Chapter 48: Management of Patients with Kidney Disorders

The nurse is caring for a client with chronic kidney disease. The client 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.

4000 Explanation: 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 client is weight. An accurate daily weight must be obtained and recorded.

A client has stage 3 chronic kidney failure. What would the nurse expect the client'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

The nurse is reviewing the potassium level of a client 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 health care provider 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.

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.

A client 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 client'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 client with a history of chronic renal failure receives hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which intervention should the nurse include in the care plan?

Assess the AV fistula for a bruit and thrill. Explanation: The nurse needs to assess the AV fistula for a bruit and thrill because if these findings aren't present, the fistula isn't functioning. The AV fistula may get wet when the client isn't being dialyzed. Immediately after a dialysis treatment, the access site should be covered with adhesive bandages, not gauze. Blood pressure readings or venipunctures shouldn't be taken in the arm with the AV fistula.

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.

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%.

The presence of prerenal azotemia is a probable indicator for hospitalization for CAP. Which of the following is an initial laboratory result that would alert a nurse to this condition?

Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20. Explanation: The normal BUN:Cr ratio is less than 15. Prerenal azotemia is caused by hypoperfusion of the kidneys due to a nonrenal cause. Over time, higher than normal blood levels of urea or other nitrogen-containing compounds will develop.

A client requires hemodialysis. Which type of drug should be withheld before this procedure?

Cardiac glycosides Explanation: 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. Phosphate binders and insulin can be administered because they aren't removed from the blood by dialysis. Some antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects. The nurse should check a formulary to determine whether a particular antibiotic should be administered before or after dialysis.

The nurse passes out medications while a client prepares for hemodialysis. The client is ordered to receive numerous medications including antihypertensives. What is the best action for the nurse to take?

Check with the nephrologist to determine the best course of action. Explanation: The nurse evaluates medications given close to or during dialysis that may promote complications. If an antihypertensive agent is taken prior to dialysis, profound hypotension may result. However, withholding blood pressure medications before dialysis should not be routine practice, but rather determined on a client-by-client basis since persistent hypertension is seen in some clients during or after treatment. It is therefore best to confer with the nephrologist before routinely omitting antihypertensive agents prior to dialysis.

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.

The nurse is educating a client who is required to restrict potassium intake. What foods would the nurse suggest the client eliminate that are rich in potassium?

Citrus fruits Explanation: Foods and fluids containing potassium or phosphorus (e.g., bananas, citrus fruits and juices, coffee) are restricted.

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 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.

The client is admitted to the hospital with a diagnosis of acute glomerulonephritis. Which clinical manifestation would the nurse expect to find?

Cola-colored urine Explanation: Clinical manifestations of acute glomerulonephritis include cola-colored urine, hematuria, edema, azotemia, and proteinuria.

During the diuresis period of acute kidney injury (AKI), the nurse should observe the client closely for what complication?

Dehydration Explanation: Dehydration is a complication during the diuresis phase related to elevated urine output and continued symptoms of uremia. The concern with acute kidney injury (AKI) is hyperkalemia. The diuresis phase of AKI is marked by normal or elevated urine output. Oliguria is urine output less than 400 mL in 24 hours and is seen in the oliguria phase. Renal calculi are a possible cause but not a complication of AKI.

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.

The client with chronic kidney disease is exhibiting signs of anemia. Which is the best nursing rationale for this symptom?

Diminished erythropoietin production Explanation: 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.

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. Explanation: 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.

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 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 recovering from hepatitis B develops acute nephrotic syndrome. Which treatment will the nurse anticipate being prescribed for this client?

Methylprednisolone Explanation: Acute nephritic syndrome is a type of acute glomerulonephritis. The focus of management is to treat symptoms, preserve kidney function, and treat complications. Treatment may include corticosteroids such as methylprednisolone. Antibiotics such as vancomycin are used to treat bacterial infections. Hepatitis B is caused by a virus. Sodium would be restricted if the client has hypertension, edema, or heart failure. Carbohydrates should be ingested liberally to provide energy and reduce the catabolism of protein.

The nurse cares for a client with a right-arm arteriovenous fistula (AVF) for hemodialysis treatments. Which nursing action is contraindicated?

Obtaining a blood pressure reading from the right arm Explanation: The nurse assesses the vascular access for patency. The bruit, or "thrill," over the venous access site must be evaluated at least every shift. The nurse takes precautions to ensure that the extremity with the vascular access is not used for measuring blood pressure or for obtaining blood specimens; tight dressings, restraints, or jewelry over the vascular access must be avoided as well.

