Chapter 67: Care of Patients with Kidney Disorders
SHORT ANSWER 1. An emergency department nurse cares for a client who is severely dehydrated and is prescribed 3 L of intravenous fluid over 6 hours. At what rate (mL/hr) should the nurse set the intravenous pump to infuse the fluids? (Record your answer using a whole number.) ____ mL/hr
500 mL/hr Because IV pumps deliver in units of milliliters per hour, the pump would have to be set at 500 mL/hr to deliver 3 L (3000 mL) over 6 hours. 6x = 3000 x = 500 DIF: Applying/Application REF: 1388 KEY: Hydration| medication safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
12. A nurse provides health screening for a community health center with a large population of African-American clients. Which priority assessment should the nurse include when working with this population? a. Measure height and weight. b. Assess blood pressure. c. Observe for any signs of abuse. d. Ask about medications.
B All interventions are important for the visiting nurse to accomplish. However, African Americans have a high rate of hypertension leading to end -stage renal disease. Each encounter that the nurse has with an African-American client provides a chance to detect hypertension and treat it. If the client is already on antihypertensive medication, assessing blood pressure monitors therapy. DIF: Applying/Application REF: 1383 KEY: Hypertension| health screening MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will take a laxative every night before going to bed. b. I must increase my intake of dietary fiber and fluids. c. I shall only use salt when I am cooking my own food. d. Ill eat white bread to minimize gastrointestinal gas.
B Clients with PKD often have constipation, which can be managed with increased fiber, exercise, and drinking plenty of water. Laxatives should be used cautiously. Clients with PKD should be on a restricted salt diet, which includes not cooking with salt. White bread has a low fiber count and would not be included in a high-fiber diet. DIF: Applying/Application REF: 1375 KEY: Polycystic kidney disease| nutritional requirements MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
5. A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the nurse recognize as a positive response to the prescribed treatment? a. The client has lost 11 pounds in the past 10 days. b. The clients urine specific gravity is 1.048. c. No blood is observed in the clients urine. d. The clients blood pressure is 152/88 mm Hg.
A Fluid retention is a major feature of acute GN. This weight loss represents fluid loss, indicating that the glomeruli are performing the function of filtration. A urine specific gravity of 1.048 is high. Blood is not usually seen in GN, so this finding would be expected. A blood pressure of 152/88 mm Hg is too high; this may indicate kidney damage or fluid overload. DIF: Applying/Application REF: 1380 KEY: Glomerulonephritis MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
5. A nurse teaches a client with polycystic kidney disease (PKD). Which statements should the nurse include in this clients discharge teaching? (Select all that apply.) a. Take your blood pressure every morning. b. Weigh yourself at the same time each day. c. Adjust your diet to prevent diarrhea. d. Contact your provider if you have visual disturbances. e. Assess your urine for renal stones.
A, B, D A client who has PKD should measure and record his or her blood pressure and weight daily, limit salt intake, and adjust dietary selections to prevent constipation. The client should notify the provider if urine smells foul or has blood in it, as these are signs of a urinary tract infection or glomerular injury. The client should also notify the provider if visual disturbances are experienced, as this is a sign of a possible berry aneurysm, which is a complication of PKD. Diarrhea and renal stones are not manifestations or complications of PKD; therefore, teaching related to these concepts would be inappropriate. DIF: Applying/Application REF: 1375 KEY: Polycystic kidney disease MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
2. A nurse assesses a client with nephrotic syndrome. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Proteinuria b. Hypoalbuminemia c. Dehydration d. Lipiduria e. Dysuria f. Costovertebral angle (CVA) tenderness
A, B, D Nephrotic syndrome is caused by glomerular damage and is characterized by proteinuria (protein level higher than 3.5 g/24 hr), hypoalbuminemia, edema, and lipiduria. Fluid overload leading to edema and hypertension is common with nephrotic syndrome; dehydration does not occur. Dysuria is present with cystitis. CVA tenderness is present with inflammatory changes in the kidney. DIF: Remembering/Knowledge REF: 1382 KEY: Nephrotic syndrome| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. An emergency department nurse assesses a client with kidney trauma and notes that the clients abdomen is tender and distended and blood is visible at the urinary meatus. Which prescription should the nurse consult the provider about before implementation? a. Assessing vital signs every 15 minutes b. Inserting an indwelling urinary catheter c. Administering intravenous fluids at 125 mL/hr d. Typing and crossmatching for blood products
B Clients with blood at the urinary meatus should not have a urinary catheter inserted via the urethra before additional diagnostic studies are done. The urethra could be torn. The nurse should question the provider about the need for a catheter; if one is needed, the provider can insert a suprapubic catheter. The nurse should monitor the clients vital signs closely, send blood for type and crossmatch in case the client needs blood products, and administer intravenous fluids. DIF: Applying/Application REF: 1387 KEY: Trauma| emergency nursing MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
6. After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition? a. I must decrease my intake of fat. b. I will increase my intake of protein. c. A decreased intake of carbohydrates will be required. d. An increased intake of vitamin C is necessary.
