MS: Ch. 54 - Kidney Disorders
An investment banker with chronic renal failure informs the nurse of the choice for continuous cyclic peritoneal dialysis. Which is the best response by the nurse?
"This type of dialysis will provide more independence." Once a treatment choice has been selected by the client, the nurse should support the client in that decision. Continuous cyclic peritoneal dialysis will provide more independence for this client and supports the client's decision for treatment mode. The risk of peritonitis is greater, and symptoms should be discussed as part of the management of the disorder. Peritoneal dialysis is an effective method of dialysis for many clients.
A client with newly diagnosed renal cancer is questioning why detection was delayed. Which is the best response by the nurse?
"Very few symptoms are associated with renal cancer." Renal cancers rarely cause symptoms in the early stage. Tumors can become quite large before causing symptoms. Painless, gross hematuria is often the first symptom in renal cancer and does not present until later stages of the disease. Adenocarcinomas are the most common renal cancer (about 80%),whereas squamous cell renal cancers are rare. It is not therapeutic to place doubt or blame for delayed diagnosis.
A client who suffered hypovolemic shock during a cardiac incident has developed acute renal failure. Which is the best nursing rationale for this complication?
Decrease in the blood flow through the kidneys Acute renal failure can be caused by poor perfusion and/or decrease in circulating volume results from hypovolemic shock. Obstruction of urine flow from the kidneys through blood clot formation and structural damage can result in postrenal disorders but not indicated in this client.
A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant?
Recent history of streptococcal infection Glomerulonephritis can occur as a result of infections from group A beta-hemolytic streptococcal infections, bacterial endocarditis, or viral infections such as hepatitis B or C or human immunodeficiency virus (HIV). A history of hyperparathyroidism or osteoporosis would place the client at risk for developing renal calculi. A history of pyelonephritis would increase the client's risk for chronic pyelonephritis.
Which of the following would a nurse classify as a prerenal cause of acute renal failure?
Septic shock Prerenal causes of acute renal failure include hypovolemic shock, cardiogenic shock secondary to congestive heart failure, septic shock, anaphylaxis, dehydration, renal artery thrombosis or stenosis, cardiac arrest, and lethal dysrhythmias. Ureteral stricture and prostatic hypertrophy would be classified as postrenal causes. Polycystic disease is classified as an intrarenal cause of acute renal failure.
A male client has doubts about performing peritoneal dialysis at home. He informs the nurse about his existing upper respiratory infection. Which of the following suggestions can the nurse offer to the client while performing an at-home peritoneal dialysis?
Wear a mask when performing exchanges. The nurse should advise the client to wear a mask while performing exchanges. This prevents contamination of the dialysis catheter and tubing, and is usually advised to clients with upper respiratory infection. Auscultation of the lungs will not prevent contamination of the catheter or tubing. The client may also be advised to perform deep-breathing exercises to promote optimal lung expansion, but this will not prevent contamination. Clients with a fistula or graft in the arm should be advised against carrying heavy items.
Which of the following is the most accurate indicator of fluid loss or gain?
Weight The most accurate indicator of fluid loss or gain in an acutely ill patient is weight, as accurate intake and output and assessment of insensible losses may be difficult. Urine output, caloric intake, and body temperature would not be the most reliable indicator of fluid loss or gain.
A client is admitted to the hospital with a prerenal disorder, a nonurologic condition that disrupts renal blood flow to the nephrons, affecting their filtering ability. One cause of prerenal acute kidney injury is:
anaphylaxis Anaphylaxis is a cause of prerenal acute renal failure. Myoglobinuria secondary to burns is a cause of intrarenal acute renal failure. Polycystic disease is a cause of intrarenal acute renal failure. Ureteral stricture is a cause of postrenal acute renal failure.
A nurse cares for an acutely ill client. The nurse understands that the most accurate indicator of fluid loss or gain in an acutely ill client is:
weight The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded. Blood pressure, pulse rate, and edema are not the most accurate indicator of fluid loss or gain.
The nurse is caring for a client with chronic kidney disease. The patient has gained 4 kg in the past 3 days. In milliliters, how much fluid retention does this equal? Enter your response as a whole number.
4000 A 1-kg weight gain is equal to 1,000 mL of retained fluid. 4 kg × 1,000 = 4,000. The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded.
