Chapter 54, Management of Patients with Kidney Disorders, pp. 1567-1614

azotemia

abnormal concentration of nitrogenous waste products in the blood

oliguria

urine output less than 0.5 mL/kg/hr

Diet modifications are part of nutritional therapy for the management of ARF. Select the high-potassium food that should be restricted. 1. Citrus fruits 2. White rice 3. Butter 4. Salad oils

1. Citrus fruits 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.

dialyzer

artificial kidney; contains a semipermeable membrane through which particles of a certain size can pass

end-stage kidney disease (ESKD)

final stage of chronic kidney disease that results in retention of uremic waste products and the need for renal replacement therapies

interstitial nephritis

inflammation within the renal tissue

continuous cyclic peritoneal dialysis (CCPD)

method of peritoneal dialysis in which a peritoneal dialysis machine (cycler) automatically performs exchanges, usually while the patient sleeps

continuous ambulatory peritoneal dialysis (CAPD)

method of peritoneal dialysis whereby a patient manually performs exchanges or cycles throughout the day

continuous renal replacement therapy (CRRT)

method used to replace normal kidney function in patients who are hemodynamically unstable by circulating the patient's blood through a hemofilter and returning it to the patient

hemodialysis

procedure during which a patient's blood is circulated through a dialyzer to remove waste products and excess fluid

peritoneal dialysis

procedure that uses the lining of the patient's peritoneal cavity as the semipermeable membrane for exchange of fluid and solutes

ultrafiltration

process whereby water is removed from the blood by means of a pressure gradient between the patient's blood and the dialysate

effluent

term used to describe the drained fluid from a peritoneal dialysis exchange

dialysate

the electrolyte solution that circulates through the dialyzer in hemodialysis and through the peritoneal membrane in peritoneal dialysis

acute tubular necrosis (ATN)

type of acute kidney injury in which there is damage to the kidney tubules

acute nephritic syndrome

type of kidney disease with glomerular inflammation

nephrotic syndrome

type of kidney disease with increased glomerular permeability and massive proteinuria

arteriovenous graft

type of surgically created vascular access for dialysis by which a piece of biologic, semibiologic, or synthetic graft material connects the patient's artery to a vein

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? 1. Gentamicin 2. Penicillin 3. Tobramycin 4. Neomycin

2. Penicillin The three nephrotoxic drugs are aminoglycerides.

anuria

total urine output less than 50 mL in 24 hours

polyuria

excessive urine production

glomerular filtration rate (GFR)

amount of plasma filtered through the glomeruli per unit of time

nephrosclerosis

hardening of the renal arteries

What is a characteristic of the intrarenal category of acute renal failure? 1. Increased BUN 2. Decreased urine sodium 3. High specific gravity 4. Decreased creatinine

1. 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.

uremia

an excess of urea and other nitrogenous wastes in the blood

glomerulonephritis

inflammation of the glomerular capillaries

peritonitis

inflammation of the peritoneal membrane (lining of the peritoneal cavity)

arteriovenous fistula

type of vascular access for dialysis; created by surgically connecting an artery to a vein

diffusion

movement of solutes (waste products) from an area of higher concentration to an area of lower concentration

Hyperkalemia is a serious side effect of acute renal failure. Identify the electrocardiogram (ECG) tracing that is diagnostic for hyperkalemia. 1. Tall, peaked T waves 2. Multiple spiked P waves 3. Prolonged ST segment 4. Shortened QRS complex

1. 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 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? 1. Acidosis 2. Pericarditis 3. Anemia 4. Hyperkalemia

3. 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.

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? 1. Increase carbohydrates and limit protein intake. 2. Increase fat intake and limit carbohydrates. 3. Increase protein, carbohydrates, and fat intake. 4. Eliminate fat intake and increase protein intake.

1. 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.

Which of the following causes should the nurse suspect in a client is diagnosed with intrarenal failure? 1. Ureteral calculus 2. Hypovolemia 3. Glomerulonephritis 4. Dysrhythmia

3. Glomerulonephritis Intrarenal causes of renal failure include prolonged renal ischemia, nephrotoxic agents, and infectious processes such as acute glomerulonephritis.

The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for? 1. Paralytic ileus caused by manipulation of the colon during surgery 2. Abdominal distention owing to reflex cessation of intestinal peristalsis 3. Hypovolemic shock caused by hemorrhage 4. Pneumonia caused by shallow breathing because of severe incisional pain

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

A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF? 1. Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL 2. Increased pH with decreased hydrogen ions 3. Increased serum levels of potassium, magnesium, and calcium 4. Uric acid analysis 3.5 mg/dL and phenolsulfonphthalein (PSP) excretion 75%

1. 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 1.5 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 client with chronic renal failure complains of intense itching. Which assessment finding would indicate the need for further nursing education? 1. Brief, hot daily showers 2. Uses moisturizing creams 3. Keeps nails trimmed short 4. Pats skin dry after bathing

1. 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.

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? 1. "It is appropriate to warm the dialysate in a microwave." 2. "It is important to use strict aseptic technique." 3. "The infusion clamp should be open during infusion." 4. "The effluent should be allowed to drain by gravity."

