Chapter 27: Nursing Management: Patients With Renal Disorders
A client is receiving hemodialysis for acute kidney failure. Which assessment finding(s) indicates to the nurse that the client is experiencing dialysis disequilibrium? Select all that apply. -Nausea -Bleeding -Vomiting -Headache -Confusion
-Nausea -Vomiting -Headache -Confusion Explanation: There are complications that can occur when receiving hemodialysis. One complication is dialysis disequilibrium, which results from cerebral fluid shifts. Signs and symptoms of dialysis disequilibrium include nausea, vomiting, headache, and decreased level of consciousness. Bleeding is not associated with dialysis disequilibrium.
A client with a history of chronic renal failure receives hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which intervention should the nurse include in the care plan?
Assess the AV fistula for a bruit and thrill. Explanation: The nurse needs to assess the AV fistula for a bruit and thrill because if these findings aren't present, the fistula isn't functioning. The AV fistula may get wet when the client isn't being dialyzed. Immediately after a dialysis treatment, the access site should be covered with adhesive bandages, not gauze. Blood pressure readings or venipunctures shouldn't be taken in the arm with the AV fistula.
Diet modifications are part of nutritional therapy for the management of ARF. Select the high-potassium food that should be restricted.
Citrus fruits Explanation: Dietary restrictions include foods and fluids containing potassium, such as bananas, citrus, tomatoes, melons, or those with phosphorus, which is found in dairy, beans, nuts legumes, and carbonated beverages. Caffeine is also restricted.
The nurse is educating a client who is required to restrict potassium intake. What foods would the nurse suggest the client eliminate that are rich in potassium?
Citrus fruits Explanation: Foods and fluids containing potassium or phosphorus (e.g., bananas, citrus fruits and juices, coffee) are restricted.
Mr. Jeung is a 60-year-old man who has been coming to the local dialysis center three times a weeks for the past year. Mr. Jeung is interested in the possibility of beginning home hemodialysis, and his wife is willing and able to assist accordingly. The dialysis nurse knows that the primary goal of performing dialysis in the patient's own home is to maximize:
The patient's independence and quality of life Explanation: The primary advantage of home hemodialysis is the ability to minimize disruptions to the patient's routine and maximize quality of life. It is not an appropriate mode of delivery for patients who struggle to adhere to treatment. It does not allow the patient to abandon a renal diet. Weight loss and fluid balance are not necessarily superior in the home setting.
The nurse cares for a client diagnosed with chronic glomerulonephritis. The nurse will observe the client for the development of
anemia. Explanation: Anemia, hyperkalemia, metabolic acidosis, and hyperphosphatemia occur during chronic glomerulonephritis.
A client who suffered hypovolemic shock during a cardiac incident has developed acute kidney injury. Which is the best nursing rationale for this complication?
Decrease in the blood flow through the kidneys Explanation: Acute kidney injury can be caused by poor perfusion and/or decrease in circulating volume results from hypovolemic shock. Obstruction of urine flow from the kidneys through blood clot formation and structural damage can result in postrenal disorders but not indicated in this client.
Glomerulonephritis is an inflammatory response in the glomerular capillary membrane, and causes disruption of the renal filtration system. Although diagnostic urinalysis can reveal glomerulonephritis, many clients with glomerulonephritis exhibit:
no symptoms. Explanation: Many clients with glomerulonephritis have no symptoms. Early symptoms may be so slight that the client does not seek medical attention.
What is a hallmark of the diagnosis of nephrotic syndrome?
Proteinuria Explanation: Proteinuria (predominantly albumin) exceeding 3.5 g per day is the hallmark of the diagnosis of nephrotic syndrome. Hypoalbuminemia, hypernatremia, and hyperkalemia may occur.
The client is admitted to the hospital with a diagnosis of acute glomerulonephritis. Which clinical manifestation would the nurse expect to find?
Cola-colored urine Explanation: Clinical manifestations of acute glomerulonephritis include cola-colored urine, hematuria, edema, azotemia, and proteinuria.
A client who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?
Compatible blood and tissue types Explanation: The donor and recipient must have compatible blood and tissue types. They should be fairly close in size and age, but these factors aren't as important as compatible blood and tissue types. When a living donor is considered, it's preferable to have a blood relative donate the organ. Need is important but it can't be the critical factor if a compatible donor isn't available.
