibit which of the following clinical manifestations? Decrease in serum creatinine levels Glucosuria Hypotension Hematuria
Hematuria The primary presenting feature of acute glomerulonephritis is hematuria (blood in the urine), which may be microscopic (identifiable through microscopic examination) or macroscopic or gross (visible to the eye). Proteinuria, primarily albumin, which is present, is due to increased permeability of the glomerular membrane. Blood urea nitrogen (BUN) and serum creatinine levels may rise as urine output drops. The patient may be anemic primarily from fluid retention. Some degree of edema and hypertension is noted in 75% of patients.
The nurse instructs a client to perform continuous ambulatory peritoneal dialysis correctly at home. Which educational information should the nurse provide to the client? Wear a mask while handling any dialysate solutions. Keep the catheter stabilized to the abdomen, below the belt line. Use an aseptic technique during the procedure. Clean the catheter insertion site daily with soap.
Use an aseptic technique during the procedure. The client should be instructed to use an aseptic technique during the procedure. The client should also demonstrate the continuous ambulatory peritoneal dialysis (CAPD) exchange procedure for the nurse using an aseptic technique (clients on continuous cycling peritoneal dialysis [CCPD] should also demonstrate an exchange procedure in case of failure or unavailability of a cycling machine). A mask is generally worn only while performing exchanges, especially when a client has an upper respiratory infection. The catheter insertion site should be cleaned daily with an antiseptic such as povidone-iodine, not with soap. In addition, the catheter should be stabilized to the abdomen above the belt line, not below the belt line, to avoid constant rubbing.
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem? Hematocrit (HCT) of 35% White blood cell (WBC) count of 20,000/mm3 Potassium level of 3.5 mEq/L Blood glucose level of 200 mg/dl
White blood cell (WBC) count of 20,000/mm3 An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia (evidenced by a blood glucose level of 200 mg/dl) occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.
A client is diagnosed with polycystic kidney disease and requires teaching on the management of the disorder. Which statement made by the client indicates a need for further teaching? "I inherited this disorder from one of my parents." "If renal failure develops, I may need to consider dialysis." "The cysts can get quite large in size." "As long as I have one normal kidney, I should be fine."
"As long as I have one normal kidney, I should be fine." Polycystic kidney disease is characterized by the formation of multiple cysts on both kidneys. Polycystic kidney disease is inherited as an autosomal dominant trait. The fluid-filled cysts can cause great enlargement of the kidneys and interfere with kidney function, which can eventually lead to renal failure.
A patient with end-stage renal disease (ESRD) is scheduled for his first hemodialysis treatment. The patient asks the nurse what common complications may occur from the treatment. What would be the nurse's best reply? "High blood sugar levels and low protein levels may occur." "Confusion and diarrhea may occur." "Bleeding and double vision may occur." "Low blood pressure and cramping sometimes occur."
"Low blood pressure and cramping sometimes occur." The most common side effects associated with hemodialysis are hypotension and cramping. Confusion is an uncommon complication related to dialysis disequilibrium syndrome, and this condition is not frequently observed with advancing hemodialysis technology. Diarrhea is not a complication related to hemodialysis. High blood sugar levels and low protein levels are complications associated with peritoneal dialysis. Blood loss is a complication related to hemodialysis, but excessive bleeding is not a common complication related to advanced technology and equipment monitors. Double vision is not associated with hemodialysis, but blurry vision may be a manifestation of hypotension.
An investment banker with chronic renal failure informs the nurse of the choice for continuous cyclic peritoneal dialysis. Which is the best response by the nurse? "The risk of peritonitis is greater with this type of dialysis." "Peritoneal dialysis will require more work for you." "This type of dialysis will provide more independence." "Peritoneal dialysis does not work well for every client."
"This type of dialysis will provide more independence." Once a treatment choice has been selected by the client, the nurse should support the client in that decision. Continuous cyclic peritoneal dialysis will provide more independence for this client and supports the client's decision for treatment mode. The risk of peritonitis is greater, and symptoms should be discussed as part of the management of the disorder. Peritoneal dialysis is an effective method of dialysis for many clients.
A client with newly diagnosed renal cancer is questioning why detection was delayed. Which is the best response by the nurse? "Painless gross hematuria is the first symptom in renal cancer." "Very few symptoms are associated with renal cancer." "Squamous cell carcinomas do not present with detectable symptoms." "You should have sought treatment earlier."
