Chapter 47: Assessment of Kidney and Urinary Function
Which nursing assessment finding indicates that the client who has undergone renal transplant has not met expected outcomes?
Fever Explanation: Fever is an indicator of infection or transplant rejection.
Which term best describes a total urine output less than 500 mL in 24 hours?
Oliguria Explanation: Oliguria is a urine output less than 500 mL in 24 hours. Polyuria is increased urine output. Nocturia is awakening at night to urinate. Dysuria is painful or difficult urination.
Retention of which electrolyte is the most life-threatening effect of renal failure?
Potassium Explanation: Retention of potassium is the most life-threatening effect of renal failure.
What is a hallmark of the diagnosis of nephrotic syndrome?
Proteinuria Explanation: Proteinuria (predominantly albumin) exceeding 3.5 g per day is the hallmark of the diagnosis of nephrotic syndrome. Hypoalbuminemia, hypernatremia, and hyperkalemia may occur.
The most frequent reason for admission to skilled care facilities includes which of the following?
Urinary incontinence Explanation: Urinary incontinence is the most common reason for admission to skilled nursing facilities.
While reviewing a client's chart, the nurse notes the client has been experiencing enuresis. To assess whether this remains an ongoing problem for the client, the nurse asks which question?
"Do you urinate while sleeping?" Explanation: Enuresis is defined as involuntary voiding during sleep. The remaining questions do not relate to this problem associated with changes in the client's voiding pattern.
While reviewing a client's chart, the nurse notes the client has been experiencing enuresis. To assess whether this remains an ongoing problem for the client, the nurse asks which question?
"Do you urinate while sleeping?" Explanation: Enuresis is defined as involuntary voiding during sleep. The remaining questions do not relate to this problem associated with changes in the client's voiding pattern.
Which nursing assessment finding indicates the client with renal dysfunction has not met expected outcomes?
Client reports increasing fatigue. Explanation: Fatigue, shortness of breath, and exercise intolerance are consistent with unexplained anemia, which can be secondary to gradual renal dysfunction.
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 Explanation: 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 history of hyperparathyroidism or osteoporosis would place the client at risk for developing renal calculi. A history of pyelonephritis would increase the client's risk for chronic pyelonephritis.
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. Explanation: 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.
The nurse is preparing the procedure room for a client who will undergo an intravenous pyelogram. Which item(s) should the nurse include?
Suction equipment Explanation: The contrast agent injected into the client for an intravenous pyelogram is allergenic and nephrotoxic. Emergency supplies and equipment should be readily available in case the client experiences an anaphylactic reaction, including airway and suction equipment, oxygen, epinephrine, corticosteroids, and vasopressors.
The most frequent reason for admission to skilled care facilities includes which of the following?
Urinary incontinence Explanation: Urinary incontinence is the most common reason for admission to skilled nursing facilities.
A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for:
fatigue and weakness. Explanation: RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue and weakness. Nausea and vomiting may occur in CRF but don't result from faulty RBC production. Dyspnea and cyanosis are associated with fluid excess, not CRF. Thrush, which signals fungal infection, and circumoral pallor, which reflects decreased oxygenation, aren't signs of CRF.
A client with a history of bladder retention hasn't voided for 8 hours. A nurse concerned that the client is retaining urine notifies the physician. He orders a bladder ultrasonic scan and placement of an indwelling catheter if the residual urine is greater than 350 mL. The nurse knows that using the bladder ultrasonic scan to measure residual urine instead of placing a straight catheter reduces the risk of:
microorganism transfer. Explanation: Bladder ultrasonic scanning, a noninvasive way of calculating the amount of urine in the bladder, reduces the risk of transferring microorganisms into the bladder. Use of a straight catheter to measure residual urine increases the transfer of microorganisms into the bladder, and increases, rather than reduces, client discomfort. A bladder ultrasonic scan doesn't reduce the risk of prostate irritation or incorrect urine output values.
The nurse is able to identify which condition as uremia?
An excess of urea in the blood Explanation: 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.
The nurse is reviewing the results of a client's renal function study. The nurse understands that which value represent a normal BUN-to-creatinine ratio?
10:1 Explanation: A normal BUN-to-creatinine ratio is about 10:1. The other values are incorrect.
The nurse is caring for a client with a history of sickle cell anemia. The nurse understands that this predisposes the client to which renal or urologic disorder?
Chronic kidney disease Explanation: A history of sickle cell anemia predisposes the client to the development of chronic kidney disease. The other disorders are not associated with the development of sickle cell anemia.
The nurse is preparing the client for magnetic resonance imaging (MRI) of the kidney. Which statement by the client requires action by the nurse?
