Chapter 67 - Care of Patients with Kidney Disorders

The nurse receives report on a client with hydronephrosis. Which laboratory study does the nurse monitor? Hemoglobin and hematocrit (H&H) White blood cell (WBC) count Blood urea nitrogen (BUN) and creatinine Correct Lipid levels

BUN and creatinine are kidney function tests. With back-pressure on the kidney, glomerular filtration is reduced or absent, resulting in permanent kidney damage. Hydronephrosis results from the backup of urine secondary to obstruction; H&H monitors for anemia and blood loss, while WBC count indicates infection. Elevated lipid levels are associated with nephrotic syndrome, not with obstruction and hydronephrosis.

The nurse is caring for a client who has just returned to the surgical unit after a radical nephrectomy. Which assessment information alarms the nurse? Blood pressure is 98/56 mm Hg; heart rate is 118 beats/min. Correct Urine output over the past hour was 80 mL. Pain is at a level 4 (on a 0-to-10 scale). Dressing has a 1-cm area of bleeding.

Bleeding is a complication of radical nephrectomy; tachycardia and hypotension may indicate impending hypovolemic or hemorrhagic shock. The surgeon should be notified immediately and fluids should be administered, complete blood count should be checked, and blood administered, if necessary. A urine output of 80 mL can be considered normal. The nurse can administer pain medication, but must address hemodynamic instability and possible hemorrhage first. Administering pain medication to a client who has developed shock will exacerbate hypotension. A dressing with a 1-cm area of bleeding is expected postoperatively.

During discharge teaching for a client with kidney disease, what does the nurse teach the client to do? "Drink 2 liters of fluid and urinate at the same time every day." "Eat breakfast and go to bed at the same time every day." "Check your blood sugar and do a urine dipstick test." "Weigh yourself and take your blood pressure." Correct

Regular weight assessment monitors fluid restriction control, while blood pressure control is necessary to reduce cardiovascular complications and slow the progression of kidney dysfunction. Fluid intake and urination, and breakfast time and bedtime, do not need to be at the same time each day. Clients with diabetes, not kidney disease, should regularly check their blood sugar and perform a urine dipstick test.

Which sign or symptom, when assessed in a client with chronic glomerulonephritis (GN), warrants a call to the health care provider? Mild proteinuria Third heart sound (S3) Correct Serum potassium of 5.0 mEq/L Itchy skin

S3 indicates fluid overload secondary to failing kidneys; the provider should be notified and instructions obtained. Mild proteinuria is an expected finding in GN. A serum potassium of 5.0 mEq/L reflects a normal value; intervention would be needed for hyperkalemia. Although itchy skin may be present as kidney function declines, it is not a priority over fluid excess.

Which clinical manifestation in a client with pyelonephritis indicates that treatment has been effective? Decreased urine output Decreased white blood cells in urine Correct Increased red blood cell count Increased urine specific gravity

A decreased presence of white blood cells in the urine indicates the eradication of infection. A decreased urine output, an increased red blood cell count, and increased urine specific gravity are not symptoms of pyelonephritis.

When caring for a client with nephrotic syndrome, which intervention should be included in the plan of care? Administering angiotensin-converting enzyme (ACE) inhibitors to decrease protein loss Correct Administering heparin to prevent deep vein thrombosis (DVT) Providing antibiotics to decrease infection Providing transfusion of clotting factors

ACE inhibitors can decrease protein loss in the urine. Heparin is administered for DVT, but in nephrotic syndrome it may reduce urine protein and kidney insufficiency. Glomerulonephritis may occur secondary to an infection, but it is an inflammatory process; antibiotics are not indicated for nephrotic syndrome. Clotting factors are not indicated unless bleeding and coagulopathy are present.