"Very few symptoms are associated with renal cancer." Renal cancers rarely cause symptoms in the early stage. Tumors can become quite large before causing symptoms. Painless, gross hematuria is often the first symptom in renal cancer and does not present until later stages of the disease. Adenocarcinomas are the most common renal cancer (about 80%),whereas squamous cell renal cancers are rare. It is not therapeutic to place doubt or blame for delayed diagnosis.
A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which disorder? Nephrotic syndrome Acute glomerulonephritis Chronic renal failure Acute renal failure
Acute glomerulonephritis Acute glomerulonephritis is also associated with varicella zoster virus, hepatitis B, and Epstein-Barr virus. Acute renal failure is associated with hypoperfusion to the kidney, parenchymal damage to the glomeruli or tubules, and obstruction at a point distal to the kidney. Chronic renal failure may be caused by systemic disease, hereditary lesions, toxic agents, infections, and medications. Nephrotic syndrome is caused by disorders such as chronic glomerulonephritis, systemic lupus erythematosus, multiple myeloma, and renal vein thrombosis.
The nurse recognizes the patient comprehends the signs and symptoms of renal transplant rejection when the patient states he will monitor for which of these signs and symptoms? Select all that apply. A. Thrill and bruit over the fistula B. Weight gain and fever C. Palpitations and thirst D. Flank pain and pyuria E. Swelling of the ankles and around the eyes
B. Weight gain and fever E. Swelling of the ankles and around the eyes Symptoms of transplant rejection include fever, edema, weight gain, leukocytosis, tenderness over the graft site, and returning symptoms of uremia. Thrill and bruit over the fistula indicate a positive outcome for the fistula. Palpitations and thirst may be symptoms of fluid volume deficit, which is not found in the renal failure patient. Flank pain and pyuria are symptoms of pyelonephritis.
The presence of prerenal azotemia is a probable indicator for hospitalization for CAP. Which of the following is an initial laboratory result that would alert a nurse to this condition? BUN of 18 mg/dL. Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20. Glomerular filtration rate (GFR) of 100 mL/min. Serum creatinine of 1.2 mg/dL.
Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20. The normal BUN:Cr ratio is less than 15. Prerenal azotemia is caused by hypoperfusion of the kidneys due to a nonrenal cause. Over time, higher than normal blood levels of urea or other nitrogen-containing compounds will develop.
The client is admitted to the hospital with a diagnosis of acute glomerulonephritis. Which clinical manifestation would the nurse expect to find? Hyperalbuminemia Cola-colored urine Peripheral neuropathy Hypotension
Cola-colored urine Clinical manifestations of acute glomerulonephritis include cola-colored urine, hematuria, edema, azotemia, and proteinuria.
A nurse identifies a nursing diagnosis of risk for ineffective breathing pattern related to incisional pain and restricted positioning for a client who has had a nephrectomy. Which of the following would be most appropriate for the nurse to include in the client's plan of care? Administer isotonic fluid therapy as ordered. Keep the drainage catheter below the level of insertion. Encourage use of incentive spirometer every 2 hours. Monitor temperature every 4 hours.
Encourage use of incentive spirometer every 2 hours. To address the issue of ineffective breathing pattern, encouraging the use of incentive spirometer would be most appropriate to help increase alveolar ventilation. Administering isotonic fluid therapy would be appropriate for issues involving fluid loss such as bleeding or hemorrhage. Keeping the drainage catheter below the level of insertion would be appropriate to reduce the risk of obstruction leading to acute pain. Monitoring the temperature every 4 hours would be appropriate to reduce the client's risk for infection.
A client is diagnosed with polycystic kidney disease. Which of the following would the nurse most likely assess? Hypertension Periorbital edema Extremity pain Fever
Hypertension Hypertension is present in approximately 75% of clients with polycystic kidney disease at the time of diagnosis. Pain from retroperitoneal bleeding, lumbar discomfort, and abdominal pain also may be noted based on the size and effects of the cysts. Fever would suggest an infection. Periorbital edema is noted with acute glomerulonephritis.
