Ch 48: Management of Patients with Kidney Disorders

d) White blood cell (WBC) count of 20,000/mm3 Pg. 1587 An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia (evidenced by a blood glucose level of 200 mg/dl) occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.

1. Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem? a) Potassium level of 3.5 mEq/L b) Blood glucose level of 200 mg/dl c) Hematocrit (HCT) of 35% d) White blood cell (WBC) count of 20,000/mm3

b) Penicillin Pg. The three nephrotoxic drugs are aminoglycerides.

25. When assessing the impact of medications on the etiology of acute renal failure, the nurse recognizes which of the following as the drug that is not nephrotoxic? a) Neomycin b) Penicillin c) Gentamicin d) Tobramycin

a) Dehydration Pg. 1567 The diuretic phase of acute renal failure is characterized by increased urine output, hypotension, and dehydration.

3. The nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure? a) Dehydration b) Crackles c) Hyperkalemia d) Hypertension

c) Tall, peaked T waves Pg. 1568 Characteristic ECG signs of hyperkalemia are tall, tented, or peaked T waves, absent P waves, and a widened QRS complex.

5. Hyperkalemia is a serious side effect of acute renal failure. Identify the electrocardiogram (ECG) tracing that is diagnostic for hyperkalemia. a) Prolonged ST segment b) Multiple spiked P waves c) Tall, peaked T waves d) Shortened QRS complex

d) Water and sodium retention secondary to a severe decrease in the glomerular filtration rate Pg. 1557 The client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys' inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.

6. A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of: a) A decreased serum phosphate level secondary to kidney failure b) An increased serum calcium level secondary to kidney failure c) Metabolic alkalosis secondary to retention of hydrogen ions d) Water and sodium retention secondary to a severe decrease in the glomerular filtration rate

d) 1,000 mL Pg. 1555 The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded. A 1-kg weight gain is equal to 1,000 mL of retained fluid.

12. The nurse notes that a patient who is retaining fluid had a 1-kg weight gain. The nurse knows that this is equivalent to about how many mL? a) 500 mL b) 750 mL c) 250 mL d) 1,000 mL

a) Proteinuria Pg. 1558 Proteinuria (predominantly albumin) exceeding 3.5 g per day is the hallmark of the diagnosis of nephrotic syndrome. Hypoalbuminemia, hypernatremia, and hyperkalemia may occur.

10. What is a hallmark of the diagnosis of nephrotic syndrome? a) Proteinuria b) Hyperalbuminemia c) Hypokalemia d) Hyponatremia

d) Encourage use of incentive spirometer every 2 hours Pg. 1593 To address the issue of ineffective breathing pattern, encouraging the use of incentive spirometer would be most appropriate to help increase alveolar ventilation. Administering isotonic fluid therapy would be appropriate for issues involving fluid loss such as bleeding or hemorrhage. Keeping the drainage catheter below the level of insertion would be appropriate to reduce the risk of obstruction leading to acute pain. Monitoring the temperature every 4 hours would be appropriate to reduce the client's risk for infection.

11. A nurse identifies a nursing diagnosis of risk for ineffective breathing pattern related to incisional pain and restricted positioning for a client who has had a nephrectomy. Which of the following would be most appropriate for the nurse to include in the client's plan of care? a) Keep the drainage catheter below the level of insertion b) Administer isotonic fluid therapy as ordered c) Monitor temperature every 4 hours d) Encourage use of incentive spirometer every 2 hours

d) "It is appropriate to warm the dialysate in a microwave" Pg. 1585 The dialysate should be warmed in a commercial warmer and never in a microwave oven. Strict aseptic technique is essential. The infusion clamp is opened during the infusion and clamped after the infusion. When the dwell time is done, the drain clamp is opened and the fluid is allowed to drain by gravity into the drainage bag.

13. After teaching a group of students about how to perform peritoneal dialysis, which statement would indicate to the instructor that the students need additional teaching? a) "The effluent should be allowed to drain by gravity" b) "The infusion clamp should be open during infusion" c) "It is important to use strict aseptic technique" d) "It is appropriate to warm the dialysate in a microwave"

c) Diminished erythropoietin production Pg. 1570 Erythropoietin is a hormone produced in the kidneys, and this production is inadequate in chronic renal failure, which results in anemia. Azotemia, impaired immune response, and electrolyte imbalance are associated with chronic renal failure but not indicated with anemia.