B In nephrotic syndrome, the renal loss of protein is significant, leading to hypoalbuminemia and edema formation. If glomerular filtration is normal or near normal, increased protein loss should be matched by increased intake of protein. The client would not need to adjust fat, carbohydrates, or vitamins based on this disorder. DIF: Applying/Application REF: 1382 KEY: Nephrotic syndrome| nutritional requirements MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
1. A nurse assesses a client with polycystic kidney disease (PKD). Which assessment finding should alert the nurse to immediately contact the health care provider? a. Flank pain b. Periorbital edema c. Bloody and cloudy urine d. Enlarged abdomen
B Periorbital edema would not be a finding related to PKD and should be investigated further. Flank pain and a distended or enlarged abdomen occur in PKD because the kidneys enlarge and displace other organs. Urine can be bloody or cloudy as a result of cyst rupture or infection. DIF: Applying/Application REF: 1374 KEY: Polycystic kidney disease MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
13. After teaching a client with renal cancer who is prescribed temsirolimus (Torisel), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will take this medication with food and plenty of water. b. I shall keep my appointment at the infusion center each week. c. Ill limit my intake of green leafy vegetables while on this medication. d. I must not take this medication if I have an infection or am feeling ill.
B Temsirolimus is administered as a weekly intravenous infusion. This medication blocks protein that is needed for cell division and therefore inhibits cell cycle progression. This medication is not taken orally, and clients do not need to follow a specific diet. DIF: Applying/Application REF: 1385 KEY: Medication safety MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
9. After teaching a client with hypertension secondary to renal disease, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I can prevent more damage to my kidneys by managing my blood pressure. b. If I have increased urination at night, I need to drink less fluid during the day. c. I need to see the registered dietitian to discuss limiting my protein intake. d. It is important that I take my antihypertensive medications as directed.
B The client should not restrict fluids during the day due to increased urination at night. Clients with renal disease may be prescribed fluid restrictions. These clients should be assessed thoroughly for potential dehydration. Increased nocturnal voiding can be decreased by consuming fluids earlier in the day. Blood pressure control is needed to slow the progression of renal dysfunction. When dietary protein is restricted, refer the client to the registered dietitian as needed. DIF: Applying/Application REF: 1383 KEY: Hypertension| hydration MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance
MULTIPLE RESPONSE 1. A nurse assesses a client who has a family history of polycystic kidney disease (PKD). For which clinical manifestations should the nurse assess? (Select all that apply.) a. Nocturia b. Flank pain c. Increased abdominal girth d. Dysuria e. Hematuria f. Diarrhea
B, C, E Clients with PKD experience abdominal distention that manifests as flank pain and increased abdominal girth. Bloody urine is also present with tissue damage secondary to PKD. Clients with PKD often experience constipation, but would not report nocturia or dysuria. DIF: Remembering/Knowledge REF: 1374 KEY: Polycystic kidney disease| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.) a. Clear drainage b. Bloody drainage at site c. Client reports headache d. Foul-smelling drainage e. Urine draining from site
B, D, E After a nephrostomy, the nurse should assess the client for complications and urgently notify the provider if drainage decreases or stops, drainage is cloudy or foul-smelling, the nephrostomy sites leaks blood or urine, or the client has back pain. Clear drainage is normal. A headache would be an unrelated finding. DIF: Applying/Application REF: 1377 KEY: Postoperative nursing MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
14. A nurse cares for a client who has pyelonephritis. The client states, I am embarrassed to talk about my symptoms. How should the nurse respond? a. I am a professional. Your symptoms will be kept in confidence. b. I understand. Elimination is a private topic and shouldnt be discussed. c. Take your time. It is okay to use words that are familiar to you. d. You seem anxious. Would you like a nurse of the same gender to care for you?