The presence of prerenal azotemia is a probable indicator for hospitalization for CAP. Which of the following is an initial laboratory result that would alert a nurse to this condition?
Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20. The normal BUN:Cr ratio is less than 15. Prerenal azotemia is caused by hypoperfusion of the kidneys due to a nonrenal cause. Over time, higher than normal blood levels of urea or other nitrogen-containing compounds will develop.
What is a hallmark of the diagnosis of nephrotic syndrome?
Proteinuria Proteinuria (predominantly albumin) exceeding 3.5 g per day is the hallmark of the diagnosis of nephrotic syndrome. Hypoalbuminemia, hypernatremia, and hyperkalemia may occur.
Diet modifications are part of nutritional therapy for the management of ARF. Select the high-potassium food that should be restricted.
Citrus fruits Dietary restrictions include foods and fluids containing potassium, such as bananas, citrus, tomatoes, melons, or those with phosphorus, which is found in dairy, beans, nuts legumes, and carbonated beverages. Caffeine is also restricted.
Sevelamer hydrochloride (Renagel) has been prescribed for a client with chronic renal failure. The physician has prescribed Renagel 800 mg orally three times per day with meals to treat the client's hyperphosphatemia. The medication is available in 400 mg tablets. How many tablets per day will the nurse administer to the client?
6 The nurse will administer 2 tablets per dose (800 mg/400 mg per tablet). The client receives a total of 3 doses per day or 6 tablets (2 tablets per dose x 3 doses).
A patient has stage 3 chronic kidney failure. What would the nurse expect the patient's glomerular filtration rate (GFR) to be?
A GFR of 30-59 mL/min/1.73 m2 Stage 3 of chronic kidney disease is defined as having a GFR of 30-59 mL/min/1.73 m2
A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which disorder?
Acute glomerulonephritis Acute glomerulonephritis is also associated with varicella zoster virus, hepatitis B, and Epstein-Barr virus. Acute renal failure is associated with hypoperfusion to the kidney, parenchymal damage to the glomeruli or tubules, and obstruction at a point distal to the kidney. Chronic renal failure may be caused by systemic disease, hereditary lesions, toxic agents, infections, and medications. Nephrotic syndrome is caused by disorders such as chronic glomerulonephritis, systemic lupus erythematosus, multiple myeloma, and renal vein thrombosis.
The nurse is reviewing the potassium level of a patient with kidney disease. The results of the test are 6.5 mEq/L, and the nurse observes peaked T waves on the ECG. What priority intervention does the nurse anticipate the physician will order to reduce the potassium level?
Administration of sodium polystyrene sulfonate [Kayexalate]) The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.
The nurse is able to identify which condition as uremia?
An excess of urea in the blood Uremia is an excess of urea and other nitrogenous wastes in the blood. Azotemia is the concentration of nitrogenous wastes in the blood. Hematuria is blood in the urine. Proteinuria is protein in the urine. Hyperproteinemia is an excess of protein in the blood.
A patient with chronic kidney failure experiences decreased levels of erythropoietin. What serious complication related to those levels should the nurse assess for when caring for this client?
Anemia Anemia develops as a result of inadequate erythropoietin production, the shortened lifespan of RBCs, nutritional deficiencies, and the patient's tendency to bleed, particularly from the GI tract. Erythropoietin, a substance normally produced by the kidneys, stimulates bone marrow to produce RBCs (Murphy, Bennett, & Jenkins, 2010). In ESKD, erythropoietin production decreases and profound anemia results, producing fatigue, angina, and shortness of breath.
A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF?
Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. A BUN level of 100 mg/dl and a serum creatinine of 6.5 mg/dl are abnormally elevated results, reflecting CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls within the normal range of 60% to 75%.
A patient admitted with electrolyte imbalance has carpopedal spasm, ECG changes, and a positive Chvostek sign. What deficit does the nurse suspect the patient has?
Calcium Calcium deficit is associated with abdominal and muscle cramps, stridor, carpopedal spasm, hyperactive reflexes, tetany, positive Chvostek's or Trousseau's sign, tingling of fingers and around mouth, and ECG changes.
What is a characteristic of the intrarenal category of acute renal failure?
