Chapter 62: Coordinating Care for Patients With Renal Disorders

A patient with acute kidney injury is complaining of a metallic taste in the mouth and has no appetite. Based on this data, which intervention by the nurse is the most appropriate? 1) Provide mouth care before meals 2) Administer an antiemetic as prescribed 3) Restrict fluids 4) Encourage the intake of protein, salt, and potassium

1 A metallic taste in the mouth is due to a build-up of uremia. The nurse should provide mouth care before meals to reduce this taste sensation and improve the patient's oral intake.

The nurse is caring for a patient who is diagnosed with acute kidney injury. When reviewing the patient's laboratory data, which finding indicates that a patient has met the expected outcomes? 1) Decreasing serum creatinine 2) Decreasing neutrophil count 3) Decreasing lymphocyte count 4) Decreasing erythrocyte count

1 Creatinine is the metabolic end product of creatinine phosphate and is excreted via the kidneys in relatively constant amounts.

The nurse is providing care to a patient who is diagnosed with renal trauma. The patient is experiencing hematuria and contusions but has normal imaging studies. Which grade of renal trauma should the nurse document? 1) Grade 1 2) Grade 2 3) Grade 3 4) Grade 4

1 Grade 1 renal trauma presents with hematuria and contusions; however, the patient will have normal imaging studies.

The nurse is providing care to a patient who may have polycystic kidney disease. Which is the first symptom the nurse should assess this patient for? 1) Hypertension 2) Hematuria 3) Urinary frequency 4) Urinary calculi

1 Hypertension is the first symptom the nurse should assess for when a patient is suspected of having polycystic kidney disease.

The nurse is providing education to a patient who is diagnosed with renal carcinoma. The patient states, "My doctor says I am a stage I. What does that mean?" Which response by the nurse is most appropriate? 1) "Your cancer is limited to the renal capsule." 2) "Your cancer involves the perirenal fat but is confined to fascia with metastasis to the adrenal gland." 3) "Your cancer involves the regional lymph node, renal vein, and vena cava." 4) "Your cancer involves metastases to other sites in the body."

1 Stage I renal carcinoma is limited to the renal capsule.

The nurse is planning care for the patient with acute kidney injury. The nurse plans the patient's care based on the nursing diagnosis of Excess Fluid Volume. Which assessment data supports this nursing diagnosis? 1) Pitting edema in the lower extremities 2) Bowel sounds positive in four quadrants 3) Wheezing in the lungs 4) Generalized weakness

1 The patient in acute kidney injury will likely be edematous, as the kidneys are not producing urine.

The nurse is concerned that an older adult patient is at risk for developing acute kidney injury. Which information in the patient's history supports the nurse's concern? Select all that apply. 1) Diagnosed with hypotension 2) Recent aortic valve replacement surgery 3) Prescribed high doses of intravenous antibiotics 4) Total hip replacement surgery five years ago 5) Taking medication for type 2 diabetes mellitus

123 Hypotension, scheduled for aortic valve replacement surgery, and receiving high doses of intravenous antibiotics increase this client's risk for developing acute kidney injury. A previous history of major surgery and current treatment for type 2 diabetes mellitus are not identified risk factors for the development of acute kidney injury.

A patient with frequent urinary tract infections is seen in the urology clinic and is at risk for acute kidney injury. The nurse reviews the patient's medical history. Which item supports the patient's being at risk for acute kidney injury? Select all that apply. 1) Dehydration 2) Renal calculi 3) Ineffective wound healing 4) Low serum albumin 5) Hypertension

125 Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury. Ineffective wound healing has not been shown to cause acute kidney injury unless the infection becomes systemic. A low serum albumin does not cause acute kidney injury.

The nurse is preparing to administer hemodialysis treatment for a patient with chronic kidney disease. Which laboratory values does the nurse anticipate prior to the patient's treatment? Select all that apply. 1) Increased blood urea nitrogen (BUN) 2) Decreased potassium 3) Decreased phosphorus 4) Increased urine osmolality 5) Increased creatinine

15 The patient will also have an increased blood urea nitrogen (BUN) level due to the damaged kidneys. Both phosphorus and potassium increase during renal failure due to the inability of the kidney to excrete them. The damaged kidney is unable to excrete solutes; therefore, the serum osmolality will be increased and the urine osmolality will be decreased. The damaged kidney is unable to excrete waste products, including creatinine, so it will be increased.