14. The client with chronic kidney disease is exhibiting signs of anemia. Which is the best nursing rationale for this symptom? a) Azotemia b) Electrolyte imbalances c) Diminished erythropoietin production d) Impaired immunologic response

b) Start IV fluids with a normal saline solution bolus followed by a maintenance dose Pg. 1566 The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment should rehydrate the client, causing his blood pressure to rise, his urine output to increase, and the BUN and creatinine levels to normalize. The client wouldn't be able to tolerate oral fluids because of the nausea, vomiting, and diarrhea. The client isn't fluid-overloaded so his urine output won't increase with furosemide, which would actually worsen the client's condition. The client doesn't require dialysis because the oliguria and elevated BUN and creatinine levels are caused by dehydration.

15. A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment? a) Administer furosemide (Lasix) 20 mg IV b) Start IV fluids with a normal saline solution bolus followed by a maintenance dose c) Encourage oral fluids d) Start hemodialysis after a temporary access is obtained

c) 1,500 mL of fluid Pg. 1555 A 1-kg weight gain is equal to 1,000 mL of retained fluid.

16. The nurse weighs a patient daily and measures urinary output every hour. The nurse notices a weight gain of 1.5 kg in a 74-kg patient over 48 hours. The nurse is aware that this weight gain is equivalent to the retention of: a) 2,000 mL of fluid b) 500 mL of fluid c) 1,500 mL of fluid d) 1,000 mL of fluid

b) Decrease in the blood flow through the kidneys Pg. 1564 Acute kidney injury can be caused by poor perfusion and/or decrease in circulating volume results from hypovolemic shock. Obstruction of urine flow from the kidneys through blood clot formation and structural damage can result in postrenal disorders but not indicated in this client.

17. A client who suffered hypovolemic shock during a cardiac incident has developed acute kidney injury. Which is the best nursing rationale for this complication? a) Blood clot formed in the kidneys interfered with the flow b) Decrease in the blood flow through the kidneys c) Obstruction of urine flow from the kidneys d) Structural damage occurred in the nephrons of the kidneys

Indicated: b) Wrap the AV fistula site in the left arm with a compression dressing c) Palpate for a thrill over the AV fistula every 8 hours e) Take blood pressure readings in the left arm Contraindicated: a) Auscultate for a bruit over AV fistula every 8 hours d) Use AV fistula site to draw blood f) Assess for redness, swelling, and drainage at AV fistula site Pg. 1590 When a client has an arteriovenous (AV) fistula for hemodialysis, the nurse must provide interventions to protect the fistula and assess its patency. The nurse auscultates the AV fistula with a stethoscope to detect a bruit, a sound generated by turbulent blood flow. The absence of a bruit may indicate blockage or clotting of the fistula. Likewise, the nurse palpates the AV fistula for a thrill (vibration), indicating turbulent blood flow through the fistula. The absence of a thrill can indicate a blockage or clotting of the fistula. The nurse also assesses for redness, swelling, or drainage at the AV fistula that might indicate infection. Blood pressures should not be taken in the arm with an AV fistula. Inflation of the blood pressure cuff can reduce the flow of blood, resulting in the clotting of blood in the fistula. Likewise, a tourniquet should not be placed around the arm to draw blood and the AV fistula should not be wrapped with a compression dressing as these procedures decrease blood flow to the fistula and increase the risk of clot formation.

18. The nurse on a telemetry unit is caring for a 54-year-old male client, admitted with chest pain, who has an arteriovenous (AV) fistula in the left arm for hemodialysis secondary to chronic kidney disease. State whether each intervention is indicated or contraindicated for this client. a) Auscultate for a bruit over AV fistula every 8 hours b) Wrap the AV fistula site in the left arm with a compression dressing c) Palpate for a thrill over the AV fistula every 8 hours d) Use AV fistula site to draw blood e) Take blood pressure readings in the left arm f) Assess for redness, swelling, and drainage at AV fistula site

b) Red blood cells in the urine c) Proteinuria Pg. 1559 The primary presenting features of an acute glomerular inflammation are hematuria, edema, azotemia (an abnormal concentration of nitrogenous wastes in the blood), and proteinuria (excess protein in the urine). The urine may appear cola colored because of red blood cells (RBCs) and protein plugs or casts; RBC casts may be present, indicating glomerular injury. Acute glomerulonephritis does not present with white blood cell (WBC) casts.