"I took my blood pressure medication with my morning coffee an hour ago." Explanation: The client should not eat for at least 1 hour before an MRI. Alcohol, caffeine-containing beverages, and smoking should be avoided for at least 2 hours before an MRI. The client can take his or her usual medications except for iron supplements prior to the procedure.
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 Explanation: 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 (Murphy, Bennett, & Jenkins, 2010). In ESKD, erythropoietin production decreases and profound anemia results, producing fatigue, angina, and shortness of breath.
A patient is being seen in the clinic for possible kidney disease. What major sensitive indicator of kidney disease does the nurse anticipate the patient will be tested for?
Creatinine clearance level Explanation: Creatinine is an endogenous waste product of skeletal muscle that is filtered at the glomerulus, passed through the tubules with minimal change, and excreted in the urine. Hence, creatinine clearance is a good measure of the glomerular filtration rate (GFR), the amount of plasma filtered through the glomeruli per unit of time. Creatinine clearance is the best approximation of renal function. As renal function declines, both creatinine clearance and renal clearance (the ability to excrete solutes) decrease.
Which is an effect of aging on upper and lower urinary tract function?
Susceptibility to develop hypernatremia Explanation: The elderly are more susceptible to developing hypernatremia. These clients typically have a decreased glomerular filtration rate, decreased blood flow to the kidney, and acid-base imbalances.
A client in a short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing postprocedure care, the nurse should:
check the client's pedal pulses frequently. Explanation: After renal angiography involving a femoral puncture site, the nurse should check the client's pedal pulses frequently to detect reduced circulation to the feet caused by vascular injury. The nurse also should monitor vital signs for evidence of internal hemorrhage and should observe the puncture site frequently for fresh bleeding. The client should be kept on bed rest for several hours so the puncture site can seal completely. Keeping the client's knee bent is unnecessary. By the time the client returns to the short-procedure unit, manual pressure over the puncture site is no longer needed because a pressure dressing is in place. The nurse should leave this dressing in place for several hours — and only remove it if instructed to do so.
A nurse is assisting the physician conducting a cystogram. The client has an intravenous (IV) infusion of D5W at 40 ml/hr. The physician inserts a urinary catheter into the bladder and instills a total of 350 ml of a contrast agent. The nurse empties 500 ml from the urinary catheter drainage bag at the conclusion of the procedure. How many milliliters does the nurse record as urine?
150 Explanation: The urinary drainage bag contains both the contrast agent and urine at the conclusion of the procedure. Total contents (500 ml) in the drainage bag consist of 350 ml of contrast agent and 150 ml of urine.
The nurse is completing a full exam of the renal system. Which assessment finding best documents the need to offer the use of the bathroom?
A dull sound when percussing over the bladder Explanation: A dull sound when percussing over the bladder indicates a full bladder. Because the bladder is full, the nurse would offer for the client to use the bathroom. Tenderness over the kidney can indicate an infection or stones. Bruits are an abnormal vascular sound that does not indicate the need to use the bathroom. Ingesting water does not mean that the client has to void at this time.
The client is admitted to the hospital with a diagnosis of acute pyelonephritis. Which clinical manifestations would the nurse expect to find?
Costovertebral angle tenderness Explanation: Acute pyelonephritis is characterized by costovertebral angle tenderness. Suprapubic pain is suggestive of bladder distention or infection. Urethral trauma and irritation of the bladder neck can cause pain after voiding. Perineal pain is experienced by male clients with prostate cancer or prostatitis.
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 Explanation: Stage 3 of chronic kidney disease is defined as having a GFR of 30-59 mL/min/1.73 m2
What is a characteristic of the intrarenal category of acute renal failure?
Increased BUN Explanation: The intrarenal category of acute renal failure encompasses an increased BUN, increased creatinine, a low specific gravity of urine, and increased urine sodium.
The term used to describe total urine output less than 0.5 mL/kg/hour is
oliguria. Explanation: Oliguria is associated with acute and chronic renal failure. Anuria is used to describe total urine output less than 50 mL in 24 hours. Nocturia refers to awakening at night to urinate. Dysuria refers to painful or difficult urination.
A client with end-stage renal disease is scheduled to undergo a kidney transplant using a sibling donated kidney. The client asks if immunosuppressive drugs can be avoided. Which is the best response by the nurse?
"Even a perfect match does not guarantee organ success." Explanation: Even a perfect match does not guarantee that a transplanted organ will not be rejected. Immunosuppressive drugs are used in all organ transplants to decrease incidence of organ rejection. To provide the client with the information needed to provide informed consent, the treatment plan is reviewed and discussed prior to transplant.
