Renal Nurse Labs AKI, CKD, and Dialysis

The nurse is assisting a client on a low-potassium diet to select food items from the menu. Which of the following food items, if selected by the client, would indicate an understanding of this dietary restriction? A. Cantaloupe B. Spinach C. Lima beans D. Strawberries

Correct Answer: C. Lima beans Lima beans (1/3 c) averages three (3) mEq per serving. Each serving of lima beans provides nearly 11 grams of protein—slightly more than other types of beans. Lima beans have a glycemic index (GI) of about 46. (Foods with a GI of 55 or below are considered low glycemic foods.) The glycemic load of a 100-gram serving of lima beans is about 7. Option A: Cantaloupe (1/4 small). Consuming foods rich in potassium can help decrease blood pressure. The American Heart Association (AHA) recommends that an average adult consume 4,700 mg of potassium a day to keep the cardiovascular system healthy. A cup of cantaloupe provides 473 mg of potassium, or 10% of a person's recommended daily intake. Option B: Spinach (1/2 cooked). Spinach provides more potassium per serving than a banana — about 12% of the AI per one cup (156 grams) frozen or three cups (100 grams) fresh. This vegetable also packs vitamins A and K, as well as folate and magnesium. Option D: Strawberries (1 ¼ cups) are high potassium foods and average 7 mEq per serving. Strawberries are rich in vitamin C, potassium, folic acid, and fiber. Due to their high potassium content, strawberries might provide benefits for people who have a raised risk of high blood pressure by helping to offset the effects of sodium in the body.

The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply. A. Excess Fluid Volume B. Imbalanced Nutrition; Less than Body Requirements C. Activity Intolerance D. Impaired Gas Exchange E. Pain

Correct Answer: A, B, & C. Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. Option A: Renal disorder impairs glomerular filtration that results in fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces. Since fluids are not reabsorbed at the venous end, fluid volume overloads the lymph system and stays in the interstitial spaces leading the patient to have edema, weight gain, pulmonary congestion, and HPN at the same time due to decrease GFR, nephron hypertrophied leading to decreased ability of the kidney to concentrate urine and impaired excretion of fluid thus leading to oliguria/anuria. Option B: Due to restricted foods and prescribed dietary regimen, an individual experiencing renal problems cannot maintain ideal body weight and sufficient nutrition. At the same time, patients may experience anemia due to decreased erythropoietic factors that cause a decrease in the production of RBC causing anemia and fatigue. Option C: Assess the extent of weakness, fatigue, ability to participate in active and passive activities. Provides information about the impact of activities on fatigue and energy reserves. Encourage quiet play, reading, watching tv, games during times of fatigue. Provides relaxation, stimulation and requires minimal energy expenditure. Option D: For optimal cell functioning the kidneys excrete potentially harmful nitrogenous products - urea, creatinine, and uric acid. But because of the loss of kidney excretory functions, there is impaired excretion of nitrogenous waste products causing an increase i

What is the appropriate infusion time for the dialysate in your 38 y.o. patient with chronic renal failure undergoing peritoneal dialysis? A. 15 minutes B. 30 minutes C. 1 hour D. 2 to 3 hours

Correct Answer: A. 15 minutes Dialysate should be infused quickly. The dialysate should be infused over 15 minutes or less when performing peritoneal dialysis. The fluid exchange takes place over a period ranging from 30 minutes to several hours. Each exchange takes about 30 to 40 minutes. During an exchange, yothe client can read, talk, watch television, or sleep. With CAPD, the client can keep the solution in the belly for 4 to 6 hours or more. The time that the dialysis solution is in the belly is called the dwell time. Usually, the client changes the solution at least four times a day and sleep with solution in the belly at night Option B: The client's schedule will change as he works his dialysis exchanges into his routine. If he does CAPD during the day, he has some control over when he does the exchanges. However, he'll still need to stop his normal activities and take about 30 minutes to perform an exchange. If he does automated peritoneal dialysis, he'll have to set up his cycler every night. Option C: Between exchanges, the client keeps his catheter and transfer set hidden inside his clothing. At the beginning of an exchange, he'll remove the disposable cap from the transfer set and connect the set to a tube that branches like the letter Y. One branch of the Y-tube connects to the drain bag, while the other connects to the bag of fresh dialysis solution. Option D: With automated peritoneal dialysis, a machine called a cycler fills and empties the belly three to five times during the night. In the morning, the client begins the day with a fresh solution in his belly. He may leave this solution in his belly all day or do one exchange in the middle of the afternoon without the machine. People sometimes call this treatment continuous cycler-assisted peritoneal dialysis or CCPD.

A client receiving hemodialysis treatment arrives at the hospital with a blood pressure of 200/100, a heart rate of 110, and a respiratory rate of 36. Oxygen saturation in room air is 89%. He complains of shortness of breath, and +2 pedal edema is noted. His last hemodialysis treatment was yesterday. Which of the following interventions should be done first? A. Administer oxygen. B. Elevate the foot of the bed. C. Restrict the client's fluids. D. Prepare the client for hemodialysis.

Correct Answer: A. Administer oxygen. Airway and oxygenation are always the first priority. Because the client is complaining of shortness of breath and his oxygen saturation is only 89%, the nurse needs to try to increase his levels by administering oxygen. Evaluate development of tachypnea, dyspnea, increased respiratory effort. Drain dialysate, and notify the physician. Option B: The foot of the bed may be elevated to reduce edema, but this isn't the priority. Turn from side to side, elevate the head of the bed, apply gentle pressure to the abdomen. May enhance outflow of fluid when the catheter is malpositioned and obstructed by the omentum. Option C: Maintain fluid restriction as indicated. Fluid restrictions may have to be continued to decrease fluid volume overload. Monitor BP and pulse, noting hypertension, bounding pulses, neck vein distension, peripheral edema; measure CVP if available. Option D: The client is in pulmonary edema from fluid overload and will need to be dialyzed and have his fluids restricted, but the first interventions should be aimed at the immediate treatment of hypoxia. Alter dialysate regimen as indicated. Changes may be needed in the glucose or sodium concentration to facilitate efficient dialysis.

A patient with ESRD has an arteriovenous fistula in the left arm for hemodialysis. Which intervention do you include in his plan of care? A. Apply pressure to the needle site upon discontinuing hemodialysis. B. Keep the head of the bed elevated 45 degrees. C. Place the left arm on an arm board for at least 30 minutes. D. Keep the left arm dry.

Correct Answer: A. Apply pressure to the needle site upon discontinuing hemodialysis. Apply pressure when discontinuing hemodialysis and after removing the venipuncture needle until all the bleeding has stopped. Bleeding may continue for 10 minutes in some patients. The AV fistula is the safest type of vascular access. It can last for years and is least likely to get infections or blood clots. A surgeon connects an artery (a large blood vessel that carries blood from the heart) and a vein (a blood vessel that carries blood to the heart) under the skin in the arm. Usually, they do the AV fistula in the non-dominant arm. Option B: Remove any restrictive clothing or jewelry from the arm. To prevent injuries, place an armband on the patient or a sign over the bed that says no BP measurements, venipunctures, or injections on the affected side. When blood flow through the vascular access is reduced, it can clot. Option C: Perform hand hygiene before you assess or touch the vascular access. If it's new vascular access with a wound, don gloves. Position the patient's arm so the vascular access is easily visualized. Palpate the vascular access to feel for a thrill or vibration that indicates arterial and venous blood flow and patency. Option D: Check the patient's circulation by palpating his pulses distal to the vascular access; observing capillary refill in his fingers; and assessing him for numbness, tingling, altered sensation, coldness, and pallor in the affected extremity.

You have a patient that is receiving peritoneal dialysis. What should you do when you notice the return fluid is slowly draining? A. Check for kinks in the outflow tubing. B. Raise the drainage bag above the level of the abdomen. C. Place the patient in a reverse Trendelenburg position. D. Ask the patient to cough.

Correct Answer: A. Check for kinks in the outflow tubing. Tubing problems are a common cause of outflow difficulties, check the tubing for kinks and ensure that all clamps are open. Other measures include having the patient change positions (moving side to side or sitting up), applying gentle pressure over the abdomen, or having a bowel movement. Assess the patency of catheter, noting difficulty in draining. Note the presence of fibrin strings and plugs. Slowing of flow rate and presence of fibrin suggests partial catheter occlusion requiring further evaluation and intervention. Option B: Check tubing for kinks; note the placement of bottles and bags. Anchor catheter so that adequate inflow/outflow is achieved. Improper functioning of equipment may result in retained fluid in the abdomen and insufficient clearance of toxins. Option C: Turn from side to side, elevate the head of the bed, apply gentle pressure to the abdomen. May enhance outflow of fluid when the catheter is malpositioned and obstructed by the omentum. Option D: Monitor BP and pulse, noting hypertension, bounding pulses, neck vein distension, peripheral edema; measure CVP if available. Elevations indicate hypervolemia. Assess heart and breath sounds, noting S3 and crackles, rhonchi. Fluid overload may potentiate HF and pulmonary edema.