The nurse cares for a client after extensive abdominal surgery. The client develops an infection that is treated with IV gentamicin. After 4 days of treatment, the client develops oliguria, and laboratory results indicate azotemia. The client is diagnosed with acute tubular necrosis and transferred to the ICU. The client is hemodynamically stable. Which dialysis method would be most appropriate for the client? Continuous venovenous hemofiltration (CVVH) Peritoneal dialysis Hemodialysis Continuous arteriovenous hemofiltration (CAVH)
Hemodialysis The client is hemodynamically stable and hemodialysis would be most appropriate. Hemodialysis is used for clients who are acutely ill and require short-term dialysis for days to weeks until kidney function resumes and for clients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) who require long-term or permanent renal replacement therapy. Peritoneal dialysis (PD) may be the treatment of choice for clients with renal failure who are unable or unwilling to undergo hemodialysis or kidney transplantation. CAVH and CVVH are used for client who are hemodynamically unstable.
A client with chronic kidney disease becomes confused and reports abdominal cramping, racing heart rate, and numbness of the extremities. The nurse relates these symptoms to which lab value? Hypocalcemia Elevated urea levels Elevated white blood cells Hyperkalemia
Hyperkalemia Hyperkalemia is the life-threatening effect of renal failure. The client can become apathetic; confused; and have abdominal cramping, dysrhythmias, nausea, muscle weakness, and numbness of the extremities. Symptoms of hypocalcemia are muscle twitching, irritability, and tetany. Elevation in urea levels can result in azotemia, which can be exhibited in fluid and electrolyte and/or acid-base imbalance. Elevation of WBCs is not indicated.
A client has end-stage renal failure. Which of the following should the nurse include when teaching the client about nutrition to limit the effects of azotemia? Increase fat intake and limit carbohydrates. Increase protein, carbohydrates, and fat intake. Eliminate fat intake and increase protein intake. Increase carbohydrates and limit protein intake.
Increase carbohydrates and limit protein intake. Calories are supplied by carbohydrates and fat to prevent wasting. Protein is restricted because the breakdown products of dietary and tissue protein (urea, uric acid, and organic acids) accumulate quickly in the blood.
What is a characteristic of the intrarenal category of acute kidney injury (AKI)? Increased BUN High specific gravity Decreased urine sodium Decreased creatinine
Increased BUN The intrarenal category of acute kidney injury (AKI) encompasses an increased BUN, increased creatinine, a low-normal specific gravity of urine, and increased urine sodium. Intrarenal AKI is the result of actual parenchymal damage to the glomeruli or kidney tubules. Acute tubular necrosis (ATN), AKI in which there is damage to the kidney tubules, is the most common type of intrinsic AKI. Characteristics of ATN are intratubular obstruction, tubular back leak (abnormal reabsorption of filtrate and decreased urine flow through the tubule), vasoconstriction, and changes in glomerular permeability. These processes result in a decrease of GFR, progressive azotemia, and fluid and electrolyte imbalances.
A client diagnosed with acute kidney injury (AKI) has developed congestive heart failure. The client has received 40 mg of intravenous push (IVP) Lasix and 2 hours later, the nurse notes that there are 50 mL of urine in the Foley catheter bag. The client's vital signs are stable. Which health care order should the nurse anticipate? Normal saline bolus of 500 mL Chest x-ray Lasix 80 mg IVP Mannitol 12.5 g IVP
Lasix 80 mg IVP Diuretic agents are often used to control fluid volume in clients with acute kidney injury (AKI). The client's urine output indicates an inadequate response to the initial dosage of Lasix and the nurse should anticipate administering Lasix 80 mg IVP. Often in this situation, the initial dosage of Lasix is doubled. The client is experiencing fluid overload, thus, a 500-mL bolus of normal saline bolus would be contraindicated. There is no need to complete a chest x-ray. Mannitol is widely used in the management of cerebral edema and increased intracranial pressure from multiple causes.
For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important? Encouraging coughing and deep breathing Providing pain-relief measures Limiting fluid intake Promoting carbohydrate intake
Limiting fluid intake During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and IV fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain.
A client recovering from hepatitis B develops acute nephrotic syndrome. Which treatment will the nurse anticipate being prescribed for this client? Increase in sodium intake Methylprednisolone Low-carbohydrate diet Vancomycin
Methylprednisolone Acute nephritic syndrome is a type of acute glomerulonephritis. The focus of management is to treat symptoms, preserve kidney function, and treat complications. Treatment may include corticosteroids such as methylprednisolone. Antibiotics such as vancomycin are used to treat bacterial infections. Hepatitis B is caused by a virus. Sodium would be restricted if the client has hypertension, edema, or heart failure. Carbohydrates should be ingested liberally to provide energy and reduce the catabolism of protein.
Patient education regarding a fistulae or graft includes which of the following? Select all that apply. No tight clothing. No IV or blood pressure taken on extremity with dialysis access. Avoid compression of the site. Check daily for thrill and bruit. Cleanse site b.i.d.
