IGGY CH. 68: Care of Patients with Acute Kidney Injury and Chronic Kidney Disease

Question 15 of 30 A client with acute kidney injury is receiving a fluid challenge of 500 mL of normal saline over 1 hour. With a drop factor of 20 drops/mL, how many drops per minute does the nurse infuse?

167 drops/min 20 gtt × 500 mL = 10,000/60 min = 167 drops/min

p. 1416, Safe and Effective Care Environment An 84-year-old male client is being admitted after surgery to remove a section of his bowel (colectomy) following a diagnosis of colon cancer. His urine output from an indwelling urinary catheter after 3 hours in the postanesthesia care unit plus the amount in the bag on admission to the medical-surgical unit totals 100 mL. The urine is cloudy and dark yellow. He also has a history of hypertension. After evaluating the patency of the collection device, what is the most appropriate action for the nurse to perform? A. Notify the health care provider of the low urine output. B. Increase the rate of intravenous fluids until urine output is 0.5 mL/kg/hr. C. Continue to assess the client and re-evaluate urine output in 4 hours. D. Ask about his typical voiding patterns and about any previous episodes of urinary problems.

Answer: A Rationale: The lowest acceptable urine output to avoid acute kidney injury (AKI) is 0.5 mL/kg/hr, which, in this 70-kg man, is about 35 mL/hr or a total of at least 105 mL. Surgery places clients at risk for both hypo- and hypervolemia. Waiting an additional 4 hours to obtain 6-hour trend data delays the prompt assessment and intervention necessary to avoid AKI. It is not appropriate to increase fluid rate, and it is unlikely the client is ready to take oral fluid this soon after surgery on the gastrointestinal tract. Voiding is not an issue with a urinary collection device.

p. 1423, Health Promotion and Maintenance A 60-year-old African-American client is newly diagnosed with mild chronic kidney disease (stage 2 CKD). She has a history of diabetes, and her current A1C is 8.0%. She asks the nurse whether any of the following factors could have caused this problem. Which factor should the nurse indicate may have influenced the development of CKD? A. She heavily salted her food as a child and teenager but added no extra salt to her food as an adult. B. Her chronic hyperglycemia caused blood vessel changes in the kidney that can damage kidney tissue. C. Her paternal grandparents had type 2 diabetes and hypertension. D. She drinks 2 cups of coffee water daily.

Answer: B Rationale: Diabetic nephropathy is the most common cause of end-stage renal disease (ESRD) needing dialysis. Managing hyperglycemia delays the onset and progression of CKD. This level of caffeine intake would not lead to either kidney damage or hypertension. The fact that she has reduced her salt intake during adulthood would only help prevent hypertensive kidney disease. The family history of type 2 diabetes and hypertension is a potential risk factor, but her own diabetes and lack of glycemic control manifested by the elevated A1C have a more direct and great adverse effect on kidney function.

p. 1418, Physiological Integrity The nurse is completing documentation for a client with acute kidney injury who is being discharged today. The nurse notices that the client has a serum potassium level of 5.8 mEq/L. Which is the priority nursing action? A. Asking the client to drink an extra 500 mL of water to dilute the electrolyte concentration and then re-checking the serum potassium level B. Encouraging the client to eat potassium-binding foods and to contact his or her primary care provider within 24 hours. C. Checking the remaining values on the electrolyte panel and informing the provider of all results before the client is discharged. D. Applying a cardiac monitor and evaluating the client's muscle strength and muscle irritability.

Answer: C Rationale: Repeating the laboratory test is a reasonable option, but the provider must make this decision after being informed about the context, including the results of the entire electrolyte panel, which will also have information about renal function (creatinine and blood urea nitrogen). Although the potassium level is slightly elevated, it is not a value commonly associated with cardiac dysrhythmias or skeletal muscle changes. Although additional fluid intake may dilute some electrolytes, potassium is not generally altered by plasma volume. There are no foods that specifically bind potassium and, depending on the rapidity of the rise in serum potassium, waiting a day may result in harm to the patient.

p. 1435, Evidence-Based Practice The patient just completed a vascular "mapping" procedure with an angiogram to plan the site of an AV fistula for hemodialysis. You are considering the care priorities for the patient's return when the AV fistula is formed 3. What else should this patient know about AV fistula care?

