Medical-Surgical Nursing 7th Edition Ch 71

2. A client is admitted to the hospital with a serum creatinine level of 2 mg/dL. When taking the client's history, which question will the nurse ask first? a. "Do you take any nonprescription medications?" b. "Does anyone in your family have kidney disease?" c. "Do you have yearly blood work done?" d. "Is your diet low in protein?"

ANS: A Acute renal failure can be caused by certain medications considered to have a nephrotoxic effect, such as NSAIDs, and acetaminophen. Asking the client if she or he takes any nonprescription drugs can help determine which medication(s) might have contributed to the problem.

1. Which of the following clients is most at risk for developing postrenal renal failure? a. Client diagnosed with renal calculi b. Client with congestive heart failure c. Client taking nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritis pain d. Client recovering from glomerulonephritis 5. Which intervention is most important for the nurse to implement in a client after renal transplant surgery? a. Flushing peritoneal dialysis catheter once per shift b. Monitoring magnesium levels daily c. Placing the client on contact isolation d. Removing indwelling (Foley) catheter as soon as possible 6. During a hot summer day, an older adult client tells the nurse that he "is not voiding that much." On taking his vital signs, the nurse notes a heart rate of 100 beats/min and a blood pressure of 90/60 mm Hg. Which action will the nurse take first? a. Have the client drink fluid. b. Insert an intravenous catheter. c. Place the client on intake and output measurement. d. Place a Foley catheter to monitor urine output. 7. To detect a common untoward effect of furosemide (Lasix), the nurse obtains which assessment? a. Breath sounds b. Heart sounds c. Intake and output d. Nutritional patterns 8. A client with acute renal failure and on dialysis asks how much fluid will be permitted each day. Which is the nurse's best response? a. "This is based on the amount of damage to your kidneys." b. "You will be permitted to drink an amount equal to the urine you excrete, plus 700 mL." c. "It is based on your body weight." d. "You will be permitted to drink approximately 2 L of fluid each day." 9. Which statement by client who has undergone renal transplantation indicates a need for more teaching? a. "I will need to continue to take insulin for my diabetes." b. "I will have to take my cyclosporine for the rest of my life." c. "I will take the antibiotics three times daily until the medication is finished." d. "My new kidney is working fine. I do not need to take medications any longer." 10. Which staff member will the nurse assign to care for a client newly diagnosed with chronic kidney disease? a. Licensed practical nurse who usually works on unit b. Nurse floated from hemodialysis unit c. Registered nurse who has taken care of him before d. Registered nurse with the most experience 11. The client has been missing some scheduled hemodialysis sessions. Which intervention is most important for the nurse to implement? a. Discussing with the client his acceptance of the disease b. Discussing with the client the option of peritoneal dialysis c. Rescheduling the sessions to another day d. Stressing to the client the importance of going to these sessions 12. Assessment findings reveal that a client with chronic kidney disease is refusing to take his medications because he thinks that they are too costly. The client also is having difficulty with performing his activities of daily living and prefers to sleep most of the day. Which health care team member is likely to be most helpful in planning this client's care? a. Home health aide b. Physical therapist c. Psychiatric nurse practitioner d. Physician 13. A client has a serum creatinine level of 2 mg/dL and a urine output of 1000 mL/day. How will the nurse categorize the client's renal failure? a. Intrarenal b. Nonoliguric c. Prerenal d. Postrenal 14. A client has a serum creatinine level of 2.5 mg/dL, a serum potassium level of 6 mmol/L, an arterial pH of 7.32. and a urine output of 250 mL/day. Which phase of acute renal failure is the client experiencing? a. Intrarenal b. Nonoliguric c. Oliguric d. Postrenal 15. Which assessment finding does the nurse associate with the client's acute renal failure, postrenal type? a. Elevated blood urea nitrogen (BUN) b. Elevated creatinine c. Feeling of urgency d. Weight gain 16. A client with chronic hypertension is seen in the