Lippincott Renal Davis Renal

2 (fluid return with peritoneal dialysis is accomplished by gravity flow. Actions that enhance gravity flow include turning the client from side to side, raising the HOB, and gently massaging the abdomen. The client is usually confined to a recumbent position during the dialysis. The nurse should not attempt to reposition the cath.)

During peritoneal dialysis, the nurse observes that the flow of dialysate stops before all the solution drained out. The nurse should: 1. have the client sit in a chair 2. turn the client from side to side 3. reposition the peritoneal cath 4. have the client walk

1,2,4,5 (Broad spectrum antibiotics may be administered to prevent infection when a peritoneal cath is inserted for peritoneal dialysis. If peritonitis is present, antibiotics may be added to the dialysate. Aseptic technique is imperative. Peritonitis, the most common and serious complication is characterized by cloudy dialysate drainage, diffuse abdominal pain and rebound tenderness.)

The client performs self peritoneal dialysis. What should the nurse teach the client about preventing peritonitis? SATA 1. Broad spectrum antibiotics may be administered to prevent infection 2. Antibiotics may be added to the dialysate to treat peritonitis 3. Clean technique is permissible for prevention of peritonitis 4. Peritonitis is characterized by cloudy dialysate drainage and abdominal discomfort 5. Peritonitis is the most common and serious complication of peritoneal dialysis

4 (Medications such as NSAIDS and some herbal remedies are nephrotoxic; and some herbal remedies are nephrotoxic, therefore asking about meds is appropriate. )

The nurse is admitting a client dx with ARF. Which question is most important for the nurse to ask during the admission interview? 1. Have you recently traveled outside the US? 2. Did you recently begin a rigorous exercise program? 3. IS there a chance you have been exposed to a virus? 4. What OTC meds do you take regulary?

3 (renal failure causes an imbalance of electrolytes, K, Na, Ca, Ph, therefore the desired client outcome is electrolytes wnl. WRONG: #1 this is an intervention, #2 this is a measurable client outcome, but ARF typically does not cause pain, #4 A Kayexalate resin enema may be administered to help decrease K levels, but this is an intervention, not an outcome)

The nurse is developing a plan of care for a client dx with ARF. Which statement is an appropriate outcome for the client? 1. Monitor I&O every shift 2. Decrease the pain by 3 levels on a 1-10 scale 3. Electrolytes are wnl 4. Admin enemas to decrease hyperkalemia

4 (S/s of an external access shunt infection include redness, tenderness, swelling and drainage from around the shunt site. The absence of a bruit would indicate closing of the shunt. Sluggish cap refill and coolness of the extremity would indicate decrease blood flow to the extremity)

The nurse teaches the client how to recognize infection in the shunt by telling the client to assess the shunt each day for: 1. absence of a bruit 2. sluggish cap refill time 3. coolness of the involved extremity 4. swelling of the shunt site

2 (weight loss is expected because of the removal of fluid. The clients weight before and after dialysis is one measure of the effectiveness of treatment. BP usually decreases because of the removal of fluid. Hematuria would not occur after completion of peritoneal dialysis. Dialysis only minimally affects the damaged kidneys ability to manufacture urine)

After completion of peritoneal dialysis, the nurse should assess the client for: 1. hematuria 2. weight loss 3. hypertension 4. increased urine output

c,e,f (The answers are: C, E, and F. These patients are at risk for an intra-renal injury, which is where there is damage to the nephrons of kidney. The patients in options A and B are at risk for POST-RENAL injury because there is an obstruction that can cause back flow of urine into the kidney, which can lead to decreased function of the kidney. The patient in option D is at risk for PRE-RENAL injury because there is an issue with perfusion to the kidney.)

Select all the patients below that are at risk for acute intra-renal injury? A. A 45 year old male with a renal calculus. B. A 65 year old male with benign prostatic hyperplasia. C. A 25 year old female receiving chemotherapy. D. A 36 year old female with renal artery stenosis. E. A 6 year old male with acute glomerulonephritis. F. An 87 year old male who is taking an aminoglycoside medication for an infection.

a (Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate.)

Nurse Tristan is caring for a male client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: A hyperkalemia. B hypercalcemia. C hypernatremia. D hypokalemia

c (In renal failure, patients become hyperkalemic because they can't excrete potassium in the urine. Polystyrene sulfonate acts to excrete potassium by pulling potassium into the bowels and exchanging it for sodium.)