Call your doctor or nurse right away if you notice any of these problems: • Bleeding from your vascular access site • Signs of infection, such as redness, swelling, soreness, pain, warmth, or pus around the site • A fever over 100.5° F (38.0° C) • The pulse (thrill) in your graft or fistula slows down or you do not feel it at all • The arm where your catheter is placed swells and the hand on that side feels cold • Your hand gets cold, numb or weak (Source: Taking care of your vascular access for hemodialysis. Patient education materials from Medline plus. http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000591.htm.)

p. 1444, Patient-Centered Care The patient is a 64-year-old man with ESRD who has been on hemodialysis for 3 years while waiting for a kidney transplant. He expresses frustration with the wait from time to time and has told you that he fears that he will be considered too old to receive a kidney if much more time goes by. He states that he feels "chained" to the dialysis center. 3. What other resources can you offer to help him be informed and to deal with the emotional aspects of dialysis?

Depression and fatigue are profound and common problems among ESRD patients. Asking him if fatigue or depression is having an effect on his life and ability to enjoy life is one strategy to determine if additional resources are needed. Many communities have support groups linked to dialysis centers and participation may help him cope or develop new coping behaviors. Contact with a social worker may help him through counseling and community resource identification. Kidney.org and organizations such as the National Kidney Foundation, the American Kidney Fund, and the National Association of Patients on Hemodialysis and Transplantation may be helpful to patients and families.

p. 1444, Patient-Centered Care The patient is a 64-year-old man with ESRD who has been on hemodialysis for 3 years while waiting for a kidney transplant. He expresses frustration with the wait from time to time and has told you that he fears that he will be considered too old to receive a kidney if much more time goes by. He states that he feels "chained" to the dialysis center. 2. How do you respond to his feeling about being chained to the dialysis center?

Dialysis patients can make arrangements to receive dialysis at distant locations with relative ease; records can be shared between providers and dialysis staff or agencies. In fact, many cruises offer dialysis services.

p. 1435, Evidence-Based Practice The patient just completed a vascular "mapping" procedure with an angiogram to plan the site of an AV fistula for hemodialysis. You are considering the care priorities for the patient's return when the AV fistula is formed 2. The patient asks if there is anything she can do to make this AV fistula last a long time. How should you respond to promote best practices in AV fistula self-management?

The life of an AV fistula varies, but some centers report duration of AV fistulas for more than 10 years with good care. Following these guidelines will help you avoid infection, blood clots, and other problems with your vascular access. • Wash your hands before touching your access. Clean the area around the access with antibacterial soap or alcohol before your dialysis treatments. • Check the pulse (also called "thrill") in your access every day. Your doctor or nurse will show you how. • Change where the needle goes into your fistula or graft for each dialysis treatment. • Do not let anyone take your blood pressure, start an IV (intravenous line), or draw blood from your access arm. • Do not sleep on your access arm. • Do not carry more than 10 lb with your access arm. • Do not wear a watch, jewelry, or tight clothes over your access site. • Be careful not to bump or cut your access.

p. 1444, Patient-Centered Care The patient is a 64-year-old man with ESRD who has been on hemodialysis for 3 years while waiting for a kidney transplant. He expresses frustration with the wait from time to time and has told you that he fears that he will be considered too old to receive a kidney if much more time goes by. He states that he feels "chained" to the dialysis center. 1. How should you respond to his concern about age possibly affecting his ability to be a transplant recipient?

The upper age of kidney transplant recipient is 80 years. Each case is decided individually, and there are reports of transplants occurring in patients much older than 80 years!

Question 8 of 30 Which finding in the first 24 hours after kidney transplantation requires immediate intervention? a. Abrupt decrease in urine output b. Blood-tinged urine c. Incisional pain d. Increase in urine output

a Abrupt decrease in urine output An abrupt decrease in urine output may indicate complications such as rejection, acute kidney injury, thrombosis, or obstruction. Blood-tinged urine, incisional pain, and an increase in urine output are expected findings after kidney transplantation.