The nurse is performing discharge teaching for a client after a nephrectomy for renal cell carcinoma. Which statement by the client indicates that teaching has been effective? "Because renal cell carcinoma usually affects both kidneys, I'll need to be watched closely." "I'll eventually require some type of renal replacement therapy." "I'll need to decrease my fluid intake to prevent stress to my remaining kidney." "My remaining kidney will provide me with normal kidney function now." Correct

After a nephrectomy, the second kidney is expected to eventually provide adequate kidney function, but this may take days or weeks. Renal cell carcinoma typically only affects one kidney. Renal replacement therapy is not the typical treatment for renal cell carcinoma. Fluids should be maintained to flush the remaining kidney.

When taking the health history of a client with acute glomerulonephritis (GN), the nurse questions the client about which related cause of the problem? Recent respiratory infection Correct Hypertension Unexplained weight loss Neoplastic disease

An infection often occurs before the kidney manifestations of acute GN. The onset of symptoms is about 10 days from the time of infection. Hypertension is a result of glomerulonephritis, not a cause. Weight gain, not weight loss, is symptomatic of fluid retention in GN. Cancers are not part of the cause of GN.

A client is hesitant to talk to the nurse about genitourinary dysfunction symptoms. What is the nurse's best response? "Don't worry, no one else will know." "Take your time. What is bothering you the most?" Correct "Why are you hesitant?" "You need to tell me so we can determine what is wrong."

Asking the client what is bothering him or her expresses patience and understanding when trying to identify the client's problem. Telling the client that others will not know is untrue because the client's symptoms will be in the medical record for other health care personnel to see. Asking why the client is hesitant can seem accusatory and threatening to the client. Admonishing the client to disclose his or her symptoms is too demanding; the nurse must be more understanding of the client's embarrassment.

Which staff member does the charge nurse assign to a client who has benign prostatic hyperplasia and hydronephrosis and needs an indwelling catheter inserted? RN float nurse who has 10 years of experience with pediatric clients LPN/LVN who has worked in the hospital's kidney dialysis unit until recently RN without recent experience who has just completed an RN refresher course LPN/LVN with 5 years of experience in an outpatient urology surgery center Correct

Catheterization of a client with an enlarged prostate, a skill within the scope of practice of the LPN/LVN, would be performed frequently in a urology center. The pediatric nurse would have little exposure to prostatic obstruction and adult catheterization. Dialysis clients do not typically have catheters inserted, so the LPN/LVN from the kidney dialysis unit would not be the best staff member to assign to the client. The nurse who has been out of practice for several years is not the best candidate to insert a catheter in a client with an enlarged prostate.

Which factor is an indicator for a diagnosis of hydronephrosis? History of nocturia History of urinary stones Correct Recent weight loss Urinary incontinence

Causes of hydronephrosis or hydroureter include tumors, stones, trauma, structural defects, and fibrosis. Nocturia is a key feature of polycystic kidney disease and pyelonephritis, but it is not associated with hydronephrosis. Recent weight loss and urinary incontinence may be factors in renal cell carcinoma, but are not associated with hydronephrosis.

Which condition may predispose a client to chronic pyelonephritis? Spinal cord injury Correct Cardiomyopathy Hepatic failure Glomerulonephritis

Chronic pyelonephritis occurs with spinal cord injury, bladder tumor, prostate enlargement, or urinary tract stones. Weakness of the heart muscle may cause kidney impairment, not an infection. Pyelonephritis may damage the kidney, not the liver. Glomerulonephritis may result from infection, but may not cause infection of the kidney.

The school nurse is counseling a teenage student about how to prevent kidney trauma. Which statement by the student indicates a need for further teaching? "I can't play any type of contact sports because my brother had kidney cancer." Correct "I avoid riding motorcycles." "I always wear pads when playing football." "I always wear a seat belt in the car."

Contact sports and high-risk activities should be avoided if a person has only one kidney. A family history of kidney cancer does not prohibit this type of activity. To prevent kidney and genitourinary trauma, caution should be taken when riding bicycles and motorcycles. People should wear appropriate protective clothing when participating in contact sports. Anyone riding in a car should wear a seat belt.