clinic. Which assessment indicates that the client's hypertension is not under control? a. Heart rate of 55 beats/min b. Elevated serum creatinine level c. Blood glucose level of 128 mg/dL d. Irregular heart sounds 17. Which client assessment finding confirms the condition of diminished renal reserve? a. Arterial blood pH of 7.30 b. Glomerular filtration rate of 50% c. Serum creatinine level of 4 mg/dL d. Urine output of 250 mL/day 18. When evaluating the effects of a low-protein diet in a client with renal failure, the nurse would be most concerned with which result? a. Albumin level of 2 g/dL b. Calcium level of 8.0 mg/dL c. Potassium level of 5.2 mmol/L d. Magnesium level of 3 mEq/L 19. To determine the effectiveness of fluid restriction on a client in renal failure, the nurse will assess for which finding? a. Absence of lung crackles b. Decreased serum creatinine level c. Decreased serum potassium level d. Increased muscle strength 20. The client with chronic kidney disease is prescribed drugs to be given at 9 AM, digoxin (Lanoxin) and epoetin alfa (Epogen). He is complaining of nausea and vomiting. Which action will the nurse take first? a. Administers both medications b. Checks the hemoglobin and hematocrit levels c. Holds the dose of digoxin d. Notifies the health care provider 21. When evaluating the effects of continuous arteriovenous hemofiltration (CAVH), the nurse will monitor the results of which laboratory test? a. Hemoglobin b. Glomerular filtration rate c. Sodium d. White blood cells 22. A client who is 2 days post-femoral vein cannulation begins to have difficulty with outflow of blood during dialysis. For which complication will the nurse be assessing? a. Hematoma at cannula insertion site b. Infection c. Oliguria d. Skin necrosis at cannula insertion site 23. Which is the nurse's highest priority for meeting the needs of a client who presents with a 3-day history of vomiting and diarrhea, blood pressure of 85/60 mm Hg, and heart rate of 105 beats/min? a. Finding the source of infection b. Preventing nutritional deficit c. Replacement of fluid loss d. Relief of nausea 24. Which response by the client indicates an understanding of measures to facilitate the flow of peritoneal dialysate fluid? a. "I will take my stool softeners every day." b. "I will keep the drainage bag at the level of my abdomen." c. "Flushing the catheter with each exchange is needed." d. "Warmed dialysate infusion increases the speed of flow." 25. When providing care for a client receiving peritoneal dialysis, the nurse notices that the effluent is cloudy. Which intervention is the most important for the nurse to carry out? a. Irrigating the peritoneal catheter b. Sending a specimen of the effluent for culture and sensitivity c. Documenting the finding d. Changing the dialysate solution and catheter tubing 26. During hemodialysis, a client with chronic kidney disease develops headache, nausea, vomiting, and restlessness. After notifying the physician, which action by the nurse is most appropriate? a. Administering an intravenous bolus of dextrose solution b. Discontinuing the hemodialysis immediately c. Ordering a blood urea nitrogen level STAT d. Preparing to administer an anticonvulsant 27. A client's temperature after dialysis is 99° F (37.2° C) and was normal predialysis. Which is the nurse's best action? a. Continuing to monitor the temperature b. Encouraging the client to drink at least 1 L of fluid c. Obtaining a white blood cell count d. Preparing to culture the fistula site 28. The RN has assigned a client with a newly placed arteriovenous (AV) fistula in his right arm to an LPN. Which information about the care of this client is most important for the RN to provide to the LPN? a. "Avoid movement of the right extremity." b. "Place gentle pressure over the fistula site after blood draws." c. "Start any IV lines below the site of the fistula." d. "Take blood pressure in the left arm." 29. A nurse is providing dietary teaching to a client who was just started on hemodialysis. Which instruction will the nurse provide to this client regarding protein intake? a. "Your protein needs will not change, but you may take more fluids." b. "You will need more protein now, because some protein is lost by dialysis." c. "Your protein intake will be adjusted according to your predialysis weight." d. "You no longer need to be on protein restriction." 