Chapter 54: Management of Patients With Kidney Disorders

A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately? Serum sodium level of 135 mEq/L Urine output of 20 ml/hour Temperature of 99.2° F (37.3° C) Serum potassium level of 4.9 mEq/L

Urine output of 20 ml/hour 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 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? Butter Cooked white rice Salad oils Citrus fruits

Citrus fruits Foods and fluids containing potassium or phosphorus (e.g., bananas, citrus fruits and juices, coffee) are restricted.

A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF? Increased serum levels of potassium, magnesium, and calcium Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL Uric acid analysis 3.5 mg/dL and phenolsulfonphthalein (PSP) excretion 75% Increased pH with decreased hydrogen ions

Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL 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%.

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 Keeps nails trimmed short Uses moisturizing creams Pats skin dry after bathing

Brief, hot daily showers 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 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? "Let's wait until after the surgery to discuss your treatment plan." "Even a perfect match does not guarantee organ success." "Immunosuppressive drugs guarantee organ success." "The doctor may decide to delay the use of immunosuppressant drugs."

"Even a perfect match does not guarantee organ success." 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.

A client's renal failure has become chronic. Which signs and symptoms are associated with chronic renal failure? Select all that apply. lethargy bleeding of the oral mucous membranes enhanced cognition muscle cramps

** lethargy muscle cramps bleeding of the oral mucous membranes Lethargy, muscle cramps, and bleeding of the oral mucous membranes are some of the signs and symptoms of chronic renal failure. With chronic renal failure, mental processes progressively slow as electrolyte imbalances become marked and nitrogenous wastes accumulate.

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? 500 mL 750 mL 250 mL 1,000 mL

1,000 mL 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.

The nurse is reviewing the potassium level of a patient with kidney disease. The results of the test are 6.5 mEq/L, and the nurse observes peaked T waves on the ECG. What priority intervention does the nurse anticipate the physician will order to reduce the potassium level? Administration of sodium polystyrene sulfonate [Kayexalate]) Administration of a loop diuretic Administration of sodium bicarbonate Administration of an insulin drip

Administration of sodium polystyrene sulfonate [Kayexalate]) 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.

A client has a decreased secretion of erythropoietin from the kidneys due to end-stage kidney disease. What outcome will the decrease in erythropoietin have? Development of male sex characteristics Decrease in blood sugar levels due to alteration in insulin levels Increase in blood sugar levels due to alteration in insulin levels Anemia from the decrease in maturation of red blood cells

Anemia from the decrease in maturation of red blood cells The kidneys secrete erythropoietin, which is a substance that promotes the maturation of red blood cells.

A client who suffered hypovolemic shock during a cardiac incident has developed acute renal failure. Which is the best nursing rationale for this complication? Blood clot formed in the kidneys interfered with the flow Decrease in the blood flow through the kidneys Obstruction of urine flow from the kidneys Structural damage occurred in the nephrons of the kidneys

Decrease in the blood flow through the kidneys Acute renal failure 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.

The nurse recognizes which condition as an integumentary manifestation of chronic renal failure? Gray-bronze skin color Seizures Tremors Asterixis

Gray-bronze skin color 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.

The nurse cares for a client with a right-arm arteriovenous fistula (AVF) for hemodialysis treatments. Which nursing action is contraindicated? Placing the client's watch on the left wrist Obtaining a blood pressure reading from the right arm Obtaining blood samples from the left arm Palpating the fistula for a "thrill"

Obtaining a blood pressure reading from the right arm The nurse assesses the vascular access for patency. The bruit, or "thrill," over the venous access site must be evaluated at least every shift. The nurse takes precautions to ensure that the extremity with the vascular access is not used for measuring blood pressure or for obtaining blood specimens; tight dressings, restraints, or jewelry over the vascular access must be avoided as well.

A nurse who provides care in a high-acuity medical setting is aware of the high incidence and morbidity of acute renal failure (ARF). To reduce patients' risks of developing ARF during their stay in hospital, it is imperative that: Patients' medication regimens be monitored closely Standard precautions be adhered to rigorously Patients be encouraged to ambulate as soon as they are able Tube feeding or parenteral nutrition be initiated for patients who cannot eat

Patients' medication regimens be monitored closely Medications are frequently implicated in cases of hospital-acquired ARF. Malnutrition, lack of infection control, and inactivity are not directly causative of ARF.

A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant? History of hyperparathyroidism Previous episode of acute pyelonephritis Recent history of streptococcal infection History of osteoporosis

Recent history of streptococcal infection Glomerulonephritis can occur as a result of infections from group A beta-hemolytic streptococcal infections, bacterial endocarditis, or viral infections such as hepatitis B or C or human immunodeficiency virus (HIV). A history of hyperparathyroidism or osteoporosis would place the client at risk for developing renal calculi. A history of pyelonephritis would increase the client's risk for chronic pyelonephritis.

Following a nephrectomy, which assessment finding is most important in determining nursing care for the client? Blood tinged drainage in Jackson-Pratt drainage tube SpO2 at 90% with fine crackles in the lung bases Pain of 3 out of 10, 1 hour after analgesic administration Urine output of 35 to 40 mL/hour

SpO2 at 90% with fine crackles in the lung bases The Risk for Ineffective Breathing Pattern is often a challenge 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.

Which of the following is the most accurate indicator of fluid loss or gain? Caloric intake Urine output Body temperature Weight

Weight The most accurate indicator of fluid loss or gain in an acutely ill patient is weight, as accurate intake and output and assessment of insensible losses may be difficult. Urine output, caloric intake, and body temperature would not be the most reliable indicator of fluid loss or gain.

