Chapter 60: Renal Review

15. What sound does the nurse expect to hear when listening over the renal artery of a client who has renal artery stenosis? A. Quiet, pulsating sound B. Swishing sound C. Occasional gurgling D. Faint wheezing

B A bruit is an audible swishing sound produced when the volume of blood or the diameter of the blood vessel changes. It often occurs with blood flow through a narrowed vessel, as in renal artery stenosis.

The nurse is admitting a client undergoing a CT scan with contrast. Which finding does the nurse report as a possible immediate hypersensitivity reaction? Select all that apply. A. Nausea B. Pruritis C. Urticaria D. Laryngeal stridor E. Flushing of the skin

B, C, D, E

Physiological Integrity A client is on a 24-hour urine collection. At midpoint during the collection, the client tells the nurse that some of the urine was discarded. What action will the nurse take? Select all that apply. A. No action is required. B. Reinforce client education. C. Notify the laboratory staff. D. Restart the urine collection. E. Document the discarded urine. F. Notify the health care provider.

B, C, E F

3. Which lab finding is indicative of renal function alterations and not dehydration? Select all that apply. A. BUN 20 mL/dL B. Creatinine 2.3 mL/dL C. Hemoglobin 14 g/dL D. Cystatin-c 105 mg/mL E. BUN/creatinine ratio 10 F. Creatinine clearance 175 mL/min

B, D, F

2. Which client assessment data is essential for the nurse to report to the health care provider before a renal scan is performed? A. Pink-tinged urine B. Reports pregnancy C. Reports claustrophobia D. History of an aneurysm clip

B

10. Which over-the-counter product will the nurse further explore with a client, for potential impact on kidney function? A. Mouthwash with alcohol B. Vitamin C C. Acetaminophen D. Fiber supplement

10. C The nurse asks for more information because high-dose or long-term use of NSAIDs or ac-etaminophen can seriously reduce kidney function.

11. What is the most common symptom that prompts clients to seek medical attention for problems with the kidneys or urinary tract? A. Pain in flank or abdomen, or pain when urinating B. Change in the frequency or amount of urination C. Exposure to one or more nephrotoxic substances D. Change in color, clarity, or odor of the urine

11. A The onset of pain in the flank, in the lower ab-domen or pelvic region, or in the perineal area causes concern and usually prompts the client to seek medical care. The nurse asks about the onset, intensity, and duration of the pain; its location; precipitating and relieving factors, and its association with any activity or event. Painful urination also leads clients medical care.

12. Which problem or complication does the nurse suspect when a client with chronic kidney dis-ease develops anorexia, nausea and vomiting, muscle cramping, and pruritus? A. Client has oliguria B. Client has anuria C. Client has uremia D. Client has azotemia

12. C Uremia is the buildup of nitrogenous waste products in the blood from inadequate elimi-nation as a result of kidney failure. Symptoms include anorexia, nausea and vomiting, muscle cramps, pruritus (itching), fatigue, and leth-argy. Anuria is failure of kidneys to produce urine; oliguria is the production of abnormally small amounts of urine; and azotemia is the buildup of nitrogenous waste products in the blood.

14. When the nurse provides care for a client with chronic kidney failure, what assessments will be made that support a finding of fluid overload? Select all that apply. A. Weigh the client and compare to baseline. B. Compare current blood pressure to baseline. C. Measure for residual urine with a bladder scanner. D. Auscultate the lung fields to determine if fluid is present. E. Check for pedal and periorbital swelling. F. Obtain a sterile urine specimen by catheterization.

14. A, B, D, E To assess for fluid overload, the nurse looks at the skin and tissues which may show edema associated with kidney disease, especially in the pedal (foot), pretibial (shin), and sacral tissues and around the eyes (periorbital). A stetho-scope is used to listen to the lungs to determine whether fluid is present. The client is weighed and blood pressure measured as a baseline for later comparisons. A client with chronic kidney failure does not make much urine, thus check-ing for residual urine with a bladder scanner is not necessary. A sterile sample is not needed unless infection is suspected

16. Which is the best technique for the nurse to use when assessing a client for bladder distention? A. Use one hand to gently depress the bladder as the client takes a deep breath, then percuss as the client slowly exhales. B. Place one hand under the client's back and palpate with the other hand over the bladder, percussing the lower abdomen until tympanic sounds are no longer heard. C. Gently palpate the outline of the bladder and percuss the lower abdomen toward the umbilicus until dull sounds are no longer produced. D. Locate the symphysis pubis, gently palpate for outline of the bladder, then auscultate for bowel sounds in the lower abdomen.