30. Which condition warrants the nurse administering protamine sulfate to a client receiving hemodialysis? a. Absent bruit and thrill over vascular access site b. Decreased activated partial thromboplastin time c. Excessive bleeding from the vascular access site d. Thrombosis of the AV fistula 31. The renal failure client's respiration rate is 40 breaths/min and increased in depth. The nurse recognizes that the client is most likely exhibiting symptoms of which condition? a. Hypoxemia b. Rising creatinine level c. Dehydration d. Metabolic alkalosis 32. Which clinical finding indicates to the nurse that a client's renal failure is getting worse? a. Hemoglobin level of 30% b. Nausea and vomiting c. Paresthesias of the lower extremities d. Soft, less audible heart sounds 33. Selection of which food indicates to the nurse that the client understands teaching about a low-sodium and low-potassium diet? a. Bananas b. Ham c. Herbs d. Salt substitutes 34. A client who is admitted to the hospital with a history of kidney disease begins to have difficulty breathing. The vital signs are as follows: blood pressure of 100/80 mm Hg, heart rate of 40 beats/min. His heart sounds are difficult to hear. Which intervention will the nurse anticipate will be done first? a. Administration of digoxin (Lanoxin) b. Draining pericardial fluid with a needle c. Hemodialysis d. Placement of a pacemaker 35. A client with chronic kidney disease states that he will be going to the dentist for a planned tooth extraction. Which is the nurse's best response? a. "Rinse your mouth with an antiseptic solution after the procedure." b. "The kidney disease is probably what caused your dental decay." c. "You should receive prophylactic antibiotics before any dental procedure." d. "You may take any medication for pain that the dentist prescribes." 36. A client hospitalized for worsening renal failure suddenly becomes restless and agitated. The assessment reveals tachycardia and crackles bilaterally at the bases of the lungs. Which is the nurse's first intervention? a. Beginning ultrafiltration b. Administering an antianxiety agent c. Placing the client on mechanical ventilation d. Placing client in a high Fowler's position 37. A nurse is caring for a client with chronic kidney disease who has developed uremia. Which assessment finding is expected in this client? a. Decreased breath sounds b. Foul-smelling urine c. Heart rate of 50/min d. Respiratory rate of 40/min 38. A nurse observes tall, peaked T waves on the electrocardiogram (ECG) of a client with end-stage kidney disease (ESKD). Which is the nurse's best action? a. Checking the serum potassium level b. Nothing. This is a normal finding for individuals with ESRD. c. Preparing to give sodium bicarbonate to correct the acidosis d. Repeating the ECG 39. Which assessment parameter will the nurse monitor in a client with chronic kidney disease to determine fluid and sodium retention status? a. Capillary refill b. Intake and output c. Muscle strength d. Weight and blood pressure 40. The nurse is caring for a client who is receiving peritoneal dialysis (PD). Which nursing intervention has the greatest priority when performing a dialysis exchange? a. Adding potassium and antibiotic to the dialysate bags b. Positioning the client on his side c. Using sterile technique when hooking up dialysate bags d. Warming the dialysate fluid in a microwave oven 41. The occurrence of which condition warrants the nurse immediately discontinuing a peritoneal dialysis exchange? a. Brown color effluent b. Outflow less than inflow c. Pain during dialysate inflow d. Poor dialysate flow ) 42. A client who is 12 hours post-kidney transplantation puts out 2000 mL of urine in 1 hour. Which assessment will the nurse carry out first? a. Skin turgor b. Blood pressure c. Serum BUN level d. Weight of the client 43. A client who underwent kidney transplantation 7 days ago has developed oliguria, an elevated temperature, lethargy, and elevations in the serum creatinine, BUN, and potassium levels. Which initial intervention will the nurse anticipate for this client? a. Hemodialysis b. Increase in the doses of immunosuppressive drugs c. Immediate removal of the transplanted kidney d. Peritoneal dialysis 1. A client asks a nurse "What are the advantages of peritoneal dialysis over hemodialysis?" Which response by the nurse is accurate? (Select all that apply.) a. "It will give you greater freedom in your scheduling." b. "You have less chance of getting an infection." c. "You only need to do it three times/week." d. "You do not need a machine to do it." e. "You will have fewer dietary restrictions."

