Ch54 Kidney Management
A client has been diagnosed with acute glomerulonephritis. This condition causes: Proteinuria
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.
A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant? Recent history of streptococcal infection
Glomerulonephritis can occur as a result of infections from group A beta-hemolytic streptococcal infections, bacterial endocarditis, or viral infections such as hepatitis B or C or human immunodeficiency virus (HIV).
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 30-59 mL/min/1.73 m2
Stage 3 of chronic kidney disease is defined as having a GFR of 30-59 mL/min/1.73 m2
Which clinical finding should a nurse look for in a client with chronic renal failure? Uremia
Uremia is the buildup of nitrogenous wastes in the blood, evidenced by an elevated blood urea nitrogen and creatine levels. Uremia, anemia, and acidosis are consistent clinical manifestations of chronic renal failure.
The nurse cares for a client with end-stage kidney disease (ESKD). Which acid-base imbalance is associated with this disorder? pH 7.20, PaCO2 36, HCO3 14-
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.
A client is diagnosed with polycystic kidney disease and requires teaching on the management of the disorder. Which statement made by the client indicates a need for further teaching? "As long as I have one normal kidney, I should be fine.
Polycystic kidney disease is characterized by the formation of multiple cysts on both kidneys. Polycystic kidney disease is inherited as an autosomal dominant trait. The fluid-filled cysts can cause great enlargement of the kidneys and interfere with kidney function, which can eventually lead to renal failure.
A client with chronic renal failure complains of generalized bone pain and tenderness. Which assessment finding would alert the nurse to an increased potential for the development of spontaneous bone fractures? Hyperphosphatemia
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.
What is a hallmark of the diagnosis of nephrotic syndrome? Proteinuria
Proteinuria (predominantly albumin) exceeding 3.5 g per day is the hallmark of the diagnosis of nephrotic syndrome
What is used to decrease potassium level seen in acute renal failure? Sodium polystyrene sulfonate
The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.
A patient with chronic kidney failure experiences decreased levels of erythropoietin. What serious complication related to those levels should the nurse assess for when caring for this client? Anemia
Anemia develops as a result of inadequate erythropoietin production, the shortened lifespan of RBCs, nutritional deficiencies, and the patient's tendency to bleed, particularly from the GI tract. Erythropoietin, a substance normally produced by the kidneys, stimulates bone marrow to produce RBCs
The nurse cares for a client with acute kidney injury (AKI). The client is experiencing an increase in the serum concentration of urea and creatinine. The nurse determines the client is experiencing which phase of AKI? Oliguria
The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]).
A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? Risk for infection
The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection.
Which of the following is a term used to describe excessive nitrogenous waste in the blood, as seen in acute glomerulonephritis? Azotemia
The primary presenting features of acute glomerulonephritis are hematuria, edema, azotemia (excessive nitrogenous wastes in the blood), and proteinuria (>3 to 5 g/day).
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? Increase carbohydrates and limit protein intake.
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.
A client diagnosed with acute kidney injury (AKI) has developed congestive heart failure. The client has received 40 mg of intravenous push (IVP) Lasix and 2 hours later, the nurse notes that there are 50 mL of urine in the Foley catheter bag. The client's vital signs are stable. Which health care order should the nurse anticipate? Lasix 80mg IVP
Diuretic agents are often used to control fluid volume in clients with acute kidney injury (AKI). The client's urine output indicates an inadequate response to the initial dosage of Lasix and the nurse should anticipate administering Lasix 80 mg IVP. Often in this situation, the initial dosage of Lasix is doubled.
Which of the following causes should the nurse suspect in a client diagnosed with intrarenal failure? glomerulonephritis
intrarenal causes of renal failure include prolonged renal ischemia, nephrotoxic agents, and infectious processes such as acute glomerulonephritis.
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? Encourage use of incentive spirometer every 2 hours.