19. The nurse is reviewing a patient's laboratory results. What findings does the nurse assess that are consistent with acute glomerulonephritis? Select all that apply. a) White blood cell casts in the urine b) Red blood cells in the urine c) Proteinuria d) Hemoglobin of 12.8 g/dL e) Polyuria

c) Bone demineralization Pg. 1576 Uremic bone disease, often called renal osteodystrophy, develops from the complex changes in calcium, phosphate, and parathormone balance. Clients on bedrest with end-stage kidney disease will have increased bone demineralization. Bone disease will cause a retention of phosphorus, low serum calcium levels, abnormal vitamin D metabolism, and elevated aluminum levels. Hypoparathyroidism and decreased secretion of the parathormone will occur with the client on bedrest.

2. A nurse is caring for a client on bedrest with end-stage kidney disease. What majormanifestation of uremia should the nurse expect to decrease with an exercise plan? a) Hyperparathyroidism b) Increased secretion of parathormone c) Bone demineralization d) A decreased serum phosphorus level

c) Gray-bronze skin color Pg. 1571 Integumentary manifestations of chronic renal failure include a gray-bronze skin color. Other manifestations are dry, flaky skin, pruritus, ecchymosis, purpura, thin, brittle nails, and coarse, thinning hair. Asterixis, tremors, and seizures are neurologic manifestations of chronic renal failure.

20. The nurse recognizes which condition as an integumentary manifestation of chronic renal failure? a) Asterixis b) Seizures c) Gray-bronze skin color d) Tremors

a) Proteinuria Pg. 1558 The disruption of membrane permeability causes red blood cells (RBCs) and protein molecules to filter from the glomeruli into Bowman's capsule and eventually become lost in the urine. Pyuria is pus in the urine. Polyuria is an increased volume of urine voided.

21. A client has been diagnosed with acute glomerulonephritis. This condition causes: a) Proteinuria b) Pyuria c) Polyuria d) No option is correct

d) Hyperacute rejection Pg. 1598 Hyperacute rejection may require removal of the transplanted kidney. Acute rejection occurs within 3 to 14 days of transplantation. Chronic rejection occurs after many years. The term simple is not used in the categorization of types of rejection of kidney transplants.

22. Rejection of a transplanted kidney within 24 hours after transplant is termed a) simple rejection b) Acute rejection c) Chronic rejection d) Hyperacute rejection

d) Increased BUN Pg. 1565 The intrarenal category of acute kidney injury (AKI) encompasses an increased BUN, increased creatinine, a low-normal specific gravity of urine, and increased urine sodium. Intrarenal AKI is the result of actual parenchymal damage to the glomeruli or kidney tubules. Acute tubular necrosis (ATN), AKI in which there is damage to the kidney tubules, is the most common type of intrinsic AKI. Characteristics of ATN are intratubular obstruction, tubular back leak (abnormal reabsorption of filtrate and decreased urine flow through the tubule), vasoconstriction, and changes in glomerular permeability. These processes result in a decrease of GFR, progressive azotemia, and fluid and electrolyte imbalances.

23. What is a characteristic of the intrarenal category of acute kidney injury (AKI)? a) Decreased creatinine b) High specific gravity c) Decreased urine sodium d) Increased BUN

c) Hyperphosphatemia Pg. 1576 Osteodystrophy is a condition in which the bone becomes demineralized due to hypocalcemia and hyperphosphatemia. In an effort to raise blood calcium levels, the parathyroid glands secrete more parathormone. Elevated creatinine, urea, nitrogen, and potassium levels are expected in chronic renal failure and do not contribute to bone fractures.