A nurse is caring for a female client reporting dysuria for several days. Which question should the nurse exclude when establishing a baseline for interventions? Select all that apply.
"Have you recently increased your alcohol consumption in the last month?" Explanation: This nurse is essentially obtaining a urologic health history. It is important to use language that the client can understand and to avoid medical jargon. The nurse should inquire about the location character and duration of dysuria if present, and its relationship to voiding, factors that precipitate dysuria and those that relieve it. The nurse should discuss fever, chills, hematuria or changes in the color or volume of urine. The nurse should also discuss hesitancy, straining to urinate or frequency of urination. Limiting the discussion to just what causes pain could lead to the nurse missing signs and symptoms of urinary tract infection and/or other urological conditions. The amount of alcohol consumption in the last month does not have a direct correlation to dysuria. Dysuria is defined as painful or difficult voiding, so this is a question the nurse would exclude during the assessment.
The nurse is providing instructions to the client prior to an intravenous pyelogram. Which statement by the client indicates teaching was effective?
"I will feel a warm sensation as the dye is injected." Explanation: A contrast agent is injected into the client for an intravenous pyelogram. The client may experience a feeling of warmth, flushing of the face, or taste a seafood flavor as the contrast infuses. Jewelry does not need to be removed before the procedure. Claustrophobia is not expected.
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." Explanation: 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. Adenocarcinomas are the most common renal cancer (about 80%),whereas squamous cell renal cancers are rare. It is not therapeutic to place doubt or blame for delayed diagnosis.
A client is scheduled for a renal ultrasound. Which of the following would the nurse include when explaining this procedure to the client?
"You don't need to do any fasting before this noninvasive test." Explanation: Renal ultrasonography identifies the kidney's shape, size, location, collecting systems, and adjacent tissues. It is not invasive, does not require the injection of a radiopaque dye, and does not require fasting or bowel preparation. An x-ray of the abdomen to view the kidneys, ureters, and bladder is called a KUB. A contrast medium is used for computed tomography of the abdomen and pelvis. A pressure dressing is applied to the groin after a renal arteriogram.
A client with chronic kidney disease (CKD) has been receiving erythropoietin injections as prescribed. Which outcome would indicate to the nurse that this medication has been effective?
Absence of pallor Explanation: Erythropoietin stimulates the bone marrow to produce more red blood cells. The absence of pallor indicates that this treatment has been effective. Lack of a paradoxical pulse indicates the absence of a pericardial effusion. Blood pressure within normal limits indicates treatment for hypertension has been effective. Formed and solid bowel movements indicate the potassium level is within normal limits.
A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which disorder?
Acute glomerulonephritis Explanation: Acute glomerulonephritis is also associated with varicella zoster virus, hepatitis B, and Epstein-Barr virus. Acute renal failure is associated with hypoperfusion to the kidney, parenchymal damage to the glomeruli or tubules, and obstruction at a point distal to the kidney. Chronic renal failure may be caused by systemic disease, hereditary lesions, toxic agents, infections, and medications. Nephrotic syndrome is caused by disorders such as chronic glomerulonephritis, systemic lupus erythematosus, multiple myeloma, and renal vein thrombosis.
The nurse is reviewing the potassium level of a patient with kidney disease. The results of the test are 6.5 mEq/L, and the nurse observes peaked T waves on the ECG. What priority intervention does the nurse anticipate the physician will order to reduce the potassium level?
Administration of sodium polystyrene sulfonate [Kayexalate]) Explanation: 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.
Which of the following diagnostic tests would the nurse expect to be ordered to determine the details of the arterial supply to the kidneys?
Angiography Explanation: Angiography provides the details of the arterial supply to the kidneys, specifically the number and location of renal arteries. Radiography shows the size and position of the kidneys, ureters, and bladder. A CT scan is useful in identifying calculi, congenital abnormalities, obstruction, infections, and polycystic diseases. Cystoscopy is used for providing a visual examination of the internal bladder.
Which of the following is a term used to describe excessive nitrogenous waste in the blood, as seen in acute glomerulonephritis?
Azotemia Explanation: The primary presenting features of acute glomerulonephritis are hematuria, edema, azotemia (excessive nitrogenous wastes in the blood), and proteinuria (>3 to 5 g/day). Bacteremia is excessive bacteria in the blood.
The nurse is providing care to a client who has had a renal biopsy. The nurse would need to be alert for signs and symptoms of which of the following?
Bleeding Explanation: Renal biopsy carries the risk of postprocedure bleeding because the kidneys receive up to 25% of the cardiac output each minute. Therefore, the nurse would need to be alert for signs and symptoms of bleeding. Although infection is also a risk, the risk for bleeding is greater. Dehydration and allergic reaction are not associated with a renal biopsy.