Which sign indicates the second phase of acute renal failure? A. Daily doubling of urine output (4 to 5 L/day). B. Urine output less than 400 ml/day. C. Urine output less than 100 ml/day. D. Stabilization of renal function.

Correct Answer: A. Daily doubling of urine output (4 to 5 L/day). Daily doubling of the urine output indicates that the nephrons are healing. This means the patient is passing into the second phase (diuresis) of acute renal failure. The GFR is stable albeit at a level determined by the severity of the initial event. This cellular repair and reorganization phase results in slowly improving cellular function and sets the stage for improvement in organ function. Option B: The initiation phase of ATN occurs when renal blood flow (RBF) decreases to a level resulting in severe cellular ATP depletion that in turn leads to acute cell injury and dysfunction. Renal tubular epithelial cell injury is a key feature of the Initiation Phase. Option C: The extension phase is ushered in by two major events: continued hypoxia following the initial ischemic event and an inflammatory response. It is during this phase that renal vascular endothelial cell damage likely plays a key role in the continued ischemia of the renal tubular epithelium, as well as, the inflammatory response observed with ischemic ARF. During this phase, cells continue to undergo injury and death with both necrosis and apoptosis being present predominantly in the outer medulla Option D: During the recovery phase cellular differentiation continues, epithelial polarity is reestablished and normal cellular and organ function returns. Thus, renal function can be directly related to the cycle of cell injury and recovery.

What change indicates recovery in a patient with nephrotic syndrome? A. Disappearance of protein from the urine. B. Decrease in blood pressure to normal. C. Increase in serum lipid levels. D. Gain in body weight.

Correct Answer: A. Disappearance of protein from the urine. With nephrotic syndrome, the glomerular basement membrane of the kidney becomes more porous, leading to loss of protein in the urine. As the patient recovers, less protein is found in the urine. Albumin is a protein that acts like a sponge, drawing extra fluid from the body into the bloodstream where it remains until removed by the kidneys. When albumin leaks into the urine, the blood loses its capacity to absorb extra fluid from the body, causing edema. Option B: Nephrotic syndrome results from a problem with the kidneys' filters, called glomeruli. Glomeruli are tiny blood vessels in the kidneys that remove wastes and excess fluids from the blood and send them to the bladder as urine. Option C: As blood passes through healthy kidneys, the glomeruli filter out the waste products and allow the blood to retain cells and proteins the body needs. However, proteins from the blood, such as albumin, can leak into the urine when the glomeruli are damaged. In nephrotic syndrome, damaged glomeruli allow 3 grams or more of protein to leak into the urine when measured over a 24-hour period, which is more than 20 times the amount that healthy glomeruli allow. Option D: The loss of different proteins from the body can lead to a variety of complications in people with nephrotic syndrome. Blood clots can form when proteins that normally prevent them are lost through the urine. Blood clots can block the flow of blood and oxygen through a blood vessel.

After the first hemodialysis treatment, your patient develops a headache, hypertension, restlessness, mental confusion, nausea, and vomiting. Which condition is indicated? A. Disequilibrium syndrome B. Respiratory distress C. Hypervolemia D. Peritonitis

Correct Answer: A. Disequilibrium syndrome Disequilibrium occurs when excess solutes are cleared from the blood more rapidly than they can diffuse from the body's cells into the vascular system. The dialysis disequilibrium syndrome is defined as a clinical syndrome of neurologic deterioration that is seen in patients who undergo hemodialysis. It is more likely to occur in patients during or immediately after their first treatment but can occur in any patient who receives hemodialysis. Option B: Patients with end-stage renal failure treated by hemodialysis have a marked increased risk for cardiovascular death. These patients have both an accelerated form of arteriosclerosis with calcification in atheromatous intimal plaques and also medial calcification due to Monckeberg's. In extreme cases, soft tissue calcification can lead to calciphylaxis resulting in skin ulceration, amputation, and death. Option C: Having too much water in the body is called fluid overload or hypervolemia. One of the main functions of the kidneys is to balance fluid in the body. If too much fluid builds up in the body, it can have harmful effects on health, such as difficulty breathing and swelling. Option D: Peritonitis is a peritoneal dialysis-related infection caused by bacteria entering the abdomen from outside the body and infecting the peritoneum. Bacteria may enter the body through the open ends of the PD catheter during exchanges.

The nurse assesses the client who has chronic renal failure and notes the following: crackles in the lung bases, elevated blood pressure, and weight gain of 2 pounds in one day. Based on these data, which of the following nursing diagnoses is appropriate? A. Excess fluid volume related to the kidney's inability to maintain fluid balance. B. Increased cardiac output related to fluid overload. C. Ineffective tissue perfusion related to interrupted arterial blood flow. D. Ineffective Therapeutic Regimen Management related to lack of knowledge about therapy.

Correct Answer: A. Excess fluid volume related to the kidney's inability to maintain fluid balance. Crackles in the lungs, weight gain, and elevated blood pressure are indicators of excess fluid volume, a common complication in chronic renal failure. The client's fluid status should be monitored carefully for imbalances on an ongoing basis. Renal disorder impairs glomerular filtration that results in fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces. Option B: The symptoms described do not indicate an increase in cardiac output. Auscultate heart and lung sounds. Evaluate the presence of peripheral edema, vascular congestion, and reports of dyspnea. S3 and S4 heart sounds with muffled tones, tachycardia, irregular heart rate, tachypnea, dyspnea, crackles, wheezes, edema, and jugular distension suggest HF. Option C: For optimal cell functioning the kidneys excrete potentially harmful nitrogenous products - urea, creatinine, and uric acid. But because of the loss of kidney excretory functions, there is impaired excretion of nitrogenous waste products causing an increase in laboratory results of BUN, creatinine, and uric acid. Option D: If fluid retention is a problem, the patient may need to restrict intake of fluid to 1100 cc (or less) and restrict dietary sodium. If a fluid overload is present, diuretic therapy or dialysis will be part of the regimen. Incidence of hypertension is increased in CRF, often requiring management with antihypertensive drugs, necessitating close observation of treatment effects (vascular response to medication).

Immunosuppression following kidney transplantation is continued: A. For life B. 24 hours after transplantation C. A week after transplantation D. Until the kidney is not anymore rejected

Correct Answer: A. For life. After an organ transplant, the client will need to take immunosuppressant (anti-rejection) drugs. These drugs help prevent the immune system from attacking ("rejecting") the donor organ. Typically, they must be taken for the lifetime of the transplanted organ. Organ rejection is a constant threat. Keeping the immune system from attacking the transplanted organ requires constant vigilance. So, it's likely that the transplant team will make adjustments to the anti-rejection drug regimen. Option B: One risk of a kidney transplant is that the body will reject (fight) the new kidney. This can happen if the body's immune system realizes that the kidney is from someone else. To prevent this from happening, the client must take medicines to weaken the immune system. These medicines are called immunosuppressants, or anti-rejection medicines. Option C: Once the client recovered from the transplant surgery, he may be able to start a new exercise routine. Exercise can help improve heart and lung health, prevent weight gain and even improve mood. Talk to the doctor about the types of exercise that are right, how often one should exercise, and for how long. Option D: Though kidney transplants are often successful, there are some cases when they are not. It is possible that the body may refuse to accept the donated kidney shortly after it is placed in the body. It is also possible the new kidney may stop working overtime.

Dialysis allows for the exchange of particles across a semipermeable membrane by which of the following actions? A. Osmosis and diffusion B. Passage of fluid toward a solution with a lower solute concentration C. Allowing the passage of blood cells and protein molecules through it. D. Passage of solute particles toward a solution with a higher concentration.

Correct Answer: A. Osmosis and diffusion Osmosis allows for the removal of fluid from the blood by allowing it to pass through the semipermeable membrane to an area of high concentrate (dialysate), and diffusion allows for passage of particles (electrolytes, urea, and creatinine) from an area of higher concentration to an area of lower concentration. Option B: Fluid passes to an area with a higher solute concentration. During osmosis, fluid moves from areas of high water concentration to lower water concentration across a semipermeable membrane until equilibrium. Option C: The pores of a semipermeable membrane are small, thus preventing the flow of blood cells and protein molecules through it. Dialysis removes the waste products and extra fluid from the blood by filtering them through a membrane/filter, similar to the way healthy kidneys would. During dialysis, blood is on one side of the membrane/filter and a special fluid called dialysate (containing water, electrolytes, and minerals) is on the other. Small waste products in the blood flow through the membrane/filter and into the dialysate. Option D: During diffusion, particles in the areas of high concentration move towards the area of low concentration. In dialysis, waste in the blood moves towards dialysate, which is a drug solution that has none (or very little waste). The amount of waste removed depends on the size of the waste, the size of the pores (holes) in the membrane, what the dialysate is made of, and, like a tea, the length of treatment.