Polystyrene sulfonate (Kayexalate) is used in renal failure to: a Correct acidosis b Reduce serum phosphate levels c Exchange potassium for sodium d Prevent constipation from sorbitol use

3 (Dialysis has no effect on hemoglobin levels because some RBCs are injured during the procedure, dialysis aggravates a low hgb concentration and may contribute to anemia. Dialysis will clear metabolic waste products from the body and correct electrolyte imbalances such as creatinine, K and Na levels)

Which abnormal blood value would not be improved by dialysis treatment? 1. elevated serum creatinine level 2. hyperkalemia 3. decreased hemoglobin concentration 4. hypernatremia

4 (Constipation may contribute to a reduced urine outflow in part because peristalsis facilitates drainage outflow. For this reason bisacodyl suppositories can be used prophylactically even without a history of constipation, D, V and flatulence typically do not cause decreased outflow in a peritoneal dialysis cath)

A client undergoing long term peritoneal dialysis at home is currently experiencing a reduced outflow from the cath. To determine if the cath is obstructed, the nurse should inquire whether the client has: 1. diarrhea 2. vomiting 3. flatulence 4. constipation

4 (Urea an end product of protein metabolism is excreted by the kidneys, Impairment in renal function caused by reduced renal blood flow results in an increase in the plasma urea level. Fluid retention, hemolysis of RBCs and lowered metabolic rate do not elevate BUN)

A client who is in ARF has an elevated BUN. What is the likely cause of this finding? 1. fluid retention 2, hemolysis of RBCs 3. below normal metabolic rate 4. reduced renal blood flow

c (he answer is C. The patient with AKI, especially in the oliguric stage of AKI, should eat a low-protein, low-potassium, and low-sodium diet. This is because the kidneys are unable to filter out waste products, excessive water, and maintain electrolyte balance. The patient will have a buildup of waste (BUN and creatinine). Remember these waste products are the byproduct of protein (urea) and muscle breakdown (creatinine). So the patient should avoid high-protein foods. In addition, the patient is at risk for hyperkalemia and fluid overload (needs low-potassium and sodium foods).)

A patient with AKI has a urinary output of 350 mL/day. In addition, morning labs showed an increased BUN and creatinine level along with potassium level of 6 mEq/L. What type of diet ordered by the physician is most appropriate for this patient? A. Low-sodium, high-protein, and low-potassium B. High-protein, low-potassium, and low-sodium C. Low-protein, low-potassium, and low-sodium D. High-protein and high-potassium

3 (Dietary restrictions with CAPD are fewer than those with standard peritoneal dialysis because dialysis is constant, not intermittent. The constant slow diffusion of CAPD helps prevent accumulation of toxins and allows for a more liberal diet. CAPD does not work more quickly, but more consistently. Both types of dialysis are effective)

The client asks about diet changes when using continuous ambulatory peritoneal dialysis. Which response by the nurse would be best? 1. Diet restrictions are more rigid with CAPD because standard peritoneal dialysis is a more effective technique 2. Diet restrictions are the same for both CAPD and standard peritoneal dialysis 3. Diet restrictions with CAPD are fewer because dialysis is constant 4. Diet restrictions with CAPD are fewer because CAPD works more quickly

3 (Carbs are increased to provide for the clients caloric intake and protein is restricted to minimize protein breakdown and to prevent accumulation of toxic waste and products. WRONG:#1 the diet is LOW potassium and calcium is not restricted in ARF. #2 This is a diet recommended for clients with cardiac disease and atherosclerosis. #4 The client must be on a therapeutic diet, but small feedings are not required.)

The client dx with ARF is admitted to the ICU and placed on a therapeutic diet. Which diet is most appropriate for this client? 1. A high potassium and low calcium diet 2. A low fat and low cholesterol diet 3. A high carb and restricted protein diet 4. A reg diet with 6 small feedings a day

3 (regular insulin along with glucose, will drive K into the cells, thereby lowering serum K levels temporarily. #1 stimulates RBC production, not affect K, #2 does help protect the heart from the effect of high K. #4 a LOOP diuretic may be ordered to decrease K level)

The client dx with ARF is experiencing hyperkalemia Which medications should the nurse prepare to administer to help decrease the K level? 1. erythropoietin 2. calcium gluconate 3. regular insulin 4. osmotic diuretic