Increased BUN The intrarenal category of acute renal failure encompasses an increased BUN, increased creatinine, a low specific gravity of urine, and increased urine sodium.
The nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure?
Dehydration The diuretic phase of acute renal failure is characterized by increased urine output, hypotension, and dehydration.
Which nursing assessment finding indicates that the client who has undergone renal transplant has not met expected outcomes?
Fever Fever is an indicator of infection or transplant rejection.
Which of the following causes should the nurse suspect in a client diagnosed with intrarenal failure?
Glomerulonephritis Intrarenal causes of renal failure include prolonged renal ischemia, nephrotoxic agents, and infectious processes such as acute glomerulonephritis.
A client in chronic renal failure becomes confused and complains of abdominal cramping, racing heart rate, and numbness of the extremities. The nurse relates these symptoms to which of the following lab values?
Hyperkalemia Hyperkalemia is the life-threatening effect of renal failure. The client can become apathetic; confused; and have abdominal cramping, dysrhythmias, nausea, muscle weakness, and numbness of the extremities. Symptoms of hypocalcemia are muscle twitching, irritability, and tetany. Elevation in urea levels can result in azotemia, which can be exhibited in fluid and electrolyte and/or acid-base imbalance. Elevation of WBCs is not indicated.
What is used to decrease potassium level seen in acute renal failure?
Sodium polystyrene sulfonate The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.
A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of:
water and sodium retention secondary to a severe decrease in the glomerular filtration rate. The client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys' inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.
A client has end-stage renal failure. Which of the following should the nurse include when teaching the client about nutrition to limit the effects of azotemia?
Increase carbohydrates and limit protein intake. Calories are supplied by carbohydrates and fat to prevent wasting. Protein is restricted because the breakdown products of dietary and tissue protein (urea, uric acid, and organic acids) accumulate quickly in the blood.
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem?
White blood cell (WBC) count of 20,000/mm3 An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia (evidenced by a blood glucose level of 200 mg/dl) occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.
A client has been diagnosed with acute glomerulonephritis. This condition causes:
proteinuria. The disruption of membrane permeability causes red blood cells (RBCs) and protein molecules to filter from the glomeruli into Bowman's capsule and eventually become lost in the urine. Pyuria is pus in the urine. Polyuria is an increased volume of urine voided.
A client is diagnosed with polycystic kidney disease. Which symptom would the nurse most likely assess?
Hypertension Hypertension is often present in clients with polycystic kidney disease at the time of diagnosis. Pain from retroperitoneal bleeding, lumbar discomfort, and abdominal pain also may be noted based on the size and effects of the cysts. Fever would suggest an infection. Periorbital edema is noted with acute glomerulonephritis.
The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for?
Hypovolemic shock caused by hemorrhage If bleeding goes undetected or is not detected promptly, the patient may lose significant amounts of blood and may experience hypoxemia. In addition to hypovolemic shock due to hemorrhage, this type of blood loss may precipitate a myocardial infarction or transient ischemic attack.
A group of students are reviewing the phases of acute renal failure. The students demonstrate understanding of the material when they identify which of the following as occurring during the second phase?
Oliguria During the second phase, the oliguric phase, oliguria occurs. Diuresis occurs during the third or diuretic phase. Acute tubular necrosis (ATN) occurs during the first, or initiation, phase in which reduced blood flow to the nephrons leads to ATN. Restoration of glomerular function, if it occurs, occurs during the fourth, or recovery, phase.
Hyperkalemia is a serious side effect of acute renal failure. Identify the electrocardiogram (ECG) tracing that is diagnostic for hyperkalemia.
Tall, peaked T waves Characteristic ECG signs of hyperkalemia are tall, tented, or peaked T waves, absent P waves, and a widened QRS complex.
Twenty-four hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for:
removal of the transplanted kidney. Hyperacute rejection isn't treatable; the only way to stop this reaction is to remove the transplanted organ or tissue. Although cyclosporine is used to treat acute transplant rejection, it doesn't halt hyperacute rejection. Bone marrow transplant isn't effective against hyperacute rejection of a kidney transplant. Methylprednisolone sodium succinate may be given IV to treat acute organ rejection, but it's ineffective against hyperacute rejection.