Question 25 of 30 A client with chronic kidney disease reports chest pain. The nurse notes tachycardia and low-grade fever. Which additional assessment is warranted? a. Auscultate for pericardial friction rub. b. Assess for crackles. c. Monitor for decreased peripheral pulses. d. Determine if the client is able to ambulate.

a Auscultate for pericardial friction rub. The client with uremia is prone to pericarditis; symptoms include inspiratory chest pain, low-grade fever, and ST-segment elevation. Crackles and tachycardia are symptomatic of fluid overload; fever is not present. Although the nurse will monitor pulses, and ambulation is important to prevent weakness and deep vein thrombosis, these are not pertinent to the constellation of symptoms of pericarditis that the client presents with.

Question 6 of 30 A client with a recently created vascular access for hemodialysis is being discharged. In planning discharge instructions, which information does the nurse include? a. Avoiding venipuncture and blood pressure measurements in the affected arm b. Modifications to allow for complete rest of the affected arm c. How to assess for a bruit in the affected arm d. How to practice proper nutrition

a Avoiding venipuncture and blood pressure measurements in the affected arm Compression of vascular access causes decreased blood flow and may cause occlusion; if this occurs, dialysis will not be possible. The arm should be exercised to encourage venous dilation, not rested. The client can palpate for a thrill; a stethoscope is not needed to auscultate the bruit at home. The nurse should take every opportunity to discuss nutrition, even as it relates to wound healing, but loss of the graft or fistula by compression or occlusion must take priority because lifesaving dialysis cannot be performed.

Question 26 of 30 The RN has just received change-of-shift report. Which of the assigned clients should be assessed first? a. Client with chronic kidney failure who was just admitted with shortness of breath b. Client with kidney insufficiency who is scheduled to have an arteriovenous fistula inserted c. Client with azotemia whose blood urea nitrogen and creatinine are increasing d. Client receiving peritoneal dialysis who needs help changing the dialysate bag

a Client with chronic kidney failure who was just admitted with shortness of breath The dyspnea of the client with chronic kidney failure may indicate pulmonary edema and should be assessed immediately. The client with kidney insufficiency is stable and assessment can be performed later. The client with azotemia requires assessment and possible interventions, but is not at immediate risk for life-threatening problems. The client receiving peritoneal dialysis can be seen last because it is a slow process and the client has no urgent needs.

Question 24 of 30 To prevent pre-renal acute kidney injury, which person is encouraged to increase fluid consumption? a. Construction worker b. Office secretary c. Schoolteacher d. Taxicab driver

a Construction worker Physical labor and working outdoors, especially in warm weather, cause diaphoresis and place the construction worker at risk for dehydration and pre-renal azotemia. The office secretary and schoolteacher work indoors and, even without air conditioning, will not lose as much fluid to diaphoresis as someone performing physical labor. The taxicab driver, even without air conditioning, will not experience diaphoresis and fluid loss like the construction worker.

Question 7 of 30 When assisting with dietary protein needs for a client on peritoneal dialysis, the nurse recommends that the client select which food? a. Eggs b. Ham c. Eggplant d. Macaroni

a Eggs Suggested protein-containing foods for a client on peritoneal dialysis are milk, meat, and eggs. Although a protein, ham is high in sodium, which should be avoided. Vegetables and pasta contain mostly carbohydrates. Peritoneal dialysis clients are allowed 1.2 to 1.5 g of protein/kg/day because protein is lost with each exchange.

Question 13 of 30 Which clinical manifestation indicates the need for increased fluids in a client with kidney failure? a. Increased blood urea nitrogen (BUN) b. Increased creatinine level c. Pale-colored urine d. Decreased sodium level

a Increased blood urea nitrogen (BUN) An increase in BUN can be an indication of dehydration, and an increase in fluids is needed. Increased creatinine indicates kidney impairment. Urine that is pale in color is diluted; an increase in fluids is not necessary. Sodium is increased, not decreased, with dehydration.