When assessing a client with acute glomerulonephritis, which finding causes the nurse to notify the provider? Purulent wound on the leg Crackles throughout the lung fields Correct History of diabetes Cola-colored urine

Crackles indicate fluid overload resulting from kidney damage; shortness of breath and dyspnea are typically associated. The provider should be notified of this finding. Glomerulonephritis may result from infection (e.g., purulent wound); it is not an emergency about which to notify the provider. The history of diabetes would have been obtained on admission. Dark urine is expected in glomerulonephritis.

Which assessment findings does the nurse expect in a client with kidney cancer? (Select all that apply.) Erythrocytosis Correct Hypokalemia Hypercalcemia Correct Hepatic dysfunction Correct Increased sedimentation rate Correct

Erythrocytosis alternating with anemia and hepatic dysfunction with elevated liver enzymes may occur with kidney cancer. Parathyroid hormone produced by tumor cells can cause hypercalcemia. An elevation in sedimentation rate may occur in paraneoplastic syndromes. Potassium levels are not altered in kidney cancer, but hypercalcemia is present.

A client with chronic kidney disease asks the nurse about the relationship between the disease and high blood pressure. What is the nurse's best response? "Because the kidneys cannot get rid of fluid, blood pressure goes up." Correct "The damaged kidneys no longer release a hormone that prevents high blood pressure." "The waste products in the blood interfere with other mechanisms that control blood pressure." "This is a compensatory mechanism that increases blood flow through the kidneys in an effort to get rid of some of the waste products."

In chronic kidney disease, fluid levels increase in the circulatory system. The statements asserting that damaged kidneys no longer release a hormone to prevent high blood pressure, waste products in the blood interfere with other mechanisms controlling blood pressure, and high blood pressure is a compensatory mechanism that increases blood flow through the kidneys in attempt excrete waste products are not accurate regarding the relationship between chronic kidney disease and high blood pressure.

Which information suggests that a client with diabetes may be in the early stages of kidney damage? Elevation in blood urea nitrogen (BUN) Oliguria Microalbuminuria Correct Painless hematuria

In the early stages of diabetic nephropathy, micro-levels of albumin are first detected in the urine. Progressive kidney damage occurs before dipstick procedures can detect protein in the urine. BUN may change in response to protein and fluid intake. Oliguria is a later finding in kidney disease and may also be present in dehydration. Painless hematuria often occurs with kidney cancer.

When caring for a client with hemorrhage secondary to kidney trauma, the nurse provides volume expansion. Which element does the nurse anticipate will be used? Fresh-frozen plasma Platelet infusions 5% dextrose in water Normal saline solution (NSS) Correct

Isotonic solutions and crystalloid solutions are administered for volume expansion; 0.9% sodium chloride (NSS) and 5% dextrose in 0.45% sodium chloride may be used. Clotting factors, contained in fresh-frozen plasma, are given for bleeding, not for volume expansion. Platelet infusions are administered for deficiency of platelets. A solution hypotonic to the client's blood, 5% dextrose, is administered for nutrition or hypernatremia, not for volume expansion.

The nurse anticipates that a client who develops hypotension and oliguria post nephrectomy may need the addition of which element to the regimen? Increase in analgesics Addition of a corticosteroid Correct Administration of a diuretic Course of antibiotic therapy

Loss of water and sodium occurs in clients with adrenal insufficiency, which is followed by hypotension and oliguria; corticosteroids may be needed. The nurse should use caution when administering analgesics to a hypotensive client; no indication suggests that pain is present in this client. A diuretic would further contribute to fluid loss and hypotension, potentially worsening kidney function. A few doses of antibiotics are used prophylactically preoperatively and postoperatively; additional therapy is used when evidence of infection exists.

Which goal for a client with diabetes will best help to prevent diabetic nephropathy? Heed the urge to void. Avoid carbohydrates in the diet. Take insulin at the same time every day. Maintain glycosylated hemoglobin (HbA1c). Correct

Maintaining long-term control of blood glucose will help prevent the progression of diabetic nephropathy. Voiding when the client has the urge prevents the backflow of urine and infection. The diabetic diet is composed of carbohydrates, proteins, and fats. Although taking insulin at the same time each day may indirectly help control blood glucose, it is not the best option.

