Exemplar 6.C - Chronic Kidney Disease
The nurse is preparing to discharge a client diagnosed with chronic kidney disease (CKD). The nurse is teaching the client and family about administering calcium acetate tablets by mouth with each meal at home. Which explanation about this medication is most appropriate for the nurse to include? A) "The calcium acetate will lower your serum phosphate levels." B) "The calcium acetate helps neutralize your gastric acids." C) "The calcium acetate will help stimulate your appetite." D) "The calcium acetate will decrease your serum creatinine levels."
A) "The calcium acetate will lower your serum phosphate levels." The client with CKD has elevated phosphate levels due to the inability of the damaged kidney to excrete this electrolyte. Calcium acetate, when given with meals, will bind serum phosphorus and therefore lower the serum level. Calcium acetate has no effect on serum creatinine. Although calcium acetate can act as an antacid and neutralize gastric acid when given between meals, this is not the reason it is given to a client with CKD. This medication has no effect on appetite stimulation.
The nurse is preparing to administer a hemodialysis treatment for a client diagnosed with chronic kidney disease (CKD). Which laboratory values should the nurse anticipate prior to the client's treatment? Select all that apply. A) Increased blood urea nitrogen (BUN) B) Decreased potassium C) Decreased phosphorus D) Increased urine osmolality E) Increased creatinine
A) Increased blood urea nitrogen (BUN) E) Increased creatinine The damaged kidney is unable to excrete waste products, including creatinine, so creatinine levels will be increased. The client will also have an increased blood urea nitrogen (BUN) level due to the damaged kidneys. The damaged kidney is unable to excrete solutes; therefore, the serum osmolality will be increased and the urine osmolality will be decreased. Both phosphorus and potassium increase during renal failure due to the inability of the kidney to excrete them.
Why is development of Kussmaul respirations problematic in a client with chronic kidney disease (CKD)? A) It suggests the client is experiencing metabolic acidosis. B) It suggests the client is dehydrated. C) It suggests the client is hypotensive. D) It suggests the client is experiencing proteinuria.
A) It suggests the client is experiencing metabolic acidosis. Kussmaul respirations involve an increase in respiratory rate and depth. Clients with CKD may exhibit these respirations when they are experiencing metabolic acidosis related to impaired hydrogen ion excretion and buffer production. Clients with CKD typically experience fluid retention and hypertension rather than dehydration and hypotension. Proteinuria is common among clients with CKD and does not contribute to Kussmaul respirations.
During a home visit, the nurse is concerned that an older adult client is developing chronic kidney disease (CKD). The client has no history of cardiovascular disease. Which data in the client's assessment caused the nurse to have this concern? Select all that apply. A) Progressive edema B) Complaints of hip joint pain C) New onset of hypertension D) Recent increase in hunger and thirst E) Warm moist skin
A) Progressive edema C) New onset of hypertension The manifestations of chronic kidney disease (CKD) often are missed in aging clients because edema may be attributed to heart failure or high blood pressure to preexisting hypertension. Hip joint pain is not a manifestation of CKD in the older client. An increase in hunger and thirst could be an indication of diabetes mellitus and not CKD in the older client. A client with CKD will have pale dry skin with poor turgor.
Rejection of a donor kidney that begins months to years after transplant surgery and does not respond to increased immunosuppression would be categorized as which type of rejection? A) Acute rejection B) Chronic rejection C) Delayed rejection D) Nonimmune rejection
B) Chronic rejection Acute rejection develops within months of the transplant. It is caused by a cellular immune response and may be managed with methylprednisolone and OKT3 monoclonal antibody. Chronic rejection, which may develop months to years following the transplant, is a major cause of graft loss. Both humoral and cellular immune responses are involved in chronic rejection. Chronic rejection does not respond to increased immunosuppression.
The nurse is planning a seminar to instruct community members on ways to reduce the development of chronic kidney disease (CKD). Which topics should the nurse include in the seminar? Select all that apply. A) Avoid eating red meat. B) Control blood glucose levels in diabetes mellitus. C) Adhere to medication regimen to control hypertension. D) Participate in regular exercise. E) Avoid smoking.
B) Control blood glucose levels in diabetes mellitus. C) Adhere to medication regimen to control hypertension. D) Participate in regular exercise. E) Avoid smoking. Prevention of CKD should focus on aggressive management of chronic disease states, especially diabetes and hypertension. In addition, clients should consume diets low in sodium, exercise regularly, keep healthcare provider appointments, avoid smoking, and limit alcohol intake. Eating red meat does not need to be avoided to prevent the development of CKD.
Which laboratory finding is suggestive of chronic kidney disease? A) Increase in creatinine clearance B) Decrease in serum sodium C) Increase in hematocrit D) Decrease in BUN
B) Decrease in serum sodium Laboratory findings associated with chronic kidney disease include decreased creatinine clearance due to a decrease in the glomerular filtration rate; decreased serum sodium because of water retention; decreased hematocrit due to decreased red blood cell production, and increased BUN due to inability of the kidneys to eliminate nitrogenous waste products.