A client is admitted to the hospital and has a diagnosis of early-stage chronic renal failure. Which of the following would the nurse expect to note on assessment of the client? A. Polyuria B. Polydipsia C. Oliguria D. Anuria

Correct Answer: A. Polyuria Polyuria occurs early in chronic renal failure and if untreated can cause severe dehydration. Polyuria progresses to anuria, and the client loses all normal functions of the kidney. It is suggested that at this stage of chronic renal failure the mechanism of a diuresis increase is not due to osmotic diuresis but rather to secretion of prostaglandin E2 which inhibits cation reabsorption and stimulates diuresis. Option B: Polydipsia is unrelated to chronic renal failure. Polydipsia is the term given to excessive thirst and is one of the initial symptoms of diabetes. It is also usually accompanied by temporary or prolonged dryness of the mouth. Option C: In patients with acute oliguria, one of the most common functional derangements that are observed is the sudden fall in the GRF, leading to acute renal failure. It results in rapid increment in plasma urea and creatinine levels, metabolic acidosis with hyperkalemia, other electrolyte abnormalities, and volume overload. Option D: Anuria is not an early sign. When loss of kidney function is mild or moderately severe, the kidneys cannot absorb water from the urine to reduce the volume of urine and concentrate it. Later, the kidneys have less ability to excrete the acids normally produced by the body and the blood becomes more acidic, a condition called acidosis.

You're developing a care plan with the nursing diagnosis risk for infection for your patient that received a kidney transplant. A goal for this patient is to: A. Remain afebrile and have negative cultures. B. Resume normal fluid intake within 2 to 3 days. C. Resume the patient's normal job within 2 to 3 weeks. D. Try to discontinue cyclosporine (Neoral) as quickly as possible.

Correct Answer: A. Remain afebrile and have negative cultures. The immunosuppressive activity of cyclosporine places the patient at risk for infection, and steroids can mask the signs of infection. The patient's BUN creatinine ratio, magnesium levels, and blood pressure require monitoring while on therapy. Uric acid monitoring is debatable. Therapeutic monitoring of cyclosporine in transplant patients is a valuable tool in adjusting drug dosage to prevent acute rejection, nephrotoxicity, and predictable dose-dependent adverse reactions. Option B: The patient may not be able to resume normal fluid intake or return to work for an extended period of time and the patient may need cyclosporine therapy for life. The range between effective cyclosporine concentrations and the concentrations associated with serious toxicity is fairly narrow. Sub-optimal doses or concentrations can lead to therapeutic failure or severe toxicity. Option C: Patients on cyclosporine are at a slight risk of lymphoproliferative malignancies and infections; thus, a thorough history and physical exam are vital at each clinic visit. Cyclosporine therapy has a much higher opportunity for patient success with the communication and collaboration of an interprofessional healthcare team. Option D: In solid organ transplantation, it has clinical use for the treatment of organ rejection in kidney, liver, and heart allogeneic transplants. Cyclosporine is subject to therapeutic monitoring based on pharmacokinetics measures. The medication has low-to-moderate within-subject variability.

Which criterion is required before a patient can be considered for continuous peritoneal dialysis? A. The patient must be hemodynamically stable. B. The vascular access must have healed. C. The patient must be in a home setting. D. Hemodialysis must have failed.

Correct Answer: A. The patient must be hemodynamically stable. Hemodynamic stability must be established before continuous peritoneal dialysis can be started. Starting dialysis with a PDC is preferable to an HDC in terms of patient morbidity, mortality, and cost. It has also been shown in large observational retrospective studies that there is a survival advantage for PD over HD in the first 1 to 3 years of dialysis. Option B: Patients selected for PD will undergo PD catheter placement using one of the several techniques described above. Once the catheter has healed, they undergo technique training at a dialysis unit for 2 to 3 weeks, learning the proper aseptic technique to use the catheter for dialysis. Option C: Peritoneal dialysis is one of the modalities utilized for dialysis. There are several advantages of PD versus HD. Patients using PD will not need to leave home every other day to get dialysis, rather they perform their treatments at home using a very simple principle for removing toxins from their body. Option D: The 2013 Annual Data Report from the United States Renal Data System also shows a significantly improved adjusted probability of 5-year survival with PD compared to HD. This early survival, for the most part, may be explained by selection bias because healthier patients may be more likely to choose PD as their modality. Patients with comorbid conditions tend to start HD after an acute illness and have high early mortality that is wrongly attributed to their HD modality.

You expect a patient in the oliguric phase of renal failure to have a 24 hour urine output less than: A. 200ml B. 400ml C. 800ml D. 1000ml

Correct Answer: B. 400ml Oliguria is defined as urine output of less than 400ml/24hours. Renal causes of oliguria arise as a result of tubular damage. As a result of the tubular damage, the kidney loses its normal function i.e., production of urine while excreting the waste metabolites. In addition to this, direct damage to the renal tubules leads to a back leak of filtered uremic metabolites from the tubular lumen into the bloodstream. Hence, in these cases, decreased production of urine leads to oliguria. Option A: The most common prerenal cause is reduced blood flow to the kidney secondary to intravascular volume depletion, heart failure, sepsis, or as a side effect of medication. Oliguria secondary to prerenal causes usually resolves with the restoration of normal renal perfusion. Option C: As a result of the decreased renal blood flow, various neurohormonal pathways are activated that result in the increased production of renin, angiotensin, aldosterone as well as catecholamines, and prostaglandins. Activation of these pathways leads to increased water and salt reabsorption resulting in the production of low quantities of concentrated urine while maintaining adequate glomerular filtration rate (GFR) and renal blood flow (RBF) to meet the metabolic requirements of the kidneys. Option D: Oliguria can arise as a result of the normal physiological response of the body or due to an underlying pathology affecting the kidney or urinary tract. The human body has a normal physiological mechanism of conserving fluids and electrolytes in episodes of hypovolemia. These mechanisms are under close neurohormonal control and are completely reversible without any subsequent injury to the kidneys.

A 30 y.o. female patient is undergoing hemodialysis with an internal arteriovenous fistula in place. What do you do to prevent complications associated with this device? A. Insert I.V. lines above the fistula. B. Avoid taking blood pressures in the arm with the fistula. C. Palpate pulses above the fistula. D. Report a bruit or thrill over the fistula to the doctor.

Correct Answer: B. Avoid taking blood pressures in the arm with the fistula. Don't take blood pressure readings in the arm with the fistula because the compression could damage the fistula. Do not let anyone put a blood pressure cuff on the access arm. An AV fistula causes extra pressure and extra blood to flow into the vein, making it grow large and strong. The larger vein provides easy, reliable access to blood vessels. Without this kind of access, regular hemodialysis sessions would not be possible. Option A: IV lines shouldn't be inserted in the arm used for hemodialysis. Untreated veins cannot withstand repeated needle insertions, because they would collapse the way a straw collapses under strong suction. Option C: Palpate pulses below the fistula. Ensuring to check the access for signs of infection or problems with blood flow before each hemodialysis treatment, even if the patient is inserting the needles. Watch for and report signs of infection, including redness, tenderness, or pus. Option D: Lack of bruit or thrill should be reported to the doctor. Check the thrill in the access every day. The thrill is the rhythmic vibration a person can feel over the vascular access. Do not wear jewelry or tight clothes over the access site. Do not sleep with the access arm under the head or body.

Your patient becomes restless and tells you she has a headache and feels nauseous during hemodialysis. Which complication do you suspect? A. Infection B. Disequilibrium syndrome C. Air embolism D. Acute hemolysis

Correct Answer: B. Disequilibrium syndrome Disequilibrium syndrome is caused by a rapid reduction in urea, sodium, and other solutes from the blood. This can lead to cerebral edema and increased intracranial pressure (ICP). Signs and symptoms include headache, nausea, restlessness, vomiting, confusion, twitching, and seizures. Option A: Patients who undergo dialysis treatment have an increased risk for getting an infection. Hemodialysis patients are at high risk for infection because the process of hemodialysis requires frequent use of catheters or insertion of needles to access the bloodstream. Option C: Air embolism during renal dialysis is extremely rare because of the safeguards built into the apparatus and procedures currently used. Air enters the circuit through the infusion bottle, the heparin syringe or line, or the blood pump insert. Emergency treatment with posture, oxygen, dextran infusion, and dexamethasone was apparently successful in reversing some of the manifestations. Prevention depends partly on better design of equipment and partly on the incorporation in the hemodialysis circuit of devices which detect air and prevent it from reaching the patient. Option D: Uncommonly, patients on dialysis can have severe (at times life-threatening) hemolysis. These patients fit into either of two categories, depending on whether hemolysis involves all or the majority of the patients being dialyzed under similar circumstances in a given dialysis center or whether the hemolysis is patient specific. Hemolysis in the former is often the result of water-borne toxins, centralized dialysis equipment failure, or blood tubing defects—whereas in the latter it results from medication or possibly inadequate dialytic therapy.