Question 10 of 30 The nurse teaches a client who is recovering from acute kidney disease to avoid which type of medication? a. Nonsteroidal anti-inflammatory drugs (NSAIDs) b. Angiotensin-converting enzyme (ACE) inhibitors c. Opiates d. Calcium channel blockers

a Nonsteroidal anti-inflammatory drugs (NSAIDs) NSAIDs may be nephrotoxic to a client with acute kidney disease, and should be avoided. ACE inhibitors are used for treatment of hypertension and to protect the kidneys, especially in the diabetic client, from progression of kidney disease. Opiates may be used by clients with kidney disease if severe pain is present; however, excretion may be delayed. Calcium channel blockers can improve the glomerular filtration rate and blood flow within the kidney.

Question 9 of 30 Which clients are at risk for acute kidney injury (AKI)? Select all that apply. a. Football player in preseason practice b. Client who underwent contrast dye radiology c. Accident victim recovering from a severe hemorrhage d. Accountant with diabetes e. Client in the intensive care unit on high doses of antibiotics f. Client recovering from gastrointestinal influenza

a, b, c, e, f a.Football player in preseason practice b. Client who underwent contrast dye radiology c. Accident victim recovering from a severe hemorrhage e. Client in the intensive care unit on high doses of antibiotics f. Client recovering from gastrointestinal influenza To prevent AKI, all people should be urged to avoid dehydration by drinking at least 2 to 3 liters of fluids daily, especially during strenuous exercise or work associated with diaphoresis, or when recovering from an illness that reduces kidney blood flow, such as influenza. Contrast media may cause acute renal failure, especially in older clients with reduced kidney function. Recent surgery or trauma, transfusions, or other factors that might lead to reduced kidney blood flow may cause AKI. Certain antibiotics may cause nephrotoxicity. Diabetes may cause acute kidney failure superimposed on chronic kidney failure.

Question 1 of 30 While managing care for a client with chronic kidney disease, which actions does the registered nurse (RN) plan to delegate to unlicensed assistive personnel (UAP)? Select all that apply. a. Obtain the client's pre-hemodialysis weight. b. Check the arteriovenous (AV) fistula for a thrill and bruit. c. Document the amount the client drinks throughout the shift. d. Auscultate the client's lung sounds every 4 hours. e. Explain the components of a low-sodium diet.

a, c Obtain the client's pre-hemodialysis weight., Document the amount the client drinks throughout the shift. Obtaining the client's weight and documenting oral fluid intake are routine tasks that can be performed by UAP. Assessment skills (checking the AV fistula and auscultating lung sounds) and client education (explaining special diet) require more education and are in the legal scope of practice of the RN.

Question 29 of 30 The nurse assists a client with acute kidney injury (AKI) to modify the diet in which ways? Select all that apply. a. Restricted protein b. Liberal sodium c. Restricted fluids d. Low potassium e. Low fat

a, c, d Restricted protein, Restricted fluids, Low potassium Breakdown of protein leads to azotemia and increased blood urea nitrogen. Fluid is restricted during the oliguric stage. Potassium intoxication may occur, so dietary potassium is also restricted. Sodium is restricted during AKI because oliguria causes fluid retention. Fats may be used for needed calories when proteins are restricted.

Question 18 of 30 The nurse wishes to reduce the incidence of hospital-acquired acute kidney injury. Which question by the nurse to the interdisciplinary health care team will result in reducing client exposure? a. "Should we filter air circulation?" b. "Can we use less radiographic contrast dye?" c. "Should we add low-dose dobutamine?" d. "Should we decrease IV rates?"

b "Can we use less radiographic contrast dye?" Contrast dye is severely nephrotoxic, and other options can be used in its place. Air circulation and low-dose dopamine are not associated with nephrotoxicity. Pre-renal status results from decreased blood flow to the kidney, such as fluid loss or dehydration; IV fluids can correct this.

Question 30 of 30 A client awaiting kidney transplantation states, "I can't stand this waiting for a kidney, I just want to give up." Which statement by the nurse is most therapeutic? a. "I'll talk to the health care provider and have your name removed from the waiting list." b. "You sound frustrated with the situation." c. "You're right, the wait is endless for some people." d. "I'm sure you'll get a phone call soon that a kidney is available."

b "You sound frustrated with the situation." Acknowledging the client's frustration reflects the feelings the client is having and offers assistance and support. Talking to the health care provider and removing the client from the waiting list does not allow the nurse to hear more and perhaps offer therapeutic listening or a solution to the problem. Telling the client that the wait is endless for some people cuts the client off from sharing his or her concerns and accentuates the negative aspects of the situation. The waiting time for kidney matches is increasing due to a shortage of organs; the nurse should not offer false hope by suggesting that the client will get a phone call soon.