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 Explanation: 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 initiation periods begins with the initial insult and ends when oliguria develops. The diuresis period is marked by a gradual increase in urine output. The recovery period signals the improvement of renal function and may take 6 to 12 months.

Which period of acute renal failure is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys?

Oliguria Explanation: The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys, such as urea and creatinine. The initiation periods begins with the initial insult and ends when oliguria develops. The diuresis period is marked by a gradual increase in urine output. The recovery period signals the improvement of renal function and may take 6 to 12 months.

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 Explanation: 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.

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?

Penicillin Explanation: The three nephrotoxic drugs are aminoglycerides.

Which of the following occurs late in chronic glomerulonephritis?

Peripheral neuropathy Explanation: Peripheral neuropathy with diminished deep tendon reflexes and neurosensory changes occur late in the disease. The client 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.

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.

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 has been diagnosed with postrenal failure. The nurse reviews the client's electronic health record and notes a possible cause. Which of the following is the possible cause?

Renal calculi Explanation: 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 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.

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.

Which of the following would a nurse classify as a prerenal cause of acute renal failure?

Septic shock Explanation: 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.

Which of the following is the most sensitive indicator of renal function?

Serum creatinine Explanation: Serum creatinine is the more sensitive indicator of renal function because of its constant production in the body.

Based on their knowledge of the primary cause of end-stage renal disease, the nurse knows to assess the most important indicator. What is that indicator?

Serum glucose Explanation: The nurse would evaluate serum and urine levels of glucose because diabetes is the primary cause of renal failure.

What is used to decrease potassium level seen in acute renal failure?

Sodium polystyrene sulfonate 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.

The nurse is caring for a client who has undergone 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: Altered Breathing Pattern and Ineffective Airway Clearance Risk are often challenges 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.

A client has undergone a renal transplant and returns to the health care agency for a follow-up evaluation. Which finding would lead the nurse to suspect that the client is experiencing rejection?

Tenderness over transplant site Explanation: Signs and symptoms of transplant rejection include abdominal pain, hypertension, weight gain, oliguria, edema, fever, increased serum creatinine levels, and swelling or tenderness over the transplanted kidney site.

A client has undergone a renal transplant and returns to the health care agency for a follow-up evaluation. Which finding would lead to the suspicion that the client is experiencing rejection?

Tenderness over transplant site Explanation: Signs and symptoms of transplant rejection include abdominal pain, hypertension, weight gain, oliguria, edema, fever, increased serum creatinine levels, and swelling or tenderness over the transplanted kidney site.

The nurse is providing supportive care to a client receiving hemodialysis in the management of acute kidney injury. Which statement from the nurse best reflects the ability of the kidneys to recover from acute kidney injury?

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 kidney injury can progress to chronic renal failure.

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)?

Urine output of 250 ml/24 hours Explanation: 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.

The nurse is caring for a client with blood loss from esophageal varices. Which assessment finding indicates that the client is exhibiting signs of acute kidney injury (AKI) related to the loss of volume?

Urine output that has been <0.5 mL/kg/hr for several hours Explanation: Acute kidney injury (AKI), describes a range of acute-onset kidney disorders that can include mild impairment of kidney function progressing to acute kidney failure that requires renal replacement therapy. AKI is marked by an abrupt loss of kidney function (sudden increase of serum creatinine of 0.3 mg/dL within 48 hours or 1.5 times baseline serum creatinine over 1 week), decrease in glomerular filtration rate (GFR), and abrupt decline in urine output (<0.5 mL/kg/hr for 6 to 12 hours). Flank pain and pyuria are symptoms of pyelonephritis. Cloudy, foul-smelling urine is suggestive of a urinary tract infection.

The nurse instructs a client to perform continuous ambulatory peritoneal dialysis correctly at home. Which educational information should the nurse provide to the client?

Use an aseptic technique during the procedure. Explanation: The client should be instructed to use an aseptic technique during the procedure. The client should also demonstrate the continuous ambulatory peritoneal dialysis (CAPD) exchange procedure for the nurse using an aseptic technique (clients on continuous cycling peritoneal dialysis [CCPD] should also demonstrate an exchange procedure in case of failure or unavailability of a cycling machine). A mask is generally worn only while performing exchanges, especially when a client has an upper respiratory infection. The catheter insertion site should be cleaned daily with an antiseptic such as povidone-iodine, not with soap. In addition, the catheter should be stabilized to the abdomen above the belt line, not below the belt line, to avoid constant rubbing.