The nurse is caring for a patient admitted with a diagnosis of acute kidney injury. The patient asks the nurse, "Are my kidneys failing? Will I need a kidney transplant?" Which response by the nurse is the most appropriate? 1) "No, don't think that. You're going to be fine." 2) "Your condition can be reversed with prompt treatment and usually will not destroy the kidney." 3) "Kidney transplantation is likely, and it would be a good idea to start talking to family members." 4) "When the doctor comes to see you, we can talk about whether you will need a transplant."

2 Acute kidney injury is often resolved without the need for transplant if treatment is initiated quickly.

While caring for a patient with chronic kidney disease, the nurse tracks the patient's serum albumin level. For which nursing diagnosis is the action most indicated? 1) Excess Fluid Volume 2) Imbalanced Nutrition: Less Than Body Requirements 3) Risk for Ineffective Perfusion 4) Risk for Infection

2 Interventions appropriate for the diagnosis of Imbalanced Nutrition: Less Than Body Requirements include monitoring laboratory values such as serum albumin.

The nurse is providing care to a patient who is diagnosed with renal trauma. The patient has a renal laceration that is greater than 1 cm in depth, but the laceration does not involve the collecting system. Which grade of renal trauma should the nurse document? 1) Grade 1 2) Grade 2 3) Grade 3 4) Grade 4

3 Grade 1 renal trauma presents with hematuria and contusions; however, the patient will have normal imaging studies. Grade 2 renal trauma will present with nonexpanding hematomas and superficial lacerations. Grade 3 renal trauma will present with renal lacerations greater than 1 cm in depth not involving the collecting system. Grade 4 renal trauma will present with renal laceration or fracture extending into the collecting system. The patient will have injuries of the renal artery or vein but with controlled hemorrhage. The expanding hematomas compress the kidney.

A patient with a history of hypertension is diagnosed with chronic kidney disease. When the patient asks the nurse how this occurred, which response by the nurse is the most appropriate? 1) "Thickening of the kidney structures and gradual death of nephrons has caused this diagnosis." 2) "Cysts compress renal tissue that destroys the kidneys, causing this diagnosis." 3) "High blood pressure reduces renal blood flow and harms the kidney tissue, causing this diagnosis." 4) "Immune complexes form in the kidney tissue that causes inflammation, causing this diagnosis."

3 Longstanding hypertension leads to sclerosis and narrowing of renal arterioles and small arteries with subsequent reduction of blood flow. This leads to ischemia, glomerular destruction, and tubular atrophy.

The nurse is planning care for a patient with chronic kidney disease and osteoporosis. After reviewing the patient's medical record, which is the priority nursing diagnosis for this patient? 1) Anxiety 2) Disturbed Body Image 3) Risk for Injury 4) Risk for Bleeding

3 The patient with chronic kidney disease with osteoporosis is at high risk for fractures; therefore, preventing injury is the priority nursing diagnosis.

A patient with renal failure is receiving peritoneal dialysis. The nurse is explaining the process to the patient. Which statement would the nurse include in a discussion with the patient? 1) "The peritoneum is more permeable because of the presence of excess metabolites." 2) "The metabolites will diffuse from the interstitial space to the bloodstream mainly through diffusion and ultrafiltration." 3) "The peritoneum acts as a semipermeable membrane through which wastes move by diffusion and osmosis." 4) "The solutes in the dialysate will enter the bloodstream through the peritoneum."

3 The peritoneum acts as a semipermeable membrane, allowing substances to move from an area of high concentration (the blood) to an area of lower concentration (the dialysate). Metabolic waste products and excess water can be eliminated through osmosis and diffusion utilizing the peritoneum as the semipermeable membrane.

The nurse is administering peritoneal dialysis to a patient with acute kidney injury. 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? 1) Measure abdominal girth 2) Document the cloudy dialysate 3) Culture the dialysate return 4) Increase dialysate instillation

3 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.