The most common early sign of kidney disease is: A. Sodium retention B. Elevated BUN level C. Development of metabolic acidosis D. Inability to dilute or concentrate urine

Correct Answer: B. Elevated BUN level Increased BUN is usually an early indicator of decreased renal function. Although, immediately after a renal insult, blood urea nitrogen (BUN) or creatinine levels may be within the normal range. The only sign of the acute kidney injury may be a decline in urine output. AKI can lead to the accumulation of water, sodium, and other metabolic products. It can also result in several electrolyte disturbances. Option A: Evaluation of AKI should include a thorough search for all possible etiologies of AKI, including prerenal, renal, and post renal disease. The timing of the onset of AKI can be especially helpful when dealing with hospitalized patients. For example, if a patient's labs are being checked every day and creatinine suddenly starts to rise on the fourth day of admission then an inciting factor can usually be found in 24-48 hours preceding the onset. Option C: The impetus for glomerular filtration is the difference in the pressures between the glomerulus and the Bowman space. This pressure gradient is affected by the renal blood flow and is under the direct control of the combined resistances of afferent and efferent vascular pathways. Nevertheless, whatever the cause of AKI, renal blood flow reduction is a common pathologic pathway for declining glomerular filtration rate. Option D: The prerenal form of AKI is because of any cause of reduced blood flow to the kidney. This may be part of systemic hypoperfusion resulting from hypovolemia or hypotension, or maybe due to selective hypoperfusion to the kidneys, such as those resulting from renal artery stenosis and aortic dissection.

What is the priority nursing diagnosis with your patient diagnosed with end-stage renal disease? A. Activity intolerance B. Fluid volume excess C. Knowledge deficit D. Pain

Correct Answer: B. Fluid volume excess Fluid volume excess because the kidneys aren't removing fluid and wastes. The other diagnoses may apply, but they don't take priority. Renal disorder impairs glomerular filtration that results in fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces. Option A: Schedule care and provide rest periods following an activity; allow the client to set own limits in the amount of exertion tolerated. Promotes autonomy and control of situations as the presence of a chronic disease may encourage independence. Option C: Review disease process and prognosis and future expectations. Provides a knowledge base from which the patient can make informed choices. If fluid overload is present, diuretic therapy or dialysis will be part of the regimen. Option D: Perform a comprehensive assessment of pain (location, onset, characteristics, and frequency) to be able to compare changes from previous reports to rule out worsening of underlying condition/developing complications.

What is the most important nursing diagnosis for a patient in end-stage renal disease? A. Risk for injury B. Fluid volume excess C. Altered nutrition: less than body requirements D. Activity intolerance

Correct Answer: B. Fluid volume excess Kidneys are unable to rid the body of excess fluids which results in fluid volume excess during ESRD. Renal disorder impairs glomerular filtration that results in fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces. Since fluids are not reabsorbed at the venous end, fluid volume overloads the lymph system and stays in the interstitial spaces. Option A: Assess I&O, electrolyte panel, and creatinine; administer diuretics as ordered. Provides an indication of renal function affecting output with water and electrolyte retention as the disease progresses and nephrons are destroyed. Option C: Due to restricted foods and prescribed dietary regimen, an individual experiencing renal problems cannot maintain ideal body weight and sufficient nutrition. At the same time, patients may experience anemia due to decreased erythropoietic factors that cause a decrease in the production of RBC causing anemia and fatigue. Option D: Assess the extent of weakness, fatigue, ability to participate in active and passive activities. Provides information about the impact of activities on fatigue and energy reserves. Schedule care and provide rest periods following an activity; allow the client to set their own limits in the amount of exertion tolerated.

Which cause of hypertension is the most common in acute renal failure? A. Pulmonary edema B. Hypervolemia C. Hypovolemia D. Anemia

Correct Answer: B. Hypervolemia Acute renal failure causes hypervolemia as a result of overexpansion of extracellular fluid and plasma volume with the hypersecretion of renin. Therefore, hypervolemia causes hypertension. Fluid overload leads to endothelial dysfunction due to inflammation and ischemia-reperfusion injury, causing damage to glycocalyx and capillary leakage. Capillary leakage leads to interstitial edema and at the same time, due to significant loss of volume to the interstitial compartment, there is reduction in circulating intravascular volume. This may then lead to reduction in renal perfusion pressure and subsequently to AKI. Option A: Interstitial edema leads to impairment in the diffusion of oxygen and metabolites from capillaries to tissues. Interstitial edema increases tissue pressure and leads to obstruction of lymphatic drainage and disturbance in cell-to-cell interaction, which will lead to progressive organ failure. The kidney's ability to accommodate increasing hydrostatic interstitial pressures is limited due to renal capsule, and thus all these effects are more prominently seen in the kidney. Option C: Fluid overload is also known to cause distension of atria and stretching of vessel walls, causing a release of ANP, which further leads to EGL damage, and cascade leads to AKI. Massive fluid resuscitation and positive fluid balance are known risk factors for intra-abdominal hypertension (IAH) development. Elevated IAP leads to compression of intra-abdominal vessels causing compromised microvascular blood flow and increased renal venous congestion. This results in impaired renal plasma flow and decreased glomerular filtration rate, causing AKI. Option D: Acute kidney injury can be classified based on the causative factor into intrinsic renal, prerenal, and postrenal AKI. Prerenal causes contri

Which statement correctly distinguishes renal failure from prerenal failure? A. With prerenal failure, vasoactive substances such as dopamine (Intropin) increase blood pressure. B. With prerenal failure, there is less response to such diuretics as furosemide (Lasix). C. With prerenal failure, an IV isotonic saline infusion increases urine output. D. With prerenal failure, hemodialysis reduces the BUN level.

Correct Answer: C. With prerenal failure, an IV isotonic saline infusion increases urine output. Prerenal failure is caused by such conditions as hypovolemia that impairs kidney perfusion; giving isotonic fluids improves urine output. Vasoactive substances can increase blood pressure in both conditions. The cells in the macula densa are sensitive to the increased delivery of NaCl and activate Type 2 adenosine receptors resulting in vasoconstriction of the glomerular arterioles and retraction of glomerular tufts. As a consequence urine output is decreased and urinary excretion of sodium is reduced providing a diagnostic flag of the tubular ischemic process. Option A: In other clinical scenarios, renal hypoperfusion can be present even in the presence of normal blood pressure. Normotensive patients are predisposed to renal hypoperfusion when intrinsic renal structural changes from premorbid conditions interfere with the reserve mechanisms, or extrinsic factors impair the compensatory mechanisms. Option B: Under normal circumstances, almost 80% of the NaCl is reabsorbed by the end of the thick ascending limb of Henle's loop. If there is a failure in the tubular reabsorption mechanism, more NaCl will reach this point. Loop diuretics reduce effective intravascular volume and impair the autoregulatory mechanism by interfering with the reabsorption of NaCl by the macula densa cells. Option D: The most important parameter to distinguish prerenal failure secondary to volume depletion or hypotension from ATN is the response to the fluid expansion. The return of the renal function to the previous baseline within 24 to 72 hours is considered to represent prerenal disease, whereas persistent renal failure is called ATN.

Your patient is complaining of muscle cramps while undergoing hemodialysis. Which intervention is effective in relieving muscle cramps? A. Increase the rate of dialysis. B. Infuse normal saline solution. C. Administer a 5% dextrose solution. D. Encourage active ROM exercises.

