Renal

A client who is admitted to the hospital with a history of kidney disease begins to have difficulty breathing. Vital signs are as follows: blood pressure, 90/70 mm Hg; heart rate, difficult to feel peripheral pulses. His heart sounds are difficult to hear. Which intervention does the nurse prepare for? a. Administration of digoxin (Lanoxin) b. Draining of pericardial fluid with a needle c. Emergency hemodialysis d. Placement of a pacemaker

ANS: B These signs and symptoms are of cardiac tamponade, an emergency situation in which fluid accumulates in the pericardial sac, making it difficult for the heart to pump normally. Treatment includes a pericardiocentesis, or withdrawing the fluid with a needle or catheter. The other interventions are not appropriate in this situation.

The nurse is providing dietary teaching to a client who was just started on peritoneal dialysis (PD). Which instruction does 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."

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 peritoneal dialysis. The other statements are inaccurate.

A client is admitted to the hospital with a serum creatinine level of 2 mg/dL. When taking the client's history, which question does 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 whether he or she takes any nonprescription drugs can help determine which medication(s) might have contributed to the problem. A family history is important but is not as vital as assessing for nephrotoxic agents that the client may have ingested. Yearly blood work might reveal a trend in kidney function, but again would not be as important. A diet low in protein would not be an important factor to assess.

Which clinical manifestation indicates the need for increased fluids in a client with kidney failure? a. Increased blood urea nitrogen (BUN) b. Increased creatinine level c. Pale-colored urine d. Decreased sodium level

ANS: A An increase in BUN can be an indication of dehydration, and an increase in fluids is needed. Increased creatinine indicates kidney impairment. Urine that is pale in color is diluted; an increase in fluids is not necessary. Sodium is increased, not decreased, with dehydration.

Which client is most at risk for developing postrenal kidney failure? a. Client diagnosed with renal calculi b. Client with congestive heart failure c. Client taking NSAIDs for arthritis pain d. Client recovering from glomerulonephritis

ANS: A Causes of postrenal kidney failure include disorders that obstruct the flow of urine, such as renal calculi. Heart failure can lead to prerenal failure, which is due to decreased blood flow to the kidneys. Both NSAIDs and glomerulonephritis can damage the kidney, leading to intrarenal failure.

When evaluating the effects of a low-protein diet in a client with chronic kidney disease, the nurse is 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

ANS: A Clients with chronic kidney disease are placed on a low-protein diet. However, decreased serum albumin levels indicate that the protein they are taking in is not enough for their metabolic needs. The electrolyte levels in the other options are not related to protein

Which response by a 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 is needed with each exchange." d. "Warmed dialysate infusion increases the speed of flow."

ANS: A Constipation is the primary cause of inflow and outflow problems. To prevent constipation, clients are placed on a bowel regimen before placement of a peritoneal catheter. The drainage bag should be lower than the abdomen. Warming the fluid helps prevent discomfort during the procedure. Flushing the catheter will not facilitate the flow of dialysate.

During a hot summer day, an older adult client tells the clinic nurse, "I am not drinking or voiding that much these days." The nurse notes a heart rate of 100 beats/min and a blood pressure of 90/60 mm Hg. Which action does the nurse take first? a. Give the client something to drink. b. Insert an intravenous catheter. c. Teach the client to drink 2 to 3 liters a day. d. Perform a bladder scan to assess urine volume.

ANS: A Severe blood volume depletion can lead to kidney failure, even in those who have no kidney problem. The client is showing signs of mild volume depletion. The first action the nurse should take is to give the client something to drink. After that, the nurse should teach the client to avoid dehydration by drinking at least 2 to 3 L of fluid daily. The client does not need an IV at this time. Performing a bladder scan will not help prevent or reverse the client's problem.

The nurse assists a client with acute kidney injury (AKI) to modify the diet in which ways? (Select all that apply.) a. Restricted protein b. Liberal sodium c. Restricted fluids d. Low potassium e. Low fat

ANS: A C D Breakdown of protein leads to azotemia and increased blood urea nitrogen. Fluid is restricted during the oliguric stage. Potassium intoxication may occur, so dietary potassium is also restricted. Sodium is restricted during AKI because oliguria causes fluid retention. Fats may be used for needed calories when proteins are restricted.

Which clients are at risk for acute kidney injury (AKI)? (Select all that apply.) a. Football player in preseason practice b. Client who underwent contrast dye radiology c. Accident victim recovering from a severe hemorrhage d. Accountant with diabetes e. Client in the intensive care unit on high doses of antibiotics f. Client recovering from gastrointestinal influenza

ANS: A, B, C, E, F To prevent AKI, all people should be urged to avoid dehydration by drinking at least 2 to 3 liters of fluids daily, especially during strenuous exercise or work associated with diaphoresis, or when recovering from an illness that reduces kidney blood flow, such as influenza. Contrast media may cause acute renal failure, especially in older clients with reduced kidney function. Recent surgery or trauma, transfusions, or other factors that might lead to reduced kidney blood flow may cause AKI. Certain antibiotics may cause nephrotoxicity. Diabetes may cause acute kidney failure superimposed on chronic kidney failure.