The nurse is caring for an older adult patient diagnosed with chronic kidney disease. The patient reports no bowel movement in the past two days. Based on this data, which condition is the patient at an increased risk for developing? 1) Metabolic acidosis 2) Hypocalcemia 3) Increased serum creatinine levels 4) Hyperkalemia

4 Constipation exacerbates hyperkalemia, and it is important to monitor CRF clients who already have impairment of potassium.

A nurse evaluating the therapeutic effect of the drug sodium polystyrene sulfonate (Kayexalate) for a patient diagnosed with chronic kidney disease. Which therapeutic effect from the medication does the nurse anticipate? 1) Decreased serum sodium 2) Increased stool excretion 3) Decreased urine specific gravity 4) Decreased serum potassium

4 The patient with chronic kidney disease is unable to excrete potassium, and therefore the drug sodium polystyrene sulfonate (Kayexalate) is utilized in order to exchange sodium for potassium in the large intestine, resulting in decreased serum potassium levels.

The nurse should inform the physician if, when assessing the patient with an AV fistula, they note which of the following? A. A loud, turbulent bruit B. A quiet swooshing bruit C. A low-pitched thrill D. A continuous thrill

Answer: A Rationale: A normal functioning graft will have a low-pitched bruit. A turbulent bruit is indicative of an increased force, mostly due to stenosis.

The nurse includes which dietary information in the teaching plan about the management of chronic kidney disease? A. Decrease fluid intake and protein intake, decrease carbohydrate intake B. Increase fluid intake, decrease carbohydrate intake and protein intake C. Decrease fluid intake and protein intake, increase carbohydrate intake D. Increase fluid intake, increase carbohydrate intake and protein intake

Answer: C Rationale: It is important to decrease fluid intake because people with CKD may have a reduction in urine output, causing fluid to build up in the body; this puts the patient at further risk for volume overload. Decreasing protein intake will limitthe buildup of waste products in the body, and increasing carbohydrates will provide patients with a good source of energy that is lost with the low-protein diet.

The nurse monitors for which clinical manifestation in Ms. Flood, who is newly diagnosed with PKD? A. Hypotension related to fluid shifts B. Bradycardia related to fluid overload C. Hypertension related to decreased renal perfusion D. Tachycardia related to fluid loss

Answer: C Rationale: Newly diagnosed PKD typically presents with hypertension. Fluid overload and fluid shifts occur later in the disease if renal failure occurs.

The nurse recognizes that genetic counseling is appropriate for which patient? A. Child with frequent urinary tract infections B. Adult with frequent urinary tract infection C. Adult with autosomal dominant polycystic kidney disease D. Adult with metastatic renal cancer

Answer: C Rationale: PKD is a genetic disorder. Individuals with PKD who are concerned about passing the disease to their children may want to consult a genetic counselor to help them identify risks for a child developing PKD as well.

The nurses recognizes that the elderly patient may have a reduced ability to concentrate urine which is attributed to which of the following? A. A reduction in bladder receptors B. Thickening of the basement membrane of the Bowman's capsule C. A decrease in the number of functioning nephrons D. A thickening of the efferent arteriole

Answer: C Rationale: The elderly have a reduced space of functioning nephrons which impairs the ability to concentrate urine.

Which is a prerenal cause of AKI? A. Acute glomerulonephritis and neoplasms B. Septic shock and nephrotoxic injury from medications C. Pyelonephritis and calculi formation D. Hypovolemia and myocardial infarction

Answer: D Rationale: Severe blood loss or hypovolemia related to cardiac events are major causes of prerenal acute kidney injury.

Which laboratory value below would be associated with the patient experiencing dehydration? A. Presence of casts B. WBCs C. Specific gravity 1.035 D. Presence of nitrates

C

The nurse is providing care to a patient diagnosed with polycystic kidney disease. Which assessment finding would indicate to the nurse that the patient is experiencing an infection? 1) Increased temperature 2) Increased blood pressure 3) Decreased white blood cell count 4) Decreased urine output

1 An increased temperature is data that indicates an infection.

During a home visit, the nurse is concerned that an older adult patient is developing chronic kidney disease. The patient has no history of cardiovascular disease. Which data in the patient's assessment caused the nurse to have this concern? 1) Progressive edema 2) Complaints of hip joint pain 3) Recent increase in hunger and thirst 4) Warm moist skin

1 The manifestations of chronic kidney disease often are missed in aging patients because edema may be attributed to heart failure or high blood pressure to preexisting hypertension.