Question 17 of 30 Which instruction by the nurse will help a client with chronic kidney disease prevent renal osteodystrophy? a. Consuming a low-calcium diet b. Avoiding peas, nuts, and legumes c. Drinking cola beverages only once daily d. Increasing dairy products enriched with vitamin D

b Avoiding peas, nuts, and legumes Kidney failure causes hyperphosphatemia; this client must restrict phosphorus-containing foods such as beans, peas, nuts (peanut butter), and legumes. Calcium should not be restricted; hyperphosphatemia results in a decrease in serum calcium and demineralization of the bone. Cola beverages and dairy products are high in phosphorus, contributing to hypocalcemia and bone breakdown.

Question 3 of 30 A client is receiving immune-suppressive therapy after kidney transplantation. Which measure for infection control is most important for the nurse to implement? a. Adherence to therapy b. Handwashing c. Monitoring for low-grade fever d. Strict clean technique

b Handwashing The most important infection control measure for the client receiving immune-suppressive therapy is handwashing. Adherence to therapy and monitoring for low-grade fever are important, but are not infection control measures. The nurse should practice aseptic technique for this client, not simply clean technique.

Question 21 of 30 Which medication is most effective in slowing the progression of kidney failure in a client with chronic kidney disease? a. Diltiazem (Cardizem) b. Lisinopril (Zestril) c. Clonidine (Catapres) d. Doxazosin (Cardura)

b Lisinopril (Zestril) Angiotensin-converting enzyme inhibitors such as lisinopril appear to be the most effective drugs to slow the progression of kidney failure. Calcium channel blockers such as diltiazem may indirectly prevent kidney disease by controlling hypertension, but are not specific to slowing progression of kidney disease. Vasodilators such as clonidine and doxazosin control blood pressure, but do not specifically protect from kidney disease.

Question 16 of 30 When caring for a client with acute kidney injury and a temporary subclavian hemodialysis catheter, which assessment finding does the nurse report to the provider? a. Mild discomfort at the insertion site b. Temperature 100.8° F c. 1+ ankle edema d. Anorexia

b Temperature 100.8° F Infection is a major complication of temporary catheters. All symptoms of infection, including fever, must be reported to the provider because the catheter may have to be removed. Mild discomfort at the insertion site is expected with a subclavian hemodialysis catheter. During acute injury, oliguria with resulting fluid retention is expected. Rising blood urea nitrogen may result in anorexia, nausea, and vomiting.

Question 20 of 30 When caring for a client with a left forearm arteriovenous fistula created for hemodialysis, which actions must the nurse take? Select all that apply. a. Check brachial pulses daily. b. Auscultate for a bruit every 8 hours. c. Teach the client to palpate for a thrill over the site. d. Elevate the arm above heart level. e. Ensure that no blood pressures are taken in that arm.

b, c, e Auscultate for a bruit every 8 hours., Teach the client to palpate for a thrill over the site., Ensure that no blood pressures are taken in that arm.

Question 11 of 30 Which signs and symptoms indicate rejection of a transplanted kidney? Select all that apply. a. Blood urea nitrogen (BUN) 21 mg/dL, creatinine 0.9 mg/dL b. Crackles in the lung fields c. Temperature of 98.8° F (37.1° C) d. Blood pressure of 164/98 mm Hg e. 3+ edema of the lower extremities

b, d, e Crackles in the lung fields, Blood pressure of 164/98 mm Hg, 3+ edema of the lower extremities Signs and symptoms of fluid retention (e.g., crackles in the lung fields and 3+ edema of the lower extremities) indicate transplant rejection. Increased blood pressure is also a symptom of transplant rejection. Increasing BUN and creatinine are symptoms of rejection; a BUN of 21 mg/dL and a creatinine of 0.9 mg/dL reflect normal values. Fever, not normothermia, is symptomatic of transplant rejection.