A client has doubts about performing peritoneal dialysis at home. They inform the nurse about their 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.

Which of the following is the most accurate indicator of fluid loss or gain?

Weight Explanation: The most accurate indicator of fluid loss or gain in an acutely ill client is weight, as accurate intake and output and assessment of insensible losses may be difficult. Urine output, caloric intake, and body temperature would not be the most reliable indicator of fluid loss or gain.

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 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.

One of the roles of the nurse in caring for clients with chronic kidney disease 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.

A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of:

water and sodium retention secondary to a severe decrease in the glomerular filtration rate. Explanation: 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.

An investment banker with chronic renal failure informs the nurse of the choice for continuous cyclic peritoneal dialysis. Which is the best response by the nurse?

"This type of dialysis will provide more independence." Explanation: Once a treatment choice has been selected by the client, the nurse should support the client in that decision. Continuous cyclic peritoneal dialysis will provide more independence for this client and supports the client's decision for treatment mode. The risk of peritonitis is greater, and symptoms should be discussed as part of the management of the disorder. Peritoneal dialysis is an effective method of dialysis for many clients.

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 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." Explanation: 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.

The nurse is providing discharge instructions to the client with acute post-streptococcal glomerulonephritis. Which statement by the client indicates a need for further teaching?

"I should drink as much as possible to keep my kidneys working." Explanation: Dietary management of acute post-streptococcal glomerulonephritis includes restrictions of protein, sodium, potassium, and fluids.

The nurse is caring for a client who underwent a kidney transplant. The client appears anxious and tearful and states, "My body is going to reject the new kidney; I know I'm going to die." What is the best response by the nurse?

"I understand your concerns, let's talk about them." Explanation: The nurse must address the client's concerns and encourage the client to express any concerns. The rejection of a transplanted kidney is of great concern to the client, the family, and the health care team for many months. An important nursing function is the assessment of the client's stress and coping. The nurse uses each visit with the client to determine if the client and family are coping effectively and if the client is adhering to the prescribed medication regimen. If indicated or requested, the nurse refers the client for counseling. The other responses are non-therapeutic.

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.

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?

"It is appropriate to warm the dialysate in a microwave." Explanation: 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.

The nurse is creating a plan of care for a client with nephrotic syndrome. Which assessment findings will dictate necessary nursing actions? Select all that apply.

-Anorexia -Weight gain -Shortness of breath -Periorbital edema Explanation: Nephrotic syndrome is not a specific glomerular disease, rather a cluster of clinical findings reflecting underlying damage to the glomerular capillary membrane. This results in increased permeability and loss of plasma proteins in the urine. This leads to edema, periorbital edema, scrotal swelling, abdominal distention, weight gain, or anasarca. Fatigue and anorexia may be reported, as well as shortness of breath, pulmonary edema, or hypertension (not hypotension). The urine may contain increased white blood cells (WBCs) as well as granular and epithelial casts. The loss of urinary immunoglobulin places the client at risk for infections. Hyperlipidemia with increased high-density lipoproteins (HDL) and hypertriglyceridemia places the client at risk for cardiovascular disease.

Client 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 client 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 is assessing a client with acute renal failure. What medications should the nurse identify as a nephrotoxic drug? Select all that apply.

-Gentamycin -Tobramycin -Neomycin Explanation: The kidneys are sensitive to the metabolic byproducts from aminoglycosides such as gentamycin, tobramycin, and neomycin. Penicillin and ceftriaxone are not known to be nephrotoxic.

A client has a family history of polycystic kidney disease. As the nurse gathers information and completes an assessment related to a polycystic kidney diagnosis, which findings would the nurse expect to find? Select all that apply.

-Hypertension -Pain from retroperitoneal bleeding -Polyuria Explanation: Hypertension is present in affected clients at the time of diagnosis. Pain from retroperitoneal bleeding is caused by the size and effects of the cysts. Polyuria can occur. Urinalysis shows mild proteinuria, hematuria, and pyuria. Renal stones are common.

The nurse is caring for a client hospitalized with a diagnosis of acute kidney injury (AKI) experiencing hyperkalemia with a peaked T-wave. Which medication therapy will the nurse prepare to implement? Select all that apply.