Correct Answer: B. Infuse normal saline solution Treatment includes administering normal saline or hypertonic normal saline solution because muscle cramps can occur when the sodium and water are removed too quickly during dialysis. Saline and/or dextrose solutions, electrolytes, and NaHCO3 may be infused in the venous side of continuous arteriovenous (CAV) hemofilter when high ultrafiltration rates are used for removal of extracellular fluid and toxic solutes. Volume expanders may be required during or following hemodialysis if sudden or marked hypotension occurs. Option A: Reducing the rate of dialysis, not increasing it, may alleviate muscle cramps. The central role of volume removal as the trigger for susceptible patients seems evident from the fact that intradialytic cramps are usually associated with hypotension and that prompt correction of hypotension by saline administration and discontinuation of ultrafiltration often improve the cramping. Option C: Most patients surveyed (76%) reported that fluid removal by dialysis was decreased, was stopped, and/or fluid was given back as the main intervention used to alleviate their cramps. When asked about all interventions to alleviate dialysis cramps, the most frequent response (29%) was a combination of decreasing fluid removal, raising the lower extremities, and massaging the extremities. Option D: Avoid trauma to shunt. Handle tubing gently, maintain cannula alignment. Limit activity of extremity. Avoid taking BP or drawing blood samples in shunt extremity. Instruct the patient not to sleep on the side with shunt or carry packages, books, purse on affected extremity.

A patient with diabetes mellitus and renal failure begins hemodialysis. Which diet is best on days between dialysis treatments? A. Low-protein diet with unlimited amounts of water. B. Low-protein diet with a prescribed amount of water. C. No protein in the diet and use of a salt substitute D. No restrictions.

Correct Answer: B. Low-protein diet with a prescribed amount of water The patient should follow a low-protein diet with a prescribed amount of water. The patient requires some protein to meet metabolic needs. Protein can help keep healthy blood protein levels and improve health. Protein also helps keep the muscles strong, helps wounds heal faster, strengthens the immune system, and helps improve overall health. Option A: Learn how much fluid you can safely drink (including coffee, tea, water, and any food that is liquid at room temperature). Diet is an important part of the treatment. The kidneys cannot get rid of enough waste products and fluids from the blood and the body now has special needs. Therefore, the client will need to limit fluids and change the intake of certain foods in the diet. Option C: Salt substitutes shouldn't be used without a doctor's order because it may contain potassium, which could make the patient hyperkalemic. Use less salt and eat fewer salty foods: This may help to control blood pressure. It may also help reduce fluid weight gains between dialysis sessions since salt increases thirst and causes the body to retain (or hold on to) fluid. Option D: Fluid and protein restrictions are needed. At first the kidney and diabetic diet appear to be very different, but they are alike in many ways. Both diets recommend eating 3 balanced meals, avoiding large amounts of protein, and limiting sodium. A balanced meal has at least 3 of the food groups (protein, grain, vegetables, fruits, and dairy). The kidney diet limits the amount of milk that you drink, but many people with diabetes already limit milk to 4 ounces a day.

A nurse is assessing the patency of an arteriovenous fistula in the left arm of a client who is receiving hemodialysis for the treatment of chronic renal failure. Which finding indicates that the fistula is patent? A. Absence of bruit on auscultation of the fistula. B. Palpation of a thrill over the fistula. C. Presence of a radial pulse in the left wrist. D. Capillary refill time less than 3 seconds in the nail beds of the fingers on the left hand.

Correct Answer: B. Palpation of a thrill over the fistula. The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. Thrill is caused by turbulence of high-pressure arterial blood flow entering a low-pressure venous system and should be palpable above the venous exit site. Option A: The presence of a thrill and bruit indicate patency of the fistula. Bruit is the sound caused by the turbulence of arterial blood entering the venous system and should be audible by stethoscope, although may be very faint. Option C: The presence of a radial pulse does not assess the patency of the fistula. Monitor temperature. Note presence of fever, chills, hypotension. Signs of infection or sepsis requiring prompt medical intervention. Option D: Although capillary refill time of less than 3 seconds in the nail beds of the fingers on the left hand are normal findings; they do not assess fistula patency. Evaluate reports of pain, numbness, or tingling; note extremity swelling distal to access. May indicate inadequate blood supply.

A client is diagnosed with chronic renal failure and told she must start hemodialysis. Client teaching would include which of the following instructions? A. Follow a high potassium diet. B. Strictly follow the hemodialysis schedule. C. There will be a few changes in your lifestyle. D. Use alcohol on the skin and clean it due to integumentary changes.

Correct Answer: B. Strictly follow the hemodialysis schedule. To prevent life-threatening complications, the client must follow the dialysis schedule. Compliance in hemodialysis patients is most often measured by monitoring levels of blood urea nitrogen, potassium, and phosphorus and by observing the amount of weight gain between dialysis treatments. The most compliant patients tend to be married, skilled professionals with a high level of self-concept. Option A: The client should follow a low-potassium diet because potassium levels increase in chronic renal failure. In regimens requiring alterations of critical behavior, such as diet, changes should be made one at a time, with the next objective being added only after the patient has demonstrated adequate knowledge of the preceding step. Option C: The client should know hemodialysis is time-consuming and will definitely cause a change in his or her current lifestyle. To improve compliance, health professionals need to assess fully the educational level and understanding of the patient. Option D: Alcohol would further dry the client's skin more than it already is. Compliance with dietary, fluid, and medication instruction is a critically significant factor in the continued health and well-being of the patient undergoing chronic hemodialysis.

In planning teaching strategies for the client with chronic renal failure, the nurse must keep in mind the neurologic impact of uremia. Which teaching strategy would be most appropriate? A. Providing all needed teaching in one extended session. B. Validating frequently the client's understanding of the material. C. Conducting a one-on-one session with the client. D. Using videotapes to reinforce the material as needed.

Correct Answer: B. Validating frequently the client's understanding of the material. Uremia can cause decreased alertness, so the nurse needs to validate the client's comprehension frequently. Assess the extent of impairment in thinking ability, memory, and orientation. Note attention span. Uremic syndrome's effect can begin with minor confusion, irritability, and progress to altered personality or inability to assimilate information and participate in care. Awareness of changes provides opportunity for evaluation and intervention. Option A: Because the client's ability to concentrate is limited, short lessons are most effective. Communicate information and instructions in simple, short sentences. Ask direct, yes, or no questions. Repeat explanations as necessary. May aid in reducing confusion, and increases the possibility that communications will be understood and remembered. Option C: If family members are present at the sessions, they can reinforce the material. Provide SO with information about the patient's status. Some improvement in mentation may be expected with the restoration of more normal levels of BUN, electrolytes, and serum pH. Option D: Written materials that the client can review are superior to videotapes, because the clients may not be able to maintain alertness during the viewing of the videotape. Provide a quiet or calm environment and judicious use of television, radio, and visitation. Minimizes environmental stimuli to reduce sensory overload and confusion while preventing sensory deprivation.

The client with chronic renal failure is at risk of developing dementia-related to excessive absorption of aluminum. The nurse teaches that this is the reason that the client is being prescribed which of the following phosphate binding agents? A. aluminum hydroxide (Alu-cap) B. calcium carbonate (Tums) C. aluminum hydroxide (Amphojel) D. aluminum hydroxide (Basaljel)

Correct Answer: B. calcium carbonate (Tums) Phosphate binding agents that contain aluminum include Alu-caps, Basaljel, and Amphojel. These products are made from aluminum hydroxide. Tums are made from calcium carbonate and also bind phosphorus. Tums are prescribed to avoid the occurrence of dementia-related to a high intake of aluminum. Phosphate binding agents are needed by the client in renal failure because the kidneys cannot eliminate phosphorus. Option A: Aluminum hydroxide [Al(OH)3] dissociates into Al3+ and OH- in the stomach. The freed hydroxide groups then bind to free protons, ultimately producing water and insoluble aluminum salts, mostly Al(Cl)3, within the stomach. The proton binding serves to increase the overall pH of the stomach, i.e., less acidic, reducing the symptoms of indigestion. Option C: Aluminum hydroxide is often administered orally for the temporary relief of heartburn or gastroesophageal reflux. It may be used topically, temporarily, to protect and relieve chafed and abraded skin, minor wounds and burns, and skin irritations resulting from friction and rubbing. Option D: Aluminum exists at a steady state within the body, so the body manages transient increases in aluminum uptake from use as an antacid with an equivalent increase in urinary excretion of unmodified aluminum. However, the setpoint of that steady-state may become elevated with prolonged increased intake of aluminum, so aluminum hydroxide treatment should not be considered as a long-term solution for patients suffering from acid indigestion.

A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the dwell clamp is opened to allow the dialysate to drain. The nurse notes that the drainage has stopped and only 500 ml has drained; the amount the dialysate instilled was 1,500 ml. Which of the following interventions would be done first? A. Change the client's position. B. Call the physician. C. Check the catheter for kinks or obstruction. D. Clamp the catheter and instill more dialysate at the next exchange time.