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 important to use strict aseptic technique." "The infusion clamp should be open during infusion." "It is appropriate to warm the dialysate in a microwave." "The effluent should be allowed to drain by gravity."

"It is appropriate to warm the dialysate in a microwave." 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.

Which statement by the client with end-stage renal disease indicates teaching by the nurse was effective? "Ultrafiltration methods take much longer than hemodialysis." "There are few complications with renal replacement therapies." "A special access is created in my vein for peritoneal dialysis." "A family member can help me perform hemodialysis in my home."

"Ultrafiltration methods take much longer than hemodialysis." Ultrafiltration methods (CVVH, CVVHD) are better tolerated by unstable clients as fluid is removed slowly, resulting in mild hemodynamic effects.

A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which disorder? Nephrotic syndrome Chronic renal failure Acute glomerulonephritis Acute renal failure

Acute glomerulonephritis 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, medications, toxic agents, infections, and medications. Nephrotic syndrome is caused by disorders such as chronic glomerulonephritis, systemic lupus erythematosus, multiple myeloma, and renal vein thrombosis.

Which nursing assessment finding indicates that the client who has undergone renal transplant has not met expected outcomes? Fever Absence of pain Weight loss Diuresis

Fever Fever is an indicator of infection or transplant rejection.

The nurse cares for a client after extensive abdominal surgery. The client develops an infection that is treated with IV gentamicin. After 4 days of treatment, the client develops oliguria, and laboratory results indicate azotemia. The client is diagnosed with acute tubular necrosis and transferred to the ICU. The client is hemodynamically stable. Which dialysis method would be most appropriate for the client? Continuous venovenous hemofiltration (CVVH) Hemodialysis Peritoneal dialysis Continuous arteriovenous hemofiltration (CAVH)

Hemodialysis The client is hemodynamically stable and hemodialysis would be most appropriate. Hemodialysis is used for clients who are acutely ill and require short-term dialysis for days to weeks until kidney function resumes and for clients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) who require long-term or permanent renal replacement therapy. Peritoneal dialysis (PD) may be the treatment of choice for clients with renal failure who are unable or unwilling to undergo hemodialysis or kidney transplantation. CAVH and CVVH are used for client who are hemodynamically unstable.

One of the roles of the nurse in caring for clients with chronic renal failure is to help them learn to minimize and manage potential complications. This would include: allowing liberal use of sodium. eating protein liberally. restricting sources of potassium usually found in fresh fruits and vegetables. limiting iron and folic acid intake.

restricting sources of potassium usually found in fresh fruits and vegetables. Restrict sources of potassium usually found in fresh fruits and vegetables; hyperkalemia can cause life-threatening changes. Restrict sodium intake as ordered; doing so prevents excess sodium and fluid accumulation. Prescribed iron and folic acid supplements or Epogen should be taken. Iron and folic acid supplements are needed for RBC production. Epogen stimulates bone marrow to produce RBCs. Restrict protein intake to foods that are complete proteins within prescribed limits. Complete proteins provide positive nitrogen balance for healing and growth.

A male client has doubts about performing peritoneal dialysis at home. He informs the nurse about his existing upper respiratory infection. Which of the following suggestions can the nurse offer to the client while performing an at-home peritoneal dialysis? Wear a mask when performing exchanges. Auscultate the lungs frequently. Perform deep-breathing exercises vigorously. Avoid carrying heavy items.

*** Wear a mask when performing exchanges. The nurse should advise the client to wear a mask while performing exchanges. This prevents contamination of the dialysis catheter and tubing, and is usually advised to clients with upper respiratory infection. Auscultation of the lungs will not prevent contamination of the catheter or tubing. The client may also be advised to perform deep-breathing exercises to promote optimal lung expansion, but this will not prevent contamination. Clients with a fistula or graft in the arm should be advised against carrying heavy items.

A client with chronic renal failure complains of generalized bone pain and tenderness. Which assessment finding would alert the nurse to an increased potential for the development of spontaneous bone fractures? Elevated urea and nitrogen Elevated serum creatinine Hyperphosphatemia Hyperkalemia

Hyperphosphatemia 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.

When assessing a client with chronic glomerulonephritis, the nurse notes that the client has generalized edema. The nurse documents this as which of the following? Periorbital edema Anasarca Hydronephrosis Uremic frost

Anasarca Generalized edema known as anasarca is a common finding with chronic glomerulonephritis. Periorbital edema refers to puffiness around the eyes. Uremic frost is a precipitate that forms on the skin in clients with chronic renal failure. Hydronephrosis refers to a condition involving distention of the renal pelvis.

The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for? Abdominal distention owing to reflex cessation of intestinal peristalsis Hypovolemic shock caused by hemorrhage Paralytic ileus caused by manipulation of the colon during surgery Pneumonia caused by shallow breathing because of severe incisional pain

Hypovolemic shock caused by hemorrhage 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 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 fat intake and limit carbohydrates. Eliminate fat intake and increase protein intake. Increase protein, carbohydrates, and fat intake. Increase carbohydrates and limit protein intake.

Increase carbohydrates and limit protein intake. 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.

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? Risk for infection Impaired urinary elimination Activity intolerance Toileting self-care deficit

Risk for infection The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection.

A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of: a decreased serum phosphate level secondary to kidney failure. water and sodium retention secondary to a severe decrease in the glomerular filtration rate. metabolic alkalosis secondary to retention of hydrogen ions. an increased serum calcium level secondary to kidney failure.

water and sodium retention secondary to a severe decrease in the glomerular filtration rate. 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.