Question 28 of 30 A client is scheduled to undergo kidney transplant surgery. Which teaching point does the nurse include in the preoperative teaching session? a. "Your diseased kidneys will be removed at the same time the transplant is performed." b. "The new kidney will be placed directly below one of your old kidneys." c. "It is essential for you to wash your hands and avoid people who are ill." d. "You will receive dialysis the day before surgery and for about a week after."

c "It is essential for you to wash your hands and avoid people who are ill." Anti-rejection medications increase the risks for infection, sepsis, and death. Strict aseptic technique and handwashing are essential. Unless severely infected, the client's kidneys are left in place and the graft is placed in the iliac fossa. Dialysis is performed the day before surgery; after the surgery, the new kidney should begin to make urine.

Question 5 of 30 Discharge teaching has been provided for a client recovering from kidney transplantation. Which information indicates that the client understands the instructions? a. "I can stop my medications when my kidney function returns to normal." b. "If my urine output is decreased, I should increase my fluids." c. "The anti-rejection medications will be taken for life." d. "I will drink 8 ounces of water with my medications."

c "The anti-rejection medications will be taken for life." Immune-suppressant therapy must be taken for life to prevent organ rejection. Adherence to immunosuppressive drugs is crucial to survival for clients with transplanted kidneys. Lack of adherence can lead to complications such as rejection, graft loss, return to dialysis, and death. Oliguria is a symptom of transplant rejection; the transplant team should be contacted immediately if this occurs. It is not necessary to take anti-rejection medication with 8 ounces of water.

Question 23 of 30 A client with end-stage kidney disease has been put on fluid restrictions. Which assessment finding indicates that the client has not adhered to this restriction? a. Blood pressure of 118/78 mm Hg b. Weight loss of 3 pounds during hospitalization c. Dyspnea and anxiety at rest d. Central venous pressure (CVP) of 6 mm Hg

c Dyspnea and anxiety at rest Dyspnea is a sign of fluid overload and possible pulmonary edema; the nurse should assist the client in correlating symptoms of fluid overload with nonadherence to fluid restriction. Nonadherence to fluid restriction results in fluid volume excess and higher blood pressures; 118/78 mm Hg is a normal blood pressure. Excess fluid intake and fluid retention are manifested by an elevated CVP (>8 mm Hg) and weight gain, not weight loss.

Question 4 of 30 A client admitted to the medical unit with a history of vomiting and diarrhea and an increased blood urea nitrogen requires 1 liter of normal saline infused over 2 hours. Which staff member should be assigned to care for the client? a. RN who has floated from pediatrics for this shift b. LPN/LVN with experience working on the medical unit c. RN who usually works on the general surgical unit d. New graduate RN who just finished a 6-week orientation

c RN who usually works on the general surgical unit The nurse with experience in taking care of surgical clients will be most capable of monitoring the client receiving rapid fluid infusions, who is at risk for complications such as pulmonary edema and acute kidney failure. The pediatric float RN and the new graduate RN will have less experience in caring for this type of client. The LPN/LVN should not be assigned to a client requiring IV therapy and who is at high risk for complications.

Question 27 of 30 While assisting a client during peritoneal dialysis, the nurse observes the drainage stop after 200 mL of peritoneal effluent drains into the bag. What action should the nurse implement first? a. Instruct the client to deep-breathe and cough. b. Document the effluent as output. c. Turn the client to the opposite side. d. Re-position the catheter.

c Turn the client to the opposite side. With peritoneal dialysis, usually 1 to 2 L of dialysate is infused by gravity into the peritoneal space. The fluid dwells in the peritoneal cavity for a specified time, then drains by gravity into a drainage bag. The dialyzing fluid is called peritoneal effluent on outflow. The outflow should be a continuous stream after the clamp is completely open. Potential causes of flow difficulty include constipation, kinked or clamped connection tubing, the client's position, fibrin clot formation, and catheter displacement. If inflow or outflow drainage is inadequate, re-position the client to stimulate inflow or outflow. Turning the client to the other side or ensuring that he or she is in good body alignment may help. Instructing the client to deep-breathe and cough will not promote dialysate drainage. Increased abdominal pressure from coughing contributes to leakage at the catheter site. The nurse needs to measure and record the total amount of outflow after each exchange. However, the nurse should re-position the client first to assist with complete dialysate drainage. An x-ray is needed to identify peritoneal dialysis catheter placement. Only the physician re-positions a displaced catheter.

