Chapter 54: Management of Patients With Kidney Disorders

A client is diagnosed with polycystic kidney disease and requires teaching on the management of the disorder. Which statement made by the client indicates a need for further teaching?

"AS long as I have one normal kidney, I should be fine" Polycystic kidney disease is characterized by the formation of multiple cysts on both kidneys. Polycystic kidney disease is inherited as an autosomal dominant trait. The fluid-filled cysts can cause great enlargement of the kidneys and interfere with kidney function, which can eventually lead to renal failure.

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 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 client is experiencing a decreasing glomerular filtration. What laboratory values should the nurse expect to follow the change? Select all that apply.

Serum creatinine increases Blood urea nitrogen (BUN) increases Creatinine clearance decreases As glomerular filtration decreases, the serum creatinine and BUN levels increase; the creatinine clearance decreases. Potassium and phosphate levels should not be affected by decreased glomerular filtration.

Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem?

White blood cell (WBC) count of 20,000/mm3 An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. 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.

A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which disorder?

acute glomerulonephritis 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, medications, 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) The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.

A patient with chronic kidney failure experiences decreased levels of erythropoietin. What serious complication related to those levels should the nurse assess for when caring for this client?

anemia Anemia develops as a result of inadequate erythropoietin production, the shortened lifespan of RBCs, nutritional deficiencies, and the patient's tendency to bleed, particularly from the GI tract. Erythropoietin, a substance normally produced by the kidneys, stimulates bone marrow to produce RBCs (Murphy, Bennett, & Jenkins, 2010). In ESKD, erythropoietin production decreases and profound anemia results, producing fatigue, angina, and shortness of breath.

The client with chronic renal failure complains of intense itching. Which assessment finding would indicate the need for further nursing education?

brief hot daily showers Hot water removes more oils from the skin and can increase dryness and itching. Tepid water temperature is preferred in the management of pruritus. The use of moisturizing lotions and creams that do not contain perfumes can be helpful. Avoid scratching and keeping nails trimmed short is indicated in the management of pruritus.

A patient admitted with electrolyte imbalance has carpopedal spasm, ECG changes, and a positive Chvostek sign. What deficit does the nurse suspect the patient has?

calcium Calcium deficit is associated with abdominal and muscle cramps, stridor, carpopedal spasm, hyperactive reflexes, tetany, positive Chvostek's or Trousseau's sign, tingling of fingers and around mouth, and ECG changes.

Hyperkalemia is a serious side effect of acute renal failure. Identify the electrocardiogram (ECG) tracing that is diagnostic for hyperkalemia.

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

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 and mask when performing exchanges The nurse should advise the client to wear a mask while performing exchanges. This prevents contamination of the dialysis catheter and tubing, and is usually advised to clients with upper respiratory infection. 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.

A change that occurs during chronic glomerulonephritis is termed

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

When caring for the patient with acute glomerulonephritis, which of the following assessment findings should the nurse anticipate?

tea-colored urine Tea-colored urine is a typical symptom of glomerulonephritis. Flank pain on the affected side, not left upper quadrant pain, would be present. Pyuria is a symptom of pyelonephritis, not glomerulonephritis. Blood pressure typically elevates in glomerulonephritis.

A client with newly diagnosed renal cancer is questioning why detection was delayed. Which is the best response by the nurse?

"Very few symptoms are associated with renal cancer" Renal cancers rarely cause symptoms in the early stage. Tumors can become quite large before causing symptoms. Painless, gross hematuria is often the first symptom in renal cancer and does not present until later stages of the disease. 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.

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" 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.

The client with polycystic kidney disease asks the nurse, "Will my kidneys ever function normally again?" The best response by the nurse is:

"As the disease progresses, you will most likely require renal replacement therapy" There is *no cure for polycystic kidney disease*. Medical management includes therapies to control blood pressure, urinary tract infections, and pain. Renal replacement therapy is indicated as the kidneys fail.

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" 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.

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 the microwave" 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.

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

0.5 kg/day 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 patient 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 patient who is retaining fluid had a 1-kg weight gain. The nurse knows that this is equivalent to about how many mL?

1000 ml The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded. *A 1-kg weight gain is equal to 1,000 mL of retained fluid.*

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

1500 ml of fluid A 1-kg weight gain is equal to 1,000 mL of retained fluid.

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

4000 A 1-kg weight gain is equal to 1,000 mL of retained fluid. 4 kg × 1,000 = 4,000. The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded.

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

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

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 The normal BUN level ranges *8 to 23 mg/dl*; the normal serum creatinine level ranges from *0.7 to 1.5mg/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. 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 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 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.

