NURSE 208 Exam 2/3 NCLEX Qs

Which actions/interventions are most important for the nurse to perform when caring for a 70-year-old client who is scheduled for a contrast-medium enhanced CT scan? (Select all that apply.) a. Assess for co-existing conditions of pre-existing diabetes, heart failure, and established CKD. b. Assess the hourly urine output for at least 6 hours prior to the procedure. c. Assess creatinine clearance using a 24-hour urine collection test. d. Alert the provider to a serum creatinine that has increased from 0.2 to 0.4 mg/dL (20 to 40 mcmol/L) in the previous 24 hours. e. Alert the provider to a glomerular filtration rate (GFR) <60 mL/min/1.73 m2. f. Assess for hypovolemia, including evaluation of the mean arterial pressure (MAP). g. Collaborate with the provider to determine whether isotonic IV fluids should be infused before the test. h. Discuss with the provider about whether the client's prescribed diuretic should be held immediately before the test.

ANS: A, E, F, G, H Identification of risk factors and correction of modifiable factors is essential to prevent contrast-induced nephropathy. Risk factors have a cumulative property, so reduction of the number of modifiable risk factors is key to good patient outcomes. Pre-existing conditions that are associated with impaired kidney function including diabetes, heart failure, and advanced age are red flags that alert the nurse to increased risk for kidney damage from toxins like contrast media. Established CKD (diagnosed via serum creatinine and GFR) also indicates that an individual may not tolerate contrast without subsequent harm. Not all clients will have a urinary catheter nor is one necessary. Do evaluate the urine characteristics, but hourly measurements of volume are not necessary. Creatinine clearance can be estimated with a single serum creatinine level; a 24-hour urine test is not an appropriate laboratory test for this situation. Although there is an increase in serum creatinine, the values are normal and the increase does not meet any criteria for AKI (i.e., increases of 0.3 to 0.5 mg/dL [26.2 to 50 mcmol/L]). This small increase may be the result of recent protein intake (diet) or exercise. More information is needed before contacting the provider. A GFR <60mL/kg/1.73 m2 is the threshold for impaired kidney function and diagnostic of significant CKD. Other conditions that increase the potential for harm from contrast include sepsis, shock, and even hypocholesteremia. Infection and vascular conditions can also increase risk for contrast-induced nephropathy. Dehydration or blood volume contraction increases risk for AKI from hypoperfusion. Adding contrast increases the number of risk factors. MAP is a marker of adequate hydration and used to reduce risk from hemodynamic instability or hypotension. IV fluid administration is one strategy to ensure adequate intravascular volume to reduce kidney hypoperfusion and to increase elimination of the contrast so that the agent has less time to damage tubular epithelium. IV fluids also dilute the contrast, reducing exposure and harm. Holding diuretic(s) prior to contrast administration reduces the possibility of hypovolemia and hypotension around the time of contrast administration. Diuretics may be given subsequent to IV fluid administration (to dilute and eliminate contrast) to maintain euvolemia but diuretics are not typically given BEFORE contrast. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Assessment

A 25-year-old sexually active female client diagnosed with cystitis tells the nurse that she doesn't understand why she has these infections yearly because she tries to avoid them by drinking very little at work so she doesn't have to use the "dirty" public toilet. Which suggestions or actions by the nurse are most likely to help this client reduce her risk for cystitis? (Select all that apply.) a. Reinforce her choice to avoid using a public toilet b. Teach her to shower immediately after having sexual intercourse c. Suggest that she drink at least 2-3 L of fluid throughout the day d. Urge her to change her method of birth control from oral contraceptives to a barrier method e. Instruct her to always wipe her perineum from front to back after each toilet use f. Reinforce that she should complete the entire course of antibiotics as prescribed g. Instruct her to empty her bladder immediately before intercourse

ANS: C, E, F, G A is incorrect because using a public toilet, even sitting on the seat, does not lead to cystitis or a UTI. Showering after intercourse does not affect the development of UTIs. Showering BEFORE intercourse can reduce the number of perineal organisms and reduce the risk for UTI. Oral contraceptives do not increase the risk for UTI; however, some barrier methods (especially a cervical cap or diaphragm) can increase because of the increased manipulation of tissues in the area. Drinking more fluids throughout the day dilute the urine and increase the frequency of urination, and both responses help reduce the number of organisms in the bladder. Wiping the perineum from front to back prevents organisms around the anus and vagina from being translocated to the area around the urethra. Completing the antibiotics prescribed for a current UTI helps eradicate the organism and prevent recurrence with resistant organisms. Emptying the bladder before intercourse decreases the risk for reflux from the bladder into the ureters from external pressure Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