A creatinine clearance test has been ordered. The nurse prepares to:
Collect the client's urine for 24 hours. Explanation: A creatinine clearance test is a 24-hour urine test and is useful in evaluating renal disease.
A client has undergone diagnostic testing that involved the insertion of a lighted tube with a telescopic lens. The nurse identifies this test as which of the following?
Cystoscopy Explanation: Cystoscopy is the visual examination of the inside of the bladder using an instrument called a cystoscope, a lighted tube with a telescopic lens. Renal angiography involves the passage of a catheter up the femoral artery into the aorta to the level of the renal vessels. Intravenous pyelography or excretory urography is a radiologic study that involves the use of a contrast medium to evaluate the kidneys' ability to excrete it.
The nurse is completing a routine urinalysis using a dipstick. The test reveals an increased specific gravity. The nurse should suspect which condition?
Decreased fluid intake Explanation: When fluid intake decreases, specific gravity normally increases. With high fluid intake, specific gravity decreases. Disorders or conditions that cause decreased urine-specific gravity include diabetes insipidus, glomerulonephritis, and severe renal damage. Disorders that can cause increased specific gravity include diabetes, nephritis, and fluid deficit.
The nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure?
Dehydration Explanation: The diuretic phase of acute renal failure is characterized by increased urine output, hypotension, and dehydration.
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 Explanation: 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.
Which type of incontinence refers to the involuntary loss of urine due to extrinsic medical factors, particularly medications?
Iatrogenic Explanation: Iatrogenic incontinence is the involuntary loss of urine due to extrinsic medical factors, predominantly medications. Reflex incontinence is the involuntary loss of urine due to hyperreflexia in the absence of normal sensations usually associated with voiding. Urge incontinence is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed. Overflow incontinence is the involuntary loss of urine associated with overdistention of the bladder.
A client reports urinary frequency, urgency, and dysuria. Which of the following would the nurse most likely suspect?
Infection Explanation: Frequency, urgency, and dysuria are commonly associated with urinary tract infection. Hesitancy and enuresis may indicate an obstruction. Oliguria or anuria and proteinuria might suggest acute renal failure. Nocturia is associated with nephrotic syndrome.
The nurse reviews a client's history and notes that the client has a history of hyperparathyroidism. The nurse would identify that this client most likely would be at risk for which of the following?
Kidney stones Explanation: A client with hyperparathyroidism is at risk for kidney stones. The client with diabetes mellitus is a risk factor for developing chronic renal failure and neurogenic bladder. A client with radiation to the pelvis is at risk for urinary tract fistula.
A patient is having an MAG3 renogram and is informed that radioactive material will be injected to determine kidney function. What should the nurse instruct the patient to do during the procedure?
Lie still on the table for approximately 35 minutes. Explanation: This relatively new scan is used to further evaluate kidney function in some centers. The patient is given an injection containing a small amount of radioactive material, which will show how the kidneys are functioning. The patient needs to lie still for about 35 minutes while special cameras take images (Albala, Gomelia, Morey, et al., 2010).
A client is scheduled for a renal angiography. Which of the following would be appropriate before the test?
Monitor the client for an allergy to iodine contrast material. Explanation: A renal angiography procedure will be contraindicated if the client is allergic to iodine contrast material. Therefore, it is important for the nurse to monitor the client for an allergy to iodine contrast material. The nurse monitors the client for the signs of electrolyte and water imbalance, mental changes, and periorbital edema at any time regardless of the test being done.
A nurse has been asked to speak to a local women's group about preventing cystitis. Which of the following would the nurse include in the presentation?
Need to urinate after engaging in sexual intercourse Explanation: Measures to prevent cystitis include voiding after sexual intercourse, wearing cotton underwear, urinating every 2 to 3 hours while awake, and taking showers instead of tub baths
A client in moderate pain is admitted for possible kidney stones. The client appears diaphoretic and has frequent periods of nausea and vomiting. The client reports sudden oliguria and initial portable bladder ultrasound shows 300 mL in the bladder after the client voided 50 mL. Which action should the nurse anticipate performing first for this client?
Place a urinary cathether. Explanation: Increased urinary urgency and frequency coupled with decreasing urine volume strongly suggest urinary retention depending on the acuity of the onset of the symptoms, immediate bladder emptying via catheterization and evaluation may be necessary to prevent kidney dysfunction. The combination of pain, sudden oliguria, nausea, vomiting and post-ressidual results are suggestive of an acute condition. Therefore, a second bladder scan is not warranted and may delay care. The pain, nausea, and vomiting may be the result of urinary retention and a full bladder. Placement of a urinary cathether may alleviate those conditions. After placing the urinary cathether, a reassessment and treatment of those conditions can occur.