1 (Carrying heavy objects in the LA could cause the fistula to clot by putting undue stress on the site. so the client should carry objects with the R arm. The fistula should ONLY be used for dialysis, do not lie on the affected side, and hand exercise IS recommended for new fistulas to help mature the fistula)

The client dx with CKD has a new arteriovenous fistula in the LFA. Which intervention should the nurse implement? 1. Teach the client to carry heavy objects with the right arm 2. Perform all lab test on L arm 3. Instruct the client to lay on the L arm during the night 4. Discuss the importance of not performing any hand excercises

4 (Because the client is in ESRD fluid MUST be removed from the body, so the output should be MORE than the amount instilled. These assessment data REQUIRE intervention. WRONG: #! peritoneal dialysis administered through a cath inserted into the peritoneal cavity, a fistula would be for hemodialysis. The other answers #2 and #3 are wnl)

The client dx with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse? 1. INability to auscultate a bruit over the fistula 2. The clients abd is soft nontender and has bowel sounds 3. The dialysate being removed from the clients abd is clear 4 The dialysate instilled was 1500 mL and removed was 1500 mL

4 (This is septic shock and not fluid volume shock, but the circ system is still compromised. Increasing the fluid volume will support the clients BP until the IVPB is infused.)

The client dx with UTI has a BP of 83/56 and a pulse of 122. What should the nurse do first? 1. notify the HCP 2. Hang the IVPB antibiotic at prescribed rate 3. Check the lab work to determine if the urine culture is completed 4. Increase the NS IV from keep open rate to 150 mL.hr

1 (The nurse should place the clients chair with the head lower than the body, which will shunt the blood to the brain. this is the Trendelenburg position. WRONG: #2 The blood in the dialysis machine must be infused back into the client before being turned off. #3 NS infusion is a last resort because one of the purposes of dialysis is to remove excess fluid from the body. #4 Hypotension is an expected occurrence in clients receiving dialysis, therefore the HCP need not be notified)

The client receiving dialysis is complaining of being dizzy and light headed. Which action should the nurse implement first? 1. Place the client in Trendelenberg position 2. Turn off the clients dialysis machine immed 3. Bolus the client with 500 mL NS 4. Notify the HCP asap

4 (Polystyrene sulfonate, a cation-exchange resin, causes the body to excrete K through the GI tract. In the intestines, particularly the colon, the Na of the resin partially replaced by K. The K is then eliminated when the resin is eliminated with feces. Although the result is to increase K excretion, the specific method of action is the exchange of Na ions for K ions. Polystyrene sulfonate does not release hydrogen ions or increase Ca absorption)

The clients serum K level is elevated in ARF, and the nurse administers sodium polystyrene sulfonate. The mechanism of action for this drug is to: 1 increase K excretion from the colon 2. release hydrogen ions for sodium ions 3. increase Calcium absorption in th colon 4. exchange sodium for potassium ions in the colon

1 (The main reason for warming the peritoneal dialysis solution is that the warm solution helps dilate peritoneal vessels, which increases urea clearance. Warmed dialyzing solution also contributes to client comfort by preventing a chilly sensation, but this is a secondary reason for warming the solution. The warmed solution does not force the K into cells or promote abd muscle relaxation)

The dialysis solution is warmed before use in peritoneal dialysis primarily to: 1 encourage the removal of serum urea 2. force K back into the cells 3. add extra warmth to the body 4. promote abdominal muscle relaxation

3 (after the initial admin of erythropoietin a clients antihypertensive med may need to be adjusted. Therefore this complaint requires notification of the HCP Erythropoietin therapy is contraindicated in pts with uncontrolled HTN. WRONG#1 flu like symptoms are expected and tend to subside with repeated doses. the nurse should suggest Tylenol prior to the injections. #2 This med takes up to 2-6 weeks to become effective in improving anemia and thereby reducing fatigue. #4 Long bone and vertebral pain is an expected occurrence because the bone marrow is being stimulated to increase production of RBCs)

The male client dx with CKD has received the initial dose of erythropoietin, a biologic response modifier, 1 week ago. Which complaint by the client indicates the need to notify the HCP? 1. The client complains of flu like symptoms 2. The client complains of being tired all the time 3. The client reports an elevation in BP 4. The client reports discomfort in the legs and back

2 (reflect and restate are therapeutic responses the nurse should use)