You admit a 68-year-old woman who was diagnosed with renal cell carcinoma after experiencing a recurrent UTI with hematuria. When her UTI did not resolve with a second course of antibiotics, the cancer was discovered with a pelvic CT scan. She is on the surgical unit for exploratory surgery and possible nephrectomy. She asks, "Is it possible that the lump that was found on my CT is not cancer? Why not just do a biopsy - that is what happened when they found a lump in my breast and it turned out not to be cancer. If it is cancer, could I walk out of here cured?" 1. What is the rationale for not using a biopsy to evaluate a kidney mass?

ANS: Imaging tests usually provide enough information for the surgeon to decide if an operation is needed. A kidney biopsy has far greater risks for bleeding and other complications compared with a breast biopsy and may cause unnecessary risk for harm when surgery is deemed necessary based on CT or MRI images.

3. Is nephrectomy a cure for renal cell cancer? Why or why not?

ANS: When cancer is local (confined to the kidney) and the stage of kidney cancer is early, surgery may provide a cure. However, surgery combined with chemotherapy and targeted therapy provides the greatest potential for cancer-free survival.

A 48-year-old African-American man is newly diagnosed with hypertension and Stage 1 chronic kidney disease (CKD). His primary health care provider has prescribed a thiazide diuretic. The client reports that he has increased his activity and changed his diet, which resulted in a 10 lbs (4.5 kg) in the past 2 months. The client says he feels well and does not want to take any drugs. What is the nurse's best response? a. "Reducing your blood pressure may slow or prevent progression of your chronic kidney disease." b. "Your provider prescribed the diuretic because it will reverse the damage caused by kidney disease." c. "Taking medications is a personal decision, and you have the right to decline this prescription." d. "Because your lifestyle changes have resulted in weight loss, this intervention is all that is needed to reduce your risk for progression of kidney disease."

ANS: A African Americans have greater risk for hypertension, CKD, and complications from both conditions. Blood pressure control is critical in the treatment of patients with CKD - lowering the blood pressure reduces the risk of stroke, MI, and progression of CKD. Stage 1 CKD already indicates some irreversible damage. Management of blood pressure at this stage of CKD can greatly slow its progression. A diuretic does not improve kidney function or reverse CKD damage. It does not alter the course of CKD progression. It does improve elimination of fluid, and fluid overload can contribute to hypertension. While personal values and preferences are essential decision points in determining a plan of care for each adult, it is also important that the client be well informed about the consequences of decisions. His risk for progression of CKD is not low and his blood pressure has not achieved a target goal, despite weight loss. It is time to consider additional interventions such as drug prescription. While this client has had a good outcome from diet and lifestyle, it has not been sufficient to meet targeted blood pressure goals and cannot slow progression of CKD. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

A client with diabetes has all of the following changes after a percutaneous nephrolithotomy procedure. Which change is most important for the nurse to immediately report to the health care provider? a. Difficulty breathing and an oxygen saturation of 88% on 2 L of oxygen by nasal cannula b. A point-of-care blood glucose of 150 mg/dL and client report of thirst c. A decreased hematocrit by 1% (compared with preoperative values and hematuria) d. An oral temperature of 38C (101F) and cloudiness of urine draining from the nephrostomy tube right after IV administration of a broad-spectrum antibiotic

ANS: A All changes are somewhat abnormal but the only one that raises the level of concern to a point at which it should be immediately is the difficulty breathing and drop in oxygen saturation. This is NOT an expected problem associated with the procedure and is potentially life-threatening. The blood glucose elevation, thirst, temperature elevation, cloudiness of the urine, and slight decrease in hematocrit are expected and do not pose an immediate threat. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Evaluation

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

ANS: A Older adults have fewer nephrons and about half of the glomerular filtration rate of younger adults. This change increases their risk for kidney dysfunction more profoundly and persistently after dehydration of other conditions that can impair the renal system. Although an allergy to contrast media can cause problems, the adult must be exposed to it first. Tests requiring contrast media are not used to diagnose or manage dehydration. Urinary incontinence can lead to poor quality of life and skin problems but does not reduce kidney function. The client receiving hydration therapy with both oral and intravenous fluids is at risk for overhydration (fluid overload), not dehydration-induced kidney damage. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Evaluation

Which statement made by a client newly diagnosed with polycystic kidney disease (PKD) in the hyperfiltration stage indicates to the nurse that additional teaching for self-management is needed? a. "I will need to decrease my daily water intake." b. "I need to make certain my brothers and sisters know about this disease." c. "Probably the best time of day to take my lisinopril each day is with breakfast." d. "Regular low-impact exercise may help me feel better, as well as help prevent constipation."