-IV insulin -IV Glucose -Oral polystyrene sulfonate Explanation: Hyperkalemia with EKG changes, such as a peaked T-wave, can be treated temporarily with IV insulin, given with glucose to prevent hypoglycemia, to temporarily shift potassium back into the cells. Calcium may be administered to treat the cardiotoxicity that has developed secondary to hyperkalemia since it directly antagonizes the membrane effects of hyperkalemia. It is important to understand that hyperkalemia is the most common metabolic cause of death in clients with AKI. Additional measures for hyperkalemia may include administering cation exchange resins (either sodium [sodium polystyrene sulfonate] or calcium [calcium polystyrene sulfonate]) orally, via NG tube, or by retention enema. Both gentamicin and cyclosporine are nephrotoxic and have no therapeutic value in this situation.

The nurse is caring for a client with acute kidney injury (AKI) in the oliguric phase. Which is a priority for the nurse to monitor indicating fluid overload? Select all that apply.

-Jugular vein distention -Crackles -Hypertension Explanation: Clients in the oliguric phase of AKI should be monitored for fluid volume overload symptoms since there is less urine output. These symptoms of fluid overload include: jugular vein distention, crackles, edema, weight gain (not loss), and hypertension. If this occurs, renal replacement therapy (RRT), such as dialysis, may be needed until kidney function returns. Tenting skin turgor would indicate possible dehydration, not fluid overload.

A client has acute kidney injury (AKI) with a negative nitrogen balance. How much weight does the nurse expect the client to lose?

0.5 kg/day Explanation: AKI causes severe nutritional imbalances (because nausea and vomiting contribute to inadequate dietary intake), impaired glucose use and protein synthesis, and increased tissue catabolism. The client is weighed daily and loses 0.2 to 0.5 kg (0.5 to 1 lb) daily if the nitrogen balance is negative (i.e., caloric intake falls below caloric requirements).

The nurse notes that a client 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 Explanation: The most accurate indicator of fluid loss or gain in an acutely ill client 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.

The nurse weighs a client daily and measures urinary output every hour. The nurse notices a weight gain of 1.5 kg in a 74-kg client over 48 hours. The nurse is aware that this weight gain is equivalent to the retention of:

1,500 mL of fluid Explanation A 1-kg weight gain is equal to 1,000 mL of retained fluid.

At the end of five peritoneal exchanges, a client's fluid loss was 500 mL. How much is this loss equal to?

1.0 lb Explanation: The most accurate indicator of fluid loss or gain in an acutely ill client is weight. An accurate daily weight must be obtained and recorded. A 1-kg (2-lb) weight loss is equal to 1,000 mL.

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?

114 Explanation: 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.

Glomerulonephritis is an inflammatory response in the glomerular capillary membrane, and causes disruption of the renal filtration system. Although diagnostic urinalysis can reveal glomerulonephritis, many clients with glomerulonephritis exhibit:

no symptoms. Explanation: Many clients with glomerulonephritis have no symptoms. Early symptoms may be so slight that the client does not seek medical attention.

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- Explanation: 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 nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the health care provider 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 health care provider 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.

An athlete is thought to have sustained an injury to a kidney. The ER nurse caring for the client reviews the initial orders written by the primary health care provider and notes an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason?

Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential. Explanation: Hematuria is the most common manifestation of renal trauma; its presence after trauma suggests renal injury. Hematuria may not occur, or it may be detectable only on microscopic examination. All urine should be saved and sent to the laboratory for analysis to detect RBCs and to evaluate the course of bleeding. Measuring intake and output is not a function of the laboratory. The laboratory does not save urine to test creatinine clearance at a later time. The laboratory does not monitor the urine for sodium or potassium concentrations.

The nurse cares for a client after extensive abdominal surgery. The client develops an infection that is treated with IV gentamicin. After 4 days of treatment, the client develops oliguria, and laboratory results indicate azotemia. The client is diagnosed with acute tubular necrosis and transferred to the ICU. The client is hemodynamically stable. Which dialysis method would be most appropriate for the client?

Hemodialysis Explanation: The client is hemodynamically stable and hemodialysis would be most appropriate. Hemodialysis is used for clients who are acutely ill and require short-term dialysis for days to weeks until kidney function resumes and for clients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) who require long-term or permanent renal replacement therapy. Peritoneal dialysis (PD) may be the treatment of choice for clients with renal failure who are unable or unwilling to undergo hemodialysis or kidney transplantation. CAVH and CVVH are used for client who are hemodynamically unstable.

A client undergoing a CT scan with contrast has a baseline creatinine level of 3 mg/dL, identifying this client as at a high risk for developing kidney failure. What is the most effective intervention to reduce the risk of developing radiocontrast-induced nephropathy (CIN)?