ANS: A Causes of postrenal renal failure include disorders that obstruct the flow of urine, such as renal calculi. 5.ANS: D Because of the increased risk for infection related to immunosuppressive drugs given to prevent rejection, the catheter is removed as soon as possible to avoid infection, usually 3 to 7 days after surgery. 6.ANS: A Severe blood volume depletion can lead to renal failure, even in those who have no kidney problem. Urge all people to avoid dehydration by drinking at least 2 to 3 L of fluid daily. 7. ANS: C Lasix is a diuretic that causes increased urine output. If too much urine output occurs, the client may be at risk for hypovolemia, which is a cause of prerenal renal failure. A marked change in fluid balance seen in the intake and output measurement can help identify the client who may be at risk for hypovolemia. 8.ANS: B Fluid intake is generally calculated to equal the amount of urine excreted plus 500 to 700 mL. 9. ANS: D A crucial role of the nurse in the long-term follow-up of the renal transplantation client is in the maintenance of prescribed drug therapy. Such clients will need to take immunosuppressants for the rest of their lives to prevent rejection of the kidney. 10.ANS: C Provide continuity of care, whenever possible, by using a consistent nurse-client relationship to decrease anxiety and promote discussions of concerns. 11.ANS: A Some people on dialysis retreat into complete or partial denial of the disease and the need for treatment. They may deny the need for dialysis and/or may not adhere to drug therapy and diet restrictions. Getting the client to accept the disease and the need for treatment is an important step in having him resume therapy. 12.ANS: C Professionals from many disciplines are resources for the client with renal failure. A psychiatric evaluation may be needed if depressive symptoms are present. Refusing treatment, difficulty performing activities of daily living, and excessive sleeping could be signs of depression. 13. ANS: B Some clients have a nonoliguric form of acute renal failure (ARF), in which urine output remains near-normal. 14.ANS: C The oliguric phase of acute renal failure is characterized by the accumulation of nitrogenous wastes, resulting in increasing levels of serum creatinine and potassium, bicarbonate deficit, and decreased or no urine output. 15.ANS: C Postrenal renal failure is identified by focusing on urinary obstructive problems. Symptoms include changes in the urine stream or difficulty starting urination. All the other distractors can be seen with prerenal and intrarenal failure. 16.ANS: B Increased blood pressure damages the delicate capillaries in the glomerulus, and eventually renal failure results. An elevated serum creatinine level is a sign of renal failure. 17.ANS: B Progression toward end-stage kidney disease (ESKD) usually starts with a gradual decrease in renal function of 30% to 50%. At first, there is a reduced renal reserve. In this stage, reduced renal function occurs without buildup of wastes in the blood because the unaffected nephrons overwork to compensate for the diseased nephrons. If renal damage continues, then metabolic wastes begin to accumulate. 18.ANS: A Clients with renal failure are placed on low-protein diets. However, decreased serum albumin levels indicate that the protein they are taking in is not enough for their metabolic needs. 19. ANS: A The client with chronic kidney disease is expected to achieve and maintain an acceptable fluid balance. Fluid restriction helps with this outcome. Absence of lung crackles can indicate that the client is not fluid-overloaded. 20. ANS: C Clients with renal failure are particularly at risk for digoxin toxicity because the drug is excreted by the kidneys. When caring for clients with chronic kidney disease (CKD) who are receiving digoxin, monitor for signs of toxicity, such as nausea and vomiting. \ 21.ANS: C CAVH is used for clients who have fluid volume overload. It continuously removes large amounts of plasma water, wastes, and electrolytes, such as sodium. Fluid removal can also affect the serum sodium level. ) 22.ANS: A The puncture site of the femoral vein is prone to hematoma formation, because positioning the extremity can cause movement of the cannula and subsequent bleeding at the site. 23.ANS: C Many types of problems can reduce renal function. Severe hypotension from shock or dehydration reduces renal blood flow and lead to prerenal acute renal failure (ARF). Volume depletion leading to prerenal azotemia is the most common cause of ARF and is usually reversible with prompt intervention. 24.ANS: A Constipation is the primary cause of inflow and outflow problems. To prevent constipation, clients are placed on a bowel regimen before the placement of a peritoneal catheter. 25.ANS: B Cloudy or opaque effluent is the earliest sign of peritonitis. The health care provider should be notified, and a sample of the outflow should be sent for culture and sensitivity. 26.ANS: D Headache, nausea, vomiting, and restlessness may be signs of dialysis disequilibrium syndrome. Rapid decreases in fluid and the BUN level can cause cerebral edema and increased intracranial pressure (ICP). Early recognition and treatment of this syndrome are essential for preventing a life-threatening situation. 27.ANS: A The client's temperature may be elevated because the dialysis machine warms the blood slightly. An excessive temperature elevation from baseline can signal sepsis. The nurse should inform the physician and obtain blood cultures if this happens. 