The male client with CKD is dx with CKD seconary to diabetes and has been receiving dialysis for 12 years. The client is notified he will not be placed on the kidney transplant list. The client tells the nurse he will not be back for anymore dialysis treatments. Which response by the nurse is most appropriate? 1. You cannot just quit your dialysis, This is not an option 2. Your angry at not being on the list and you want to quit dialysis? 3 I will call your nephrologist right now so you can talk to the HCP 4. Make your funeral arrangements because you are going to die

4 (Noncompliance is a choice the client has a right to make. but the nurse should determine the reason for it and then take appropriate action based on the clients rationale. For example the client may have financial difficulty, the nurse may suggest how the client can afford the proper foods along with medications or refer to a social worker. The other options do not address the clients choice of noncompliance)

The nurse caring for a client dx with CKD writes a client problem of "noncompliance with dietary restrictions" Which intervention should be included in the plan of care? 1. Teach the client the proper diet to eat while undergoing dialysis 2. Refer the client and significant other to the dietician 3. Explain the importance of eating proper foods 4. Determine the reason for the client not adhering to the diet

4 (oliguria is the most common initial symptom of ARF. Anuria is rarely the initial symptom. Dysuria and hematuria are not assoc with ARF)

Which initial manifestation of ARF is most common? 1. dysuria 2 anuria 3. hematuria 4. oliguria

b (Treatment includes administering normal saline or hypertonic normal saline solution because muscle cramps can occur when the sodium and water are removed to quickly during dialysis. Reducing the rate of dialysis, not increasing it, may alleviate muscle cramps.)

Your patient is complaining of muscle cramps while undergoing hemodialysis. Which intervention is effective in relieving muscle cramps? a Increase the rate of dialysis b Infuse normal saline solution c Administer a 5% dextrose solution d Encourage active ROM exercises

d (The answer is D. The adrenal glands are responsible for maintaining cortisol production not the kidneys.)

The kidneys are responsible for performing all the following functions EXCEPT? A. Activating Vitamin D B. Secreting Renin C. Secreting Erythropoietin D. Maintaining cortisol production

2 (Hypotension is a possible complication of peritoneal dialysis, the nurse records I&O's. VS. and observes the clients behavior. The nurse also encourages visiting and other diversional activities. A client on dialysis does not need to be kept NPO or have padded side rails)

Which should be included in the clients plan of care during dialysis therapy? 1. Limit the clients visitors 2. Monitor the clients BP 3. Pad the side rails of the bed 4. Keep the client NPO

3 (Dehydration results in concentrated serum, causing lab values to increase because the blood has normal constituents but not enough volume to dilute the values to wnl or lower. WRONG: #4 In renal failure the kidneys cannot excrete urine and this results in TOO MUCH fluid in the body. #1 Clients who are OVERhydrated or have FVE, experience DILUTED values of Na and RBCs. The levels are lower not higher)

The client admitted to a nursing unit from a LTC with a hct of 56% and Na 152. Which condition is a cause for these findings? 1. OVerhydration 2. Anemia 3. dehydration 4. renal failure

a (Tubing problems are a common cause of outflow difficulties, check the tubing for kinks and ensure that all clamps are open. Other measures include having the patient change positions (moving side to side or sitting up), applying gentle pressure over the abdomen, or having a bowel movement.)

You have a patient that is receiving peritoneal dialysis. What should you do when you notice the return fluid is slowly draining? a Check for kinks in the outflow tubing b Raise the drainage bag above the level of the abdomen c Place the patient in a reverse Trendelenburg position d Ask the patient to cough

b (The answer is B. During the diuresis stage of AKI, the patient will be losing an excessive amount of urine (3-6 Liters/day) and is at risk for fluid volume deficient and electrolyte imbalance. The nurse must monitor the patient's electrolyte levels, especially potassium (hypokalemia).)

You're developing a nursing care plan for a patient in the diuresis stage of AKI. What nursing diagnosis would you include in the care plan? A. Excess fluid volume B. Risk for electrolyte imbalance C. Urinary retention D. Acute pain

b

Your 60 y.o. patient with pyelonephritis and possible septicemia has had five UTIs over the past two years. She is fatigued from lack of sleep, has lost weight, and urinates frequently even in the night. Her labs show: sodium, 154 mEq/L; osmolarity 340 mOsm/L; glucose, 127 mg/dl; and potassium, 3.9 mEq/L. Which nursing diagnosis is priority? a Fluid volume deficit related to osmotic diuresis induced by hyponatremia b Fluid volume deficit related to inability to conserve water c Altered nutrition: Less than body requirements related to hypermetabolic state d Altered nutrition: Less than body requirements related to catabolic effects of insulin deficiency

b (Disequilibrium syndrome is caused by a rapid reduction in urea, sodium, and other solutes from the blood. This can lead to cerebral edema and increased intracranial pressure (ICP). Signs and symptoms include headache, nausea, restlessness, vomiting, confusion, twitching, and seizures.)