A client asks the 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 need to do it only three times a week." d. "You do not need a machine to do it." e. "You will have fewer dietary restrictions."

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 greater 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).

The client is taking a medication for an endocrine problem that inhibits aldosterone secretion and release. To what complications of this therapy should the nurse be alert? A. Dehydration, hypokalemia B. Dehydration, hyperkalemia C. Overhydration, hyponatremia D. Overhydration, hypernatremia

ANS: B Aldosterone is a mineralocorticoid that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss and potassium reabsorption.

When providing care for a client receiving peritoneal dialysis, the nurse notices that the effluent is cloudy. Which intervention is most important for the nurse to carry out? a. Irrigate the peritoneal catheter with saline. b. Send a specimen for culture and sensitivity. c. Document the finding in the client's chart. d. Change the dialysate solution and catheter tubing.

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. Irrigating the catheter or changing the solution and tubing will not help reveal the cause of the problem so that appropriate treatment can be started. Documentation is important but is not the priority.

A client with acute kidney 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 can drink an amount equal to your urine output, plus 500 mL." c. "It is based on your body weight and changes daily." d. "You can drink approximately 2 liters of fluid each day."

ANS: B For clients on dialysis, fluid intake is generally calculated to equal the amount of urine excreted plus 500 to 700 mL.

Which instruction by the nurse will help a client with chronic kidney disease prevent renal osteodystrophy? a. Consuming a low-calcium diet b. Avoiding peas, nuts, and legumes c. Drinking cola beverages only once daily d. Increasing dairy products enriched with vitamin D

ANS: B Kidney failure causes hyperphosphatemia; this client must restrict phosphorus-containing foods such as beans, peas, nuts (peanut butter), and legumes. Calcium should not be restricted; hyperphosphatemia results in a decrease in serum calcium and demineralization of the bone. Cola beverages and dairy products are high in phosphorus, contributing to hypocalcemia and bone breakdown.

A client is receiving continuous arteriovenous hemofiltration (CAVH). Which laboratory value does the nurse monitor most closely? a. Hemoglobin b. Glomerular filtration rate c. Sodium d. White blood cells

ANS: C CAVH is used for clients who have fluid volume overload. It continuously removes large quantities of plasma, water, waste, and electrolytes, such as sodium. Fluid removal can also affect the serum sodium level.

The nurse is caring for a client who is receiving peritoneal dialysis (PD). Which nursing intervention has the greatest priority when a dialysis exchange is performed? a. Adding potassium and antibiotic to the dialysate bags b. Positioning the client on either side c. Using sterile technique when hooking up dialysate bags d. Warming the dialysate fluid in a microwave oven

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. This safety precaution is the priority. Never warm dialysate fluid in the microwave. Positioning the client may help with the flow of fluid. Clients may need additives to their dialysate fluid, but potassium and antibiotics are not added together because interactions between them can reduce the effectiveness of the antibiotic.

A client has been diagnosed with acute postrenal kidney injury. Which assessment finding does the nurse assess most carefully for? a. Blood urea nitrogen (BUN), 35 mg/dL b. Creatinine, 2.5 mg/dL c. Feeling of urgency d. Weight gain and edema

ANS: C Postrenal kidney 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 kidney injury.

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 kidney failure is the client experiencing? a. Intrarenal b. Nonoliguric c. Oliguric d. Postrenal

ANS: C The oliguric phase of acute kidney 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. Intrarenal and postrenal refer to causes of kidney injury. Nonoliguric is not a classification.

A client with chronic kidney disease is scheduled to be given the following medications: digoxin (Lanoxin) and epoetin alfa (Epogen). The client reports nausea and vomiting and wishes to wait to take the medications. Which action by the nurse is most appropriate? a. Administer both medications with soda crackers. b. Allow the client to wait an hour before taking the medications. c. Review today's potassium level and notify the health care provider. d. Call the health care provider to get an order for anti-nausea medication.

ANS: C Clients with kidney 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. Potassium imbalances can alter digoxin levels as well. The nurse should hold the dose, check the current potassium level, and notify the provider. Giving the digoxin could be dangerous, so the nurse should not administer it with crackers, give it later, or ask for an anti-nausea medication.

The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8° F (37.6° C). What is the most appropriate action by the nurse? a. Administer fluid to increase blood pressure. b. Check the white blood cell count. c. Monitor the client's temperature. d. Connect the client to an electrocardiographic (ECG) monitor.

ANS: C During hemodialysis, the dialysate is warmed to increase diffusion and prevent hypothermia. The client's temperature could reflect the temperature of the dialysate. There is no indication to check the white blood cell count or connect the client to an ECG monitor. The other vital signs are within normal limits.

A client has end-stage kidney disease (ESKD). Which food selection by the client demonstrates understanding of a low-sodium, low-potassium diet? a. Bananas b. Ham c. Herbs and spices d. Salt substitutes

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.

The client has an elevated blood urea nitrogen (BUN) level and an increased ratio of blood urea nitrogen to creatinine. What is the nurse's interpretation of these laboratory results? A. The client probably has a urinary tract infection. B. The client may be overhydrated. C. The kidney may be hypoperfused. D. The kidney may be damaged.