The nurse is preparing to discharge a patient with chronic kidney disease. The nurse is teaching the patient and family about administering calcium acetate tablets by mouth with each meal at home. Which explanation about this medication is the most appropriate? 1) "The calcium acetate will lower your serum phosphate levels." 2) "The calcium acetate helps to neutralize your gastric acids." 3) "The calcium acetate will help to stimulate your appetite." 4) "The calcium acetate will decrease your serum creatinine levels."

1 The patient with chronic kidney disease has elevated phosphate levels due to the inability of the damaged kidney to excrete this electrolyte. Calcium acetate, when given with meals, will bind serum phosphorus and therefore lower the serum level.

The risk factor or factors most often associated with CKD include which of the following? (Select all that apply.) A. Hypertension B. Diabetes mellitus C. Malnutrition D. Peripheral vascular disease E. Smoking

Answer: A and B Rationale: The most common causes of CKD are high blood pressure and diabetes. The risk for CKD increases when either or both of these conditions are uncontrolled.

The nurse recognizes which patient has the greatest risk of renal cancer? A. A 76-year-old African American female B. A 50-year-old Caucasian male C. A 24-year-old Caucasian male D. A 50-year-old African American male

Answer: D Rationale: Renal cancer is more common in men than women, more common in African Americans, and more common in the 50 to 70 age group.

The nurse is caring for a patient with chronic kidney disease who is pale and experiencing fatigue. The nurse attributes these symptoms to anemia secondary to chronic kidney disease. The patient's spouse asks why the patient is anemic. Which response by the nurse is the most appropriate? 1) "Your spouse has a genetic tendency for the development of anemia." 2) "The increased metabolic waste products in the body depress the bone marrow and cause anemia." 3) "There is a decreased production by the kidneys of the hormone erythropoietin, which is the cause of anemia." 4) "The patient is not eating enough iron-rich foods, which is causing anemia."

3 Anemia is common in patients with renal disease. Among the factors causing the anemia are decreased production of erythropoietin by the kidneys and shortened red blood cell (RBC) life. Erythropoietin is involved in the stimulation of the bone marrow to produce RBCs.

The nurse is providing care for a patient diagnosed with chronic kidney disease who is experiencing hyperkalemia. When planning meals for this patient, which choice would be most appropriate for this patient? 1) Hamburger on a bun, banana 2) Cold cuts with bun with fresh pears 3) Spaghetti and meat sauce, breadsticks 4) Carrots and green, leafy vegetables

3 Spaghetti and meat sauce with breadsticks would be the most appropriate meal from the choices provided.

A patient with chronic kidney disease is experiencing manifestations of anemia. Based on this data, which treatment does the nurse anticipate for this patient? 1) Begin fluid restriction. 2) Administer intravenous glucose and insulin. 3) Begin a low-sodium diet. 4) Epoetin injections

4 Epoetin injections are used in the treatment of anemia caused by chronic kidney disease. This medication supplies a hormone typically created in the kidneys that signals the bone marrow to produce more red blood cells. In chronic kidney disease, this hormone production will be reduced.

A patient agrees to receive long-term hemodialysis to treat chronic kidney disease. For which surgical procedure should the nurse instruct this patient? 1) Insertion of a double-lumen catheter into the subclavian artery 2) Placement of a peritoneal catheter 3) Insertion of a subarachnoid-peritoneal shunt 4) Placement of an arteriovenous fistula

4 For long-term vascular access needed for hemodialysis, an arteriovenous (AV) fistula is created. The fistula is created by surgical anastomosis of an artery and vein, usually the radial artery and cephalic vein. It takes about a month for the fistula to mature so that it can be used for taking and replacing blood during dialysis.

The nurse instructs a patient with chronic kidney disease on the prescribed medication furosemide (Lasix). Which patient statement indicates that teaching has been effective? 1) "I will take this medication to keep my calcium balance normal." 2) "This medication will make sure I have enough red blood cells in my body." 3) "I will take this pill to keep the protein level in my body stable." 4) "This pill will reduce the swelling in my body and get rid of the extra potassium."