Your patient becomes restless and tells you she has a headache and feels nauseous during hemodialysis. Which complication do you suspect? a Infection b Disequilibrium syndrome c Air embolus d Acute hemolysis

b

________ failure is caused by Acute damage to renal tissue and nephrons or acute tubular necrosis: abrupt decline in tubular and glomerular function due to either prolonged ischemia and/or exposure to nephrotoxins. (Acute glomerulonephritis, malignant hypertension, ischemia; nephrotoxic drugs or substances; red blood cell destruction; muscle tissue breakdown due to trauma, heatstroke) A Perirenal B Intrarenal C Postrenal D Prerenal

1

The client in ARF has an external cannula inserted in the forearm for hemodialysis. Which nursing measure is appropriate for the care of this client? 1. use the unaffected arm for BP 2,. draw blood work from the cannula for routine labs 3. percuss the cannula for bruits each shift 4. inject heparin into the cannula each shift

1 (Preventing and treating shock with blood and fluid replacement will prevent acute renal failure from hypoperfusion of the kidneys. Significant blood loss is expected to the client with a gunshot wound. The other actions are appropriate but not aimed at preventing ARF)

The client is admitted to the ED after a gunshot wound to the abdomen, Which nursing intervention should the nurse implement first to prevent ARF? 1. Administer NS IV 2. Take VS 3. Place client on telemetry 4. Assess the abdominal dressing

4 (Maintaining the clients BP to greater than 100/60 ensures perfusion of the kidneys. ARF occurs when the kidneys have not been adequately perfused. Vasopressor drips are used to maintain the BP)

The client is in the ICU after a MVA in which the client had 3 units blood. Which action by the nurse could prevent the client from developing ARF? 1. Take and document the VS every hour 2. Assess the clients dressing every 2 hrs 3. Check the clients urinary output every shift 4. Maintain the clients BP greater than 100/60

1 (There are 3 categories of ARF. Prerenal, intrarenal, and postrenal. Cause of prerenal failure occur outside the kidney and include poor perfusion and decreased circulating volume resulting from such factors as trauma, septic shock, impaired cardiac function, and dehydration. In this case of severe MI, there was a decrease in the perfusion of the kidneys caused by impaired cardiac function. An obstruction within the urinary tract, such as from kidney stones, tumors, or BPH is called post renal failure. STructural damage to the kidney resulting from acute tubular necrosis is called intrarenal failure. It is caused by such conditions as hypersensitivity (allergic disorders) renal vessel obstruction and nephrotoxic agents)

A client developed cardiogenic shock after a severe MI and has now developed ARF. The clients family asks the nurse why the client has developed ARF The nurse should base the response on the knowledge that there was: 1 a decrease in the blood flow through the kidneys 2. an obstruction of urine flow from the kidneys 3. a blood clot formed in the kidneys 4. structural damage to the kidney resulting in acute tubular necrosis

2 (during dwell time the dialysis solution is allowed to remain in the peritoneal cavity for the time prescribed by the HCP, usually 20-45 mins) During this time, the nurse should monitor the clients respiratory status because the pressure of the dialysis solution on the diaphragm can creat respiratory distress. The dialysis solution would not cause urticaria or affect the circ to the fingers. The clients lab values are obtained before beginning treatment and are monitored every 4-8 hrs during the treatment not just during the dwell time)

A client is receiving peritoneal dialysis. While the dialysis solution is dwelling in the clients abdomen, the nurse should: 1. assess for urticaria 2. observe respiratory status 3. check capillary refill time 4. monitor the electrolyte status

4 (Solution for peritoneal dialysis should be warmed to body temp in a warmer or with a heating pad. do not use the microwave. Cold dialysate increases discomfort. Assessment for a bruit and thrill is necessary with hemodialysis when the client has a fistula, graft, or shunt An indwelling cath is not required. The nurse should position the client in a supine or low fowlers position.)