To address the issue of ineffective breathing pattern, encouraging the use of incentive spirometer would be most appropriate to help increase alveolar ventilation
The nurse recognizes which condition as an integumentary manifestation of chronic renal failure? Grey-bronze skin color
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.
Following a nephrectomy, which assessment finding is most important in determining nursing care for the client? SpO2 at 90% with fine crackles in the lung bases
The Risk for Ineffective Breathing Pattern is often a challenge in caring for clients postnephrectomy due to location of incision. Nursing interventions should be directed to improve and maintain SpO2 levels at 90% or greater and keep lungs clear of adventitious sounds. Intake and output is monitored to maintain a urine output of greater than 30 mL/hour
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? Start IV fluids with a normal saline solution bolus followed by a maintenance dose
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 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? 1,000 mL
A 1-kg weight gain is equal to 1,000 mL of retained fluid.
A client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, the nurse knows that the client is most likely to experience: weight loss
Because CRF causes loss of renal function, the client with this disorder retains fluid. Hemodialysis removes this fluid, causing weight loss.
A client requires hemodialysis. Which type of drug should be withheld before this procedure? Cardiac glycosides
Cardiac glycosides such as digoxin (Lanoxin) should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digoxin toxicity.
Hyperkalemia is a serious side effect of acute renal failure. Identify the electrocardiogram (ECG) tracing that is diagnostic for hyperkalemia. Tall, peaked T waves
Characteristic ECG signs of hyperkalemia are tall, tented, or peaked T waves, absent P waves, and a widened QRS complex.
Which of the following occurs late in chronic glomerulonephritis? Peripheral neuropathy
Peripheral neuropathy with diminished deep tendon reflexes and neurosensory changes occur late in the disease. The patient becomes confused and demonstrates a limited attention span. An additional late finding includes evidence of pericarditis with or without a pericardial friction rub. The first indication of disease may be a sudden, severe nosebleed, a stroke, or a seizure.
A patient has been diagnosed with postrenal failure. The nurse reviews the patient's electronic health record and notes a possible cause. Which of the following is the possible cause? Renal calculi
Postrenal ARF is the result of an obstruction that develops anywhere from the collecting ducts of the kidney to the urethra. This results from ureteral blockage, such as from bilateral renal calculi or benign prostatic hypertrophy (BPH).
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? Donors are selected from compatible living or deceased donors
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.
What is a characteristic of the intrarenal category of acute kidney injury (AKI)? Increased BUN
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.
The client with polycystic kidney disease asks the nurse, "Will my kidneys ever function normally again?" The best response by the nurse is: "As the disease progresses, you will most likely require renal replacement therapy."
There is no cure for polycystic kidney disease. Medical management includes therapies to control blood pressure, urinary tract infections, and pain. Renal replacement therapy is indicated as the kidneys fail.
The nurse is caring for a patient in the oliguric phase of acute kidney injury (AKI). What does the nurse know would be the daily urine output? Less than 400 mL
The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The minimum amount of urine needed to rid the body of normal metabolic waste products is 400 mL. In this phase, uremic symptoms first appear and life-threatening conditions such as hyperkalemia develop.
A client in chronic renal failure becomes confused and complains of abdominal cramping, racing heart rate, and numbness of the extremities. The nurse relates these symptoms to which of the following lab values? Hyperkalemia
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.
The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for? Hypovolemic shock caused by hemorrhage
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.
A client, aged 75, is diagnosed with a renal disease and administered nephrotoxic drugs in normal doses. The nurse is aware that it is important to observe the client closely for any changes in renal status. Which of the following measures may help a nurse determine a change in renal status? Observing the clients urinary output
Nephrotoxic drugs are not administered to a client with renal disease unless the client's life is in danger and no other therapeutic agent is of value. Since the client is given nephrotoxic drugs in normal doses, observing the client's urinary output can help the nurse determine a change in the renal status.
A client with newly diagnosed renal cancer is questioning why detection was delayed. Which is the best response by the nurse? Very few symptoms are associated with renal cancer.
