Chronic Kidney Disease HESI Case Study

21. What is the maximum amount of weight that Judy should gain between each dialysis treatment? a. 1.5 kg. b. 2 kg. c. 2.5 kg. d. 3 kg.

"1.5 kg." The goal for hemodialysis clients is to keep their interdialytic (between dialysis treatments) weight gain under 1.5 kg.

16. Judy is at increased risk for the development of which problem if she chooses peritoneal dialysis as a course of treatment? a. Abdominal infection. b. Osteoarthritis. c. Hepatitis B and C. d. Hypertension.

"Abdominal infection." Peritoneal dialysis places the client at high risk for peritonitis since the catheter and fluid enter the peritoneal cavity. The client must be heparinized during hemodialysis. Therefore, bleeding is a more likely potential complication than thrombosis.

7. Which explanation best describes the pathology resulting in her hypertension? a. Irritation of the pericardial lining of the heart due to uremic toxins increases blood pressure. b. An increase in the excretion of sodium and water from the kidneys causes hypertension. c. Activation of the renin-angiotensin cycle and excretion of aldosterone causes hypertension. d. The increase of uremic waste products in the blood stream increases the blood pressure.

"Activation of the renin-angiotensin cycle and excretion of aldosterone causes hypertension." The renin-angiotensin cycle causes vasoconstriction of the periphery which increases the blood pressure. In addition, the excretion of aldosterone causes the retention of sodium and water, further increasing the fluid volume which increases the blood pressure.

27. Which action should the nurse implement first? a. Change the surgical dressing. b. Administer an analgesic. c. Convert the IV to a saline lock. d.Remove the indwelling catheter.

"Administer an analgesic." This intervention will reduce the client's pain and anxiety. It will also reduce discomfort when other procedures such as a dressing change are performed.

30. Which instructions should the nurse give Judy? a. Take her prescribed diuretic and analgesic and record when she voids. b. Increase her fluid intake and report any increase in her weight. c. Monitor her temperature and report a fever over 101° F (38.3° C). d. Advise her to come to the clinic right away for further evaluation.

"Advise her to come to the clinic right away for further evaluation." Judy is exhibiting symptoms consistent with organ rejection. She needs immediate assessment and evaluation for this potentially fatal complication. The nurse should assess for kidney pain, oliguria or anuria, hypertension, lethargy, fever, and fluid retention, as well as increased serum BUN, creatinine, and potassium.

13. What intervention should the nurse implement? a. Administer the prescribed tablet. b. Request a faxed copy of the prescription. c. Obtain the name of the office nurse. d. Ask to speak directly with the HCP.

"Ask to speak directly with the HCP." The medication prescription is unsafe and requires direct communication with the prescribing HCP.

9. Which assessment should the nurse perform to determine if the desired outcome of the captopril (Capoten) has been achieved? a. Apical pulse. b. Blood pressure. c. Intake and output. d. Fingerstick glucose.

"Blood pressure." Captopril (Capoten) is an ACE inhibitor used as an antihypertensive agent.

20. Which expected outcome should be included in the nurse's teaching plan? a. Client will adhere to a low-protein diet. b. Client will select foods high in iron and calcium from a menu. c. Client will identify the need to avoid fresh fruits and vegetables. d. Client will identify the need to increase her sodium and fluid intake.

"Client will select foods high in iron and calcium from a menu." Clients with CKD frequently suffer from anemia and hypocalcemia, requiring dietary supplementation with iron and calcium.

10. Which assessment data indicates to the nurse that the desired outcome of the epoetin alfa (Epogen) has been achieved? a. Conjunctival sac returns to a reddish-pink color. b. Consumed 100% of diet. c. No evidence of edema. d. Normo-active bowel sounds.

"Conjunctival sac returns to a reddish-pink color." This assessment finding reflects an improvement in the client's anemia. Epogen stimulates the production of RBCs, resulting in an increase in hematocrit. It is used to treat the anemia common in clients with CKD.

29. What is the best initial response by the nurse? a. "Going home often causes anxiety, which can increase your pain." b. "You may have developed a tolerance to your pain medication." c. "Describe the location and type of pain you are having." d. "The HCP will need to call you back later if you need more pain medication."