While caring for a client diagnosed with end-stage renal disease (ESRD), the nurse tracks the client's serum albumin level. For which nursing diagnosis is this action most indicated? A) Excess Fluid Volume B) Imbalanced Nutrition: Less than Body Requirements C) Risk for Ineffective Perfusion D) Risk for Infection
B) Imbalanced Nutrition: Less than Body Requirements Interventions appropriate for the diagnosis of Imbalanced Nutrition: Less than Body Requirements include monitoring laboratory values such as such as serum albumin. Assessing for edema and monitoring heart rate and blood pressure would be interventions for the diagnosis of Excess Fluid Volume. Monitoring for orthostatic blood pressure changes would be appropriate for the diagnosis of Risk for Ineffective Perfusion. Monitoring the white blood cell count would be an intervention appropriate for the diagnosis of Risk for Infection.
A client with a history of hypertension is diagnosed with chronic kidney disease (CKD). When the client asks the nurse how this disease developed, which response by the nurse is the most appropriate? A) "Thickening of the kidney structures and gradual death of nephrons has led to this diagnosis." B) "Cysts have compressed your renal tissue and destroyed your kidneys, causing this diagnosis." C) "High blood pressure has reduced your renal blood flow, harming the kidney tissue and causing this diagnosis." D) "Immune complexes have formed in your kidney tissue, causing inflammation that has led to this diagnosis."
C) "High blood pressure has reduced your renal blood flow, harming the kidney tissue and causing this diagnosis." Long-standing hypertension leads to sclerosis and narrowing of renal arterioles and small arteries with subsequent reduction of blood flow. This leads to ischemia, glomerular destruction, and tubular atrophy. In contrast, diabetic nephropathy causes chronic kidney disease (CKD) by thickening and sclerosis of the glomerular basement membrane and the glomerulus with a gradual destruction of nephrons. Polycystic kidney disease causes CKD by multiple bilateral cysts gradually compressing renal tissue, impairing renal perfusion and leading to ischemia, which damages and destroys normal kidney tissue. Finally, systemic lupus erythematosus causes CKD by the formation of immune complexes in the capillary basement membrane, which lead to inflammation and sclerosis.
The nurse is administering peritoneal dialysis to a client with a diagnosis of chronic kidney disease (CKD). The nurse notes the presence of a cloudy dialysate return. After notifying the healthcare provider, which action by the nurse is the most appropriate and of highest priority? A) Measure the client's abdominal girth. B) Document the cloudy dialysate. C) Culture the dialysate return. D) Increase dialysate instillation.
C) Culture the dialysate return. The client's dialysate return should be clear. The presence of cloudy drainage might indicate peritonitis, so the nurse should culture the return in order to help identify the presence and type of organism that could be causing the infection. Documenting the cloudy dialysate would be a necessary nursing action, but is not the next-priority action. Measurement of abdominal girth is performed prior to the dialysis procedure, and even though increased girth could indicate peritonitis, culturing the return is more important. The instillation part of the procedure is completed prior to the collection of the dialysate return, and the rate of the instillation has no relationship to the development of an infection.
The nurse is planning care for a client diagnosed with chronic kidney disease (CKD) and osteoporosis. Based on this information, which should be the nurse's priority diagnosis for this client? A) Anxiety B) Disturbed Body Image C) Risk for Injury D) Risk for Bleeding
C) Risk for Injury The client with CKD and osteoporosis is at high risk for fractures; therefore, preventing injury should be the priority nursing diagnosis. The client is at risk for anemia, but not bleeding. The client on hemodialysis may have a disturbed body image, but in this case, the client is not undergoing hemodialysis. Anxiety is not related to osteoporosis.
The nurse is caring for a client diagnosed with chronic kidney disease (CKD) who is pale and experiencing fatigue. The nurse attributes these symptoms to anemia secondary to CKD. The client's spouse asks why the client is anemic. Which response by the nurse is the most appropriate? A) "Your spouse has a genetic tendency for the development of anemia." B) "The increased metabolic waste products in your spouse's body depress the bone marrow and cause anemia." C) "Your spouse's kidneys are producing reduced amounts of the hormone erythropoietin, and this is the cause of the anemia." D) "Your spouse is not eating enough iron-rich foods, and this has led to anemia."
C. "Your spouse's kidneys are producing reduced amounts of the hormone erythropoietin, and this is the cause of the anemia." Anemia is common in clients with chronic kidney disease. Among the factors causing the anemia are decreased production of erythropoietin by the kidneys and shortened red blood cell (RBC) life. Erythropoietin is involved in stimulating the bone marrow to produce RBCs. Metabolic wastes do not suppress bone marrow, and diet and heredity do not factor into the production of erythropoietin.