Renal cancers rarely cause symptoms in the early stage. Tumors can become quite large before causing symptoms. Painless, gross hematuria is often the first symptom in renal cancer and does not present until later stages of the disease.
A male client has doubts about performing peritoneal dialysis at home. He informs the nurse about his existing upper respiratory infection. Which of the following suggestions can the nurse offer to the client while performing an at-home peritoneal dialysis? Wear a mask when performing exchanges
The nurse should advise the client to wear a mask while performing exchanges. This prevents contamination of the dialysis catheter and tubing, and is usually advised to clients with upper respiratory infection.
The nurse is providing supportive care to a client receiving hemodialysis in the management of acute renal failure. Which statement from the nurse best reflects the ability of the kidneys to recover from acute renal failure? The kidneys can improve over a period of months.
The kidneys have a remarkable ability to recover from serious insult. Recovery may take 3 to 12 months. As long as recovery is continuing, there is no need to consider transplant or permanent hemodialysis. Acute renal failure can progress to chronic renal failure.
The nurse is caring for a patient with a medical history of untreated CKD that has progressed to ESKD. Which of the following serum values and associated signs and symptoms will the nurse expect the patient to exhibit? Select all that apply. Calcium 7.5 mg/dL; hypotension and irritability Potassium 6.4 mEq/L; dysrhythmias and abdominal distention Phosphate 5.0 mg/dL; tachycardia and nausea and emesis
Decreased calcium, increased potassium, and increased phosphate levels are associated with ESKD, along with the signs and symptoms associated with these serum values. Decreased magnesium and chloride levels are not associated with ESKD.
Which nursing assessment finding indicates that the client who has undergone renal transplant has not met expected outcomes? Fever
Fever is an indicator of infection or transplant rejection.
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem? White blood cell (WBC) count of 20,000/mm3
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.
One of the roles of the nurse in caring for clients with chronic renal failure is to help them learn to minimize and manage potential complications. This would include: restricting sources of potassium usually found in fresh fruits and vegetables.
Restrict sources of potassium usually found in fresh fruits and vegetables; hyperkalemia can cause life-threatening changes. Restrict sodium intake as ordered; doing so prevents excess sodium and fluid accumulation. Prescribed iron and folic acid supplements or Epogen should be taken. Iron and folic acid supplements are needed for RBC production. Epogen stimulates bone marrow to produce RBCs. Restrict protein intake to foods that are complete proteins within prescribed limits.
A client with acute renal failure progresses through four phases. Which describes the onset phase? It is accompanied by reduced blood flow to the nephrons.
The onset phase is accompanied by reduced blood flow to the nephrons. In the oliguric phase, fluid volume excess develops, which leads to edema, hypertension, and cardiopulmonary complications. During the diuretic phase, excretion of wastes and electrolytes continues to be impaired despite increased water content of the urine. During the recovery phase, normal glomerular filtration and tubular function are restored.
A change that occurs during chronic glomerulonephritis is termed anemia
Anemia, hyperkalemia, metabolic acidosis, and hyperphosphatemia occur during chronic glomerulonephritis.
A group of students are reviewing the phases of acute renal failure. The students demonstrate understanding of the material when they identify which of the following as occurring during the second phase? Oliguria
During the second phase, the oliguric phase, oliguria occurs. Diuresis occurs during the third or diuretic phase. Acute tubular necrosis (ATN) occurs during the first, or initiation, phase in which reduced blood flow to the nephrons leads to ATN. Restoration of glomerular function, if it occurs, occurs during the fourth, or recovery, phase.
Which of the following would a nurse classify as a prerenal cause of acute renal failure? Spetic shock
Prerenal causes of acute renal failure include hypovolemic shock, cardiogenic shock secondary to congestive heart failure, septic shock, anaphylaxis, dehydration, renal artery thrombosis or stenosis, cardiac arrest, and lethal dysrhythmias. Ureteral stricture and prostatic hypertrophy would be classified as postrenal causes. Polycystic disease is classified as an intrarenal cause of acute renal failure