"Describe the location and type of pain you are having." The nurse must always assess first as complete data is needed to determine the nature of the problem and then to intervene appropriately.

11. Based on these diagnoses, which nursing intervention should be included in Judy's plan of care? a. Avoid any subcutaneous and intramuscular injections. b. Encourage Judy to ask questions and discuss fears about diagnosis. c. Offer frequent high-protein snacks. d. Encourage oral fluid intake.

"Encourage Judy to ask questions and discuss fears about diagnosis." An open atmosphere that allows for discussion can decrease anxiety. Facilitate discussions with family members about the prognosis and the impact on lifestyle.

4. Judy's hemoglobin level is 7.8. Which underlying pathology does the nurse recognize as the cause of this abnormal lab value? a. Hematuria results in blood loss. b. Fewer red blood cells are being formed. c. Dehydration causes dilutional anemia. d. Renal waste products destroy red blood cells.

"Fewer red blood cells are being formed." Hemoglobin is decreased as the kidneys become less able to produce erythropoietin necessary for the formation of red blood cells.

12. Which intervention is most important for the nurse to implement? a. Ask the pharmacist to supply a tablet rather than an elixir since Judy is on fluid restriction. b. Hold the dose of Kay Ciel and contact the HCP to report the serum potassium level. c. Administer the dose of Kay Ciel and document the serum potassium level in the medical record. d. Calculate the milliliters of medication needed and record the amount on the fluid intake record.

"Hold the dose of Kay Ciel and contact the HCP to report the serum potassium level." The serum potassium level is elevated, and administering additional potassium in any form is potentially dangerous to the client.

2. What additional information in Judy's history may be related to the onset of ESRD? Select all that apply. a. Female gender. b. Hypertension. c. Hysterectomy at age 35. d. Polycystic Kidney Disease. e. African American ethnicity.

"Hypertension." Hypertension is one of the primary causes of CKD. The vast majority of clients with CKD have hypertension, which may be either the cause or the result of CKD. "Polycystic Kidney Disease." PKD gene mutation will develop kidney cysts by age 30. Half of these people develop chronic kidney disease (CKD) by age 50 years. "African American ethnicity." African-American clients are more likely to develop ESKD and to have hypertensive ESKD.

26. Which interventions are important to include in Judy's plan of care while she is receiving multiple immunosuppressants? Select all that apply a. Restrict Judy's activity to bedrest with use of the bedside commode. b. Instruct visitors that fresh flowers should not be taken into the room. c. Change the IV site daily. d. Reinforce, but do not routinely change any dressings. e. Educate Judy to avoid consumption of grapefruit or grapefruit juice.

"Instruct visitors that fresh flowers should not be taken into the room." Fresh flowers, plants, and fruits are a source of bacteria and should be restricted from the client's room. In addition, visitors should be restricted to healthy adults, and extra precautions should be taken to avoid sharing hospital equipment and to ensure a clean room environment. "Educate Judy to avoid consumption of grapefruit or grapefruit juice." Grapefruit/grapefruit juice potentially increases the blood concentration of cyclosporine.

1. Which explanation by the nurse is an accurate description of CKD? a. Symptoms are reversible with life long medication. b. The condition has a rapid onset with frequent remissions. c. It is a fatal disorder unless renal replacement therapy is received. d. There are frequent exacerbations since half of all nephrons are damaged.

"It is a fatal disorder unless renal replacement therapy is received." CKD is fatal unless some form of renal replacement therapy (dialysis or organ transplantation) is done, whereas acute renal failure has a good prognosis for the return of kidney function if appropriate supportive care is provided during the acute period.

28. Which action can be delegated to the unlicensed assistive personnel (UAP)? a. Change the surgical dressing. b. Administer an analgesic. c. Convert the IV to a saline lock. d. Measure the client's urinary output.

"Measure the client's urinary output."

5. What is the correct interpretation of these ABGs? a. Respiratory acidosis (compensated). b. Respiratory alkalosis (compensated). c. Metabolic acidosis (compensated). d. Metabolic alkalosis (compensated).