The nurse helps a client to correctly perform peritoneal dialysis at home. The nurse must educate the client about the procedure. Which educational information should the nurse provide to the client?

Keep the dialysis tubing in a clean area away from children and pets It is important to keep the dialysis supplies in a clean area, away from children and pets, because the supplies may be dangerous for them. 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 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 IVPB 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.

Following a nephrectomy, which assessment finding is most important in determining nursing care for the client?

Spo2 90% with fine crackles at the lung bases The Risk for Ineffective Breathing Pattern is often a challenge in caring for clients postnephrectomy due to location of incision. Nursing interventions should be directed to improve and maintain SpO2 levels at 90% or greater and keep lungs clear of adventitious sounds. Intake and output is monitored to maintain a urine output of greater than 30 mL/hour. 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 a decreased secretion of erythropoietin from the kidneys due to end-stage kidney disease. What outcome will the decrease in erythropoietin have?

anemia from the decrease in maturation of red blood cells The kidneys secrete erythropoietin, which is a substance that promotes the maturation of red blood cells.

The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for?

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

A patient has stage 3 chronic kidney failure. What would the nurse expect the patient's glomerular filtration rate (GFR) to be?

a GRF of 30-59 ml/min/1.73 m2 Stage 3 of chronic kidney disease is defined as having a GFR of 30-59 mL/min/1.73 m2

renal

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

A client 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 site for bruit and thrill 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 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 requires hemodialysis. Which type of drug should be withheld before this procedure?

cardiac glycosides Cardiac glycosides such as digoxin (Lanoxin) should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digoxin toxicity. 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 client is admitted to the hospital with a diagnosis of acute glomerulonephritis. Which clinical manifestation would the nurse expect to find?

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

A client who suffered hypovolemic shock during a cardiac incident has developed acute renal failure. Which is the best nursing rationale for this complication?

decrease in blood flow to the kidneys Acute renal failure can be caused by poor perfusion and/or decrease in circulating volume results from hypovolemic shock. Obstruction of urine flow from the kidneys through blood clot formation and structural damage can result in postrenal disorders but not indicated in this client.

The nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure?

dehydration The diuretic phase of acute renal failure is characterized by increased urine output, hypotension, and dehydration.

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

dehydration 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 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 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 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.

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 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.

Which nursing assessment finding indicates that the client who has undergone renal transplant has not met expected outcomes?

fever Fever is an indicator of infection or transplant rejection.

Which of the following is the priority nursing diagnosis for the client in the oliguric phase of acute renal failure?

fluid volume excess 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 Intrarenal causes of renal failure include prolonged renal ischemia, nephrotoxic agents, and infectious processes such as acute glomerulonephritis.

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 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.

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?

hold the medications until afterdialysis Antihypertensive therapy, often part of the regimen of clients on dialysis, is one example when communication, education, and evaluation can make a difference in client outcomes. The client must know when—and when not—to take the medication. For example, if an antihypertensive agent is taken on a dialysis day, hypotension may occur during dialysis, causing dangerously low blood pressure. Many medications that are taken once daily can be held until after dialysis treatment.

Rejection of a transplanted kidney within 24 hours after transplant is termed

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

A client in chronic renal failure becomes confused and complains of abdominal cramping, racing heart rate, and numbness of the extremities. The nurse relates these symptoms to which of the following lab values?

hyperkalemia Hyperkalemia is the life-threatening effect of renal failure. The client can become apathetic; confused; and have abdominal cramping, dysrhythmias, nausea, muscle weakness, and numbness of the extremities. 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 renal failure complains of generalized bone pain and tenderness. Which assessment finding would alert the nurse to an increased potential for the development of spontaneous bone fractures?

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

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

hypertension 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.

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 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.

What is a characteristic of the intrarenal category of acute kidney injury (AKI)?

increased BUN The intrarenal category of acute kidney injury (AKI) encompasses an increased BUN, increased creatinine, a low-normal specific gravity of urine, and increased urine sodium. Intrarenal AKI is the result of actual parenchymal damage to the glomeruli or kidney tubules. 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.

What is a characteristic of the intrarenal category of acute renal failure?

increased BUN The intrarenal category of acute renal failure encompasses an increased BUN, increased creatinine, a low specific gravity of urine, and increased urine sodium.

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

less than 400 ml The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The minimum amount of urine needed to rid the body of normal metabolic waste products is 400 mL. In this phase, uremic symptoms first appear and life-threatening conditions such as hyperkalemia develop.

