Acute Renal Failure
The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention would the nurse implement first to prevent ARF? 1. Administer normal saline IV. 2. Take vital signs. 3. Place client on telemetry. 4. Assess abdominal dressing.
***1. Preventing and treating shock with blood and fluid replacement will prevent acute renal failure from hypoperfusion of the kidneys. Significant blood loss would be ex- pected in the client with a gunshot wound. 2. Taking and evaluating the client's vital signs is an appropriate action, but regardless of the results, this will not prevent ARF. 3. Placing the client on telemetry is an appropri- ate action, but telemetry is an assessment tool for the nurse and will not prevent ARF. 4. Assessment is often the first action, but assess- ing the abdominal dressing will not help prevent ARF. TEST-TAKING HINT: The test taker must read the stem carefully and understand what the question is asking. Options "2," "3," and "4" are all forms of assessment and would not help prevent ARF because they are not treatment.
The client is diagnosed with ARF. Which signs/symptoms would indicate to the nurse that the client is in the recovery period? Select all that apply. 1. Increased alertness and no seizure activity. 2. Increase in hemoglobin and hematocrit. 3. Denial of nausea and vomiting. 4. Decreased urine-specific gravity. 5. Increased serum creatinine level.
***1. Renal failure affects almost every system in the body. Neurologically the client may have drowsiness, headache, muscle twitch- ing, and seizures. In the recovery period, the client would be alert and not have seizures. ***2. In renal failure, levels of erythropoietin are decreased, leading to anemia. An increase in hemoglobin and hematocrit indicates the client is in the recovery period. ***3. Nausea, vomiting, and diarrhea are com- mon in the client with ARF; therefore, an absence of these indicates the client is in the recovery period. 4. The client in the recovery period would have increased urine-specific gravity. 5. The client in the recovery period would have a decreased serum creatinine level. TEST-TAKING HINT: This is an alternate-type question in which the test taker may choose as many correct answers as warranted. The test taker should not immediately assume that the option that says urine is the correct answer. The nurse must realize that renal failure affects every body system.
The nurse and unlicensed nursing assistant are caring for clients on a medical floor. Which nursing task would be most appropriate for the nurse to delegate? 1. Collect a clean voided midstream urine specimen. 2. Evaluate the client's 8-hour intake and output. 3. Assist in checking a unit of blood prior to hanging. 4. Administer a cation-exchange resin enema.
***1. The assistant can collect specimens. Col- lecting a midstream urine specimen req- uires the client to clean the perineal area, to urinate a little, and then collect the rest of the urine output in a sterile container. 2. The assistant can obtain the client's intake and output, but the nurse must evaluate the data to determine if interventions are needed or if interventions are effective. 3. Two registered nurses must check the unit of blood at the bedside prior to administering. 4. This is a medication enema and assistants cannot administer medications. Also, for this to be ordered, the client must be unstable with an excessively high serum potassium level. TEST-TAKING HINT: Nursing tasks that may not be delegated include any task that requires nursing judgment, medication administration, teaching, evaluating, or assessing.
The client diagnosed with ARF is placed on bed rest. The client asks the nurse, "Why do I have to stay in bed, I don't feel that bad." Which scientific rationale would support the nurse's response? 1. Bed rest helps increase the blood return to the renal circulation. 2. Bed rest reduces the metabolic rate during the acute stage. 3. Bed rest decreases the workload of the left side of the heart. 4. Bed rest aids in reduction of peripheral and sacral edema.
1. Kidney function is improved about 40% when recumbent, but this is not the scientific ration- ale for bed rest in ARF. ***2. Bed rest reduces exertion and the meta- bolic rate, thereby reducing catabolism and subsequent release of potassium and accumulation of endogenous waste products (urea and creatinine). 3. This is a scientific rationale for prescribing bed rest in clients with heart failure. 4. This is not the scientific rationale for prescribing bed rest. The foot of the bed may be elevated to help decrease peripheral edema, and bed rest causes an increase in sacral edema. TEST-TAKING HINT: The test taker should not jump to conclusions and select the only option that has "renal" in the sentence. The nurse must know normal anatomy and physiology of the body and be aware that keeping someone in bed will not restore kidney function when the kidneys have failed.
The unlicensed nursing assistant tells the nurse that the client with ARF has a white layer on top of the skin that looks like crystals. Which intervention should the nurse implement? 1. Have the assistant apply a moisture barrier cream to the skin. 2. Instruct the nursing assistant to bathe the client in cool water. 3. Tell the nursing assistant not to turn the client in this condition. 4. Explain that this is normal and do not do anything to the client.
1. Moisture barrier cream will keep the crystals on the skin. ***2. These crystals are uremic frost resulting from irritating toxins deposited in the client's tissues. Bathing in cool water will remove the crystals, promote client com- fort, and decrease the itching that occurs from uremic frost. 3. The client should be turned every two (2) hours or more frequently to prevent skin breakdown. 4. This may occur with ARF, and it does require a nursing intervention. TEST-TAKING HINT: The nurse must know what is normal for specific disease processes, and something coming out of the skin would require some action even if the test taker was not familiar with the disease process. Option "4" could be eliminated based on this test-taking strategy. The test taker should also eliminate option "3" because there are very few instances in which the client is not turned or moved; turning and movement are necessary to pre- vent the development of pressure ulcers.
The client is diagnosed with ARF. Which laboratory values are most significant for diagnosing ARF? 1. BUN and creatinine. 2. WBC and hemoglobin. 3. Potassium and sodium. 4. Bilirubin and ammonia level.