A client is to receive peritoneal dialysis to prepare for the procedure, the nurse should: 1. assess the dialysis access for a bruit and thrill 2. Insert an indwelling urinary cath 3. ask the client to turn towards the left side 4. warm the dialysate in the warmer

2 (The clients dialysis access is compromised. and should be assessed first. WRONG: #1 These labs are low but do not require a blood transfusion, and are often expected in ESRD #3 It is not uncommon for a client undergoing dialysis to be exhausted and sleep thru treatment. #4 Clients are instructed not to take the antihypertensive meds before dialysis to prevent episodes of hypotension)

The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first? 1 The client who has a hgb of 9.8 and hct of 30% 2 The client who does not have a palpable thrill or auscultated bruit 3 The client who is complaining of being exhausted and is sleeping 4. The client who did not take antihypertensive medication this morning

b,c,d (The answers are: B, C, and D. This patient is in the DIURESIS stage of AKI. The nephrons are now starting to filter out waste but cannot concentrate the urine. There is now a high amount of urea in the filtrate (because the nephrons can filter the urea out of the blood) and this causes osmotic diuresis. Urinary output will be excessive (3 to 6 L/day). Therefore, the patient is at risk for hypotension, diluted urine (low urine specific gravity), and hypokalemia (waste potassium in the urine). The patient is not at risk for water intoxication and will not have a normal GFR until the recovery stage.)

A 36 year old male patient is diagnosed with acute kidney injury. The patient is voiding 4 L/day of urine. What complication can arise based on the stage of AKI this patient is in? Select all that apply: A. Water intoxication B. Hypotension C. Low urine specific gravity D. Hypokalemia E. Normal GFR

c (The answer is C. Pre-renal injury is due to decreased perfusion to the kidneys secondary to a cause (massive GI bleeding...patient is losing blood volume). This leads to a major decrease in kidney function because the kidneys are deprived of nutrients to function and the amount of blood it can filter. Pre-renal injury can eventually lead to intrarenal damage where the nephrons become damaged.)

A 55 year old male patient is admitted with a massive GI bleed. The patient is at risk for what type of acute kidney injury? A. Post-renal B. Intra-renal C. Pre-renal D. Intrinsic renal

1 (Hyperkalemia places the client at risk for serious cardiac arrhythmias and cardiac arrest. )

A client with ARF has an increase in the serum K level. The nurse should monitor the client for : 1. cardiac arrest 2. pulmonary edema 3. circulatory collapse 4. hemorrhage

2 (The nurse must always auscultate for a bruit and palpate for a thrill in the arm with the fistula and promptly report the absence of either to the HCP. as it indicates occlusion. The client SHOULD NOT have a pressure dressing or wear tight clothing, or carry heavy items on that side, no procedures such as IV access BP or blood draws are done on that arm)

A client with chronic renal failure is receiving hemodialysis three times a week. In order to protect the fistula the nurse should; 1. take the BP in the arm with the fistula 2. report the loss of a thrill or bruit on the arm with the fistula 3. maintain a pressure dressing on the shunt 4 start a second IV in the arm with the fistula

a (Apply pressure when discontinuing hemodialysis and after removing the venipuncture needle until all the bleeding has stopped. Bleeding may continue for 10 minutes in some patients.)

A patient with ESRD has an arteriovenous fistula in the left arm for hemodialysis. Which intervention do you include in his plan of care? a Apply pressure to the needle site upon discontinuing hemodialysis b Keep the head of the bed elevated 45 degrees c Place the left arm on an arm board for at least 30 minutes d Keep the left arm dry

a,c (The answers are A and C. The glomerular filtration rate indicates how well the glomerulus is filtering the blood. A normal GFR tends to be 90 mL/min or higher. A GFR of 40 mL/min indicates that the kidney's ability to filter the blood is decreased. Therefore, the kidneys will be unable to remove waste and excessive water from the blood...hence hypervolemia and an increased BUN level will present in this patient. The patient will experience HYPERkalemia (not hypo) because the kidneys are unable to remove potassium from the blood. In addition, an INCREASED creatinine level (not decreased) will present because the kidneys cannot remove excessive waste products, such as creatinine.)

A patient with acute renal injury has a GFR (glomerular filtration rate) of 40 mL/min. Which signs and symptoms below may this patient present with? Select all that apply: A. Hypervolemia B. Hypokalemia C. Increased BUN level D. Decreased Creatinine level

a (The answer is A. The patient should follow this type of diet because protein breaks down into urea (remember patients will have increased urea levels), low sodium to prevent fluid retention, low potassium to prevent hyperkalemia (remember glomerulus isn't filtering out potassium/phosphate as it should), and low phosphate to prevent hyperphosphatemia.)