4 Furosemide (Lasix) is a loop diuretic that may be prescribed to reduce extracellular fluid volume and edema. Diuretic therapy also can reduce hypertension and cause potassium wasting, lowering serum potassium levels.

The nurse is caring for a patient from another country who was admitted with hypertension and chronic kidney disease. The patient is receiving hemodialysis three times a week. The nurse is assessing the client's diet, and the patient reports the use of salt substitutes. When teaching the patient to avoid salt substitute, which rationale supports this teaching point? 1) They will increase the risk of AV fistula infection. 2) They will cause the patient to retain fluid. 3) They will interact with the client's antihypertensive medications. 4) They can potentiate hyperkalemia.

4 Many salt substitutes use potassium chloride. Potassium intake is carefully regulated in clients with renal failure, and the use of salt substitutes will worsen hyperkalemia.

A young school-age patient is in the hospital with acute kidney injury following a streptococcus infection. The parents are Spanish-speaking and speak little English. The parents, through an interpreter, ask the nurse what mistake they made that caused the child to be so sick. Which response by the nurse is the most appropriate? 1) "Your child does not have enough dietary protein." 2) "Your child has a congenital defect that led to renal failure." 3) "Your child's renal failure has been caused by a low calcium level." 4) "Your child's recent infection may have caused the renal failure."

4 Patients with streptococcus are at risk for kidney and cardiac sequelae.

The patient with clinical manifestations of oliguria and elevated creatinine clearance would be most consistent with: A. Tubular necrosis B. Tubular secretion C. Glomerular filtration D. Capillary permeability

A

Which laboratory value provides the best indication of renal function? A. GFR B. Serum potassium level C. Ionized calcium level D. Serum creatinine

A

The nurse correlates which clinical manifestation with the pathophysiology of acute pyelonephritis? (Select all that apply.) A. Nausea and vomiting B. Hematuria C. Flank pain D. Fever E. Abdominal pain

Answer: A, B, C, and D Rationale: All above symptoms except abdominal pain may be associated with the presence of acute pyelonephritis. Pain is usually in the back, groin, or flank.

What is the etiological process in glomerulonephritis? A. Tubular necrosis caused by bacteria and antibody reactions B. Deposition of immunological complexes and complement along the GBM C. Deposition of bacteria and immunological components within the loop of Henle D. Destruction of proteolytic enzymes contained in the GBM

Answer: B Rationale: Antibody-induced immunological conditions result in the deposition of immunoglobulins and complements along the basement membrane.

The nurse providing care for the patient post-motor vehicle accident with a suspected injury to the renal system anticipates which of the following orders? A. Perform an electrocardiogram (ECG) B. Send a urinalysis to the laboratory C. Administer diuretics D. Administer antihypertensives

Answer: B Rationale: Blood in the urine (hematuria) is the best indicator of blunt kidney injury. Microscopic hematuria is easily detected by a simple urinalysis.

The nurse understands CRRT is indicated for which of the following patients? A. A hospitalized but hemodynamically stable patient B. A hospitalized, hemodynamically unstable patient C. A hospitalized ESRD patient being discharged home soon D. A hospitalized ESRD patient who is stable but in an intensive care setting

Answer: B Rationale: CRRT is indicated for the unstable patient who may not tolerate the rapid fluid shifts of HD.

The nurse understands that CKD is characterized by which of the following? A. Rapid decrease in urine output with a CKD-elevated BUN B. Progressive irreversible destruction to the kidneys C. Abrupt increasing creatinine clearance with a decrease in urinary output D. Confusion and somnolence leading to coma and death

Answer: B Rationale: Chronic kidney disease (CKD) is progressive, irreversible loss of kidney function. CKD is defined as the presence of kidney damage or a glomerular filtration rate less than 60 ml/min for 3 months or longer.

The nurse should intervene immediately if the patient post renal transplantation is noted to have which of the following symptoms? A. Weight loss, hypotension, reduced urine output B. Fever, reduced urine output, elevated blood pressure C. Weight gain, hypotension, increased urine output D. Increased urine output, hypertension, fever

Answer: B Rationale: Fever, reduced urine output, and elevated BP may be indicative of the presence of AKI related to transplant rejection.