"Metabolic acidosis (compensated)." As excessive bicarbonate is excreted, the HCO3 level decreases, causing metabolic acidosis (decreased pH). Compensation occurs when an increased rate and depth of respirations reduce the CO2 levels, returning the pH to low normal.

23. Which intervention should be included in the plan of care during the immediate postoperative period? a. Monitor Judy's urinary output hourly using an urimeter. b. Assess Judy's surgical incision every shift. c. Monitor Judy's nasogastric tube every 4 hours. d. Encourage Judy to use the incentive spirometer daily.

"Monitor Judy's urinary output hourly using an urimeter." A kidney from a living donor related to the client usually begins to function immediately after surgery and may produce large amounts of dilute urine. Therefore, the output should be closely monitored.

15. Which risk factors relate to the use of hemodialysis? Select all that apply a. Ascites. b. Orthostatic hypotension. c. Bowel or bladder perforation. d. Non-compliance because treatments require more time. e. Hemorrhage.

"Orthostatic hypotension." Hypotension can occur in up to 50% of HD treatments. "Hemorrhage." The heparin required during HD increases the risk for excessive bleeding. All invasive procedures must be avoided for 4 to 6 hours after dialysis. Continually monitor the client for hemorrhage during and for at least 1 hour after dialysis.

19. Which intervention should the nurse include in Judy's plan of care? Select all that apply. a. Instruct lab personnel to obtain blood specimens from the dual-lumen catheter. b. Perform sterile dressing changes at the dual-lumen catheter site. c. Empty and record the drainage from the graft tubing regularly. d. Regularly rotate IV insertion sites above and below the graft site. e. Assess Judy's distal pulses and circulation in the arm with the access.

"Perform sterile dressing changes at the dual-lumen catheter site." Central vein insertion sites are major sources of nosocomial infection, and they should be cleaned weekly using a strict aseptic technique. "Assess Judy's distal pulses and circulation in the arm with the access." Ischemia occurs in a few clients with vascular access when the fistula decreases arterial blood flow to areas below the fistula (steal syndrome). Manifestations vary from cold or numb fingers to gangrene. If the collateral circulation is poor, the fistula may need to be surgically tied off and a new one created in another area to preserve extremity circulation.

25. Which nursing diagnosis has the greatest priority when caring for a client receiving immunosuppressive agents? a. Pain. b. Fatigue. c. Diarrhea. d. Risk for infection.

"Risk for infection." Suppression of the normal immune response causes leukopenia that can reduce the client's ability to fight infection, resulting in the potential for life-threatening sepsis.

3. Which lab value is likely to be decreased in a client with chronic kidney disease? a. Serum calcium. b. Serum creatinine and BUN. c. Serum potassium. d. Serum phosphorous.

"Serum calcium." Serum calcium is decreased in CKD in response to an increase in serum phosphorous.

8. Which assessment finding indicates to the nurse that the desired outcome of the calcium acetate (PhosLo) has been achieved? a. Serum glucose of 90 mg/dL. b. Serum phosphorous of 4.0 mg/dL. c. Serum hematocrit of 32%. d. Serum hemoglobin of 12 g/dL.

"Serum phosphorous of 4.0 mg/dL." Calcium acetate (PhosLo) acts as a phosphate binder, reducing the high serum phosphorous levels commonly found in the client with CKD.

17. What is the best description of an AV graft? a. Internal surgical anastomosis between an artery and a vein. b. External loop of synthetic tubing connecting an artery and a vein. c. Synthetic tubing tunneled beneath the skin connecting an artery and a vein. d. Central line tunneled catheter with a barrier cuff.

"Synthetic tubing tunneled beneath the skin connecting an artery and a vein." These grafts can be placed in the arm or inner thigh and can be used within 1 to 2 weeks of surgery.

14. Which statement should serve as the basis for the nurse's reply? a. The professional nurse can be held accountable for the administration of any unsafe medication. b. The nurse's job description in most hospital policy manuals clearly states that adhering to the HCP's prescriptions is required. c. Only the prescribing HCP is legally liable for the administration of a prescribed, but unsafe, medication. d. State nurse practice acts indicate that the professional nurse should only administer legally prescribed medications.