A patient with stage 4 chronic kidney disease asks what type of diet they should follow. You explain the patient should follow a: A. Low protein, low sodium, low potassium, low phosphate diet B. High protein, low sodium, low potassium, high phosphate diet C. Low protein, high sodium, high potassium, high phosphate diet D. Low protein, low sodium, low potassium, high phosphate diet

2 (because the client has a perm cath in place, blood tinged drainage should not occur. Persistent blood tinged drainage could indicate damage to the abdominal vessels and the HCP should be notified. The bleeding is originating in the peritoneal cavity, not the kidneys. Too rapid infusion of the dialysate can cause pain, but not blood tinged drainage)

During the peritoneal dialysis, the nurse observes the solution draining from the clients abdomen is consistently blood tinged. The client has a permanent peritoneal cath in place. The nurse should recognize that the bleeding: 1. is expected with a permanent peritoneal cath 2. Indicates abd blood vessel damage 3. can indicate kidney damage 4. is caused by too rapid infusion of the dialysate

1,2,3 (renal failure affects almost every system in the body. Neurologically, the client may have drowsiness, headache, muscle twitching, and seizures, in recovery period, the client is alert and has no seizure activity. In renal failure levels of erythropoietin are decreased, leading to anemia. An increase in hbg and hct indicates the client is in recovery. N/V and D are common in the client with ARF; therefore an absence of these indicates the client is in recovery. WRONG: #4/#5 The client in the recovery period has an INCREASED specific gravity, and has a DECREASED creatinine level)

The client diagnosed with ARF. Which S/S indicate to the nurse the client is in the recovery period? SATA 1. Increased alertness and no seizure activity 2. Increase in hgb and hct 3. Denial of N/V 4 Decreased urine specific gravity 5. Increased serum creatinine level

4 (Normal K level is 3.5-5.5 mEq/L A level of 6.8 is life- threatening. and could lead to cardiac dysrhythmias. Therefore the client may be dialyzed to decrease the potassium level quickly. This requires a HCP order, so it is a collaborative intervention. WRONG: #1 phosphate binders are used to treat elevated phosphorous levels, not K. #2 Anemia is not the result of elevated K. #3 assessment is a independent action)

The client dx with ARF has a serum potassium level of 6.8 mEq/L. Which collaborative treatment should the nurse anticipate for the client? 1. Administer a phosphate binder 2. Type and crossmatch for whole blood 3. Assess the client for leg cramps 4. Prepare the client for dialysis

1 (The kidneys have a remarkable recovery ability from serious insult. The client should be taught how to recognize the signs and symptoms of decreasing renal function and to notify the HCP if they occur. Recovery may take 3-12 months. Chronic renal failure develops BEFORE ESRF)

The client with ARF is recovering and asks the nurse "Will my kidneys ever function normally again?" The nurses response is based on knowledge that the clients renal status most likely : 1. continue to improve over a period of weeks 2. result in the need for permanent hemodialysis 3. improve only if the client receives a renal transplant 4. result in end stage renal failure

1,2,4 (These are called the pre and post weights, the pre weight determines the amount of fluid to be removed during the tx and the post weight is used to determine if the goal met. Clients experiencing renal failure are not processing fluids in their body, restrictions are prescribed to allow for some fluid so the client does not become dehydrated but limited so the heart is not overtaxed causing HF. The clients entire blood supply is being removed from the body and being returned after being filtered, the client could bleed out in minutes if the access becomes dislodged. WRONG: Low salt options only! and #5 most like to rest during)

The client with CRF is prescribed hemodialysis on M, W, and F. Which interventions should the dialysis nurse implement?SATA 1. Weigh the client before each treatment 2. discuss the recommended fluid restriction 3. Provide the potato chips and pretzels as a snack 4. Monitor the hemodialysis access site continuously 5. Keep up the lively conversation during the treatments

2 (hypotension which causes a decreased blood supply to the kidney is one of the most common causes of prerenal failure which means before the kidney. WRONG: #1 Diabetes may lead to CRF, #2 Nephrotoxic meds are a cause of INTRArenal failure, which means directly to the kidney. #4 BPH is a cause of POST renal failure or after the kidney)