24. A client with chronic kidney disease reports generalized bone pain and tenderness. Which assessment finding would alert the nurse to an increased potential for the development of spontaneous bone fractures? a) Elevated serum creatinine b) Elevated urea and nitrogen c) Hyperphosphatemia d) Hyperkalemia

6 tablets/day Pg. 1572 The nurse will administer 2 tablets per dose (800 mg/400 mg per tablet). The client receives a total of 3 doses per day or 6 tablets (2 tablets per dose x 3 doses).

26. Sevelamer hydrochloride (Renagel) has been prescribed for a client with chronic renal failure. The physician has prescribed Renagel 800 mg orally three times per day with meals to treat the client's hyperphosphatemia. The medication is available in 400 mg tablets. How many tablets per day will the nurse administer to the client?

114 grams/day Pg. 1572 To calculate the amount of protein the client is to ingest per day, first determine the client's weight in kg by dividing the weight in lbs by 2.2 or 209/2.2 = 95 kg. Then multiply the client's weight in kg by 1.2 or 95 x 1.2 = 114 grams. The client is to ingest 114 grams of protein per day.

27. A client with chronic kidney disease weighs 209 lbs (95 kg) and is prescribed 1.2 grams of protein per kg per day. Which amount of protein will the client ingest per day?

b) Donors are selected from compatible living or deceased donors Pg. 1596 Donors are selected from compatible living donors. Donors do not have to be relatives as long as they are compatible. Potential donors with a history of hypertension, malignant disease, or diabetes are excluded from donation. Each local hospital does not have its own transplant list, instead the client will be placed on a national computerized transplant waiting list.

28. A client is in end-stage chronic renal failure and is being added to the transplant list. The nurse explains to the client how donors are found for clients needing kidneys. Which statement is accurate? a) Donors must be relatives b) Donors are selected from compatible living or deceased donors c) The client is placed on a transplant list at the local hospital d) Donors with hypertension may qualify

a) pH 7.20, PaCO2 36, HCO3 14- Pg. 1570 Metabolic acidosis occurs in end-stage kidney disease (ESKD) because the kidneys are unable to excrete increased loads of acid. Decreased acid secretion results from the inability of the kidney tubules to excrete ammonia (NH3-) and to reabsorb sodium bicarbonate (HCO3-). There is also decreased excretion of phosphates and other organic acids.

29. The nurse cares for a client with end-stage kidney disease (ESKD). Which acid-base imbalance is associated with this disorder? a) pH 7.20, PaCO2 36, HCO3 14- b) pH 7.47, PaCO2 45, HCO3 33- c) pH 7.50, PaCO2 29, HCO3 22- d) pH 7.31, PaCO2 48, HCO3 24-

c) Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL Pg. 1565 The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. A BUN level of 100 mg/dl and a serum creatinine of 6.5 mg/dl are abnormally elevated results, reflecting CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls within the normal range of 60% to 75%.

30. A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF? a) Increased pH with decreased hydrogen ions b) Uric acid analysis 3.5 mg/dL and phenolsulfonphthalein (PSP) excretion 75% c) Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL d) Increased serum levels of potassium, magnesium, and calcium

d) Increase carbohydrates and limit protein intake Pg. 1569 Calories are supplied by carbohydrates and fat to prevent wasting. Protein is restricted because the breakdown products of dietary and tissue protein (urea, uric acid, and organic acids) accumulate quickly in the blood.

31. A client has end-stage renal failure. Which of the following should the nurse include when teaching the client about nutrition to limit the effects of azotemia? a) Increase fat intake and limit carbohydrates b) Increase protein, carbohydrates, and fat intake c) Eliminate fat intake and increase protein intake d) Increase carbohydrates and limit protein intake

a) Diuretic Pg. 1565 The oliguric period is accompanied by an increase in the serum concentration of wastes such as urea, creatinine, organic acids, and the electrolytes potassium, phosphorous, and magnesium. The initiation period begins with the initial insult and ends when cellular injury and oliguria develops. The diuretic phase is marked by a gradual increase in urine output, which signals that glomerular filtration has started to recover. The recovery period signals the improvement of renal function and energy level and may take 6 to 12 months.