The nurse is aware, when caring for patients with renal disease, that which substance made in the glomeruli directly controls blood pressure?
Renin Explanation: Renin is directly involved in the control of arterial blood pressure. It is also essential for the proper functioning of the glomerulus and management of the body's renin-angiotensin system (RAS).
A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?
Risk for infection Explanation: 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.
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 Explanation: 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. Pain control is important and should allow for movement, deep breathing, and rest. Blood-tinged drainage from the JP tube is expected in the initial postoperative period.
The nurse is caring for a client who has presented to the walk-in clinic. The client verbalizes pain on urination, feelings of fatigue, and diffuse back pain. When completing a head-to-toe assessment, at which specific location would the nurse assess the client's kidneys for tenderness?
The costovertebral angle Explanation: The nurse is correct to assess the kidneys for tenderness at the costovertebral angle. The other options are incorrect.
The client presents with nausea and vomiting, absent bowel sounds, and colicky flank pain. The nurse interprets these findings as consistent with:
Ureteral colic Explanation: These clinical manifestations are consistent with ureteral colic.
The nurse is assigned to care for a patient in the oliguric phase of kidney failure. When does the nurse understand that oliguria is said to be present?
When the urine output is less than 30 mL/h Explanation: Oliguria is defined as urine output <0.5 mL/kg/h
The nurse is assigned to care for a patient in the oliguric phase of kidney failure. When does the nurse understand that oliguria is said to be present?
When the urine output is less than 30 mL/h Explanation: Oliguria is defined as urine output <0.5 mL/kg/h
A client is experiencing some secretion abnormalities, for which diagnostics are being performed. Which substance is typically reabsorbed and not secreted in urine?
glucose Explanation: Amino acids and glucose typically are reabsorbed and not excreted in the urine. The filtrate that is secreted as urine usually contains water, sodium, chloride, bicarbonate, potassium, urea, creatinine, and uric acid.
Diet modifications are part of nutritional therapy for the management of ARF. Select the high-potassium food that should be restricted.
Citrus fruits Explanation: Dietary restrictions include foods and fluids containing potassium, such as bananas, citrus, tomatoes, melons, or those with phosphorus, which is found in dairy, beans, nuts legumes, and carbonated beverages. Caffeine is also restricted.
Patient education regarding a fistulae or graft includes which of the following? Select all that apply
Check daily for thrill and bruit. Avoid compression of the site. No IV or blood pressure taken on extremity with dialysis access. No tight clothing. Explanation: The nurse teaches the patient with fistulae or grafts to check daily for a thrill and bruit. Further teaching includes avoiding compression of the site; not permitting blood to be drawn, an IV to be inserted, or blood pressure to be taken on the extremity with the dialysis access; not to wear tight clothing, carry bags or pocketbooks on that side, and not lie on or sleep on the area. The site is not cleansed unless it is being accessed for hemodialysis.
A nurse receives her client care assignment. Following the report, she should give priority assessment to the client:
Correct response: who, following a kidney transplant, has returned from hemodialysis with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L. Explanation: A sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L in a client immediately following dialysis should be the priority assessment. Pinkish mucus discharge in the appliance bag is a normal finding for a client who's had an ileal conduit, as are a sodium level of 135 mEq/L and a potassium level of 3.7 mEq/L in a client who's had a kidney transplant. Although the nurse should further assess mild pain from urolithiasis, this is an expected finding and not a priority in relation to the client with abnormal sodium and potassium levels.
Which is an effect of aging on upper and lower urinary tract function?
Susceptibility to develop hypernatremia Explanation: The elderly are more susceptible to developing hypernatremia. These clients typically have a decreased glomerular filtration rate, decreased blood flow to the kidney, and acid-base imbalances.
The nurse is preparing a client for a nuclear scan of the kidneys. Following the procedure, the nurse instructs the client to
drink liberal amounts of fluids. Explanation: After the procedure is completed, the client is encouraged to drink fluids to promote excretion of the radioisotope by the kidneys. The remaining instructions are not associated with a nuclear scan.
The nurse is caring for a client who reports orange urine. The nurse suspects which factor as the cause of the urine discoloration?
phenazopyridine hydrochloride Explanation: Orange to amber-colored urine is caused by concentrated urine due to dehydration, fever, bile, excess bilirubin or carotene, and the medications phenazopyridine hydrochloride and nitrofurantoin. Infection would cause yellow to milky white urine. Phenytoin would cause the urine to become pink to red. Metronidazole would cause the urine to become brown to black.
The nurse is caring for a patient that has developed oliguria. Oliguria is defined as urine output less than ___________mL/kg/hr.