16. C A distended bladder sounds dull when per-cussed. After gently palpating to determine the outline of the distended bladder, the nurse begins percussion on the lower abdomen and continues in the direction of the umbilicus un-til dull sounds are no longer produced. If the nurse suspects bladder distention, a portable bladder scanner is used to determine amount of retained urine.

17. Which equipment and actions will the nurse use to assess a female client's urethra prior to inserting a urinary catheter? Select all that apply. A. Ensure a good light source is available. B. Record any discharge from the meatus. C. Assess for lesions or rashes and record. D. Remind the client to wipe from back to front. E. Ask about discomfort with urination. F. Wear well-fitting gloves during the assessment

17. A, B, C, E, F Using a good light source and wearing gloves, the nurse inspects the urethra by examining the meatus and the tissues around it. Any unusual discharge such as blood, mucus, or pus is noted and recorded. The skin and mucous mem-branes of surrounding tissues are inspected. The nurse records the presence of lesions, rashes, or other abnormalities of the labia or vaginal opening. Urethral irritation is sus-pected when the client reports discomfort with urination. The nurse uses this opportunity to remind female clients to clean the perineum by wiping from front to back (not back to front). The client is taught that the front-to-back tech-nique keeps organisms in stool from coming close to the urethra and decreases the risk for infection.

18. What question does the nurse ask to help inter-pret the result when a healthy adult client's urinalysis reveals a protein level of 0.9 mg/dL? A. "Have you ever been treated for a urinary tract infection?" B. "Are you sexually active and if so, do you use condoms?" C. "Do you have a family history of cardiac or biliary disease?" D. "Have you recently performed any strenuous exercise?"

18. D A random finding of proteinuria (usually albu-min in the urine) followed by a series of nega-tive (normal) findings does not imply kidney disease. Normal value for protein in the urine is 0-8 mg/dL. The nurse asks the client about re-cent strenuous exercise because urinary protein levels may be increased with exercise. Other causes of increased protein level include stress, infection, and glomerular disorders.

19. Which laboratory values will the nurse monitor as specific indicators of a client's kidney function? Select all that apply. A. Creatinine B. Blood urea nitrogen (BUN) C. Cystatin-C D. Blood osmolarity E. BUN/creatinine ratio F. White blood cell count

19. A, C, D, E Serum creatinine is produced when muscle and other proteins are broken down. Because protein breakdown is usually constant, the se-rum creatinine level is a good indicator of kidney function. Cystatin-C measures glomer-ular filtration rate. Increased levels can be con-sidered a predictor of chronic renal disease. Blood osmolarity is a measure of the overall concentration of particles in the blood and is a good indicator of hydration status. The kid-neys excrete or reabsorb water to keep blood osmolarity in the range of 280 to 300 mOsm/ kg (mmol/kg). When both the BUN and serum creatinine levels increase at the same rate, the BUN/creatinine ratio remains normal. How-ever, elevations of both serum creatinine and BUN levels suggest kidney dysfunction. Blood urea nitrogen (BUN) measures the effective-ness of kidney excretion of urea nitrogen, a by-product of protein breakdown in the liver. Other factors influence the BUN level, and an elevation does not always mean that kidney disease is present. WBC level provides more useful information about infection.

2. Which substances will the nurse consider an abnormal finding in a client's routine urine sample? Select all that apply. A. Electrolytes B. Red blood cells C. Proteins D. Water E. Albumin F. Creatinine

2. B, C, E Large particles, such as blood cells, albumin, and other proteins, are too large to filter through the glomerular capillary walls. Therefore, these substances are not normally present in the excreted final urine.

20. Which questions will the nurse ask a client with a blood urea nitrogen (BUN) of 26 mg/dL to identify non-renal factors that may contribute to this laboratory result? Select all that apply. A. "Have you been trying to lose weight with severe calorie restrictions?" B. "Have you noticed any blood in your stool or vomited any blood?" C. "Have you been on a high-protein diet or been drinking high-protein drinks?" D. "Did you drink a lot of extra fluid before the blood sample was drawn?" E. "Are you taking or have you recently taken any steroid medications?" F. "Have you recently experienced any physical or emotional stress?"

20. B, C, E, F An increased BUN level may indicate liver or kidney disease, dehydration or decreased kid-ney perfusion, a high-protein diet, infection, stress, steroid use, Gl bleeding, or other situa-tions in which blood is in body tissues. The nurse asks questions about these non-kidney factors that can cause increases in BUN.