The nurse is working on the renal transplant unit. To reduce the risk of infection in a patient with a transplanted kidney, it is imperative for the nurse to do what?
Wash hands carefully and frequently Explanation: The nurse ensures that the patient is protected from exposure to infection by hospital staff, visitors, and other patients with active infections. Careful hand-washing is imperative; face masks may be worn by hospital staff and visitors to reduce the risk for transmitting infectious agents while the patient is receiving high doses of immunosuppressants. The nurse would not ensure immediate functioning of the donated kidney and would not necessarily instruct the patient to wear a face mask or restrict visitors.
What is a characteristic of the intrarenal category of acute kidney injury (AKI)?
Increased BUN Explanation: The intrarenal category of acute kidney injury (AKI) encompasses an increased BUN, increased creatinine, a low-normal specific gravity of urine, and increased urine sodium. Intrarenal AKI is the result of actual parenchymal damage to the glomeruli or kidney tubules. Acute tubular necrosis (ATN), AKI in which there is damage to the kidney tubules, is the most common type of intrinsic AKI. Characteristics of ATN are intratubular obstruction, tubular back leak (abnormal reabsorption of filtrate and decreased urine flow through the tubule), vasoconstriction, and changes in glomerular permeability. These processes result in a decrease of GFR, progressive azotemia, and fluid and electrolyte imbalances.
A patient with end-stage renal failure has made the decision to be put on the kidney transplant waiting list and now eagerly anticipates the possibility of eventually being matched with a donor. How can the patient maximize his chances of being able to undergo a transplant when a kidney becomes available?
Trying to stay free of infections Explanation: Due to the need for immunosuppressant drugs after surgery, the presence of infection negates the possibility of transplantation. A high-protein diet is contraindicated, and withholding prescribed medications is unsafe. Increasing the frequency of dialysis does not influence the chance of successful transplantation.
The client with chronic renal failure complains of intense itching. Which assessment finding would indicate the need for further nursing education?
Brief, hot daily showers Explanation: Hot water removes more oils from the skin and can increase dryness and itching. Tepid water temperature is preferred in the management of pruritus. The use of moisturizing lotions and creams that do not contain perfumes can be helpful. Avoid scratching and keeping nails trimmed short is indicated in the management of pruritus.
A patient admitted with nephrotic syndrome is being cared for on a medical unit. When writing this patient's care plan, what nursing diagnoses should the nurse prioritize?
Excess fluid volume related to excessive protein losses in the urine Explanation: The major clinical manifestations of nephrotic syndrome include edema, so an appropriate nursing diagnosis is excess fluid volume related to generalized edema. Edema is usually soft, pitting, and commonly occurs around the eyes, in dependent areas, and in the abdomen. The other options are incorrect nursing diagnoses for this patient.
The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for?
Hypovolemic shock caused by hemorrhage Explanation: If bleeding goes undetected or is not detected promptly, the patient may lose significant amounts of blood and may experience hypoxemia. In addition to hypovolemic shock due to hemorrhage, this type of blood loss may precipitate a myocardial infarction or transient ischemic attack.
A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
Urine output of 20 ml/hour Explanation: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. A serum potassium level of 4.9 mEq/L, a serum sodium level of 135 mEq/L, and a temperature of 99.2° F are normal assessment findings.
The client with polycystic kidney disease asks the nurse, "Will my kidneys ever function normally again?" The best response by the nurse is:
"As the disease progresses, you will most likely require renal replacement therapy." Explanation: There is no cure for polycystic kidney disease. Medical management includes therapies to control blood pressure, urinary tract infections, and pain. Renal replacement therapy is indicated as the kidneys fail.
Which of the following is the most sensitive indicator of renal function?
Serum creatinine Explanation: Serum creatinine is the more sensitive indicator of renal function because of its constant production in the body.
The nurse is caring for a patient receiving hemodialysis treatments and who has an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient?
Taking a blood pressure reading on the affected arm can cause clotting of the fistula. Explanation: When blood flow is reduced through the access for any reason (hypotension, application of blood pressure cuff or tourniquet), the access can clot. Auscultation of a bruit in the fistula is one way to determine patency. Typically, patients feel fatigued immediately after hemodialysis because of the rapid change in fluid and electrolyte status. Although the area over the fistula may have some decreased sensation, the needle stick is still painful.