0.5 Explanation: Oliguria is defined as urine output less than 0.5 mL/kg/hr.
A 24-year-old patient was admitted to the emergency room after a water skiing accident. The X-rays revealed two fractured vertebrae, T-12 and L1. Based on this information, the nurse would know to perform which of the following actions?
Check the patient's urine for hematuria. Explanation: The kidneys are located from the 12th thoracic vertebrae to the third lumbar vertebrae. Therefore, the accident may have caused blunt force trauma damage to the kidneys. Ice is always applied for the first 24 hours, then heat, if not contraindicated. Activity will be restricted but bed rest is not necessary.
What is a characteristic of the intrarenal category of acute kidney injury (AKI)?
Increased BUN Explanation: 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.
A nurse is reviewing the laboratory test results of a client with renal disease. Which of the following would the nurse expect to find?
Increased serum creatinine Explanation: In clients with renal disease, the serum creatinine level would be increased. The BUN also would be increased, serum albumin would be decreased, and potassium would likely be increased
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. Explanation: 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.
For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important?
Limiting fluid intake Explanation: During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and IV fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain.
A client with a genitourinary problem is being examined in the emergency department. When palpating the client's kidneys, the nurse should keep in mind which anatomic fact?
The left kidney usually is slightly higher than the right one. Explanation: The left kidney usually is slightly higher than the right one. An adrenal gland lies atop each kidney. The average kidney measures approximately 11 cm (4??) long, 5 to 5.8 cm (2? to 2¼?) wide, and 2.5 cm (1?) thick. The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of the vertebral column. They lie between the 12th thoracic and 3rd lumbar vertebrae.
Which of the following is the priority nursing diagnosis for the client in the oliguric phase of acute renal failure?
Fluid volume excess Explanation: The oliguric phase is characterized by fluid retention.
Which of the following causes should the nurse suspect in a client diagnosed with intrarenal failure?
Glomerulonephritis Explanation: Intrarenal causes of renal failure include prolonged renal ischemia, nephrotoxic agents, and infectious processes such as acute glomerulonephritis.
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. Explanation: 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.
The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for?
Correct response: Hypovolemic shock caused by hemorrhage Explanation: 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 develops decreased renal function and requires a change in antibiotic dosage. On which factor should the physician base the dosage change?
Creatinine clearance Explanation: The physician should base changes to antibiotic dosages on creatinine clearance test results, which gauge the kidney's glomerular filtration rate; this factor is important because most drugs are excreted at least partially by the kidneys. The GI absorption rate, therapeutic index, and liver function studies don't help determine dosage change in a client with decreased renal function
The health care provider ordered four tests of renal function for a patient suspected of having renal disease. Which of the four is the most sensitive indicator?
Creatinine clearance level Explanation: The creatinine clearance measures the volume of blood cleared of endogenous creatinine in 1 minute. This serves as a measure of the glomerular filtration rate. Therefore the creatinine clearance test is a sensitive indicator of renal disease progression.
The wall of the bladder is comprised of four layers. Which of the following is the layer responsible for micturition?
Detrusor muscle Explanation: The bladder wall contains four layers. The smooth muscle layer beneath the adventitia is known as the detrusor layer. When this muscle contracts, urine is released from the bladder. When the bladder is relaxed, the muscle fibers are closed and act as a sphincter.
During hemodialysis, toxins and wastes in the blood are removed by which of the following?
Diffusion Explanation: The toxins and wastes in the blood are removed by diffusion, in which particles move from an area of higher concentration in the blood to an area of lower concentration into the dialysate.
A client has a full bladder. Which sound would the nurse expect to hear on percussion?
Dullness Explanation: Dullness on percussion indicates a full bladder; tympany indicates an empty bladder. Resonance is heard over areas that are part air and part solid, such as the lungs. Flatness is heard over very dense tissue, such as the bone or muscle.
The nurse is reviewing the client's urinalysis results. The finding that is most suggestive of dehydration of the client is:
Specific gravity 1.035 Explanation: Specific gravity is reflective of hydration status. A concentrated specific gravity, such as 1.035, is suggestive of dehydration. Bright yellow urine suggests ingestion of multiple vitamins. Proteinuria can be benign or be caused by conditions which alter kidney function. Creatinine measures the ability of the kidney to filter the blood. A level of 0.7 is within normal limits.
The nurse is caring for a client who is brought to the emergency department after being found unconscious outside in hot weather. Dehydration is suspected. Baseline lab work including a urine specific gravity is ordered. Which relation between the client's symptoms and urine specific gravity is anticipated?