ANS: A Water restriction is avoided with a diagnosis of polycystic kidney disease (PKD) until the client transitions to dialysis. A liberal water intake can reduce the harm from reduced blood flow to the kidney, including decreasing the stimulus for vasopressin release, a hormone that decreases kidney perfusion. Once daily ACE inhibitors are first line drugs for management of hypertension in clients with PKD and developing a routine for daily administration is a good self-management approach. Complementary approaches to pain management that the client can initiate will increase in benefit from practice (rehearsal) and regular use. PKD is a genetic disorder. This client's brothers and sisters also have a risk for inheriting the disorder, and early diagnosis can help ensure the correct management options are used. Thus, informing siblings is an important and ethical action in this situation. Constipation is a frequent problem for clients with PKD. Fluid intake and exercise can help ameliorate this problem. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementing

4. Which member(s) of the interprofessional team will you notify and why?

ANS: A physician or nurse practitioner needs to be notified immediately so that an advanced assessment can be completed urgently. This may be an emergency with potential for kidney arterial disruption or kidney, ureteral, bladder, or urethral damage. Do not place a urinary catheter until this patient is examined further. If a urethral injury exists, the urethra could be further damaged with the insertion of a catheter.

When providing care to a client who has undergone a nephrostomy for hydronephrosis, which observation alerts the nurse to a possible complication? (Select all that apply.) a. Urine output of 15 mL for the first hour and then diminishes b. Tenderness at the surgical site c. Pink-tinged urine draining from the nephrostomy d. A hematocrit value 3% lower than the preoperative value e. Sudden onset of abdominal pain that worsens after abdominal palpation f. Blood pressure of 180/90 that persists despite administration of pain medication g. The presence of a few small (less that 0.5 cm) clots with irrigation of the nephrostomy h. Bright red drainage through the nephrostomy tube 12 hours after the procedure

ANS: A, D, E, F, H Low output is concerning immediately after nephrostomy placement; most clients have a diuresis. After nephrostomy placement, most clients have bloody urine (red- or pink-tinged) for several hours. Irrigation may be required to maintain patency and clots may be dislodged with irrigation and this helps maintain nephrostomy patency. Clots interfere with patency. The presence of small clots in the returned irrigation fluid is not a concern. There is pain and tenderness at the surgical site but bleeding at the site is not common. New onset of abdominal pain with rebound tenderness may indicate a perforation, an uncommon but potentially life-threatening complication of manipulating the needles during nephrostomy placement. Similarly, blood loss either through the nephrostomy or surgical site can be related to a clinical important decrease in hematocrit; diuresis means that the change in hematocrit is unlikely to be from hemodilution. Inform the provider whenever this change occurs post-operatively. Hypertension can contribute to bleeding risk and occurrence; generally as will most post-operative or post-interventional procedures, a reasonable blood pressure goal is 120-140/80-90. Cognitive Level: Applying or higher Client Needs Category: Physiological Integrity Nursing Process Step: Evaluating

Jamie is a 48-year-old woman who received a living-related donor (LRD) kidney transplant 6 months ago. Today she learns that her blood sugar, which has been elevated since starting immunosuppressant therapy, is 180 mg/dL and her A1C is 8. You find her crying after her visit to the transplant surgeon who advises that she start on an antidiabetic drug. The surgeon has left to consult with the nephrologist and primary health care provider to determine the best drug or drugs for glycemic control. Jamie states "I cannot take another med - I already take 10 tablets each day! Why is this happening to me?" 1. How do you respond to her feelings of anxiety or concern related to the number of tablets taken daily and feelings of "why me/why now"?

ANS: Acknowledge these feelings are real and may be shared by many transplant patients. The emotional impact of transplantation can be a traumatic event. It can alter relationships when the donor is a family member. Self-care and management of the complex regimen of daily monitoring, frequent drug dose adjustments and multiple drug administrations can be confusing or overwhelming at times. The financial costs for treatment can add to anxiety and disrupt previously successful coping strategies.