The nurse caring for a client dx with rule out ARF. Which condition predisposes the client to developing prerenal failure? 1. Diabetes mellitus 2. hypotension 3. aminoglycosides 4. BPH

3 (This is the correct scientific rationale for metabolic acidosis occurring in the client with CKD. WRONG: #1 There is a DECREASE in the excretion of phosphate and organic acids, not an increase. #2 The RBC destruction does not affect PH #4 The compensatory mechanism occurs to maintain the arterial blood PH between 7.35 and 7.45, but does not occur as a result of CKD)

The nurse caring for the client dx with CKD who is experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in the client? 1 There is an increased excretion of phosphates and organic acids, which leads to an increase in arterial blood PH 2. A shortened life span of RBCs because of damage secondary to dialysis treatments in turn leads to metabolic acidosis 3. The kidney cannot excrete increased levels of acid because they cannot excrete ammonia or cannot reabsorb sodium bicarbonate 4. An increase in N/V causes a loss of hydrochloric acid and the respiratory system cannot compensate adequately

1 (The BUN levels reflect the balance between the production and excretion of urea from the kidneys. Creatinine is a by product of the metabolism of the muscles and is excreted by the kidneys. Creatinine is the ideal substance for determining renal clearance because it is relatively constant in the body and is the lab value most significant in diagnosing renal failure. WRONg: #2 WBC for infection, hgb for blood loss #3 K intracellular, and Na interstitial are electrolytes monitored for a variety of diseases or conditions not specific to renal function. K will increase with renal failure, but the level is not diagnostic indicator for renal failure.)

The nurse is caring for a client dx with ARF. Which lab values are most significant for diagnosing ARF? 1. BUN and creatinine 2. WBC and hemoglobin 3. Potassium and sodium 4. Bilirubin and ammonia level

4 (excess fluid volume is the priority because of the stress placed on the heart and vessels, which lead to heart failure, pulmonary edema and death. )

The nurse is developing a nursing care plan for the client dx with CKD. Which nursing problem is priority for the client? 1. low self esteem 2. knowledge deficit 3. Activity intolerance 4. Excess fluid volume

f (The answer is FALSE. Some patients will skip the oliguric stage of AKI and progress to the diuresis stage)

True or False: All patients with acute renal injury will progress through the oliguric stage of AKI but not all patients will progress through the diuresis stage. True False

a

Which criterion is required before a patient can be considered for continuous peritoneal dialysis? a The patient must be hemodynamically stable b The vascular access must have healed c The patient must be in a home setting d Hemodialysis must have failed

2 (Uremia can cause decreased alertness, so the nurse needs to validate the clients comprehension frequently. Because the clients ability to concentrate is limited, short lessons are most effective. If family members are present at the sessions, they can reinforce the material. WRitten materials that the client can review are superior to videos because the client may not be able to maintain alertness during the viewing of the videotape)

Which teaching approach for the client with chronic renal failure who has difficulty concentrating due to high uremia levels would be most appropriate? 1. Provide all needed teaching in one extended session 2, validate the clients understanding of the material freq 3. conduct one on one session with the client 4 use video clips to reinforce the material as needed

b (The answer is B. A normal phosphate level is 2.7-4.5 mg/dL. This patient is experiencing HYPERphosphatemia. When hyperphosphatemia presents the calcium level DECREASES because phosphate and calcium bind to each. When there is too much phosphate in the blood it takes too much calcium with it and it decreases the calcium in the blood. Therefore, the nurse would expect to find the calcium level decreased.)

While assessing morning labs on your patient with CKD. You note the patient's phosphate level is 6.2 mg/dL. As the nurse, you expect to find the calcium level to be? A. Elevated B. Low C. Normal D. Same as the phosphate level

b,d (The answers are B and D. Calcium acetate (also known as PhosLo) is a phosphate binder, which will help keep the patient's phosphate level from becoming too high. It helps excrete the phosphate taken in the food by excreting it out of the stool. Therefore, it should be taken with meals or immediately after. Option C is wrong because the patient should AVOID these types of foods high in phosphate.)

You are providing education to a patient with CKD about calcium acetate. Which statement by the patient demonstrates they understood your teaching about this medication? Select-all-that-apply: A. "This medication will help keep my calcium level normal." B. "I will take this medication with meals or immediately after." C. "It is important I consume high amounts of oatmeal, poultry, fish, and dairy products while taking this medication." D. "This medication will help prevent my phosphate level from increasing."