The nurse includes which information in the teaching plan about management of PKD? A. "Your blood pressure will normalize when we successfully manage your PKD." B. "Your UTI will not recur if you finish your antibiotic prescription." C. "Staying on your antihypertensive medication is necessary to control your blood pressure." D. "This disease is reversible if you closely follow your provider's orders."

Answer: C Rationale: BP and UTI are chronic problems with PKD. Continued BP medication will be necessary. PKD is not reversible.

The nurse caring for Ms. Flood incorporates which priority nursing diagnosis into the plan of care? A. Pain related to irritation on urination secondary to UTI B. Imbalanced nutrition related to excessive loss of protein in the urine C. Decreased cardiac output related to dysrhythmias secondary to electrolyte imbalance D. Impaired perfusion related to decreased circulating volume secondary to diuresis

Answer: C Rationale: Decreased cardiac output is a risk due to the potential risk electrolyte imbalances that occur with renal failure.

Prior to the patient's CT scan, which information should be obtained from the patient or family member? A. Family history of CT scans B. Time of patient's last meal C. List of patient's allergies D. Time of last pain medication

Answer: C Rationale: It is not uncommon for patients to be allergic to the IV contrast used for CAT scans. It is important to rule out the presence of this allergy to avoid serious allergic reactions such as anaphylaxis.

When the patient is in the diuretic phase of AKI, the nurse must monitor which serum electrolyte imbalance? A. Hypokalemia and hyponatremia B. Hypokalemia and hypernatremia C. Hyperkalemia and hyponatremia D. Hyperkalemia and hypernatremia

Answer: C Rationale: There is a decreased excretion of potassium and an increase in sodium losses.

The nurse is screening patient for their risk of developing renal cell cancer. The nurse should consider which patient at greatest risk? A. 76-year-old African American female B. 50-year-old Caucasian male C. 24-year-old male Caucasian male D. 50-year-old African American male

Answer: D Rationale: African Americans and American Indians and Alaskan natives have slightly higher rates of RCC than whites; the exact reasons are unclear. RCC is twice as common in men than women. This is attributed to men more likely to be smokers and have increased exposure chemicals and occupational hazards.

The nurse understands which diagnostic study is most specific in identifying PKD? A. Abdominal x-ray B. Serum creatinine level C. Urinalysis D. Computed tomography scan

Answer: D Rationale: All of the test may indicate renal disease but a CT scan will provide more precise results.

Which statement by Ms. Flood indicates that teaching has been effective? A. "I'm glad we can control this disease with medications." B. "I'm glad we caught this early so I won't need dialysis forever." C. "Getting a new kidney will help even if I develop the cysts again." D. "Do I have a choice between hemodialysis or peritoneal dialysis."

Answer: D Rationale: Chronic dialysis is a part of treatment for the renal failure that accompanies PKD.

Which of the following risk factors has been associated with renal cancer? A. Aspirin use B. Alcohol abuse C. Use of artificial sweeteners D. Cigarette smoking

Answer: D Rationale: Cigarette smoking is the most common risk factor for developing renal cancer. Majority of renal cancers are associated with a history of cigarette smoking or some form of tobacco use.

The nurse providing care for Ms. Flood should include which activity into the plan of care? A. Providing cranberry juice at meals to reduce the risk of UTIs B. Frequent range-of-motion exercises to reduce stiffness due to inactivity C. Encourage fluids to maintain adequate volume and perfusion to the kidneys D. Restrict fluids to reduce the risk of fluid overload

Answer: D Rationale: Fluid overload is a chronic problem due to renal failure requiring a fluid restriction.

Case Study

Doris Flood's diagnosis of PKD is confirmed by IVP. Her blood pressure remains elevated at 178/102 mm Hg. Laboratory testing reveals a BUN of 30 mg/dL and creatinine of 2.5 mg/dL, indicating renal impairment is already occurring. Ms. Flood is complaining of abdominal pain and continued urinary frequency and burning on urination. She expresses extreme anxiety over this diagnosis. Ms. Flood's provider orders antibiotics to treat the UTI. She is started on an ACE inhibitor, captopril, for her hypertension. Ms. Flood and her provider begin discussions on how to treat her renal insufficiency. A social worker is contacted to help her obtain the resources necessary to adequately manage her medical condition. The nurse talks with her about her anxiety and helps her explore options to deal with this new diagnosis.