The patient is a 72-year-old woman who reports loss of a large volume of urine just as she enters the bathroom both at home and away from home. The problem started only recently and occurred about four times during the past week. She is an active church volunteer, lives independently with her husband, and recently passes a safe driving course to assure herself that she is still safe to drive around town. The patient wants to continue to participate in her active lifestyle and wants to discuss options for preventing managing this embarrassing condition. 1. What other information will you obtain from this patient?

ANS: Ask her about any other symptoms of a urinary tract infection beyond the urgency, such as frequency, pain or burning on urination, pressure in the suprapubic region, urine color, and odor. Ask about her usual daily fluid intake and whether she uses any substance that can irritate the bladder, such as artificial sweeteners, caffeine, alcohol, and citric foods. Also ask what drugs she uses and whether or not she smokes (or uses nicotine in any form).

2. What additional information should you ask the patient and what else should you consider?

ANS: Ask the patient whether rust-colored urine is usual for him or her. (Some foods, such as beets, and drugs, such as rifampin) can change urine color. Ask about all drugs and food the patient has ingested in the past 24 hours. Examine the external urethra for injury or blood. Review the laboratory results of creatinine and blood urea nitrogen (BUN) to determine baseline kidney function. Send the urine for analysis immediately to determine the presence or absence of blood in the urine.

The client is a 62-year-old admitted 2 days ago with traumatic injuries and hypovolemic shock from a car crash. The nurse reviewing the client's daily laboratory test results notices the following values. Which result is most important to report to the health care provider immediately? a. Serum sodium 132 mEq/L (mmol/L) b. Serum potassium 6.9 mEq/L (mmol/L) c. Blood urea nitrogen 24 mg/dL (mmol/L) d. Hematocrit 32% (0.32 volume fraction); hemoglobin 9.2 g/dL (92 g/L)

ANS: B All listed laboratory values are out of the normal range. However, the only value that has reached or is approaching a critical level is the serum potassium, which shows hyperkalemia. This problem must be addressed immediately. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Assessment

Which question does the nurse ask the client who has a urinary tract infection to assess the risk for possible pyelonephritis? a. What drugs do you take for asthma? b. How long have you had diabetes? c. How much fluid do you drink daily? d. Do you take your antihypertensive drugs at night or in the morning?

ANS: B Pyelonephritis risk is increased in the client who has diabetes and a urinary tract infection (UTI). While it is important to know all the drugs that a client takes, neither asthma drugs nor asthma itself increases the risk for pyelonephritis. (An exception would be high-dose systemic corticosteroids; however, these are rarely recommended in current asthma therapy). Although insufficient fluid intake may make a UTI worse, it does not increase the risk for pyelonephritis. Antihypertensives are not a risk factor for pyelonephritis. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Assessing

The charge nurse is preparing assignments on a busy medical unit. For this shift, there are two LPNs, two RNs, and one nursing assistant. Which client assignments are most appropriate? (Select all that apply.) a. An LPN is assigned to a client who is receiving the first dose of an oral immunomodulating agent to manage acute glomerulonephritis. b. An RN is assigned to the client who is receiving an IV corticosteroid twice daily to manage systemic lupus erythematous that has resulted in chronic glomerulonephritis. c. An LPN is assigned to replace a urinary catheter (in place >2 weeks) in a client with a fever who requires a chronic urinary catheter to assist healing from a genitourinary fistula. d. An RN is assigned to administer IV antibiotics to a client admitted with pyelonephritis. e. A nursing assistant is assigned to do all the morning baths. f. LPNs are assigned to clients who have oral drugs prescribed and will perform the vital signs for those clients. g. An RN is assigned to the client who is being discharged with a new diagnosis of diabetic nephropathy that is serious (stage 3 CKD).