***1. Blood urea nitrogen (BUN) levels reflect the balance between the production and excretion of urea from the kidneys. Creati- nine is a byproduct of the metabolism of the muscles and is excreted by the kidneys. Creatinine is the ideal substance for deter- mining renal clearance because it is rela- tively constant in the body and is the laboratory value most significant in diag- nosing renal failure. 2. WBCs (white blood cells) are monitored for infection, and hemoglobin is monitored for blood loss. 3. Potassium (intracellular) and sodium (intersti- tial) are electrolytes and are monitored for a variety of diseases or conditions not specific to renal function. Potassium levels will increase with renal failure, but the level is not a diag- nostic indicator for renal failure. 4. Bilirubin and ammonia levels are laboratory values that determine the functioning of the liver, not the kidneys. TEST-TAKING HINT: The nurse must know spe- cific laboratory tests for specific organ func- tioning or conditions. This is memorizing, but it must be done.
The client is diagnosed with rule out ARF. Which condition would predispose the client to developing pre-renal failure? 1. Diabetes mellitus. 2. Hypotension. 3. Aminoglycosides. 4. Benign prostatic hypertrophy.
1. Diabetes mellitus is a disease that will lead to chronic renal failure. ***2. Hypotension, which causes a decreased blood supply to the kidney, is one of the most common causes of pre-renal failure (before the kidney). 3. Nephrotoxic medications are a cause of intrarenal failure (directly to kidney). 4. Benign prostatic hypertrophy (BPH) is a cause of post-renal failure (after the kidney). TEST-TAKING HINT: The test taker must be cautious of adjectives, those words that describe something; "pre-renal" is the key to selecting the correct answer. The prefix means before.
The client diagnosed with ARF is experiencing hyperkalemia. Which medication should the nurse prepare to administer to help decrease the potassium level? 1. Erythropoietin. 2. Calcium gluconate. 3. Regular insulin. 4. Osmotic diuretic.
1. Erythropoietin is a chemical catalyst that is produced by the kidneys to stimulate red blood cell production; it does not affect potassium level. 2. Calcium gluconate helps protect the heart from the effects of high potassium levels ***3. Regular insulin, along with glucose, will drive potassium into the cells, thereby lowering serum potassium levels temporarily. 4. A loop diuretic, not an osmotic diuretic, may be ordered to help decrease the potassium level. TEST-TAKING HINT: The test taker must be familiar with medical terms such as hyperkalemia and know the rationale for administering medications.
The client diagnosed with ARF has a serum potassium level of 6.8 mEq/L. Which collaborative treatment would the nurse anticipate for the client? 1. Administer a phosphate binder. 2. Type and cross-match for whole blood. 3. Assess the client for leg cramps. 4. Prepare the client for dialysis.
1. Phosphate binders are used to treat elevated phosphorus levels, not elevated potassium levels. 2. Anemia is not the result of an elevated potassium level. 3. Assessment is an independent nursing action, which would be appropriate for the elevated potassium level, but the question asks for a collaborative treatment. ***4. Normal potassium level is 3.5-5.5 mEq/L. A level of a 6.8 mEq/L is life threatening and could lead to cardiac dysrhythmias. Therefore, the client may be dialyzed to decrease the potassium level quickly. This would be done with an order from a health- care provider, so it is a collaborative intervention. TEST-TAKING HINT: Adjectives must be noted when reading the stem of the intervention.
The client diagnosed with ARF is admitted to the intensive care department and placed on a therapeutic diet. Which diet would be most appropriate for the client? 1. A high-potassium and low-calcium diet. 2. A low-fat and low-cholesterol diet. 3. A high-carbohydrate and restricted-protein diet. 4. A regular diet with six (6) small feedings a day.
1. The diet would be low potassium, and calcium is not restricted in ARF. 2. This is a diet recommended for clients with cardiac disease and atherosclerosis. ***3. Carbohydrates are increased to provide for the client's caloric intake and protein is re- stricted to minimize protein breakdown and to prevent accumulation of toxic end products. 4. The client must be on a therapeutic diet, and small feedings are not required. TEST-TAKING HINTS: The test taker must notice adjectives. A "therapeutic" diet should cause the test taker to eliminate option "4" because it is a regular diet.
The nurse is developing a plan of care for a client diagnosed with ARF. Which statement would be an appropriate outcome for the client? 1. Monitor intake and output every shift. 2. Decrease of pain by 3 levels on a 1-10 scale. 3. Electrolytes are within normal limits. 4. Administer enemas to decrease hyperkalemia.
1. This is a nursing intervention, not a client out- come. 2. This is a measurable client outcome, but acute renal failure does not cause pain. ***3. Renal failure causes an imbalance of electrolytes (potassium, sodium, calcium, phosphorus). Therefore the desired client outcome would be that all the electrolytes are within normal limits. 4. A Kayexalate resin enema may be administered to help decrease the potassium level, but this is an intervention, not a client outcome. TEST-TAKING HINT: The nurse must be knowledgeable of the nursing process. Client out- comes are used to evaluate the planning part of the nursing process. The outcomes must be measurable, client focused, and realistic.
The nurse is admitting a client diagnosed with acute renal failure (ARF). Which ques- tion would be most important for the nurse to ask during the admission interview? 1. "Have you recently traveled outside the United States?" 2. "Did you recently begin a vigorous exercise program?" 3. "Is there a chance you have been exposed to a virus?" 4. "What over-the-counter medications do you take regularly?"
1. Usually there are no diseases or conditions that would warrant this question when discussing ARF. 2. Vigorous exercise will not impede blood flow to the kidneys, leading to ARF. 3. Usually viruses do not cause ARF. ***4. Medications such as nonsteroidal anti- inflammatory drugs (NSAIDs) and some herbal remedies are nephrotoxic; therefore, asking about medications is appropriate. TEST-TAKING HINT: Asking about medications, especially over-the-counter and herbal remedies, during the admission interview is an important intervention because many of these are nephrotoxic and hepatotoxic.
