Chapter 58: Caring for Clients with Disorders of the Kidneys and Ureters

The nurse is planning client teaching for a client with end-stage kidney disease who is scheduled for the creation of a fistula. The nurse should teach the client what information about the fistula?

"A vein and an artery in your arm will be attached surgically." Explanation: The fistula joins an artery and a vein, either side-to-side or end-to-end. This access will need several weeks to "mature" before it can be used. The client is encouraged to perform exercises to increase the size of the affected vessels (e.g., squeezing a rubber ball for forearm fistulas). Two needles will be inserted into the fistula for each dialysis treatment.

The nurse notes that a patient who is retaining fluid had a 1-kg weight gain. The nurse knows that this is equivalent to about how many mL?

1,000 mL Explanation: The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded. A 1-kg weight gain is equal to 1,000 mL of retained fluid

The nurse is caring for a client with chronic kidney disease. The patient has gained 4 kg in the past 3 days. In milliliters, how much fluid retention does this equal? Enter your response as a whole number.

4000 Explanation: A 1-kg weight gain is equal to 1,000 mL of retained fluid. 4 kg × 1,000 = 4,000. The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded.

A patient has stage 3 chronic kidney failure. What would the nurse expect the patient's glomerular filtration rate (GFR) to be?

A GFR of 30-59 mL/min/1.73 m2 Explanation: Stage 3 of chronic kidney disease is defined as having a GFR of 30-59 mL/min/1.73 m2

The critical care nurse is monitoring the client's urine output and drains following renal surgery. What should the nurse promptly report to the primary care provider?

Absence of drain output Explanation: Urine output and drainage from tubes inserted during surgery are monitored for amount, color, and type or characteristics. Decreased or absent drainage is promptly reported because it may indicate obstruction that could cause pain, infection, and disruption of the suture lines. Reporting increased pain on movement has nothing to do with the scenario described. Increased urine output and serosanguineous drainage are expected.

A patient with chronic kidney failure experiences decreased levels of erythropoietin. What serious complication related to those levels should the nurse assess for when caring for this client?

Anemia Explanation: Anemia develops as a result of inadequate erythropoietin production, the shortened lifespan of RBCs, nutritional deficiencies, and the patient's tendency to bleed, particularly from the GI tract. Erythropoietin, a substance normally produced by the kidneys, stimulates bone marrow to produce RBCs (Murphy, Bennett, & Jenkins, 2010). In ESKD, erythropoietin production decreases and profound anemia results, producing fatigue, angina, and shortness of breath.

The nurse is caring for a client who has returned to the postsurgical suite after postanesthetic recovery from a nephrectomy. The nurse's most recent assessment reveals increased sedation, shortness of breath, hypotension, and low urine output over the last 2 hours. What is the nurse's best response?

Assess the client for signs of bleeding and inform the primary provider. Explanation: Bleeding is a major complication of kidney surgery, and if missed can lead to hypovolemic (decreased volume of circulating blood) and hemorrhagic shock. Bleeding can be suspected when the client experiences fatigue, shortness of breath, and urine output of less than 400 mL within 24 hours. The postoperative client is monitored closely and these findings should be reported to the primary care provider. Ruling out the complication of the life-threatening condition of bleeding is the priority decision for this client. Performing a full neurological assessment will be warranted after the priority complications of surgery are ruled out. Increasing the monitoring of vital signs and urine output are just small parts of assessing the client for bleeding. Palpating the client's torso for flank pain may increase the client's pain and does not (in itself) address the most common cause of the client's signs and symptoms.

Which of the following is a term used to describe excessive nitrogenous waste in the blood, as seen in acute glomerulonephritis?

Azotemia Explanation: The primary presenting features of acute glomerulonephritis are hematuria, edema, azotemia (excessive nitrogenous wastes in the blood), and proteinuria (>3 to 5 g/day). Bacteremia is excessive bacteria in the blood

Which of the following causes should the nurse suspect in a client diagnosed with intrarenal failure?

Glomerulonephritis Explanation: Intrarenal causes of renal failure include prolonged renal ischemia, nephrotoxic agents, and infectious processes such as acute glomerulonephritis.

The nurse recognizes which condition as an integumentary manifestation of chronic renal failure?

Gray-bronze skin color Explanation: Integumentary manifestations of chronic renal failure include a gray-bronze skin color. Other manifestations are dry, flaky skin, pruritus, ecchymosis, purpura, thin, brittle nails, and coarse, thinning hair. Asterixis, tremors, and seizures are neurologic manifestations of chronic renal failure.