One of the roles of the nurse in caring for clients with chronic kidney disease is to help them learn to minimize and manage potential complications. This would include:
restricting sources of potassium. Explanation: The nurse will teach the client to restrict sources of potassium, such as fresh fruits and vegetables, because hyperkalemia can cause life-threatening changes. The client will restrict sodium intake as ordered; doing so prevents fluid accumulation. Prescribed iron and folic acid supplements or Epogen should be taken; iron and folic acid supplements are needed for red blood cell (RBC) production, and Epogen stimulates the bone marrow to produce RBCs. The client will restrict protein intake to foods that are complete proteins within prescribed limits; complete proteins provide positive nitrogen balance for healing and growth.
A client with end-stage renal disease is scheduled to undergo a kidney transplant using a sibling donated kidney. The client asks if immunosuppressive drugs can be avoided. Which is the best response by the nurse?
"Even a perfect match does not guarantee organ success." Explanation: Even a perfect match does not guarantee that a transplanted organ will not be rejected. Immunosuppressive drugs are used in all organ transplants to decrease incidence of organ rejection. To provide the client with the information needed to provide informed consent, the treatment plan is reviewed and discussed prior to transplant.
The nurse is caring for a client who underwent a kidney transplant. The client appears anxious and tearful and states, "My body is going to reject the new kidney; I know I'm going to die." What is the best response by the nurse?
"I understand your concerns, let's talk about them." Explanation: The nurse must address the client's concerns and encourage the client to express any concerns. The rejection of a transplanted kidney is of great concern to the client, the family, and the health care team for many months. An important nursing function is the assessment of the client's stress and coping. The nurse uses each visit with the client to determine if the client and family are coping effectively and if the client is adhering to the prescribed medication regimen. If indicated or requested, the nurse refers the client for counseling. The other responses are non-therapeutic.
After teaching a group of students about how to perform peritoneal dialysis, which statement would indicate to the instructor that the students need additional teaching?
"It is appropriate to warm the dialysate in a microwave." Explanation: The dialysate should be warmed in a commercial warmer and never in a microwave oven. Strict aseptic technique is essential. The infusion clamp is opened during the infusion and clamped after the infusion. When the dwell time is done, the drain clamp is opened and the fluid is allowed to drain by gravity into the drainage bag.
A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which disorder?
Acute glomerulonephritis Explanation: Acute glomerulonephritis is also associated with varicella zoster virus, hepatitis B, and Epstein-Barr virus. Acute renal failure is associated with hypoperfusion to the kidney, parenchymal damage to the glomeruli or tubules, and obstruction at a point distal to the kidney. Chronic renal failure may be caused by systemic disease, hereditary lesions, toxic agents, infections, and medications. Nephrotic syndrome is caused by disorders such as chronic glomerulonephritis, systemic lupus erythematosus, multiple myeloma, and renal vein thrombosis.
A client is in end-stage chronic renal failure and is being added to the transplant list. The nurse explains to the client how donors are found for clients needing kidneys. Which statement is accurate?
Donors are selected from compatible living or deceased donors. Explanation: Donors are selected from compatible living donors. Donors do not have to be relatives as long as they are compatible. Potential donors with a history of hypertension, malignant disease, or diabetes are excluded from donation. Each local hospital does not have its own transplant list, instead the client will be placed on a national computerized transplant waiting list.
A college football player is brought to the emergency room by paramedics after a blunt trauma injury received during game. There is a high suspicion that the patient has sustained an injury to his kidneys from being tackled from behind. The emergency room nurse caring for the patient reviews the initial orders written by the health care provider and notes that an order has been written to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important because:
Hematuria is the most common manifestation of renal trauma, and blood losses may be microscopic, so laboratory analysis is essential. Explanation: Hematuria is the most common manifestation of renal trauma; its presence after trauma suggests renal injury. Hematuria may not occur, or it may be detectable only on microscopic examination. All urine should be saved and sent to the laboratory for analysis to detect red blood cells (RBCs) and to evaluate the course of bleeding. Measuring intake and output is not a function of the laboratory. The laboratory does not save urine to do a creatinine clearance at a later time. The laboratory does not monitor the urine for sodium concentrations.