When assessing a client with acute pyelonephritis, which findings does the nurse anticipate will be present? (Select all that apply.) Suprapubic pain Vomiting Correct Chills Correct Dysuria Correct Oliguria

Nausea and vomiting are symptoms of acute pyelonephritis. Chills along with fever may also occur, as well as burning (dysuria), urgency, and frequency. Suprapubic pain is indicative of cystitis, not kidney infection (pyelonephritis). Oliguria is related to kidney impairment from severe or long-standing pyelonephritis.

When caring for a client with polycystic kidney disease, which goal is most important? Preventing progression of the disease Correct Performing genetic testing Assessing for related causes Consulting with the dialysis unit

Preventing complications and progression of the disease is the goal. Genetic testing should be done, but this is not a priority. Assessment for related causes is an intervention, not a goal. Not all clients with polycystic kidney disease require dialysis.

A newly admitted client who is diabetic and has pyelonephritis and prescriptions for intravenous antibiotics, blood glucose monitoring every 2 hours, and insulin administration should be cared for by which staff member? RN whose other assignments include a client receiving chemotherapy for renal cell carcinoma RN who is caring for a client who just returned after having renal artery balloon angioplasty RN who has just completed preoperative teaching for a client who is scheduled for nephrectomy Correct RN who is currently admitting a client with acute hypertension and possible renal artery stenosis

The client scheduled for nephrectomy is the most stable client; the RN caring for this client will have time to perform the frequent monitoring and interventions that are needed for the newly admitted client. The client receiving chemotherapy will require frequent monitoring by the RN. The client after angioplasty will require frequent vital sign assessment and observation for hemorrhage and arterial occlusion. The client with acute hypertension will need frequent monitoring and medication administration.

When caring for a client 24 hours after a nephrectomy, the nurse notes that the client's abdomen is distended. Which action does the nurse perform next? Check vital signs. Correct Notify the surgeon. Continue to monitor. Insert a nasogastric (NG) tube.

The client's abdomen may be distended from bleeding; hemorrhage or adrenal insufficiency causes hypotension, so vital signs should be taken to see if a change in blood pressure has occurred. The surgeon should be notified after vital signs are assessed. An NG tube is not indicated for this client.

After receiving change-of-shift report on the urology unit, which client does the nurse assess first? Client post radical nephrectomy whose temperature is 99.8° F (37.6° C) Client with glomerulonephritis who has cola-colored urine Client who was involved in a motor vehicle crash and has hematuria Correct Client with nephrotic syndrome who has gained 2 kg since yesterday

The nurse should be aware of the risk for kidney trauma after a motor vehicle crash; this client needs further assessment and evaluation to determine the extent of blood loss and the reason for the hematuria because hemorrhage can be life-threatening. Although slightly elevated, the low-grade fever of the client who is post radical nephrectomy is not life-threatening in the same way as a trauma victim with bleeding. Cola-colored urine is an expected finding in glomerulonephritis. Because of loss of albumin, fluid shifts and weight gain can be anticipated in a client with nephrotic syndrome.

When preparing a client for nephrostomy tube insertion, it is essential for the nurse to monitor which factor before the procedure? Blood urea nitrogen (BUN) and creatinine Hemoglobin and hematocrit (H&H) Intake and output (I&O) Prothrombin time (PT) and international normalized ratio (INR) Correct

The procedure will be cancelled or delayed if coagulopathy in the form of prolonged PT/INR exists because dangerous bleeding may result. Nephrostomy tubes are placed to prevent and treat kidney damage; monitoring BUN and creatinine is important, but is not essential before this procedure. H&H is monitored to detect anemia and blood loss; this would not occur before the procedure. This client should be on I&O during the entire hospitalization; it is not necessary only before the procedure, but throughout the admission.