ANS: C When dehydration or renal hypoperfusion exist, the BUN level rises more rapidly than the serum creatinine level, causing the ratio to be increased, even when no renal dysfunction is present.

A client who has chronic kidney disease is being discharged from the hospital after receiving treatment for a hip fracture. Which information is most important for the nurse to provide to the client before 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; this makes a client prone to fracture. Increasing protein may not be feasible for a client with chronic kidney disease and would not help prevent fracture. Intake and output will not be helpful for orthopedic problems. Bedrest will promote complications.

Which intervention is most important for the nurse to implement in a client after kidney transplant surgery? a. Promote acceptance of new body image. b. Monitor magnesium levels daily. c. Place the client on protective isolation. d. Remove the indwelling (Foley) catheter as soon as possible.

ANS: D Because of increased risk for infection related to immune suppressive drugs given to prevent rejection, the catheter is removed as soon as possible to avoid infection, usually 3 to 7 days after surgery. The client may need assistance with changes in body image, but this is not the priority. The client does not require protective precautions. Laboratory values will be monitored frequently in a post-transplant client, but this is not as important as preventing a complication by removing the catheter.

A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the client's nose and around the intravenous catheter. What action by the nurse is the priority? a. Hold pressure over the client's nose for 10 minutes. b. Take the client's pulse, blood pressure, and temperature. c. Assess for a bruit or thrill over the arteriovenous fistula. d. Prepare protamine sulfate for administration.

ANS: D Heparin is used with hemodialysis treatments. The bleeding alerts the nurse that too much anticoagulant is in the client's system and protamine sulfate should be administered. Pressure, taking vital signs, and assessing for a bruit or thrill are not as important as medication administration.

A client has end-stage kidney disease (ESKD). The nurse observes tall, peaked T waves on the client's cardiac monitor. Which action by the nurse is best? a. Check the serum potassium level. b. Document the finding in the client's chart. c. Prepare to give sodium bicarbonate. d. Call the health care provider to request an electrocardiogram (ECG).

ANS: A Tall, peaked T waves are a manifestation of hyperkalemia. Thus, the nurse should check the potassium level. Afterward, the nurse should report findings to the provider. The client may need an ECG, but treatment may be based on monitor tracings and potassium levels. Sodium bicarbonate is not warranted. Documentation is important but is not the priority.

A client with acute kidney injury is placed on a fluid restriction. To determine whether outcomes related to fluid balance are being met, the nurse assesses for which finding? a. Absence of lung crackles b. Decreased serum creatinine level c. Decreased serum potassium level d. Increased muscle strength

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. The other options are not related to fluid balance.

What would be the response if a person's nephrons were not able to filter normally due to scarring of the proximal convoluted tubule leading to inhibition of reabsorption? A. Increased urine output, fluid volume deficit B. Decreased urine output, fluid volume deficit C. Increased urine output, fluid volume overload D. Decreased urine output, fluid volume overload

ANS: A The nephrons filter about 120 mL/min. Most of this filtrate is reabsorbed in the proximal convoluted tubule. If the tubule were not able to reabsorb the fluid that has been filtered, urine output would greatly increase, leading to rapid and severe dehydration.

While assisting a client during peritoneal dialysis, the nurse observes the drainage stop after 200 mL of peritoneal effluent drains into the bag. What action should the nurse implement first? a. Instruct the client to deep-breathe and cough. b. Document the effluent as output. c. Turn the client to the opposite side. d. Re-position the catheter.

ANS: C With peritoneal dialysis, usually 1 to 2 L of dialysate is infused by gravity into the peritoneal space. The fluid dwells in the peritoneal cavity for a specified time, then drains by gravity into a drainage bag. The dialyzing fluid is called peritoneal effluent on outflow. The outflow should be a continuous stream after the clamp is completely open. Potential causes of flow difficulty include constipation, kinked or clamped connection tubing, the client's position, fibrin clot formation, and catheter displacement. If inflow or outflow drainage is inadequate, re-position the client to stimulate inflow or outflow. Turning the client to the other side or ensuring that he or she is in good body alignment may help. Instructing the client to deep-breathe and cough will not promote dialysate drainage. Increased abdominal pressure from coughing contributes to leakage at the catheter site. The nurse needs to measure and record the total amount of outflow after each exchange. However, the nurse should re-position the client first to assist with complete dialysate drainage. An x-ray is needed to identify peritoneal dialysis catheter placement. Only the physician re-positions a displaced catheter.

The nurse is caring for a client with chronic kidney disease who has developed uremia. Which assessment finding does the nurse correlate with this problem? a. Decreased breath sounds b. Foul-smelling urine c. Heart rate of 50 beats/min d. Respiratory rate of 40 breaths/min

ANS: D A client with uremia will also have metabolic acidosis. With severe metabolic acidosis, the client will develop hyperventilation, or Kussmaul respirations, as the body attempts to compensate for the falling pH. The other manifestations would not be associated with acidosis.