The nurse instructs a client diagnosed with chronic kidney disease (CKD) regarding the prescribed medication furosemide (Lasix). Which client statement indicates that the teaching has been effective? A) "I will take this medication to keep my calcium balance normal." B) "This medication will make sure I have enough red blood cells in my body." C) "I will take this pill to keep my protein level in my body stable." D) "This pill will reduce the swelling in my body and get rid of the extra potassium."
D) "This pill will reduce the swelling in my body and get rid of the extra potassium." Furosemide (Lasix) is a loop diuretic that may be prescribed to reduce extracellular fluid volume and edema. Diuretic therapy also can reduce hypertension and cause potassium wasting, lowering serum potassium levels. Oral phosphorus-binding agents, such as calcium carbonate or calcium acetate, are given to lower serum phosphate levels and normalize serum calcium levels. Folic acid and iron supplements are given to combat anemia associated with chronic kidney disease. There is no medication provided to a client with CKD that is used to stabilize protein levels in the body.
A client with a diagnosis of chronic kidney disease (CKD) is experiencing manifestations of anemia. Based on this data, which treatment should the nurse anticipate for this client? A) Begin fluid restriction. B) Administer intravenous glucose and insulin. C) Begin a low-sodium diet. D) Administer epoetin injections.
D) Administer epoetin injections. Epoetin injections are used in the treatment of anemia caused by CKD. This medication supplies a hormone typically created in the kidneys that signals the bone marrow to produce more red blood cells. In CKD, production of this hormone will be reduced. Fluid restriction would be indicated for uremia caused by CKD. Intravenous glucose and insulin may be used to reduce excessive potassium that is caused by CKD. A low-sodium diet is used to help reduce fluid volume excess that is caused by CKD.
A nurse is evaluating whether the drug sodium polystyrene sulfonate (Kayexalate) is exerting the desired therapeutic effect for a client diagnosed with chronic kidney disease (CKD). Which therapeutic effect should the nurse anticipate from this medication? A) Increased serum sodium B) Increased stool excretion C) Decreased urine specific gravity D) Decreased serum potassium
D) Decreased serum potassium The client with CKD is unable to excrete potassium. Therefore, the drug sodium polystyrene sulfonate (Kayexalate) is used in order to exchange sodium for potassium in the large intestine, resulting in decreased serum potassium levels. Although the client might have increased stools, the therapeutic effectiveness of the drug is measured by monitoring the serum potassium. This drug does not affect either the serum sodium level or the urine specific gravity.
The nurse is caring for an older adult client diagnosed with chronic kidney disease (CKD). The client reports no bowel movements in the past 2 days. Based on this data, which condition is the client at risk for developing? A) Metabolic acidosis B) Hypercalcemia C) Increased serum creatinine levels D) Hyperkalemia
D) Hyperkalemia Constipation exacerbates hyperkalemia, so it is important to monitor clients with CKD who already have elevated potassium levels. Hypercalcemia is not affected by constipation. Metabolic acidosis and serum creatinine levels may not directly correlate with a decrease in the glomerular filtration rate in the elderly and are not directly affected by constipation.
Which stage of chronic kidney disease is characterized by hypertension, anemia, malnutrition, altered bone metabolism, metabolic acidosis, and a severely decreased glomerular filtration rate? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4
D) Stage 4 Clients in stage 1 of chronic kidney disease (CKD) are asymptomatic and have a normal or increased glomerular filtration rate (GFR). During stage 2, the GFR mildly decreases and hypertension may develop. In stage 3, there is a moderate GFR decrease, as well as hypertension, possible anemia and fatigue, anorexia, possible malnutrition, and bone pain. Stage 4 involves a severely decreased GFR as well as hypertension, anemia, malnutrition, altered bone metabolism, edema, metabolic acidosis, hypercalcemia, possible uremia, and azotemia.
The nurse is caring for a client from another country who was admitted to the hospital with a diagnosis of hypertension and chronic kidney disease. The client is receiving hemodialysis three times a week. When the nurse inquires about diet, the client reports the use of salt substitutes. Why should the nurse teach the client to avoid these products? A) They will increase the risk of AV fistula infection. B) They will cause the client to retain fluid. C) They will interact with the client's antihypertensive medications. D) They can contribute to hyperkalemia.
D) They can contribute to hyperkalemia. Many salt substitutes contain high levels of potassium chloride. Potassium intake must be carefully regulated in clients with chronic kidney disease, and use of salt substitutes can worsen hyperkalemia. Increases in weight do need to be reported to the healthcare provider as a possible indication of fluid volume excess, but this is not the reason why salt substitutes should be avoided. Control of hypertension is essential in the management of a client with kidney disease, but salt substitutes are not known to interact with antihypertensive medications. An AV fistula does need to be protected from injury and infection, but this is unrelated to use of salt substitutes.