21. Which assessment will the nurse complete before notifying the health care provider about an older client's blood osmolarity result of 313 mOsm/L? A. Checking lungs for respiratory status B. Assessing for any discomfort or pain C. Looking for signs of dehydration D. Smelling urine for odor and looking for particles

21. C The normal range for blood osmolarity is 280 to 300 mOsm/kg (mmol/kg). When blood osmolarity increases, vasopressin is released. Vasopressin increases the permeability of the distal tubules to water. The nurse assesses the client for signs of dehydration from water loss.

22. Which annual examinations to screen for kidney problems would the nurse recommend for an African-American client? A. Urinalysis, microalbuminuria, and serum creatinine B. Kidney ultrasound, blood urea nitrogen, and serum glucose C. Serum creatinine, blood urea nitrogen, and renal scan D. 24-hour urine collection, blood urea nitrogen, and urinalysis

22. A African-American clients are at greater risk for kidney failure than are white clients. The nurse recommends yearly health examinations including urinalysis, checking for the presence of microalbuminuria, and evaluating serum creatinine.

23. Which client does the nurse expect is most likely to produce a urinalysis with a specific gravity (SG) of 1.004? A. Client with hypovolemia due to blood loss B. Client who has dehydration secondary to vomiting C. Client with syndrome of inappropriate antidiuretic hormone (SIADH) D. Client who is prescribed the diuretic medication furosemide every day

23. D The normal urine SG is 1.005 to 1.030; usually 1.010 to 1.025. A client may have decreased SG in chronic kidney disease, diabetes insipidus, malignant hypertension, diuretic administra-tion (e.g. furosemide, hydrochlorothiazide), and lithium toxicity

24. Which instruction will the nurse give the assistive personnel (AP) about when it is best to collect a client's urinalysis sample? A. In the evening before bedtime B. An hour after any meal C. With the first morning void D. After drinking two full glasses of water

24. C Ideally, the urine specimen is collected at the morning's first voiding. Specimens obtained at other times may be too dilated

25. Which actions will the nurse take to ensure that a client's 24-hour urine collection is completed appropriately? Select all that apply. A. Teach the client that a 24-hour collection of urine is necessary to quantify or calculate the rate of clearance of a particular substance. B. Check with the laboratory or procedure manual for proper technique to maintain the 24-hour collection. C. Do not remove urine from the collection container for other specimens during the 24-hour period. D. On initiation of the collection, ask the client to void, discard the urine, and note the time, then begin the collection. E. Twenty-four hours after initiation, ask the client to empty the bladder 24 hours after initiation and add that urine to the container. F. Place signs appropriately, then inform all personnel or family caregivers that the test is in progress.

25. A, B, C, D, E, F ' All of these options are appropriate actions for the nurse to implement to ensure that a 24-hour urine collection is successfully com-pleted. See Box 60.1 Collection of Urine Speci-mens in your text for additional information.

26. Which action will the nurse include in postpro-cedural care for a client who has a renal scan? A. Administer captopril to increase renal blood flow. B. Encourage oral fluids to assist with excretion of the isotope. C. Insert a urinary catheter to measure urine output. D. Administer prescribed laxatives to cleanse the bowel.

26. B This imaging test is used to examine the perfu-sion, function, and structure of the kidneys by the IV administration of a radioisotope. The isotope is eliminated 6 to 24 hours after the procedure. The nurse encourages the client to drink fluids to aid in excretion of the isotope

27. What preprocedural instruction will the nurse provide for a client scheduled for an ultrasonography? A. "Empty your bladder just before the test begins." B. "Stop taking your routine medications 24 hours before the test." C. "You must have nothing to eat or drink after midnight before the test." D. "Drink 500 to 1000 mL of water 2 to 3 hours before the test."

27. D Ultrasonography usually requires a full bladder. The nurse asks the client to drink 500 to 1000 mL of water about 2 to 3 hours before the test to help fill the bladder. The nurse instructs the client not to void after drinking the water until the test is complete.

28. Which actions will the nurse include in postprocedural care for a client who had a cystoscopy with general anesthesia? Select all that apply. A. Monitor for airway patency and breathing. B. Provide frequent vital sign checks including temperature. C. Record and monitor for any changes in urine output. D. Report pink-tinged urine to the urology care provider immediately. E. Irrigate the urinary catheter with sterile saline if prescribed. F. Encourage the client to take oral fluids to increase urine output.