ANS: B, C, D, E, F, G Consider which tasks are within the scope of practice for the RN, LPN, and NA. Giving a bath is within the scope of NA practice - this assignment is OK. LPNs may administer oral drugs and do vital signs - this assignment is also OK. In some states, LPNs can administer intravenous drugs after the first dose has already been given and the client's responses documented. RNs administer IV drugs, especially the first dose, and assess client responses. An LPN can insert a urinary catheter, and urinary catheters should be replaced in patients who have catheters longer than 2 weeks and appear to be symptomatic (fever) with UTI - this assignment is OK. An RN provides discharge teaching, particularly with complex or new diagnoses and interventions - this assignment is OK. Client teaching around new drug administration is reserved to the RN scope of practice - assignment to an LPN is not an assignment within the LPN scope of practice. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Planning

Which adverse drug effects does the nurse assess for a client who is hospitalized for an acute problem and is also prescribed an anticholinergic drug to manage incontinence? (Select all that apply.) a. Insomnia b. Blurred vision c. Constipation d. Dry mouth e. Loss of sphincter control f. Increased sweating g. Worsening mental function h. Hypotension

ANS: B, C, D, G Anticholinergic drugs tend to block the parasympathetic nervous system and mimic the sympathetic nervous system responses. In addition to reducing urinary output, these commonly include dry mouth, reduced gastric motility, constipation, blurred vision, hypertension, increasing confusion, dizziness, and sleepiness. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Assessment

When obtaining a health history from a 22-year-old female client who has new onset urinary incontinence, which findings or factors does the nurse consider significant? (Select all that apply.) a. Chemical exposure in the workplace b. A burning sensation occurring on urination c. Urinating 10 times daily although fluid intake remains unchanged d. A recent change in the client's oral contraceptive prescription e. A new inability to hold urine (urgency) f. A "stinky" odor from the urine

ANS: B, C, E, F Burning on urination, frequent urination without increasing fluid intake, urgency, and malodorous urine are concerning changes in urine elimination. Although chemical exposure in the workplace may cause kidney damage, it is not associated with new onset incontinence in a young adult. Oral contraceptives do not contribute to problems with urination. Cognitive Level: Applying or higher Client Needs Category: Physiological Integrity Nursing Process Step: Assessment

The nurse is admitting a client who has type 2 diabetes (T2D) and is scheduled for surgery. Which laboratory findings from this client's admission panel does the nurse report as indicating possible abnormal kidney function? (Select all that apply.) a. Presence of ammonia in the urine b. Urine microalbumin 240 mcg/24 hour (0.240 g/24 hour) c. Urine specific gravity of 1.028 d. Blood urea nitrogen of 38 mg/dL (13.5 mmol/L) f. Serum creatinine 2.2 mg/dL (294.3 mcmol/L) g. Blood osmolarity 290 mOsm/kg (290 mmol/kg)

ANS: B, D, E Urine normally has a small amount of ammonia in it as a breakdown product of nitrogen. Other normal values include the urine specific gravity (normal range of 1.005 to 1.030) and the blood osmolarity (280 to 300 mOsm/kg; 280 to 300 mmol/kg). The urine microalbumin is much higher than the normal levels (30 to 80 mcg/24 hour; 0.03 to 0.08 g/24 hour) and indicates abnormal kidney function. Blood urea nitrogen is high (normal ranges 10 to 120 mg/dL; 3.6 to 7.1 mmol/L) as is the serum creatinine (normal ranges 0.5 to 1.2 mg/dL; 44 to 106 mcmol/L). Both of these values indicate abnormal kidney function. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Evaluation

A 70-year-old client is seeing his primary care provider for an annual examination. Which assessment finding alerts the nurse to an increased risk for bladder cancer? a. A 5-pack year history of smoking 45 years ago b. Difficulty starting and stopping the urine stream c. A 30-year occupation as a long-distance truck driver d. A recent colon cancer diagnosis in his 72-year-old brother

ANS: C Although cigarette smoking is a risk factor for bladder cancer, a 5-pack year history more than 45 years ago is not significant as a potential cause of cancer. Bladder cancer does not appear to have a familial or genetic predisposition. Difficulty starting or stopping urination is a symptom, usually of prostate issues, not a harbinger of bladder cancer. The latest research indicates exposure to gasoline and diesel fuel is a major risk factor for bladder cancer. Cognitive Level: Applying or higher Client Needs Category: Physiological Integrity Nursing Process Step: Assessment

When assessing a client with acute glomerulonephritis, which question about self-management will the nurse ask to determine whether the client is currently following best practices to slow progression of kidney damage? a. "Have you increased your protein intake to promote healing of the damaged nephrons?" b. "Do you avoid contact sports while you are taking cyclosporine?" c. "How are you evaluating the amount of daily fluid you drink?" d. "Have you contacted anyone from our dialysis support services?"