The nurse is caring for a client who has undergone a nephrectomy. Which assessment finding is most important in determining nursing care for the client?
SpO2 at 90% with fine crackles in the lung bases Explanation: Altered Breathing Pattern and Ineffective Airway Clearance Risk are often challenges in caring for clients postnephrectomy due to location of incision. Nursing interventions should be directed to improve and maintain SpO2 levels at 90% or greater and keep lungs clear of adventitious sounds. Intake and output is monitored to maintain a urine output of greater than 30 mL/hour. Pain control is important and should allow for movement, deep breathing, and rest. Blood-tinged drainage from the JP tube is expected in the initial postoperative period.
Hyperkalemia is a serious side effect of acute renal failure. Identify the electrocardiogram (ECG) tracing that is diagnostic for hyperkalemia.
Tall, peaked T waves Explanation: Characteristic ECG signs of hyperkalemia are tall, tented, or peaked T waves, absent P waves, and a widened QRS complex.
The nurse is providing supportive care to a client receiving hemodialysis in the management of acute kidney injury. Which statement from the nurse best reflects the ability of the kidneys to recover from acute kidney injury?
The kidneys can improve over a period of months. Explanation: The kidneys have a remarkable ability to recover from serious insult. Recovery may take 3 to 12 months. As long as recovery is continuing, there is no need to consider transplant or permanent hemodialysis. Acute kidney injury can progress to chronic renal failure.
A client with chronic renal failure comes to the clinic for a visit. During the visit, he complains of pruritus. Which suggestion by the nurse would be most appropriate?
"Keep your showers brief, patting your skin dry after showering." Explanation: The client with pruritus needs to keep the skin clean and dry. The client should take brief showers with tepid water, pat the skin dry, use moisturizing lotions or creams, and avoid scratching. In addition, the client should use a mild laundry detergent to wash clothes and an extra rinse cycle to remove all detergent or add 1 tsp vinegar per quart of water to the rinse cycle to remove any detergent residue.
The nurse notes that a patient who is retaining fluid had a 1-kg weight gain. The nurse knows that this is equivalent to about how many mL?
1,000 mL Explanation: The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded. A 1-kg weight gain is equal to 1,000 mL of retained fluid.
A nurse cares for an acutely ill client. The nurse understands that the most accurate indicator of fluid loss or gain in an acutely ill client is:
weight. Explanation: The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded. Blood pressure, pulse rate, and edema are not the most accurate indicator of fluid loss or gain.
A patient with end-stage renal disease (ESRD) is scheduled for his first hemodialysis treatment. The patient asks the nurse what common complications may occur from the treatment. What would be the nurse's best reply?
"Low blood pressure and cramping sometimes occur." Explanation: The most common side effects associated with hemodialysis are hypotension and cramping. Confusion is an uncommon complication related to dialysis disequilibrium syndrome, and this condition is not frequently observed with advancing hemodialysis technology. Diarrhea is not a complication related to hemodialysis. High blood sugar levels and low protein levels are complications associated with peritoneal dialysis. Blood loss is a complication related to hemodialysis, but excessive bleeding is not a common complication related to advanced technology and equipment monitors. Double vision is not associated with hemodialysis, but blurry vision may be a manifestation of hypotension.
A client with chronic kidney disease weighs 209 lbs (95 kg) and is prescribed 1.2 grams of protein per kg per day. Which amount of protein will the client ingest per day?
114 Explanation: To calculate the amount of protein the client is to ingest per day, first determine the client's weight in kg by dividing the weight in lbs by 2.2 or 209/2.2 = 95 kg. Then multiply the client's weight in kg by 1.2 or 95 x 1.2 = 114 grams. The client is to ingest 114 grams of protein per day.
A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment?
Start IV fluids with a normal saline solution bolus followed by a maintenance dose. Explanation: The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment should rehydrate the client, causing his blood pressure to rise, his urine output to increase, and the BUN and creatinine levels to normalize. The client wouldn't be able to tolerate oral fluids because of the nausea, vomiting, and diarrhea. The client isn't fluid-overloaded so his urine output won't increase with furosemide, which would actually worsen the client's condition. The client doesn't require dialysis because the oliguria and elevated BUN and creatinine levels are caused by dehydration.