Correct Answer: C. Check the catheter for kinks or obstruction. The first intervention should be to check for kinks and obstructions because that could be preventing drainage. Peritoneal catheter outflow problems are common and many PD patients transfer to hemodialysis because of catheter related issues. Peritoneal outflow failure can be defined as the incomplete recovery of instilled dialysate consistently within 45 minutes of beginning a drain. Option A: After checking for kinks, have the client change position to promote drainage. Check tubing for kinks; note placement of bottles and bags. Anchor catheter so that adequate inflow/outflow is achieved. Improper functioning of equipment may result in retained fluid in the abdomen and insufficient clearance of toxins. Option B: If unable to get more output despite checking for kinks and changing the client's position, the nurse should then call the physician to determine the proper intervention. Evaluate the development of tachypnea, dyspnea, increased respiratory effort. Drain dialysate, and notify the physician. Abdominal distension and diaphragmatic compression may cause respiratory distress. Option D: Don't give the next scheduled exchange until the dialysate is drained because abdominal distention will occur unless the output is within parameters set by the physician. Alter dialysate regimen as indicated. Changes may be needed in the glucose or sodium concentration to facilitate efficient dialysis

Polystyrene sulfonate (Kayexalate) is used in renal failure to: A. Correct acidosis. B. Reduce serum phosphate levels. C. Exchange potassium for sodium. D. Prevent constipation from sorbitol use.

Correct Answer: C. Exchange potassium for sodium. In renal failure, patients become hyperkalemic because they can't excrete potassium in the urine. Polystyrene sulfonate acts to excrete potassium by pulling potassium into the bowels and exchanging it for sodium. Sodium polystyrene sulfonate helps by removing extra potassium from the body. Due to its slow onset of action, it is a second-line agent in emergent situations. Data on the non-FDA approved use of this drug is limited. This drug can also help to remove excess calcium, sodium from solutions in technical applications. Option A: Sodium polystyrene sulfonate (SPS) is an insoluble polymer cation-exchange resin. After ingestion of oral formulation or application through the rectal route, this resin exchanges sodium with potassium ions from the intestinal cells. Then the potassium binds with SPS, continues to move through the gastrointestinal tract, and is finally eliminated in the feces. But sodium polystyrene sulfonate is not selective for potassium; it may bind with calcium and magnesium. Option B: The exchange capacity of SPS is approximately 33% or 1 mEq of potassium per 1 gram of resin, and this number is not constant. It may be as low as 0.4 to 0.8 mEq/gram of SPS resin. Competition from other cations, especially sodium, calcium, and magnesium, contributes to this reduction of this exchange capacity. Option D: Clinicians should not use SPS in patients who have abnormal bowel functions, such as bowel obstruction, Ileus, and postoperative patients. Using SPS in these patients may increase the risk of bowel ischemia, necrosis, and serious constipation.

You suspect kidney transplant rejection when the patient shows which symptoms? A. Pain in the incision, general malaise, and hypotension. B. Pain in the incision, general malaise, and depression. C. Fever, weight gain, and diminished urine output. D. Diminished urine output and hypotension.

Correct Answer: C. Fever, weight gain, and diminished urine output. Symptoms of rejection include fever, rapid weight gain, hypertension, pain over the graft site, peripheral edema, and diminished urine output. Kidney transplantation is the treatment of choice in patients with end-stage renal disease or severe chronic kidney disease as it improves the quality of life and has better survival advantages compared to dialysis. Various factors merit consideration to match the donor kidney with the recipient, as the donor kidney acts as an alloantigen. Option A: In general, when transplanting tissue or cells from a genetically different donor to the graft recipient, the alloantigen of the donor induces an immune response in the recipient against the graft. This response can destroy the graft if not controlled. The whole process is called allograft rejection. Option B: Most patients who have acute rejection episodes are asymptomatic and have abnormal allograft dysfunction evidence from the routine blood workups; when there is a sudden rise of serum creatinine to more than 25% of the baseline value, the clinicians should suspect allograft rejection. Option D: Even when the creatinine is not trending down as expected in the early post-transplant phase, the possibility of rejection should be a consideration. Any new-onset or worsening proteinuria and new-onset or worsening hypertension should raise the suspicion for rejection.

The nurse helps the client with chronic renal failure develop a home diet plan with the goal of helping the client maintain adequate nutritional intake. Which of the following diets would be most appropriate for a client with chronic renal failure? A. High carbohydrate, high protein B. High calcium, high potassium, high protein C. Low protein, low sodium, low potassium D. Low protein, high potassium

Correct Answer: C. Low protein, low sodium, low potassium Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. Reducing sodium in the diet helps to control high blood pressure. It also keeps one from being thirsty and prevents the body from holding onto extra fluid. Option A: People on dialysis need this special diet to limit the buildup of waste products in the body. Limiting fluids between dialysis treatments is very important because most people on dialysis urinate very little. Without urination, fluid will build up in the body and cause too much fluid in the heart and lungs. Option B: Too much potassium can build up when the kidneys no longer function well. It can cause an irregular heartbeat or a heart attack. Low-protein diets may be helpful before the client starts dialysis. The provider or dietitian may advise a lower-protein diet based on weight, stage of disease, how much muscle the client has, and other factors. Option D: Normal blood levels of potassium help keep the heart beating steadily. However, too much potassium can build up when the kidneys no longer function well. Dangerous heart rhythms may result, which can lead to death. Fruits and vegetables contain large amounts of potassium, and for that reason should be avoided to maintain a healthy heart.

Your patient returns from the operating room after abdominal aortic aneurysm repair. Which symptom is a sign of acute renal failure? A. Anuria B. Diarrhea C. Oliguria D. Vomiting

Correct Answer: C. Oliguria Urine output less than 50ml in 24 hours signifies oliguria, an early sign of renal failure. In patients with acute oliguria, one of the most common functional derangements that are observed is the sudden fall in the GRF, leading to acute renal failure. It results in rapid increment in plasma urea and creatinine levels, metabolic acidosis with hyperkalemia, other electrolyte abnormalities, and volume overload. Option A: Anuria is uncommon except in obstructive renal disorders. Anuria is non-passage of urine, in practice is defined as the passage of less than 100 milliliters of urine in a day. Anuria is often caused by a failure in the function of the kidneys. It may also occur because of some severe obstruction like kidney stones or tumors. Option B: Acute diarrhea is defined as an episode lasting less than 2 weeks. Infection most commonly causes acute diarrhea. Most cases are the result of a viral infection, and the course is self-limited. Chronic diarrhea is defined as a duration lasting longer than 4 weeks and tends to be non-infectious. Common causes include malabsorption, inflammatory bowel disease, and medication side effects. Option D: When loss of kidney function is mild or moderately severe, the kidneys cannot absorb water from the urine to reduce the volume of urine and concentrate it. Later, the kidneys have less ability to excrete the acids normally produced by the body and the blood becomes more acidic, a condition called acidosis.

The client with acute renal failure has a serum potassium level of 5.8 mEq/L. The nurse would plan which of the following as a priority action? A. Allow an extra 500 ml of fluid intake to dilute the electrolyte concentration. B. Encourage increased vegetables in the diet. C. Place the client on a cardiac monitor. D. Check the sodium level.

Correct Answer: C. Place the client on a cardiac monitor. The client with hyperkalemia is at risk for developing cardiac dysrhythmias and cardiac arrest. Because of this, the client should be placed on a cardiac monitor. Observe ECG or telemetry for changes in rhythm. Changes in electromechanical function may become evident in response to progressing renal failure and accumulation of toxins and electrolyte imbalance. Peaked T wave, wide QRS, prolonged PR interval is usually associated with hyperkalemia. Option A: Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly. Monitor BP and HR. Fluid volume excess, combined with hypertension (common in renal failure) and effects of uremia, increases cardiac workload and can lead to cardiac failure. In ARF, cardiac failure is usually reversible. Option B: Vegetables are a natural source of potassium in the diet, and their use would not be increased. During the oliguric phase, hyperkalemia is present but often shifts to hypokalemia in the diuretic or recovery phase. Any potassium value associated with ECG changes requires intervention. Note: A serum level of 6.5 mEq or higher constitutes a medical emergency. Option D: The nurse may also assess the sodium level because sodium is another electrolyte commonly measured with the potassium level. However, this is not a priority action at this time. Investigate reports of muscle cramps, numbness of fingers, muscle twitching, hyperreflexia. Neuromuscular indicators of hypocalcemia, which can also affect cardiac contractility and function.