ANS: C Protein intake may be increased early in Chronic Kidney Disease (CKD) and reduced late in CKD. Since you do not have information about the extent of CKF (stage), this question may be incorrect. Cyclosporine is a cytotoxic agent that reduces immune responses, which would require the client to avoid sick contacts. Because the client needs to find a balance between too much and too little fluid intake (both are harmful), this is a good question to see how the individual ensures adequate kidney blood flow (perhaps with systemic blood pressure assessment) while providing sufficient intake to eliminate waste (perhaps through urine volume or color or via staying within a target of fluid intake. A target fluid intake is generally 1.5 to 2 L daily if not receiving dialysis). The client may not progress to needing dialysis; this intervention is usually reserved until the last stage of CKD before dialysis occurs; there is no indication that CKD has been staged at this point. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Assessing

A client who performs home continuous ambulatory peritoneal dialysis reports that the drainage (effluent) has become cloudy in the past 24 hours. What is the nurse's best first action? a. Remove the peritoneal catheter. b. Notify the health care provider immediately. c. Obtain a sample of effluent for culture and sensitivity. d. Explain to the client the need to keep the dialysate in the refrigerator to prevent bacterial overgrowth.

ANS: C The client most likely has beginning peritonitis. This problem needs to be confirmed and interventions started quickly. A culture is needed to identify that an infection is indeed present. Although the health care provider does need to be notified, obtaining the culture is performed first. The peritoneal catheter should not be removed at this time because it may be needed to instill intraperitoneal antibiotics. Also, removal of this catheter in not within the scope of practice for registered nurses in most states. Dialysate for peritoneal dialysis is sterile and does not need to be refrigerated. Cognitive Level: Applying or higher Client Needs Category: Physiological Integrity Nursing Process Step: Implementation

2. What are the characteristics of abnormal tissue that is cancer, distinctive from tissue that is not cancer? (You may need to refer to Chapter 21.)

ANS: Cancer is unchecked cell growth as a result of lost cellular regulation. These cells are characterized by having larger-than-normal nuclei. Cancer cells acquire the ability to reproduce uncontrollably; normal cells reproduce to replenish cells that age or become damaged via mitosis. Cancer cells reproduce uncontrollably as a result of mutations that produce their own growth signals; they do not experience biological aging nor do they cease replication after multiple reproductions as do normal cells. Cancer cells lose the ability to communicate with other cells and, more specifically, they do not respond to anti-growth signals from surrounding cells. Cancer cells lose the adhesion molecules that keep them bonded to neighboring cells. Cancer cells lose their specialization. For this scenario, kidney cancer cells no longer function as kidney tissue. Cancer cells do not have normal programmed cell death and the mutations in cancer cells do not trigger apoptosis. Without treatment, RCC leads to death. Chapter 21 reviews cancer cell properties.

When the nurse caring for a client with severe chronic kidney disease asks what dietary modifications he has made for the disease, he reports the following actions. Which action indicates to the nurse that additional client education is needed? a. Using a scale to measure protein weight b. Taking calcium and vitamin D supplements daily c. Eliminating bananas, citrus fruits, and avocados d. Using a salt-substitute instead of ordinary table salt

ANS: D Salt substitutes contain very little sodium, which is a good thing because sodium restriction is needed. However, the sodium is replaced with potassium. Clients with CKD must restrict their intake of potassium severely to avoid life-threatening cardiac dysrhythmias. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter? a. A 35-year-old woman who was admitted with a splenic laceration and femur fracture (closed repair completed) following a car crash b. A 48-year-old man who has established paraplegia and is admitted for pneumonia c. A 61-year-old woman who is admitted following a fall at home and has new-onset dysrhythmia d. A 74-year-old man who has lung cancer with brain metastasis and is bring transitioned to hospice for end-of-life care

ANS: D The man with advanced lung cancer and brain metastasis is dying and likely to be incontinent, in a lot of pain, and confused. An indwelling catheter can help provide comfort at this time by reducing the amount of manipulation needed to keep him and his bed dry. The other clients have no conditions for which use of a bedpan or intermittent catheterization would be contraindicated. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Evaluation