The specific gravity will be high. xplanation: The nurse assesses all of the data to make an informed decision on client status. On a hot day, the client found outside will be perspiring. When dehydration occurs, a client will have low urine output and increased specific gravity of urine. Normal specific gravity is inversely proportional. The density of distilled water is one. A low specific gravity is noted in a client with high fluid intake and who is not losing systemic fluid.
A group of students is reviewing for a test on the urinary and renal system. The students demonstrate understanding of the information when they identify which of the following as part of the upper urinary tract?
Ureters Explanation: The upper urinary tract is composed of the kidneys, renal pelvis, and ureters. The lower urinary tract consists of the bladder, urethra, and pelvic floor muscles.
A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
Urine output of 20 ml/hour Explanation: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. A serum potassium level of 4.9 mEq/L, a serum sodium level of 135 mEq/L, and a temperature of 99.2° F are normal assessment findings.
The nurse is reviewing the client's lab results. Which lab result requires follow up by the nurse? Select all that apply.
Urine: RBC 20 BUN 28 mg/dL Explanation: Hematuria (> 3RBCs) and an elevated BUN are both suggestive of a problem within the genitourinary tract. A serum creatinine of 0.8 mg/dL and a urine specific gravity of 1.020 are within normal limits. A rare white blood cell is not clinically significant.
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?
With food Explanation: 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.
A nurse is caring for a client diagnosed with acute renal failure. The nurse notes on the intake and output record that the total urine output for the previous 24 hours was 35 mL. Urine output that's less than 50 ml in 24 hours is known as:
anuria. Explanation: Urine output less than 50 ml in 24 hours is called anuria. Urine output of less than 400 ml in 24 hours is called oliguria. Polyuria is excessive urination. Hematuria is the presence of blood in the urine.
A client with renal dysfunction of acute onset comes to the emergency department complaining of fatigue, oliguria, and coffee-colored urine. When obtaining the client's history to check for significant findings, the nurse should ask about:
recent streptococcal infection. Explanation: A skin or upper respiratory infection of streptococcal origin may lead to acute glomerulonephritis. Other infections that may be linked to renal dysfunction include infectious mononucleosis, mumps, measles, and cytomegalovirus. Chronic, excessive acetaminophen use isn't nephrotoxic, although it may be hepatotoxic. Childhood asthma and a family history of pernicious anemia aren't significant history findings for a client with renal dysfunction.
A client presents to the emergency department complaining of a dull, constant ache along the right costovertebral angle along with nausea and vomiting. The most likely cause of the client's symptoms is:
renal calculi. Explanation: Renal calculi usually presents as a dull, constant ache at the costovertebral angle. The client may also present with nausea and vomiting, diaphoresis, and pallor. The client with an overdistended bladder and interstitial cystitis presents with dull, continuous pain at the suprapubic area that's intense with voiding. The client also complains of urinary urgency and straining to void. The client with acute prostatitis presents with a feeling of fullness in the perineum and vague back pain, along with frequency, urgency, and dysuria.
Which hormone causes the kidneys to reabsorb sodium?
Aldosterone Explanation: Aldosterone is a hormone synthesized and released by the adrenal cortex. Antidiuretic hormone is secreted by the posterior pituitary gland. Growth hormone and prostaglandins do not cause the kidneys to reabsorb sodium.
A client who has been treated for chronic renal failure (CRF) is ready for discharge. The nurse should reinforce which dietary instruction?
"Increase your carbohydrate intake." Explanation: A client with CRF requires extra carbohydrates to prevent protein catabolism. In a client with CRF, unrestricted intake of sodium, protein, potassium, and fluid may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit intake of sodium; meat, which is high in protein; bananas, which are high in potassium; and fluid, because the failing kidneys can't secrete adequate urine. Salt substitutes are high in potassium and should be avoided.
The nurse is visiting the home of a client who is receiving at-home peritoneal dialysis therapy. Which finding indicates to the nurse that the client is developing peritonitis?
Cloudy dialysate effluent Explanation: Most complications of peritoneal dialysis are minor; however, if left untreated, it can lead to serious consequences. Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate effluent. Low back pain can occur from the weight of the fluid in the abdomen. Bloody effluent can occur in young menstruating female clients. It is also common during the first few exchanges after a new catheter is inserted, which most often clears up after several exchanges. Clients with peritonitis are more likely to report anorexia than pronounced hunger.
A female client presents to the health clinic for a routine physical examination. The nurse observes that the client's urine is bright yellow. Which question is most appropriate for the nurse to ask the client?