When caring for a client who had a nephrostomy tube inserted 4 hours ago, which is essential for the nurse to report to the health care provider? Dark pink-colored urine Small amount of urine leaking around the catheter Tube that has stopped draining Correct Creatinine of 1.8 mg/dL

The provider must be notified when a nephrostomy tube does not drain; it could be obstructed or dislodged. Pink or red drainage is expected for 12 to 24 hours after insertion and should gradually clear. The nurse may reinforce the dressing around the catheter to address leaking urine; however, the provider should be notified if there is a large quantity of leaking drainage, which may indicate tube obstruction. A creatinine level of 1.8 mg/dL is expected in a client early after nephrostomy tube placement (due to the minor kidney damage that required the nephrostomy tube).

A client, who is a mother of two, has autosomal dominant polycystic kidney disease (ADPKD). Which statement by the client indicates a need for further education about her disease? "By maintaining a low-salt diet in our house, I can prevent ADPKD in my children." Correct "Even though my children don't have symptoms at the same age I did, they can still have ADPKD." "If my children have the ADPKD gene, they will have cysts by the age of 30." "My children have a 50% chance of inheriting the ADPKD gene that causes the disease."

There is no way to prevent ADPKD, although early detection and management of hypertension may slow the progression of kidney damage. Limiting salt intake can help control blood pressure. Presentation of ADPKD can vary by age of onset, manifestations, and illness severity, even in one family. Almost 100% of those who inherit a polycystic kidney disease (PKD) gene will develop kidney cysts by age 30. Children of parents who have the autosomal dominant form of PKD have a 50% chance of inheriting the gene that causes the disease.

The RN is working with unlicensed assistive personnel (UAP) in caring for a group of clients. Which action is best for the RN to delegate to UAP? Assessing the vital signs of a client who was just admitted with blunt flank trauma and hematuria Assisting a client who had a radical nephrectomy 2 days ago to turn in bed Correct Helping the provider with a kidney biopsy for a client admitted with acute glomerulonephritis Palpating for bladder distention on a client recently admitted with a ureteral stricture

UAP would be working within legal guidelines when assisting a client to turn in bed. Although assessment of vital signs is within the scope of practice for UAP, the trauma victim should be assessed by the RN because interpretation of the vital signs is needed. Assisting with procedures such as kidney biopsy and assessment for bladder distention are responsibilities of the professional nurse that should not be delegated to staff members with a limited scope of education.

A client with pyelonephritis has been prescribed urinary antiseptic medication. What purpose does this medication serve? Decreases bacterial count Destroys white blood cells Enhances the action of antibiotics Provides comfort Correct

Urinary antiseptic drugs such as nitrofurantoin (Macrodantin) are prescribed to provide comfort for clients with pyelonephritis. Antibiotics, not antiseptics, are used to decrease bacterial count and treat pyelonephritis infection; the action of antibiotics is not enhanced with antiseptics. White blood cells, along with antibiotics, fight infection.

What is the appropriate range of urine output for the client who has just undergone a nephrectomy? 23 to 30 mL/hr 30 to 50 mL/hr Correct 41 to 60 mL/hr 50 to 70 mL/hr

Urine output of 30 to 50 mL/hr or 0.5 to 1 mL/kg/hr is considered within acceptable range for the client who is post nephrectomy. Output of less than 25 to 30 mL/hr suggests decreased blood flow to the kidney and the onset or worsening of acute kidney injury. A large urine output, followed by hypotension and oliguria, is a sign of hemorrhage and adrenal insufficiency.

Which statement by a client with diabetic nephropathy indicates a need for further education about the disease? "Diabetes is the leading cause of kidney failure." "I need less insulin, so I am getting better." Correct "My blood sugar may drop really low at times." "I must call my provider if the urine dipstick shows protein."

When kidney function is reduced, insulin is available for a longer time and thus less of it is needed. Unfortunately, many clients believe this means that their diabetes is improving. It is true that diabetes mellitus is the leading cause of end-stage kidney disease among Caucasians in the United States. Clients with worsening kidney function may begin to have frequent hypoglycemic episodes. Proteinuria, which may be mild, moderate, or severe, indicates a need for follow-up.