C Clients may be uncomfortable discussing issues related to elimination and the genitourinary area. The nurse should encourage the client to use language that is familiar to the client. The nurse should not make promises that cannot be kept, like keeping the clients symptoms confidential. The nurse must assess the client and canno take the time to stop the discussion or find another nurse to complete the assessment. DIF: Applying/Application REF: 1378 KEY: Psychosocial response MSC: Integrated Process: Caring NOT: Client Needs Category: Psychological Integrity
4. A nurse cares for a middle-aged female client with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, What can I do to help prevent these infections? How should the nurse respond? a. Test your urine daily for the presence of ketone bodies and proteins. b. Use tampons rather than sanitary napkins during your menstrual period. c. Drink more water and empty your bladder more frequently during the day. d. Keep your hemoglobin A1c under 9% by keeping your blood sugar controlled.
C Clients with long-standing diabetes mellitus are at risk for pyelonephritis for many reasons. Chronically elevated blood glucose levels spill glucose into the urine, changing the pH and providing a favorable climate for bacterial growth. The neuropathy associated with diabetes reduces bladder tone and reduces the clients sensation of bladder fullness. Thus, even with large amounts of urine, the client voids less frequently, allowing stasis and overgrowth of microorganisms. Increasing fluid intake (specifically water) and voiding frequently prevent stasis and bacterial overgrowth. Testing urine and using tampons will not help prevent pyelonephritis. A hemoglobin A1c of 9% is too high. DIF: Applying/Application REF: 1377 KEY: Diabetes mellitus| pyelonephritis MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance
3. A nurse reviews laboratory results for a client with glomerulonephritis. The clients glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.) a. Excessive GFR b. Normal GFR c. Reduced GFR d. Potential for fluid overload e. Potential for dehydration
C, D The GFR refers to the initial amount of urine that the kidneys filter from the blood. In the healthy adult, the normal GFR ranges between 100 and 120 mL/min, most of which is reabsorbed in the kidney tubules. A GFR of 40 mL/min is drastically reduced, with the client experiencing fluid retention and risks for hypertension and pulmonary edema as a result of excess vascular fluid. DIF: Applying/Application REF: 1382 KEY: Glomerulonephritis| hydration MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
2. A nurse cares for a client with autosomal dominant polycystic kidney disease (ADPKD). The client asks, Will my children develop this disease? How should the nurse respond? a. No genetic link is known, so your children are not at increased risk. b. Your sons will develop this disease because it has a sex-linked gene. c. Only if both you and your spouse are carriers of this disease. d. Each of your children has a 50% risk of having ADPKD.
D Children whose parent has the autosomal dominant form of PKD have a 50% chance of inheriting the gene that causes the disease. ADPKD is transmitted as an autosomal dominant trait and therefore is not gender specific. Both parents do not need to have this disorder. DIF: Understanding/Comprehension REF: 1374 KEY: Polycystic kidney disease| genetics MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
11. A nurse teaches a client who is recovering from a nephrectomy secondary to kidney trauma. Which statement should the nurse include in this clients teaching? a. Since you only have one kidney, a salt and fluid restriction is required. b. Your therapy will include hemodialysis while you recover. c. Medication will be prescribed to control your high blood pressure. d. You need to avoid participating in contact sports like football.
D Clients with one kidney need to avoid contact sports because the kidneys are easily injured. The client will not be required to restrict salt and fluids, end up on dialysis, or have new hypertension because of the nephrectomy. DIF: Applying/Application REF: 1386 KEY: Trauma MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
10. A nurse cares for a client who is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take? a. Document the finding in the clients record. b. Evaluate the tube as working in the hand-off report. c. Clamp the tube in preparation for removing it. d. Assess the clients abdomen and vital signs.
D The nephrostomy tube should continue to have a consistent amount of drainage. If the drainage slows or stops, it may be obstructed. The nurse must notify the provider, but first should carefully assess the clients abdomen for pain and distention and check vital signs so that this information can be reported as well. The other interventions are not appropriate. DIF: Applying/Application REF: 1377 KEY: Postoperative nursing MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
7. A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the clients blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take? a. Position the client to lay on the surgical incision. b. Measure the specific gravity of the clients urine. c. Administer intravenous pain medications. d. Assess the rate and quality of the clients pulse.
D The nurse should first fully assess the client for signs of volume depletion and shock, and then notify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Re-positioning the client, measuring specific gravity, and administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time. DIF: Applying/Application REF: 1386 KEY: Renal cancer| postoperative nursing MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care