1. "It is appropriate to warm the dialysate in a 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 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? 1. Chest x-ray 2. Mannitol 12.5 g IVP 3. Normal saline bolus of 500 mL 4. Lasix 80 mg IVP

4. Lasix 80 mg IVP Diuretic agents are often used to control fluid volume in clients with acute kidney injury (AKI). The client's urine output indicates an inadequate response to the initial dosage of Lasix and the nurse should anticipate administering Lasix 80 mg IVP. Often in this situation, the initial dosage of Lasix is doubled. 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 recognizes which condition as an integumentary manifestation of chronic renal failure? 1. Tremors 2. Seizures 3. Asterixis 4. Gray-bronze skin color

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

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? 1. The kidneys can improve over a period of months. 2. Kidney function will improve with transplant. 3. Once on dialysis, the need will be permanent. 4 Acute renal failure tends to turn to end-stage failure.

1. 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.

Twenty-four hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for: 1. removal of the transplanted kidney. 2. high-dose IV cyclosporine (Sandimmune) therapy. 3. bone marrow transplant. 4. intra-abdominal instillation of methylprednisolone sodium succinate (Solu-Medrol).

1. removal of the transplanted kidney. Hyperacute rejection isn't treatable; the only way to stop this reaction is to remove the transplanted organ or tissue. Although cyclosporine is used to treat acute transplant rejection, it doesn't halt hyperacute rejection. Bone marrow transplant isn't effective against hyperacute rejection of a kidney transplant. Methylprednisolone sodium succinate may be given IV to treat acute organ rejection, but it's ineffective against hyperacute rejection.

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? 1. Encourage oral fluids. 2. Start IV fluids with a normal saline solution bolus followed by a maintenance dose. 3. Start hemodialysis after a temporary access is obtained. 4. Administer furosemide (Lasix) 20 mg IV

2. Start IV fluids with a normal saline solution bolus followed by a maintenance dose. The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment should rehydrate the client, causing his blood pressure to rise, his urine output to increase, and the BUN and creatinine levels to normalize. The client wouldn't be able to tolerate oral fluids because of the nausea, vomiting, and diarrhea. The 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 diagnosed with acute kidney injury (AKI) has a serum potassium level of 6.5 mEq/L. The nurse anticipates administering: 1. IV dextrose 50% 2. sodium polystyrene sulfonate (Kayexalate) 3. Sorbitol 4. Calcium supplements

2. 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. Sorbitol may be administered in combination with Kayexalate to induce a diarrhea-type effect (it induces water loss in the GI tract). If the client is hemodynamically unstable (low blood pressure, changes in mental status, dysrhythmia), IV dextrose 50%, insulin, and calcium replacement may be administered to shift potassium back into the cells.

A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which disorder? 1. Chronic renal failure 2. Acute renal failure 3. Acute glomerulonephritis 4. Nephrotic syndrome

3. 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.

Following a nephrectomy, which assessment finding is most important in determining nursing care for the client? 1. Pain of 3 out of 10, 1 hour after analgesic administration 2. Blood tinged drainage in Jackson-Pratt drainage tube 3. SpO2 at 90% with fine crackles in the lung bases 4. Urine output of 35 to 40 mL/hour

3. SpO2 at 90% with fine crackles in the lung bases The Risk for Ineffective Breathing Pattern is often a challenge in caring for clients postnephrectomy due to location of incision. Nursing interventions should be directed to improve and maintain SpO2 levels at 90% or greater and keep lungs clear of adventitious sounds. Intake and output is monitored to maintain a urine output of greater than 30 mL/hour. 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.

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: 1. fever. 2. polyuria. 3. no symptoms. 4. headache.

3. 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 notes that a patient who is retaining fluid had a 1-kg weight gain. The nurse knows that this is equivalent to about how many mL? 1. 750 mL 2. 250 mL 3. 500 mL 4. 1,000 mL

4. 1,000 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.

When preparing a client for hemodialysis, which of the following would be most important for the nurse to do? 1. Warm the solution to body temperature. 2. Add the prescribed drug to the dialysate. 3. Inspect the catheter insertion site for infection. 4. Check for thrill or bruit over the access site.

4. Check for thrill or bruit over the access site. When preparing a client for hemodialysis, the nurse would need to check for a thrill or bruit over the vascular access site to ensure patency. Inspecting the catheter insertion site for infection, adding the prescribed drug to the dialysate, and warming the solution to body temperature would be necessary when preparing a client for peritoneal dialysis.

A nurse receives her client care assignment. Following the report, she should give priority assessment to the client: 1. who has a sodium level of 135 mEq/L and a potassium level of 3.7 mEq/L 7 days after a kidney transplant. 2. who is experiencing mild pain from urolithiasis. 3. with pinkish mucus discharge in the appliance bag 2 days after an ileal conduit. 4. 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.

4. 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.

nephrotoxic

any substance, medication, or action that destroys kidney tissue

exchange

denotes a complete cycle including fill, dwell, and drain phases of peritoneal dialysis

chronic kidney disease

kidney damage or a decrease in the glomerular filtration rate lasting for 3 or more months

osmosis

procedure that uses the lining of the patient's peritoneal cavity as the semipermeable membrane for exchange of fluid and solutes

urinary casts

proteins secreted by damaged kidney tubules

acute kidney injury (AKI)

rapid loss of renal function due to damage to the kidneys; formerly called acute kidney injury