28.ANS: D Repeated compression of a fistula site can result in the loss of the vascular access. Therefore, avoid taking blood pressures and performing venipunctures or IV placement in the arm with the vascular access. 29.ANS: B When renal disease has progressed and requires treatment with dialysis, increased protein is required in the diet to compensate for protein losses through dialysis. 30.ANS: C To prevent blood clots from forming within the dialyzer or blood tubing, anticoagulation is needed during hemodialysis treatment. The drug used is heparin, which makes the client at risk for hemorrhage. Protamine sulfate is an antidote to heparin and should be available in the dialysis setting. 31.ANS: B As renal failure worsens and acid retention increases, increased respiratory action is needed to keep the blood pH normal. The respiratory system adjusts by increasing the rate and depth of breathing to increase the flow of carbon dioxide through the lungs. 32.ANS: D Soft, less audible heart sounds can signal the accumulation of fluid within the pericardial sac. Fluid accumulation results from the accumulation of uremic toxins, which cause inflammation of the pericardium and subsequent fluid buildup. Excess amounts of fluid within the pericardial sac can result in cardiac tamponade, a medical-surgical emergency. 33.ANS: C Herbs and spices can be used in place of salt to enhance food flavor. Bananas are high in potassium. Ham is high in sodium. Many salt substitutes contain potassium chloride and should not be used. 34/ANS: B Pericarditis occurs in clients with chronic kidney disease. If not treated, this inflammation can lead to pericardial effusion, cardiac tamponade, and death. Manifestations include severe chest pain, an increased pulse rate, shortness of breath, and decreased chest pain. Treatment of tamponade requires removal of pericardial fluid by placement of a needle, catheter, or drainage tube into the pericardium. 35.ANS: C To prevent sepsis from oral cavity bacteria, the client should be given prophylactic antibiotics before any dental procedure. 36.ANS: D Restlessness, anxiety, tachycardia, dyspnea, and crackles at the bases of the lungs are early manifestations of pulmonary edema, which is a complication of renal failure. Initial treatment of pulmonary edema is to place the client in a high Fowler's position and administer oxygen. Mechanical ventilation and ultrafiltration may be indicated if the symptoms become worse. 37.ANS: D A client with uremia will also have metabolic acidosis. With severe metabolic acidosis, the client will develop hyperventilation, or Kussmaul respiration. 38.ANS: A Tall, peaked T waves are a manifestation of hyperkalemia. Thus, the nurse should check the potassium level. 39.ANS: D Weight and blood pressure are helpful in estimating fluid and sodium retention. Weight and blood pressure rise with excess fluid and sodium. 40. ANS: C Peritonitis is the major complication of PD. The most common cause of peritonitis is connection site contamination. To prevent peritonitis, use meticulous sterile technique when caring for the PD catheter and when hooking up or clamping off dialysate bags. 41. ANS: A All the answers can be seen with a peritoneal dialysis exchange. However, brown effluent could indicate bowel perforation, which is a serious complication. It warrants immediate discontinuing of the exchange. 42.ANS: B After a transplantation, the client may have diuresis. Excessive diuresis might cause hypotension. Hypotension needs to be prevented because this can reduce blood flow and oxygen to the new kidney, threatening graft survival. 43.ANS: B Oliguria, lethargy, elevated temperature, and increases in serum electrolyte levels 1 week to 2 years post-transplantation are hallmarks of acute rejection, which can be reversible with increased immunosuppressive therapy. 1.ANS: A, D, E Although peritoneal dialysis is slower than hemodialysis, it does not require a specially trained registered nurse and can be done at home, allowing for more flexibility in scheduling. Peritoneal dialysis is ambulatory, and a machine is not needed. Nursing implications for hemodialysis include vascular access care and diet restrictions, whereas peritoneal dialysis allows for a more flexible diet (abdominal catheter care is still necessary).

3. A client with a decreased glomerular filtration rate asks how to prevent further damage to the kidneys. Which is the nurse's best response? a. "The diuretics you are taking will prevent further damage." b. "Kidney damage is inevitable as you age." c. "Avoid taking nonsteroidal anti-inflammatory drugs." d. "You will need to follow a high-protein diet."

ANS: C Renal failure causes many problems, including decreased glomerular filtration rate. Nephrotoxins can worsen renal failure, especially in someone who already has some loss of kidney function.

4. A client who has chronic kidney disease is being discharged from the hospital after being treated for a hip fracture. Which information is most important for the nurse to provide the client prior to discharge? a. "Increase your intake of foods with protein." b. "Monitor your daily intake and output." c. "Maintain bedrest until the fracture is healed." d. "Take your aluminum hydroxide (Nephrox) with meals."

ANS: D Aluminum hydroxide lowers serum phosphate levels by binding phosphorus present in food. High blood phosphate levels cause hypocalcemia and osteodystrophy, which makes a client prone to fractures.