"The professional nurse can be held accountable for the administration of any unsafe medication." The professional nurse can be held legally liable for the administration of an unsafe medication.

31. What is the best response by the nurse? a. "Don't blame the HCPs. They're doing everything possible." b. "Why do you think the HCPs are at fault?" c. "This is a very difficult time for you and your family." d. "Your obvious anger will not help Judy now."

"This is a very difficult time for you and your family." Acknowledgment of the stress being experienced will encourage the brother to continue to express his feelings.

18. Which documentation should the nurse enter into the nurses' notes? a. +4 bounding pulse palpated. b. Bruit intact and palpated. c. Thrill present and palpated. d. Health care provider notified of graft occlusion.

"Thrill present and palpated." This buzzing sensation indicates that the graft is patent. In addition to palpating for a thrill, the nurse should auscultate for a bruit, the sound heard at a patent graft site, as well as for intact pulses distal to the graft site.

22. Which nursing assessment has the highest priority during the first 24-hour postoperative period? a. Vital signs. b. Bowel sounds. c. Range of motion. d. Pedal pulses.

"Vital signs." Vital signs should be monitored frequently to assess for postoperative bleeding, infection, or organ rejection.

6. Which additional assessment finding is consistent with ESRD? Select all that apply. a. Yellow-gray pallor. b. Clay-colored stool. c. Decreased attention span. d. Stridor. e. Tall tented T waves on electrocardiogram.

"Yellow-gray pallor." The client with ESRD often exhibits a yellow-gray pallor as the result of anemia and uremia. In addition, the client with ESRD may exhibit other skin manifestations such as bruising and uremic frost (a very late manifestation). "Decreased attention span." Problems ranging from lethargy to seizures or coma, which may indicate uremic encephalopathy. "Tall tented T waves on electrocardiogram." Potassium excretion occurs mainly through the kidney. Any increase in potassium load during the later stages of CKD can lead to hyperkalemia (high serum potassium levels).

24. The nurse is preparing to give Judy's medications. The cyclosporine (Sandimmune) comes in a vial with 50 mg/mL. Judy weighs 132 lbs (60 kg). How many milliliters of the medication should the nurse draw up? (Enter numeric value only. If rounding is necessary, round to the tenth.)

4.8 mL

Kidney Transplantation

After receiving hemodialysis for about a year, Judy is scheduled to receive a kidney transplant from her older brother. Following surgery, Judy is transferred to the Surgical Intensive Care Unit. She is drowsy but awakens easily. She is able to swallow sips of water. Her incision is clean, dry, and intact.

CKD is a disorder with a complex etiology involving many interrelated factors.

Diabetes mellitus is a known risk factor for renal failure.

Etiology

End-stage renal disease (ESRD) is the last stage in the progressive clinical syndrome called chronic kidney disease (CKD).

Meet the Client

Judy HarrisonJudy Harrison is a 38-year-old African American female with a long history of diabetes mellitus type 2 and hypertension. She has experienced renal insufficiency for the last two years. Her current medications include an angiotensin converting enzyme inhibitor (ACEI), a diuretic, and an oral hypoglycemic agent. She reports to the nurse at the clinic that she has lost her appetite and is very fatigued. She adds that she has to get up to go to the bathroom several times during the night and has trouble catching her breath at times. Her current weight is 114 lbs (51.7 kg). She is scheduled for diagnostic studies to evaluate for the onset of end-stage renal disease (ESRD).

Vascular Access Devices

Judy decides that hemodialysis is the best choice for her. An arteriovenous (AV) graft is surgically placed in her right forearm, and a dual-lumen hemodialysis catheter is placed for temporary use until her permanent AV graft site heals.

Nursing Diagnoses and Interventions

Judy is admitted to an acute care facility for management of her ESRD. The nurse's plan of care includes the following nursing diagnoses: Excess Fluid Volume Potential for pulmonary edema related to fluid overload Decreased Cardiac Output Inadequate nutrition Risk for Infection Risk for Injury Fatigue Anxiety Constipation

Client Teaching: Dietary Management

Judy is tolerating dialysis well, and she is scheduled for discharge. The nurse completes discharge teaching for the goal "Client will manage her diet effectively while receiving hemodialysis 3 times a week."