No tight clothing. No IV or blood pressure taken on extremity with dialysis access. Avoid compression of the site. Check daily for thrill and bruit. The nurse teaches the patient with fistulae or grafts to check daily for a thrill and bruit. Further teaching includes avoiding compression of the site; not permitting blood to be drawn, an IV to be inserted, or blood pressure to be taken on the extremity with the dialysis access; not to wear tight clothing, carry bags or pocketbooks on that side, and not lie on or sleep on the area. The site is not cleansed unless it is being accessed for hemodialysis.
A group of students are reviewing the phases of acute renal failure. The students demonstrate understanding of the material when they identify which of the following as occurring during the second phase? Oliguria Acute tubular necrosis Diuresis Restored glomerular function
Oliguria During the second phase, the oliguric phase, oliguria occurs. Diuresis occurs during the third or diuretic phase. Acute tubular necrosis (ATN) occurs during the first, or initiation, phase in which reduced blood flow to the nephrons leads to ATN. Restoration of glomerular function, if it occurs, occurs during the fourth, or recovery, phase.
The nurse cares for a client with acute kidney injury (AKI). The client is experiencing an increase in the serum concentration of urea and creatinine. The nurse determines the client is experiencing which phase of AKI? Recovery Diuresis Initiation Oliguria
Oliguria The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The initiation periods begins with the initial insult and ends when oliguria develops. The diuresis period is marked by a gradual increase in urine output. The recovery period signals the improvement of renal function and may take 6 to 12 months.
Which of the following occurs late in chronic glomerulonephritis? Nosebleed Peripheral neuropathy Stroke Seizure
Peripheral neuropathy Peripheral neuropathy with diminished deep tendon reflexes and neurosensory changes occur late in the disease. The patient becomes confused and demonstrates a limited attention span. An additional late finding includes evidence of pericarditis with or without a pericardial friction rub. The first indication of disease may be a sudden, severe nosebleed, a stroke, or a seizure.
A 58-year-old man has a longstanding diagnosis of poorly controlled type 2 diabetes. As a result of hyperglycemia, the man has developed chronic glomerulonephritis. In light of this new diagnosis, the nurse who is caring for this patient would anticipate that he will exhibit: Proteinuria Arrhythmias Hypokalemia Hematuria
Proteinuria Chronic glomerulonephritis is characterized by proteinuria, usually caused by repeated episodes of glomerular injury that results in renal destruction. Hypokalemia does not typically accompany renal disease, and arrhythmias are unlikely to be evident at this stage of kidney disease. Hematuria may or may not be present.
A child has been receiving care in a children's hospital for the past several days after being diagnosed with nephrotic syndrome. In anticipation of discharge, the nurse is now performing health education with the child's parents. What teaching point should the nurse emphasize? The importance of closely following the prescribed dietary regimen The importance of frequent physical activity The correct technique for monitoring the child's blood pressure Signs and symptoms of the cardiac and gastrointestinal complications of nephrotic syndrome
The importance of closely following the prescribed dietary regimen Patients with nephrotic syndrome need instruction about the importance of following medication and dietary regimens, so that their condition can remain stable as long as possible; this is a priority over physical activity and blood pressure monitoring. Gastrointestinal and cardiac complications are not common.
Mr. Jeung is a 60-year-old man who has been coming to the local dialysis center three times a weeks for the past year. Mr. Jeung is interested in the possibility of beginning home hemodialysis, and his wife is willing and able to assist accordingly. The dialysis nurse knows that the primary goal of performing dialysis in the patient's own home is to maximize: The patient's independence and quality of life The patient's weight loss and consistency of fluid balance The patient's adherence to the prescribed regimen The patient's ability to resume a normal diet
The patient's independence and quality of life The primary advantage of home hemodialysis is the ability to minimize disruptions to the patient's routine and maximize quality of life. It is not an appropriate mode of delivery for patients who struggle to adhere to treatment. It does not allow the patient to abandon a renal diet. Weight loss and fluid balance are not necessarily superior in the home setting.
Which of the following is the most accurate indicator of fluid loss or gain? Urine output Body temperature Caloric intake Weight
Weight The most accurate indicator of fluid loss or gain in an acutely ill patient is weight, as accurate intake and output and assessment of insensible losses may be difficult. Urine output, caloric intake, and body temperature would not be the most reliable indicator of fluid loss or gain.