A patient with diabetes has had many renal calculi over the past 20 years and now has chronic renal failure. Which substance must be reduced in this patient's diet? A. Carbohydrates B. Fats C. Protein D. Vitamin C

Correct Answer: C. Protein Because of damage to the nephrons, the kidney can't excrete all the metabolic wastes of protein, so this patient's protein intake must be restricted. Eating animal protein may increase the chances of developing kidney stones. Although you may need to limit how much animal protein you eat each day, you still need to make sure you get enough protein. Consider replacing some of the meat and animal protein you would typically eat with beans, dried peas, and lentils, which are plant-based foods that are high in protein and low in oxalate. Option A: Eat oxalates wisely. Foods high in this chemical may increase formation of kidney stones. If you've already had kidney stones, you may wish to reduce or eliminate oxalates from your diet completely. If you're trying to avoid kidney stones, check with your doctor to determine if limiting these foods is enough. Option B: Good sources of calcium include milk, yogurt, cottage cheese, and other types of cheeses. Vegetarian sources of calcium include legumes, calcium-set tofu, dark green vegetables, nuts, seeds, and blackstrap molasses. If you don't like the taste of cow's milk, or, if it doesn't agree with you, try lactose-free milk, fortified soy milk, or goat's milk. Option D: Citrus fruit, and their juice, can help reduce or block the formation of stones due to naturally occurring citrate. Good sources of citrus include lemons, oranges, and grapefruit. A higher intake of carbs, fats, and vitamin supplements is needed to ensure the growth and maintenance of the patient's tissues.

A 22 y.o. patient with diabetic nephropathy says, "I have two kidneys and I'm still young. If I stick to my insulin schedule, I don't have to worry about kidney damage, right?" Which of the following statements is the best response? A. "You have little to worry about as long as your kidneys keep making urine." B. "You should talk to your doctor because statistics show that you're being unrealistic." C. "You would be correct if your diabetes could be managed with insulin." D. "Even with insulin, kidney damage is still a concern."

Correct Answer: D. "Even with insulin, kidney damage is still a concern." Kidney damage is still a concern. Microvascular changes occur in both of the patient's kidneys as a complication of the diabetes. Diabetic nephropathy is the leading cause of end-stage renal disease. The kidneys continue to produce urine until the end stage. Nephropathy occurs even with insulin management. Option A: In T2DM, UKPDS (United Kingdom Prospective Diabetes Study) showed that targeting an HbA1C of 7% led to a lower risk of microvascular complications, including nephropathy. However, blood pressure (BP) control also led to a decrease in cardiovascular mortality. Option B: The benefits of good glycemic control early in the onset of disease carried over even after a long time, despite glycemic control being similar in both groups on longer follow up. This effect is "metabolic memory," a term coined by DCCT/EDIC investigators. Option C: Studies in patients with T1DM and overt proteinuria have also shown that ACE inhibitors slow the progress of diabetic nephropathy. The IDNT and RENAAL studies have shown similar benefits in T2DM patients. These studies provide clear evidence of the benefit of RAS-blocking medication on slowing progression of diabetic nephropathy, independent of their effect on BP.

Which of the following clients is at greatest risk for developing acute renal failure? A. A dialysis client who gets influenza. B. A teenager who has an appendectomy. C. A pregnant woman who has a fractured femur. D. A client with diabetes who has a heart catheterization.

Correct Answer: D. A client with diabetes who has a heart catheterization Clients with diabetes are prone to renal insufficiency and renal failure. The contrast used for heart catheterization must be eliminated by the kidneys, which further stresses them and may produce acute renal failure. The development of Acute Kidney Injury (AKI) following cardiac catheterization or Percutaneous Coronary Interventions (PCI) is a serious complication. Around 10% to 15% of patients develop AKI after coronary interventions. Option A: A dialysis client already has end-stage renal disease and wouldn't develop acute renal failure. As the kidneys failed, the level of creatinine in the blood rose. The amount of creatinine in the blood is a factor used in calculating the GFR (glomerular filtration rate, a measure of kidney function). As creatinine goes up, GFR goes down. Option B: A teenager who has an appendectomy isn't at risk for renal failure. Postoperative abscesses, hematomas, and wound complications are all complications that can be seen after appendectomies. If the wound does get infected, one may grow Bacteroides. "Recurrent" appendicitis can occur if too much of the appendiceal stump is left after an appendectomy. This acts just like an appendix and can become occluded and infected just as with the initial episode. Option C: A pregnant woman with a fractured femur isn't at increased risk for renal failure. Orthopedic injury in pregnancy, though rare, is associated with significant morbidity and mortality to the mother and fetus. Some reports estimate that the risk of intrauterine fetal demise (IUFD) is as high as 40.1%, depending on the location of the fracture.

Which of the following factors causes the nausea associated with renal failure? A. Oliguria B. Gastric ulcers C. Electrolyte imbalances D. Accumulation of waste products

Correct Answer: D. Accumulation of waste products Although clients with renal failure can develop stress ulcers, the nausea is usually related to the poisons of metabolic wastes that accumulate when the kidneys are unable to eliminate them. Nausea and vomiting are very common in kidney patients and have many causes. These causes include the build-up of uremic toxins, medications, gastroparesis, ulcers, gastroesophageal reflux disease, gallbladder disease, and many many more. Option A: The client has oliguria, but this doesn't directly cause nausea. In patients with acute oliguria, one of the most common functional derangements that are observed is the sudden fall in the GRF, leading to acute renal failure. It results in rapid increment in plasma urea and creatinine levels, metabolic acidosis with hyperkalemia, other electrolyte abnormalities, and volume overload. Option B: The occurrence and pathophysiology of peptic ulcer was studied in 117 uraemic patients. Ulcer disease was unusually frequent, and the highest incidence was found in patients on regular dialysis (48%). Factors implicated were hyperacidity, hypergastrinemia, and the effect of dialysis itself. Option C: In renal failure, acute or chronic, one most commonly sees patients who have a tendency to develop hypervolemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and bicarbonate deficiency (metabolic acidosis). Sodium is generally retained, but may appear normal, or hyponatremic, because of dilution from fluid retention.

A client has a history of chronic renal failure and received hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which of the following interventions is included in this client's plan of care? A. Keep the AV fistula site dry. B. Keep the AV fistula wrapped in gauze. C. Take the blood pressure in the left arm. D. Assess the AV fistula for a bruit and thrill.

Correct Answer: D. Assess the AV fistula for a bruit and thrill. Assessment of the AV fistula for bruit and thrill is important because, if not present, it indicates a non-functioning fistula. Thrill is caused by turbulence of high-pressure arterial blood flow entering a low-pressure venous system and should be palpable above the venous exit site. Bruit is the sound caused by the turbulence of arterial blood entering the venous system and should be audible by stethoscope, although may be very faint. Option A: When not being dialyzed, the AV fistula site may get wet. Avoid contamination of the access site. Use aseptic technique and masks when giving shunt care, applying or changing dressings, and when starting or completing dialysis process. Prevents the introduction of organisms that can cause infection. Option B: Immediately after a dialysis treatment, the access site is covered with adhesive bandages. Assess skin around vascular access, noting redness, swelling, local warmth, exudate, tenderness. Signs of local infection, which can progress to sepsis if untreated. Option C: No blood pressures or venipunctures should be taken in the arm with the AV fistula. Avoid trauma to shunt. Handle tubing gently, maintain cannula alignment. Limit activity of extremity. Avoid taking BP or drawing blood samples in shunt extremity. Instruct the patient not to sleep on side with shunt or carry packages, books, purse on affected extremity.

Frequent PVCs are noted on the cardiac monitor of a patient with end-stage renal disease. The priority intervention is: A. Call the doctor immediately. B. Give the patient IV lidocaine (Xylocaine). C. Prepare to defibrillate the patient. D. Check the patient's latest potassium level.