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

ANS: D The most serious complication after a kidney biopsy is excessive bleeding. Nausea and vomiting are not signs of bleeding. Some discomfort at the biopsy site is expected and not considered a complication unless there is swelling and a large amount of bruising/discoloration in the flank area. The kidneys are not in the abdomen. Bleeding from the kidney would cause flank pain and swelling, not abdominal pain and swelling. The elevated pulse rate, thready peripheral pulses, and low diastolic blood pressure are consistent with excessive bleeding. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Evaluation

The nurse is preparing a client for discharge who experienced an acute kidney injury during coronary artery by-pass graft surgery. The nurse notices that the client has a serum creatinine of 1.2 mg/dL (106 mcmol/L) and a glomerular filtration rate (GFR) of 75 mL/kg/1.73 m2. Which is the priority nursing action? a. Reminding the client to remain hydrated by drinking 500 mL of an electrolyte-based solution daily. b. Encouraging the client to reduce protein intake to reduce creatinine production until the follow-up visit with the nephrologist occurs. c. Checking the remaining values on the metabolic panel and informing the primary care provider of all results before the client is discharged. d. Educating the client about the need for follow-up, including re-evaluation of serum creatinine with the primary care provider or nephrologist in 8 to 12 weeks.

ANS: D The serum creatinine is within normal limits but the GFR is reduced, indicating risk for CKD. Follow-up is needed but not urgently and follow-up should occur within the health care team members who are familiar with her hospital course and general health. Protein is an essential nutrient needed for wound healing after surgery. A normal creatinine typically does not require protein restriction to avoid progression of kidney problems. Water or electrolyte-free fluid is recommended for hydration unless there is an indication that electrolytes are being excreted in urine. Although the rest of the metabolic panel should be evaluated by the discharge nurse, the primary care provider need only be informed of critical values in an urgent manner. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Evaluation

5. What are the next steps in communicating the patient concerns and emotional state to the interprofessional team members who are involved in Jamie's care?

ANS: Encourage her to speak to the transplant surgeon today and share her concerns. Offer to be present for support during the conversation. Offer to include a supportive friend or family member (in person or on the phone) during this conversation. Help her consider strategies to adjust to the change, including support groups or referral to a mental health professional or program. Review her medications and work with her to simplify her administration regimen. Remind her of her recent successes in self-management post-transplant. If Jamie is unable to speak about her concerns today, let her know that you will be sharing this conversation with her interprofessional team and that you will help her schedule a follow-up appointment to have further conversation. You know that management of anxiety and depression will improve Jamie's ability to adhere to her post-kidney transplant regiment and have good long-term outcomes. Do not ignore her concerns. Do not provide false reassurance or minimize her distress. Be sure that all members of the interprofessional team are informed of her distress and that a follow-up appointment to either additional evaluation or ongoing assessment is in place before she leaves today.

4. What possibility exists that some of Jamie's current emotional state is influenced by her antirejection drug therapy regimen? If a possibility does exist, which category of drugs is most likely to have a negative influence and why?

ANS: Evaluate Jamie's corticosteroid dose. High-dose steroids not only reduce rejection of a donated organ but they also cause hyperglycemia. In some case, a reduction in the steroid may be possible without increasing risk for rejection. Additionally, steroids contribute to emotional liability; it may be that part of her current distress is drug-induced.

3. What will you tell her regarding options for care?

ANS: Explain that there are different types of incontinence and that help is available for most types. Also explain that a complete assessment of the problem is needed to determine what is causing her problem and what methods would be best to control it, including drug therapy. Help her to understand that in the worst case scenario (unlikely) many products are available to help her maintain her active lifestyle without embarrassment.

2. What additional information would you gather to better understand the patient's emotional reaction to the new treatment plan?

ANS: Explore the following issues and questions to assess specific areas that could contribute to Jamie's distress. How has she been adjusting to life after transplantation? Is she eating and sleeping adequately? Is she enjoying relationships and has she been able to assume or return to roles that are meaningful or pleasurable (family, work, community)? After transplant, roles may need to be renegotiated as a result of having more time (not in dialysis 12 hours weekly) and energy (no uremic fatigue). Fear of organ rejection can be emotionally draining, and behaviors that may contribute to organ rejection (e.g., drinking alcohol) may increase family tension or change supportive relationships. Are there changes in body image after transplantation, which are adding to Jamie's perceived symptoms or emotional burden? How does she rate her current quality of life? What is most concerning about the news of high glucose and the need for a new drug? Are there financial stressors - transplant drugs are expensive and have variable coverage unlike dialysis (dialysis is fully covered by Medicaid).