Hydrating with saline intravenously before the test Explanation: Radiocontrast-induced nephropathy (CIN) is a major cause of hospital-acquired AKI. This is a potentially preventable condition. Baseline levels of creatinine greater than 2 mg/dL identify clients at high risk. Limiting the client's exposure to contrast agents and nephrotoxic medications will reduce the risk of CIN (Murphy & Byrne, 2010; Rank, 2013). Administration of N-acetylcysteine and sodium bicarbonate before and during procedures reduces risk, but prehydration with saline is considered the most effective method to prevent CIN (Murphy & Byrne, 2010; Rank, 2013).

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?

Hyperkalemia Explanation: 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.

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?

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.

Acute dialysis is indicated during which situation?

Impending pulmonary edema Explanation: Acute dialysis is indicated when there is a high and increasing level of serum potassium, fluid overload, or impending pulmonary edema, or increasing acidosis.

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.

Which of the following would the nurse expect to find when reviewing the laboratory test results of a client with renal failure?

Increased serum creatinine level Explanation: In renal failure, laboratory blood tests reveal elevations in BUN, creatinine, potassium, magnesium, and phosphorus. Calcium levels are low. The RBC count, hematocrit, and hemoglobin are decreased.

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. For each intervention, click to specify if the intervention is indicated or contraindicated for this client. -Take blood pressure readings in the left arm. -Auscultate for a bruit over AV fistula every 8 hours -Assess for redness, swelling, and drainage at AV fistula site. -Use AV fistula site to draw blood. -Palpate for a thrill over the AV fistula every 8 hours. -Wrap the AV fistula site in the left arm with a compression dressing.

Indicated: -Auscultate for a bruit over AV fistula every 8 hours -Assess for redness, swelling, and drainage at AV fistula site. -Palpate for a thrill over the AV fistula every 8 hours. Contraindicated: -Take blood pressure readings in the left arm. -Use AV fistula site to draw blood. -Wrap the AV fistula site in the left arm with a compression dressing. Explanation: 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.

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 80 mg IVP Explanation: 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. The client is experiencing fluid overload, thus, a 500-mL bolus of normal saline bolus would be contraindicated. There is no need to complete a chest x-ray. Mannitol is widely used in the management of cerebral edema and increased intracranial pressure from multiple causes.

The nurse is caring for a client in the oliguric phase of acute kidney injury (AKI). What does the nurse know would be the daily urine output?

Less than 400 mL Explanation: 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.

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.

The nurse performs acute intermittent peritoneal dialysis (PD) on a client who is experiencing uremic signs and symptoms. The peritoneal fluid is not draining as expected. What is the best response by the nurse?

Turn the client from side to side. Explanation: If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by turning the client from side to side or raising the head of the bed. The catheter should never be pushed further into the peritoneal cavity. Other measures to promote drainage include checking the patency of the catheter by inspecting for kinks, closed clamps, or an air lock.

Which clinical finding should a nurse look for in a client with chronic renal failure?

Uremia Explanation: 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. Metabolic acidosis results from the inability to excrete hydrogen ions. Anemia results from a lack of erythropoietin. Hypertension (from fluid overload) may or may not be present in chronic renal failure. Hypotension, metabolic alkalosis, and polycythemia aren't present in renal failure.

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 Explanation: 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.

The nurse is administering calcium acetate (PhosLo) to a client 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.

The nurse cares for a client diagnosed with chronic glomerulonephritis. The nurse will observe the client for the development of

anemia Explanation: Anemia, hyperkalemia, metabolic acidosis, and hyperphosphatemia occur during chronic glomerulonephritis.

A client develops acute renal failure (ARF) after receiving IV therapy with a nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 mL, the nurse suspects that the client is at risk for:

cardiac arrhythmia. Explanation: As urine output decreases, the serum potassium level rises; if it rises sufficiently, hyperkalemia may occur, possibly triggering a cardiac arrhythmia. Hyperkalemia doesn't cause paresthesia (sensations of numbness and tingling). Dehydration doesn't occur during this oliguric phase of ARF, although typically it does arise during the diuretic phase. In the client with ARF, pruritus results from increased phosphates and isn't associated with hyperkalemia.

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 is diagnosed with polycystic kidney disease. Which of the following would the nurse most likely assess?

hypertension Explanation: Hypertension is present in approximately 75% of clients with polycystic kidney disease at the time of diagnosis. Pain from retroperitoneal bleeding, lumbar discomfort, and abdominal pain also may be noted based on the size and effects of the cysts. Fever would suggest an infection. Periorbital edema is noted with acute glomerulonephritis.

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.