28. A, B, C, E, F All of these actions are appropriate to the post-procedural care of a client after a cystoscopy with general anesthesia except option D. Pink-tinged urine is expected after this procedure. However, gross bleeding is not and should be reported immediately. Also, notify the urolo-gist for obvious blood clots and a decrease or absence of urine output. Irrigate the Foley catheter with sterile saline, if prescribed by the urologist.

29. What is the priority nursing assessment for a client who has undergone a kidney biopsy? A. Monitor for urinary retention. B. Assess for onset of hypertension. C. Perform frequent checks for hemorrhage. D. Observe for signs of nephrotoxicity.

29. C After a percutaneous kidney biopsy, the major risk is bleeding into the kidney or into the tissues external from the kidney at the biopsy site. For 24 hours after the biopsy, the nurse monitors the dressing site, vital signs (espe-cially fluctuations in blood pressure), urine output, hemoglobin level, and hematocrit.

3. Which blood pressure reading does the nurse expect will result in compromised kidney func-tion for a client who sustained major injuries in an automobile accident? A. 160/80 mm Hg B. 140/100 mm Hg C. 80/60 mm Hg D. 68/40 mm Hg

3. D Glomerular filtration rate (GFR) is controlled by blood pressure and blood flow. The kidneys self-regulate their own blood pressure and blood flow, which keeps GFR constant. GFR is controlled by selectively constricting and dilat-ing the afferent and efferent arterioles. When systolic pressure drops below 65 to 70 mm Hg, these self-regulation processes do not maintain GFR.

13. Which step will the nurse perform first on a client during assessment of the renal system? A. Listen for a bruit over each renal artery. B. Lightly palpate the abdomen in all four quadrants. C. Percuss from the lower abdomen toward the umbilicus. D. Observe the flank region for asymmetry or discoloration

3. D With assessment, inspection comes first. The nurse inspects the abdomen and the flank regions with the client in both supine and sitting positions. He or she observes for asymmetry (e.g., swelling) or discoloration (e.g., bruising or redness) in the flank region, especially in the area of the costovertebral angle (CVA). The CVA is located between the lower portion of the 12th rib and the vertebral column. Auscultation for bruits comes next. Auscultation is com-pleted before percussion and palpation because these activities can alter bowel sounds and ob-scure abdominal vascular sounds. Palpation and percussion are usually completed by the health care provider or nurse practitioner

30. For which circumstance will the nurse select the male icon for a female client when performing a bladder scan? A. Female who self identifies as a male B. Woman with a history of hysterectomy C. Female who is 5 years postmenopausal D. Woman with a history of bladder cancer

30. B Before bladder scanning, the nurse selects the male or female icon on the bladder scanner. Using the female icon allows the scanner soft-ware to subtract the volume of the uterus from any measurement. Use the male icon on all men and on women who have undergone a hysterectomy.

31. Which priority teaching will the nurse provide to prevent harm for a client after a renal biopsy? A. Avoid lifting heavy objects for 1 to 2 weeks after the procedure. B. Do not go up or down stairs for at least 10 days. C. Avoid light house work including cooking and washing dishes. D. Stay out of the sun until after your follow-up appointment.

31. A If no bleeding occurs, the nurse teaches the cli-ent that he or she can resume general activities after 24 hours (e.g., light housework, such as cooking or washing dishes). The client is instructed to avoid lifting heavy objects, exer-cising, or performing other strenuous activities for 1 to 2 weeks after the biopsy procedure. Driving may also be restricted

4. What instructions would the nurse give an assistive personnel (AP) about the proper handling of a client's routine urinalysis specimen? Select all that apply. A. Leave the specimen in the bathroom. B. Ensure the container is tightly covered. C. Place the sample in a sterile container. D. Take the sample to the laboratory within 1 hour. E. Put the sample in a plastic sample bag. F. Refrigerate a sample that cannot be taken to the laboratory right away

4. B, D, E, F The nurse teaches the AP that urine specimens become more alkaline when left standing unre-frigerated for more than 1 hour, when bacteria are present, or when a specimen is left uncov-ered. Alkaline urine increases cell breakdown. So, the presence of red blood cells may be missed on analysis. The AP ensures that urine specimens are covered and delivered to the laboratory promptly. A plastic bag protects against contact with urine that may be on the outside the cup. Urine specimen delayed 2 or more hours require refrigeration or other specific storage and transport precautions to ensure the integrity of the urine specimen. This is a routine urinalysis and does not need to be sterile. The sample should not be left in the bathroom.

5. When a client's kidney hormonal function is not working properly, which condition does the nurse expect to occur? A. Leukemia B. Thrombocytopenia C. Anemia D. Neutropenia

5. C The kidneys produce the hormone erythropoietin for red blood cell (RBC) synthesis. When kidney function is poor, erythropoietin production decreases and anemia results.