A client with chronic kidney disease reports generalized bone pain and tenderness. Which assessment finding would alert the nurse to an increased potential for the development of spontaneous bone fractures?
Hyperphosphatemia Explanation: Osteodystrophy is a condition in which the bone becomes demineralized due to hypocalcemia and hyperphosphatemia. In an effort to raise blood calcium levels, the parathyroid glands secrete more parathormone. Elevated creatinine, urea, nitrogen, and potassium levels are expected in chronic renal failure and do not contribute to bone fractures.
What is used to decrease potassium level seen in acute renal failure?
Sodium polystyrene sulfonate Explanation: The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.
The nurse weighs a patient daily and measures urinary output every hour. The nurse notices a weight gain of 1.5 kg in a 74-kg patient over 48 hours. The nurse is aware that this weight gain is equivalent to the retention of:
1,500 mL of fluid Explanation: A 1-kg weight gain is equal to 1,000 mL of retained fluid.
Which of the following is a term used to describe excessive nitrogenous waste in the blood, as seen in acute glomerulonephritis?
Azotemia Explanation: The primary presenting features of acute glomerulonephritis are hematuria, edema, azotemia (excessive nitrogenous wastes in the blood), and proteinuria (>3 to 5 g/day). Bacteremia is excessive bacteria in the blood.
A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF?
Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL Explanation: The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. A BUN level of 100 mg/dl and a serum creatinine of 6.5 mg/dl are abnormally elevated results, reflecting CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls within the normal range of 60% to 75%.
A patient admitted with electrolyte imbalance has carpopedal spasm, ECG changes, and a positive Chvostek sign. What deficit does the nurse suspect the patient has?
Calcium Explanation: Calcium deficit is associated with abdominal and muscle cramps, stridor, carpopedal spasm, hyperactive reflexes, tetany, positive Chvostek's or Trousseau's sign, tingling of fingers and around mouth, and ECG changes.
A client requires hemodialysis. Which type of drug should be withheld before this procedure?
Cardiac glycosides Explanation: Cardiac glycosides such as digoxin (Lanoxin) should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digoxin toxicity. Phosphate binders and insulin can be administered because they aren't removed from the blood by dialysis. Some antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects. The nurse should check a formulary to determine whether a particular antibiotic should be administered before or after dialysis.
When caring for the patient with acute glomerulonephritis, which of the following assessment findings should the nurse anticipate?
Cola-colored urine Explanation: Cola-colored urine is a typical symptom of glomerulonephritis. Flank pain on the affected side, not left upper quadrant pain, would be present. Pyuria is a symptom of pyelonephritis, not glomerulonephritis. Blood pressure typically elevates in glomerulonephritis.
A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of:
water and sodium retention secondary to a severe decrease in the glomerular filtration rate. Explanation: The client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys' inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.
A client has end-stage renal failure. Which of the following should the nurse include when teaching the client about nutrition to limit the effects of azotemia?
Increase carbohydrates and limit protein intake. Explanation: Calories are supplied by carbohydrates and fat to prevent wasting. Protein is restricted because the breakdown products of dietary and tissue protein (urea, uric acid, and organic acids) accumulate quickly in the blood.
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem?
White blood cell (WBC) count of 20,000/mm3 Explanation: An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia (evidenced by a blood glucose level of 200 mg/dl) occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.
The nurse recognizes which condition as an integumentary manifestation of chronic renal failure?
Gray-bronze skin color Explanation: Integumentary manifestations of chronic renal failure include a gray-bronze skin color. Other manifestations are dry, flaky skin, pruritus, ecchymosis, purpura, thin, brittle nails, and coarse, thinning hair. Asterixis, tremors, and seizures are neurologic manifestations of chronic renal failure.
Which of the following would the nurse expect to find when reviewing the laboratory test results of a client with renal failure?
Increased serum creatinine level Explanation: In renal failure, laboratory blood tests reveal elevations in BUN, creatinine, potassium, magnesium, and phosphorus. Calcium levels are low. The RBC count, hematocrit, and hemoglobin are decreased.