For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important?

limiting fluid intake 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's renal failure has become chronic. Which signs and symptoms are associated with chronic renal failure? Select all that apply.

muscle cramps lethargy bleeding of the mucous membranes Lethargy, muscle cramps, and bleeding of the oral mucous membranes are some of the signs and symptoms of chronic renal failure. With chronic renal failure, mental processes progressively slow as electrolyte imbalances become marked and nitrogenous wastes accumulate.

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 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 a right-arm arteriovenous fistula (AVF) for hemodialysis treatments. Which nursing action is contraindicated?

obtaining a blood pressure reading from the right arm 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.

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

oliguria 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.

The nurse cares for a client with end-stage kidney disease (ESKD). Which acid-base imbalance is associated with this disorder?

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

Which of the following occurs late in chronic glomerulonephritis?

peripheral neuropathy Peripheral neuropathy with diminished deep tendon reflexes and neurosensory changes occur late in the disease. The patient becomes confused and demonstrates a limited attention span. An additional late finding includes evidence of pericarditis with or without a pericardial friction rub. The first indication of disease may be a sudden, severe nosebleed, a stroke, or a seizure.

What is a hallmark of the diagnosis of nephrotic syndrome?

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

A client has been diagnosed with acute glomerulonephritis. This condition causes:

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

A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant?

recent history of streptococcal infection Glomerulonephritis can occur as a result of infections from group A beta-hemolytic streptococcal infections, bacterial endocarditis, or viral infections such as hepatitis B or C or human immunodeficiency virus (HIV). A 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 patient has been diagnosed with postrenal failure. The nurse reviews the patient's electronic health record and notes a possible cause. Which of the following is the possible cause?

renal calculi Postrenal ARF is the result of an obstruction that develops anywhere from the collecting ducts of the kidney to the urethra. This results from ureteral blockage, such as from bilateral *renal calculi or benign prostatic hypertrophy (BPH)*.

One of the roles of the nurse in caring for clients with chronic renal failure is to help them learn to minimize and manage potential complications. This would include:

restricting sources of potassium usually found in fresh fruits and vegetables Restrict sources of potassium usually found in fresh fruits and vegetables; hyperkalemia can cause life-threatening changes. Restrict sodium intake as ordered; doing so prevents excess sodium and fluid accumulation. Prescribed iron and folic acid supplements or Epogen should be taken. Iron and folic acid supplements are needed for RBC production. Epogen stimulates bone marrow to produce RBCs. Restrict protein intake to foods that are complete proteins within prescribed limits. Complete proteins provide positive nitrogen balance for healing and growth.

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?

risk for infection The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection.

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

septic shock Prerenal causes of acute renal failure include *hypovolemic shock, cardiogenic shock secondary to congestive heart failure, septic shock, anaphylaxis, dehydration, renal artery thrombosis or stenosis, cardiac arrest, and lethal dysrhythmias*. Ureteral stricture and prostatic hypertrophy would be classified as postrenal causes. Polycystic disease is classified as an intrarenal cause of acute renal failure.

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

sodium polystyrene sulfonate The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.

A 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 fluid with NS solution bolus followed by maintenance doses 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.

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 the transplant site 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 renal failure. Which statement from the nurse best reflects the ability of the kidneys to recover from acute renal failure?

the kidneys can improve over a period of months The kidneys have a remarkable ability to recover from serious insult. Recovery may take 3 to 12 months. As long as recovery is continuing, there is no need to consider transplant or permanent hemodialysis. Acute renal failure can progress to chronic renal failure.

A patient is placed on hemodialysis for the first time. The patient complains of a headache with nausea and begins to vomit, and the nurse observes a decreased level of consciousness. What does the nurse determine has happened?

the patient is experiencing a cerebral fluid shift Dialysis disequilibrium results from cerebral fluid shifts. Signs and symptoms include headache, nausea and vomiting, restlessness, decreased level of consciousness, and seizures. It is rare and more likely to occur in AKI or when BUN levels are very high (exceeding 150 mg/dL).

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 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 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.

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 250 ml/24 hours 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.

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

use aseptic technique during the procedure 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.

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

weight The most accurate indicator of fluid loss or gain in an acutely ill patient 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 with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, the nurse knows that the client is most likely to experience:

weight loss Because CRF causes loss of renal function, the client with this disorder retains fluid. Hemodialysis removes this fluid, causing weight loss. Hematuria is unlikely to follow hemodialysis because the client with CRF usually forms little or no urine. Hemodialysis doesn't increase urine output because it doesn't correct the loss of kidney function, which severely decreases urine production in this disorder. By removing fluids, hemodialysis decreases rather than increases the blood pressure.

A nurse receives her client care assignment. Following the report, she should give priority assessment to the client:

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. 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.

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 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.