Correct response: "Do you take multiple vitamin preparations?" Explanation: Urine that is bright yellow is an anticipated abnormal finding in the client taking a multivitamin preparation. Urine that is orange may be caused by intake of phenytoin or other medications. Orange- to amber-colored urine may also indicate concentrated urine due to dehydration or fever. Urine that is pink to red may indicate lower urinary tract bleeding. Yellow to milky white urine may indicate infection, pyuria, or, in the female client, the use of vaginal creams.
A client has been diagnosed with acute glomerulonephritis. This condition causes:
proteinuria. Explanation: 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.
A 24-hour urine collection is scheduled to begin at 8:00 am. When should the nurse initiate the procedure?
After discarding the 8:00 am specimen Explanation: A 24-hour collection of urine is the primary test of renal clearance used to evaluate how well the kidney performs this important excretory function. The client is initially instructed to void and discard the urine. The collection bottle is marked with the time the client voided. Thereafter, all the urine is collected for the entire 24 hours. The last urine is voided at the same time the test originally began.
After undergoing renal arteriogram, in which the left groin was accessed, a client complains of left calf pain. Which intervention should the nurse perform first?
Assess peripheral pulses in the left leg. Explanation: The nurse should begin by assessing peripheral pulses in the left leg to determine if blood flow was interrupted by the procedure. The client may also have thrombophlebitis. Cool compresses aren't used to relieve pain and inflammation in thrombophlebitis. The leg should remain straight after the procedure. Calf pain isn't a symptom of anaphylaxis.
Following a renal biopsy, a client reports severe pain in the back, the arms, and the shoulders. Which intervention should be offered by the nurse?
Assess the patient's back and shoulder areas for signs of internal bleeding. Explanation: After a renal biopsy, the client should be on bed rest. The nurse observes the urine for signs of hematuria. It is important to assess the dressing frequently for signs of bleeding, monitor vital signs, and evaluate the type and severity of pain. Severe pain in the back, shoulder, or abdomen may indicate bleeding. In such a case, the nurse should notify the physician about these signs and symptoms. The nurse should also assess the client for difficulty voiding and encourage adequate fluid intake.
A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF?
Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL Explanation: 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%.
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. Explanation: 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. Auscultation of the lungs will not prevent contamination of the catheter or tubing. The client may also be advised to perform deep-breathing exercises to promote optimal lung expansion, but this will not prevent contamination. Clients with a fistula or graft in the arm should be advised against carrying heavy items.
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. Explanation: The nurse will teach the client to restrict sources of potassium, such as fresh fruits and vegetables, because hyperkalemia can cause life-threatening changes. The client will restrict sodium intake as ordered; doing so prevents fluid accumulation. Prescribed iron and folic acid supplements or Epogen should be taken; iron and folic acid supplements are needed for red blood cell (RBC) production, and Epogen stimulates the bone marrow to produce RBCs. The client will restrict protein intake to foods that are complete proteins within prescribed limits; complete proteins provide positive nitrogen balance for healing and growth.
The nurse has been asked to provide health information to a female patient diagnosed with a urinary tract infection. What appropriate instructions will the nurse provide? Select all that apply.
Cleanse around the perineum and urethral meatus after each bowel movement to reduce pathogens. Drink liberal amounts of fluid to flush out bacteria. Void every 2-3 hours to prevent overdistention of the bladder Explanation: Clients with a urinary tract infection should clean the perineum and urethral meatus from front to back after each bowel movement to help reduce concentrations of pathogens at the urethral opening and, in women, the vaginal opening; void every 2-3 hours during the day to prevent overdistention of the bladder and compromised blood supply to the bladder wall as both predispose the patient to urinary tract infection; and drink liberal amounts of fluid to flush out bacteria. Clients with a urinary tract infection should shower rather than bathe because during a bath bacteria may enter the urethra. Clients with a urinary tract infection should avoid coffee, tea, colas, alcohol, and other fluids that are urinary tract irritants.
Which nursing assessment finding indicates the client has not met expected outcomes?
The client voids 75 cc four hours post cystoscopy. Explanation: Urinary retention is an undesirable outcome following cystoscopy. A pain rating of 3 is an achievable and expected outcome following kidney biopsy. Blood-tinged urine is an expected finding following cystoscopy due to trauma of the procedure. A client would be expected to eat and retain a meal following an intravenous pyelogram.
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. Explanation: 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.
Twenty-four hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for:
removal of the transplanted kidney. Explanation: Hyperacute rejection isn't treatable; the only way to stop this reaction is to remove the transplanted organ or tissue. Although cyclosporine is used to treat acute transplant rejection, it doesn't halt hyperacute rejection. Bone marrow transplant isn't effective against hyperacute rejection of a kidney transplant. Methylprednisolone sodium succinate may be given IV to treat acute organ rejection, but it's ineffective against hyperacute rejection.