The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for?

Hypovolemic shock caused by hemorrhage Explanation: If bleeding goes undetected or is not detected promptly, the patient may lose significant amounts of blood and may experience hypoxemia. In addition to hypovolemic shock due to hemorrhage, this type of blood loss may precipitate a myocardial infarction or transient ischemic attack.

A client with end-stage renal disease receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurse's most appropriate action?

Inform the health care provider and assess the client for signs of infection. Explanation: Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate drainage fluid, so prompt reporting to the primary provider and rapid assessment for other signs of infection are warranted. Administration of an IV bolus is not necessary or appropriate and the health care provider would determine whether removal of the catheter is required. Flushing the catheter does not address the risk for infection.

A client is brought to the renal unit from the PACU status postresection of a renal tumor. Which of the following nursing actions should the nurse prioritize in the care of this client?

Managing postoperative pain Explanation: The client requires frequent analgesia during the postoperative period and assistance with turning, coughing, use of incentive spirometry, and deep breathing to prevent atelectasis and other pulmonary complications. Increasing oral intake and mobility are not priority nursing actions in the immediate postoperative care of this client. Dialysis is not necessary following kidney surgery.

A client recovering from hepatitis B develops acute nephrotic syndrome. Which treatment will the nurse anticipate being prescribed for this client?

Methylprednisolone Explanation: 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

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?

Oliguria Explanation: 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.

What is a hallmark of the diagnosis of nephrotic syndrome?

Proteinuria Explanation: Proteinuria (predominantly albumin) exceeding 3.5 g per day is the hallmark of the diagnosis of nephrotic syndrome. Hypoalbuminemia, hypernatremia, and hyperkalemia may occur. Reference

Two weeks after being diagnosed with a streptococcal infection, a client develops fatigue, a low-grade fever, and shortness of breath. The nurse auscultates bilateral crackles and observes jugular vein distention. Urinalysis reveals red and white blood cells and protein. After the physician diagnoses poststreptococcal glomerulonephritis, the client is admitted to the medical-surgical unit. Which immediate action should the nurse take?

Provide a high-protein, fluid-monitored diet. Explanation: The nurse must provide a high-protein diet to supply energy and reduce catabolism of protein. The nurse must also closely monitor the client's fluid intake and output. It isn't necessary for the client to be on bed rest. Because of the risk of altered urinary elimination related to oliguria, this client may require hemodialysis or plasmapheresis for several weeks until renal function improves; however, a Tenckhoff catheter is used in peritoneal dialysis, not hemodialysis. Although providing comfort measures (such as placing the client on a sheepskin) are important, this action isn't a priority.

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?

Risk for infection Explanation: 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 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event?

Streptococcal infection Explanation: Postinfectious causes of postinfectious glomerular disease are group A beta-hemolytic streptococcal infection of the throat that precedes the onset of glomerulonephritis by 2 to 3 weeks. Menarche, stress, and hypersensitivity are not typical causes.

Hyperkalemia is a serious side effect of acute renal failure. Identify the electrocardiogram (ECG) tracing that is diagnostic for hyperkalemia.

Tall, peaked T waves Explanation: Characteristic ECG signs of hyperkalemia are tall, tented, or peaked T waves, absent P waves, and a widened QRS complex.

Which of the following is the most accurate indicator of fluid loss or gain?

Weight Explanation: 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.

The nurse is caring for a client with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The client has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the client to take the prescribed medication at what time?

With each meal Explanation: Both calcium carbonate and calcium acetate are medications that bind with the phosphate and assist in excreting the phosphate from the body, in turn lowering the phosphate levels. Phosphate-binding medications must be given with food to be effective.

One of the roles of the nurse in caring for clients with chronic renal failure is to help them learn to minimize and manage potential complications. This would include:

restricting sources of potassium. Explanation: The nurse will teach the client to restrict sources of potassium, such as fresh fruits and vegetables, because hyperkalemia can cause life-threatening changes. The client will restrict sodium intake as ordered; doing so prevents fluid accumulation. Prescribed iron and folic acid supplements or Epogen should be taken; iron and folic acid supplements are needed for red blood cell (RBC) production, and Epogen stimulates the bone marrow to produce RBCs. The client will restrict protein intake to foods that are complete proteins within prescribed limits; complete proteins provide positive nitrogen balance for healing and growth.