Pharmacologic Management

Judy receives prescriptions for the following medications: - Calcium acetate (PhosLo) 2 gelcaps (667 mg each) PO with each meal - Ferrous sulfate (Feosol) 1 tablet PO (65 mg) daily - Epoetin alfa (Epogen) 3900 units subcutaneously 3 times per week (dosed at 75 U/kg three times a week) - Glipizide (Glucotrol) 10 mg PO daily - take 30 minutes before breakfast - Furosemide (Lasix) 40 mg PO twice daily - Captopril (Capoten) 25 mg PO twice daily - Potassium chloride (Kay Ciel) elixir 40 mEq PO three times daily.

Therapeutic Communication: Grief Response

Judy returns to the clinic, where her vital signs are: T 100.6° F (38.7° C), P 88, R 24, BP 178/96. A renal scan is performed, and it is determined that Judy is experiencing acute organ rejection. Three types of rejection can occur after transplant: hyperacute, acute, and chronic. Hyperacute rejection occurs within the first 48 hours after transplantation and requires immediate removal of the transplanted kidney. Acute rejection occurs up to 2 years after surgery, most commonly within the first 2 weeks. It can often be managed effectively with increased doses of immunosuppressive medications. Chronic rejection is a gradual process, occurring over a period of months to years. Conservative management, including a careful balance of fluid and protein intake helps control the rejection, but the eventual outcome is the need for dialysis. Judy is started on a regimen of high-dose immunosuppressants. During the acute rejection period, Judy's brother states to the nurse, "She can't be having a rejection; I gave up my kidney for her. The doctors must have messed up something. I'll sue every one of them if this doesn't work."

Case Outcome

Judy's brother is able to share his frustration and anger with other family members. He physically vents his anger by tearing down an old fence. In the meantime, the medical regimen of immunosuppressants is successful in reversing the organ rejection, and Judy is discharged home with the support of her family and the home care nursing agency.

Clinical Manifestations

Judy's diagnostic tests confirm the medical diagnosis of end-stage renal disease. In addition to Judy's report of fatigue, anorexia, dyspnea, and nocturia, the nurse's assessment findings include: +1 pedal edema, basilar crackles in both lungs, and clear, pale urine. Judy's vital signs: T 98.8° F (37.1° C), P 86, R 28, and BP 178/92.

Immunosuppressive Agents

Judy's postoperative medications include immunosuppressive agents, which are used to reduce the risk of organ rejection. Azathioprine (Imuran) 3 mg/kg IV daily. Cyclosporine (Sandimmune) 4 mg/kg IV daily. Solu-Medrol 60 mg IV every 6 hours.

Hemodialysis

Judy's urinary output continues to diminish, and her lab values indicate worsening kidney function. The HCP and nurse discuss types of dialysis with Judy. She must consider the benefits and risks of both peritoneal dialysis and hemodialysis.

Ethical/Legal Considerations:

Medication Administration The nurse notes that the prescribed medications include potassium chloride (Kay Ciel) elixir 40 mEq PO 3 times a day. Prior to administering the medication, the nurse monitors Judy's serum potassium level, which is 6.5 mmol/L.

A Complication Occurs

One week after surgery, Judy is discharged home. Three days later, she calls the nurse to report that she is experiencing more pain than she thinks she should be having.

Diagnostic evaluation.

The following diagnostic tests were performed: Hemoglobin Serum creatinine and BUN Serum calcium Arterial blood gases Serum potassium Serum phosphorus Urinary creatinine clearance

Management Issues: Priorities and Delegation

When Judy is transferred from the Surgical Intensive Care Unit (SICU) back to the Surgical Nursing Care Unit, the nurse receives report on her condition. The report includes information that Judy's IV needs to be converted to a saline lock and that her urinary catheter needs to be removed. During the nursing assessment, Judy reports that she is experiencing incisional pain from all the activity and that the tape on her surgical dressing became loose during the transfer.

Judy's arterial blood gas (ABG) results are:

pH 7.35 PO2 96.00 mmHg PCO 2 30.00 mmHg HCO 3 18.00 mEq/L.