4. She asks if there is anything she can do now to stop this problem of involuntary loss of urine. How do you respond?

ANS: For the moment, especially because she describes the urine volume lost as "large," urge her to empty her bladder more frequently, perhaps as often as every 1-2 hours while awake, to prevent a large build-up of urine. Because she says that this has happened only four times within a week and not either daily or with every voiding, this behavior change can make a big difference. Also tell her to avoid substances that can irritate the bladder. Teaching her to use pelvic muscle exercises is always helpful regardless of the specific cause of intermittent incontinence for this active, cognitively aware woman.

2. What type or types of incontinence is she most likely to have from the information she has provided thus far?

ANS: From the information provided, she may have urge incontinence (overactive bladder). This type of incontinence is the loss of urine for no apparent reason after suddenly feeling the need or urge to urinate. Those who suffer from urge incontinence have a sudden strong urge to void and can leak large amounts of urine. It is common among older women. It is also possible that she could have a urinary tract infection causing urgency and frequency leading to incontinence.

4. Following a nephrectomy, what are the concerns for this patient that require follow-up monitoring?

ANS: Ongoing health adult surveillance and care for someone greater than 65 years old include annual visits to the primary care provider. She will need ongoing contact with the cancer center to monitor her response to the biological response modifier (BRM) or targeted therapy, if prescribed, and she will need to take actions to reduce her exposure to infection while her immune system response is reduced during administration of BRM drugs. In addition, this adult will need monitoring of kidney function at least annually as she is at risk for worsening kidney function and CKD. She is at higher risk for hypertension with only one kidney and the effects of hypertension on the function of her remaining kidney have greater potential for harm, so she needs increased vigilance and monitoring of blood pressure, including regular self-assessments by herself, her provider, or at community settings. She will need ongoing assessment and management of cardiovascular health, including serum lipid assessment and management to prevent cardiovascular events as she is at greater risk for cardiovascular complications from even mild CKD. She will need ongoing evaluation for potential extrarenal metastases for at least 5 years following surgery. And she will need education and emotional support to maintain the motivation and thoughtful self-management all of these steps require. Teamwork and communication with all interprofessional health care team members - nurses, the surgeon, the oncologist, and the primary care provider are essential to maintaining health and preventing complications. Ensuring that records are accessible and lab reports are consistently reported to all providers is important in terms of monitoring kidney function, detecting changes in health that indicate complications from surgery or chemotherapy, and modifying the treatment plan are essential components of care and communication.

3 Organize your thoughts into a SBAR communication (Chapter1).

ANS: Situation: Probable hematuria of unknown origin Background: The patient was admitted with a hip fracture following a car crash while belted and hitting a telephone pole at 45 to 50 miles per hour. Assessment: The patient may have a traumatic urinary tract or kidney injury from blunt force (to the lower extremity and pelvic area) as a consequence of the type of crash. Recommendation: This patient needs additional and advanced assessment by the provider and may need a pelvic CT scan before the surgery. If not already established, an IV access should be obtained now.

You are assessing a 66-year-old patient who is scheduled for surgical repair of a hip fracture from a car crash 4 hours ago. The patient hit a telephone pole while traveling at 45 to 50 miles per hour and was wearing a seat belt at the time of the accident. When the patient voids, you notice that the urine is rust-colored. The patient reports a sensation of burning during this voiding but no other subjective urinary symptoms. 1. What assessment information will you document in the chart?

ANS: Urine amount, color, odor, and clarity. Also record the patient's reported sensation with voiding. Perform and record a flank assessment, noting whether there is any bruising or tenderness on either flank. Examine the hip with the broken bone for the presence of a large hematoma. Rust-colored urine could also indicate a massive breakdown of damaged muscle following traumatic injury (rhabdomyolysis).

3. Should you ask about who donated the kidney? Why or why not?

ANS: Yes, you should ask these questions. Jamie received a kidney from a living-related donor. She may feel pressure to show gratitude toward this person and to demonstrate that she is caring for this kidney well. These problems can be more profound if the donor was at all hesitant to make the donation. It is possible that Jamie blames herself for the glucose control problem and may feel she is not doing all she can to be well. At times, the donor may be the person suggesting these issues; whereas some recipients have these emotions and feelings without any donor pressure. If the donor is making such suggestions or accusations, offer to include the donor in an informational session to help him or her understand the health problems associated with the antirejection drug therapy.