6. Which client does the nurse expect is most likely to exceed the renal threshold when he or she is noncompliant with the prescribed therapeutic regimen? A. 45-year-old with biliary obstruction B. 55-year-old with type 2 diabetes mellitus C. 65-year-old with recurrent kidney stones D. 75-year-old with functional incontinence

6. B The point where the kidney is overwhelmed with glucose (e.g., diabetes mellitus) and can no longer reabsorb is called the renal threshold or transport maximum (tm) for glucose reabsorp-tion. The renal threshold for glucose is greater than 180 mg/dL (10 mmol/L). When blood glucose levels are greater than 180 mg/dL (10 mmol/L), some glucose stays in the filtrate and is present in the urine.

7. Which nursing actions will the nurse take to provide safe care and prevent harm for an older client experiencing increased nocturia? Select all that apply. A. Ensure adequate lighting and a hazard-free environment. B. Use caution administering nephrotoxic drugs. C. Ensure the availability of a bedside toilet, bedpan, or urinal if needed. D. Encourage the client to use the toilet, bedpan, or urinal at least every 2 hours. E. Discourage excessive fluid intake for 2 to 4 hours before the client goes to bed. F. Respond as soon as possible to the client's indication of the need to void.

7. A, C, E, F Actions A, C, E, and F are appropriate for pre-venting harm associated with falls related to frequent nocturia. Option B is an appropriate action for a client with decreased GFR. Option D is an appropriate action for a client with decreased bladder capacity. Option F is appro-priate for decreased bladder capacity, but also appropriate for a client with nocturia to prevent falls

8. Which symptom will the nurse expect when caring for an older male client with an enlarged prostate? A. Passing a large amount of dilute urine B. Difficulty starting the urine stream C. Inability to sense the urge to urinate D. Burning sensation when voiding

8. B As male clients age, an enlarged prostate gland makes starting the urine stream difficult and may cause urinary retention.

9. Which topics will the nurse be sure to ask about when taking a history of a client with a change in urinary patterns? Select all that apply. A. History of chronic health problems such as diabetes and hypertension B. Status of financial resources for payment of treatments C. Likelihood of complying with treatment recommendations D. Occupational exposure to toxins and use of illicit substances E. Recent travel to geographic regions that pose infectious disease risk F. Previous kidney or urologic problems, including tumors, infections, stones

9. A, D, E, F Options A, D, E, and F contribute important information to the client's history of urinary pattern changes. Finances and likelihood of compliance, although important, do not con-tribute to understanding the client's urinary pattern changes. Additional topics include the client's medical and surgical history, as well as previous kidney function laboratory values (e.g., proteinuria or albuminuria). See the sec-tion on taking a client history in your text for additional suggestions.

1. Which client being managed for dehydration does the nurse consider at greatest risk for possible reduced kidney function? A. An 80-year-old man who has benign prostatic hyperplasia B. A 62-year-old woman with a known allergy to contrast media C. A 48-year-old woman with established urinary incontinence D. A 45-year-old man receiving oral and intravenous fluid therapy

A

Which assessment finding would require the nurse to take immediate action in a client who is 1 hour post kidney biopsy? Select all that apply. A. Pink-tinged urine B. Nausea and vomiting C. Increased bowel sounds D. Reports of flank pain E. The patient is ambulating to the bathroom

A

1. For which client does the nurse expect increased production of renin? A. 35-year-old who sustains significant blood loss B. 45-year-old diagnosed with hypertension C. 55-year-old who ingests an excessive amount of fluid D. 65-year-old who gets up two to three times nightly to void

A Renin assists in blood pressure control. It is formed and released when there is a decrease in blood flow, blood volume (e.g., blood loss), or blood pressure through the renal arterioles or when too little sodium is present in kidney blood.

When obtaining a health history and physical assessment from a 68-year-old male client who has a history of an enlarged prostate, which finding does the nurse consider significant? Select all that apply. A. Distended bladder B. Absence of a bruit C. Frequency of urination D. Dribbling urine after voiding E. Chemical exposure in the workplace

A, C, D

4. Which symptom(s) in a client during the first 12 hours after a kidney biopsy indicates to the nurse a possible complication from the procedure? A. The client experiences nausea and vomiting after drinking juice. B. The biopsy site is tender to light palpation. C. The abdomen is distended, and the client reports abdominal discomfort. D. The heart rate is 118, blood pressure is 108/50, and peripheral pulses are thready.

D