Question 14 of 30 Which factor represents a sign or symptom of digoxin toxicity? a. Serum digoxin level of 1.2 ng/mL b. Polyphagia c. Visual changes d. Serum potassium of 5.0 mEq/L

c Visual changes Visual changes, anorexia, nausea, and vomiting are symptoms of digoxin toxicity. A digoxin level of 1.2 ng/mL is normal (0.5 to 2.0 ng/mL). Polyphagia is a symptom of diabetes. Although hypokalemia may predispose to digoxin toxicity, this represents a normal, not low, potassium value.

Question 19 of 30 A client is being treated for kidney failure. Which statement by the nurse encourages the client to express his or her feelings and concerns about the risk for death and the disruption of lifestyle? a. "All of this is new. What can't you do?" b. "Are you afraid of dying?" c. "How are you doing this morning?" d. "What concerns do you have about your kidney disease?"

d "What concerns do you have about your kidney disease?" Asking the client about any concerns is open-ended and specific to the client's concerns. Asking the client to explain what he or she can't do implies inadequacy on the client's part. Asking the client if he or she is afraid of dying is too direct and would likely cause the client to be anxious. Asking the client how he or she is doing is too general and does not encourage the client to share thoughts on a specific topic.

Question 12 of 30 Which assessment finding represents a positive response to erythropoietin (Epogen, Procrit) therapy? a. Hematocrit of 26.7% b. Potassium within normal range c. Absence of spontaneous fractures d. Less fatigue

d Less fatigue Treatment of anemia with erythropoietin will result in increased hemoglobin and hematocrit (H&H) and decreased shortness of breath and fatigue. A hematocrit value of 26.7% is low; erythropoietin should restore the hematocrit to at least 36% to be effective. Erythropoietin causes more red blood cells to be produced, increasing H&H, not potassium. Calcium supplements and phosphate binders prevent renal osteodystrophy; erythropoietin treats anemia.

Question 2 of 30 Which problem excludes a client hoping to receive a kidney transplant from undergoing the procedure? a. History of hiatal hernia b. Presence of diabetes and glycosylated hemoglobin of 6.8% c. History of basal cell carcinoma on the nose 5 years ago d. Presence of tuberculosis

d Presence of tuberculosis Long-standing pulmonary disease and chronic infection typically exclude clients from transplantation; these conditions worsen with the immune suppressants that are required to prevent rejection. A client with a history of hiatal hernia is not exempt from undergoing a kidney transplant. Good control of diabetes is a positive point, and would not exclude the client from transplantation. Basal cell carcinoma is considered curable and occurred 5 years ago, consistent with appropriate candidates for transplantation.

Question 22 of 30 When caring for a client who receives peritoneal dialysis (PD), which finding does the nurse report to the provider immediately? a. Pulse oximetry reading of 95% b. Sinus bradycardia, rate of 58 beats/min c. Blood pressure of 148/90 mm Hg d. Temperature of 101.2° F (38.4° C)

d Temperature of 101.2° F (38.4° C) Peritonitis is the major complication of PD, caused by intra-abdominal catheter site contamination; meticulous aseptic technique must be used when caring for PD equipment. A pulse oximetry reading of 95% is a normal saturation. Although a heart rate of 58 beats/min is slightly bradycardic, the provider can be informed upon visiting the client. Clients with kidney failure tend to have slightly higher blood pressures due to fluid retention; this is not as serious as a fever.

p. 1435, Evidence-Based Practice The patient just completed a vascular "mapping" procedure with an angiogram to plan the site of an AV fistula for hemodialysis. You are considering the care priorities for the patient's return when the AV fistula is formed 1. What are important teaching points for the period immediately after AV fistula formation?

• Prop your arm on pillows and keep your elbow straight to cut down on swelling. • You can use your arm the same day as surgery but do not lift more than 10 lb (a gallon of milk weighs 8 lb). • Keep the dressing dry for the first 2 days. You can bathe or shower as usual after the dressing is removed.