32. Which phase of acute renal failure signals that glomerular filtration has started to recover? a) Diuretic b) Oliguric c) Recovery d) Initiation

d) Hypovolemic shock caused by hemorrhage Pg. 1595 If bleeding goes undetected or is not detected promptly, the patient may lose significant amounts of blood and may experience hypoxemia. In addition to hypovolemic shock due to hemorrhage, this type of blood loss may precipitate a myocardial infarction or transient ischemic attack.

33. The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for? a) Pneumonia caused by shallow breathing because of severe incisional pain b) Abdominal distention owing to reflex cessation of intestinal peristalsis c) Paralytic ileus caused by manipulation of the colon during surgery d) Hypovolemic shock caused by hemorrhage

a) Hyperkalemia Pg. 1568 Hyperkalemia is the life-threatening effect of renal failure. The client can become apathetic; confused; and have abdominal cramping, dysrhythmias, nausea, muscle weakness, and numbness of the extremities. Symptoms of hypocalcemia are muscle twitching, irritability, and tetany. Elevation in urea levels can result in azotemia, which can be exhibited in fluid and electrolyte and/or acid-base imbalance. Elevation of WBCs is not indicated.

34. A client with chronic kidney disease becomes confused and reports abdominal cramping, racing heart rate, and numbness of the extremities. The nurse relates these symptoms to which lab value? a) Hyperkalemia b) Elevated urea levels c) Elevated white blood cells d) Hypocalcemia

a) With food Pg. 1572 Hyperphosphatemia and hypocalcemia are treated with medications that bind dietary phosphorus in the GI tract. Binders such as calcium carbonate (Os-Cal) or calcium acetate (PhosLo) are prescribed, but there is a risk of hypercalcemia. The nurse administers phosphate binders with food for them to be effective.

35. The nurse is administering calcium acetate (PhosLo) to a patient with end-stage renal disease. When is the best time for the nurse to administer this medication? a) With food b) 2 hours before meals c) At bedtime with 8 ounces of fluid d) 2 hours after meals

c) Cola-colored urine Pg. 1559 Clinical manifestations of acute glomerulonephritis include cola-colored urine, hematuria, edema, azotemia, and proteinuria.

36. The client is admitted to the hospital with a diagnosis of acute glomerulonephritis. Which clinical manifestation would the nurse expect to find? a) Hypotension b) Peripheral neuropathy c) Cola-colored urine d) Hyperalbuminemia

c) Urine output of 250 ml/24 hours Pg. 1566 ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is characterized by a urine output of 250 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn't diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn't result from this disorder.

4. A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. IV fluid is being infused at 150 mL/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)? a) Temperature of 100.2° F (37.8° C) b) Serum creatinine level of 1.2 mg/dl c) Urine output of 250 ml/24 hours d) Blood urea nitrogen (BUN) level of 22 mg/dl

d) GFR of 30-59 mL/min/1.73 m2 Pg. 1557 Stage 3 of chronic kidney disease is defined as having a GFR of 30-59 mL/min/1.73 m2

7. A patient has stage 3 chronic kidney failure. What would the nurse expect the patient's glomerular filtration rate (GFR) to be? a) GFR of 85 mL/min/1.73 m2 b) GFR of 90 mL/min/1.73 m2 c) GFR of 120 mL/min/1.73 m2 d) GFR of 30-59 mL/min/1.73 m2

4,000 mL Pg. 1555 A 1-kg weight gain is equal to 1,000 mL of retained fluid. 4 kg × 1,000 = 4,000. The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded.

8. The nurse is caring for a client with chronic kidney disease. The patient has gained 4 kg in the past 3 days. In milliliters, how much fluid retention does this equal? Enter your response as a whole number.

a) An excess of urea in the blood Pg. 1559 Uremia is an excess of urea and other nitrogenous wastes in the blood. Azotemia is the concentration of nitrogenous wastes in the blood. Hematuria is blood in the urine. Proteinuria is protein in the urine. Hyperproteinemia is an excess of protein in the blood.

9. The nurse is able to identify which condition as uremia? a) An excess of urea in the blood b) An excess of protein in the blood c) An excess of protein in the urine d) An excess of blood in the urine