Correct Answer: D. Check the patient's latest potassium level The patient with ESRD may develop arrhythmias caused by hypokalemia. The incidence of PVCs, as well as complex PVCs in patients with ESRD, was comparable to that of the patients who had had myocardial infarction but was significantly higher than that found in low-risk subjects. The high incidence of complex PVCs in patients with ESRD may predispose them to increased cardiovascular death, and further investigation of this finding is indicated. Option A: Call the doctor after checking the patient's potassium values. The observation that two distinct patterns of arrhythmia appearance can be identified among arrhythmic dialysis patients was first made by Abe et al. They showed patients having almost constant PCV throughout the 24-h ECG recording and patients with a marked increase during dialysis and the early post-dialysis period. Option B: Lidocaine may be ordered if the PVCs are frequent and the patient is symptomatic. In conventional HD with constant and low potassium (range 0-2.5 mEq/l) a large amount of potassium is abruptly removed from the extracellular space. Most of this potassium originates from the cells, crosses the cell membrane, the extracellular space (the blood), and the dialysis membrane before reaching the dialysate. The depletion of the potassium reserves within the cells may have important repercussions on cardiac electrophysiology. Option C: Potassium fluxes during HD have been associated with an increase in QT interval, an increase in the dispersion of QT, and in the inhomogeneous repolarisation revealed by the analysis of the spatial aspects of T-wave complexity. The resulting repolarization heterogeneity allows for the onset of distinctive reentrant arrhythmias, and hypokalemia may act as a triggering factor in the genesis of prema

In a client with renal failure, which assessment finding may indicate hypocalcemia? A. Headache B. Serum calcium level of 5 mEq/L C. Increased blood coagulation D. Diarrhea

Correct Answer: D. Diarrhea In renal failure, calcium absorption from the intestine declines, leading to increased smooth muscle contractions, causing diarrhea. The presence of chronic diarrhea or intestinal disease (e.g, Crohn's disease, sprue, chronic pancreatitis) suggests the possibility of hypocalcemia due to malabsorption of calcium and/or vitamin D. Option A: CNS changes in renal failure rarely include headache. Chronic renal failure causes a variety of neurologic disorders affecting the central nervous system and the peripheral nervous system. These complications include diffuse encephalopathy, seizures, stroke, movement disorders, sleep alterations, polyneuropathy, mononeuropathies, and myopathy. Option B: A serum calcium level of 5 mEq/L indicates hypercalcemia. Hypercalcemia is defined as serum calcium concentration two standard deviations above the mean values. The normal serum calcium ranges from 8.8 mg/dL-10.8 mg/dL. Primary hyperparathyroidism and malignancy account for 90% of the cases of hypercalcemia. Option C: As renal failure progresses, bleeding tendencies increase. Bleeding has been reported in 40-50% of patients with chronic renal failure or on hemodialysis (HD). Another study reported bleeding events in 24% of patients on HD. A hospital-based study showed that the risk of bleeding episodes is increased ?2-fold in patients with renal failure.

The nurse is reviewing a list of components contained in the peritoneal dialysis solution with the client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse bases the response knowing that the glucose: A. Prevents excess glucose from being removed from the client. B. Decreases risk of peritonitis. C. Prevents disequilibrium syndrome. D. Increased osmotic pressure to produce ultrafiltration.

Correct Answer: D. Increases osmotic pressure to produce ultrafiltration. Increasing the glucose concentration makes the solution increasingly more hypertonic. The more hypertonic the solution, the greater the osmotic pressure for ultrafiltration and thus the greater amount of fluid removed from the client during an exchange. Option A: Conventional PD solutions contain high levels of glucose (dextrose; 75.5-214 mmol/L) as a principal osmotic agent to achieve fluid removal (i.e. ultrafiltration across the peritoneal membrane). Option B: The appreciable peritoneal glucose absorption has been linked with adverse local peritoneal membrane effects and systemic metabolic effects. Glucose in PD solutions triggers protein glycosylation and activates the polyol and protein kinase C pathways. Option C: Systemic glucose absorption has also been associated with worsening hyperglycemia in diabetic patients, new?onset hyperglycemia in incident non?diabetic PD patients, visceral obesity and dyslipidemia, characterized by elevated levels of total cholesterol, triglyceride, very low?density lipoprotein (VLDL) and low?density lipoprotein (LDL).

Your patient with chronic renal failure reports pruritus. Which instruction should you include in this patient's teaching plan? A. Rub the skin vigorously with a towel. B. Take frequent baths. C. Apply alcohol-based emollients to the skin. D. Keep fingernails short and clean.

Correct Answer: D. Keep fingernails short and clean. Calcium-phosphate deposits in the skin may cause pruritus. Scratching leads to excoriation and breaks in the skin that increase the patient's risk of infection. Keeping fingernails short and clean helps reduce the risk of infection. Although dialysis has largely eliminated skin problems associated with uremic frost, itching can occur because the skin is an excretory route for waste products such as phosphate crystals (associated with hyperparathyroidism in ESRD). Option A: Keep linens dry, wrinkle-free. Reduces dermal irritation and risk of skin breakdown. Change position frequently; move patient carefully; pad bony prominences with sheepskin, elbow, or heel protectors. Decreases pressure on edematous, poorly perfused tissues to reduce ischemia. Option B: Recommend the patient use cool, moist compresses to apply pressure (rather than scratch) pruritic areas. Keep fingernails short; encourage the use of gloves during sleep if needed. Alleviates discomfort and reduces the risk of dermal injury. Option C: Provide soothing skincare. Restrict the use of soaps. Apply ointments or creams (lanolin, Aquaphor). Baking soda, cornstarch baths decrease itching and are less drying than soaps. Lotions and ointments may be desired to relieve dry, cracked skin.

What is the best way to check for patency of the arteriovenous fistula for hemodialysis? A. Pinch the fistula and note the speed of filling on release. B. Use a needle and syringe to aspirate blood from the fistula. C. Check for capillary refill of the nail beds on that extremity. D. Palpate the fistula throughout its length to assess for a thrill.

Correct Answer: D. Palpate the fistula throughout its length to assess for a thrill. The vibration or thrill felt during palpation ensures that the fistula has the desired turbulent blood flow. Assess for patency at least every 8 hours. Palpate the vascular access to feel for a thrill or vibration that indicates arterial and venous blood flow and patency. Auscultate the vascular access with a stethoscope to detect a bruit or "swishing" sound that indicates patency. Option A: Pinching the fistula could cause damage. To prevent injuries, place an armband on the patient or a sign over the bed that says no BP measurements, venipunctures, or injections on the affected side. When blood flow through the vascular access is reduced, it can clot. Option B: Aspirating blood is a needless invasive procedure. Narrowing, also known as stenosis, of the blood vessel is the most common problem. This results in insufficient blood flow through the fistula or graft. Clotting can also cause decreased flow. If you don't feel a thrill (vibration), the access may be clotted. Option C: Patients with an AVF for hemodialysis will present with evidence of a surgical incision on the lateral wrist, volar forearm, or upper arm. A working AVF will have a palpable thrill and continuous bruit. Superficial fistulas have a palpable thrill, a bruit, or even a pulsatile mass. It may be possible to auscultate a machinery-like murmur over the fistula.

Your patient had surgery to form an arteriovenous fistula for hemodialysis. Which information is important for providing care for the patient? A. The patient shouldn't feel pain during initiation of dialysis. B. The patient feels best immediately after the dialysis treatment. C. Using a stethoscope for auscultating the fistula is contraindicated. D. Taking a blood pressure reading on the affected arm can cause clotting of the fistula.

Correct Answer: D. Taking a blood pressure reading on the affected arm can cause clotting of the fistula. Pressure on the fistula or the extremity can decrease blood flow and precipitate clotting, so avoid taking blood pressure on the affected arm. For the most effective hemodialysis, the patient needs good vascular access with an arteriovenous (AV) fistula or an AV graft that provides adequate blood flow. To prevent injuries, place an armband on the patient or a sign over the bed that says no BP measurements, venipunctures, or injections on the affected side. When blood flow through the vascular access is reduced, it can clot. Option A: Check the patient's circulation by palpating his pulses distal to the vascular access; observing capillary refill in his fingers; and assessing him for numbness, tingling, altered sensation, coldness, and pallor in the affected extremity. Option B: Auscultate the vascular access with a stethoscope to detect a bruit or "swishing" sound that indicates patency. Palpate the vascular access to feel for a thrill or vibration that indicates arterial and venous blood flow and patency. Option C: Assess the vascular access for signs and symptoms of infection such as redness, warmth, tenderness, purulent drainage, open sores, or swelling. Patients with end-stage kidney disease are at increased risk of infection.

A client with chronic renal failure has completed a hemodialysis treatment. The nurse would use which of the following standard indicators to evaluate the client's status after dialysis? A. Potassium level and weight. B. BUN and creatinine levels. C. VS and BUN. D. VS and weight.

Correct Answer: D. VS and weight. Following dialysis, the client's vital signs are monitored to determine whether the client is remaining hemodynamically stable. Weight is measured and compared with the client's predialysis weight to determine the effectiveness of fluid extraction. Option A: Monitor serum electrolytes, blood urea nitrogen, creatinine, and hemoglobin and hematocrit levels before and after dialysis. Monitor fluid status. Monitor coagulation studies because heparin is used to prevent clotting during dialysis. Option B: The blood urea concentration is artificially low immediately following high-efficiency dialysis. Post-dialysis urea rebound correlates with hemodialysis efficiency and is inversely correlated with dialysis treatment time. Post-dialysis urea rebound varies among patients but should remain relatively constant in a given patient with stable hemodynamic parameters. Option C: Laboratory studies are done as per protocol but are not necessarily done after the hemodialysis treatment has ended. After dialysis, assess the vascular access for any bleeding or hemorrhage. When you move the patient or help with ambulation, avoid trauma to or excessive pressure on the affected arm.