nclex renal
The nurse has performed a nutritional assessment on a client with cystitis. The nurse should tell the client to consume which beverage to minimize recurrence of cystitis?
2 Water Water helps flush bacteria out of the bladder, and an intake of 6 to 8 glasses per day is encouraged. Caffeine and alcohol can irritate the bladder. Therefore, alcohol- and caffeine-containing beverages such as coffee, tea, and wine are avoided to minimize risk.
The nurse instructs a client about continuous ambulatory peritoneal dialysis (CAPD). Which statement by the client indicates an accurate understanding of CAPD?
1 No machinery is involved, and I can pursue my usual activities." CAPD closely approximates normal renal function, and the client will need to infuse and drain the dialysis solution several times a day. No machinery is used, and CAPD is a manual procedure.
Which client is most at risk for developing a Candida urinary tract infection (UTI)?
3 A young woman on antibiotic therapy Candida infections, which are fungal infections, develop in persons who are on long-term antibiotic therapy because an alteration of normal flora occurs. These infections also are commonly seen in clients with blood dyscrasias, diabetes mellitus, cancer, or immunosuppression and in those with a drug addiction.
The nurse is monitoring the fluid balance of an assigned client. The nurse determines that the client has proper fluid balance if which 24-hour intake and output totals are noted?
4 Intake 1800 mL, output 1750 mL For the client on a normal diet, the normal fluid intake is approximately 1200 to 1800 mL of measurable fluids per day. The client's output in the same period should be about the same and does not include insensible losses, which are extra. Insensible losses are offset by the fluid in solid foods, which also is not measured.
The nurse is creating a plan of care for a client with a diagnosis of nephrotic syndrome whose glomerular filtration rate (GFR) is normal. Which interventions should the nurse include in the plan of care? Select all that apply.
1.Monitor daily weight. 2.Maintain sodium restrictions. 4.Monitor intake and output (I&O). 5.Maintain bed rest when edema is severe. controlling edema is a critical aspect of therapeutic management of nephrotic syndrome. If the GFR is normal, dietary intake of proteins is needed to restore normal plasma oncotic pressure and thereby decrease edema. Daily measurement of weight and abdominal girth, and careful monitoring of I&O will determine whether weight loss is caused by diuresis or protein loss. Dietary modifications may include salt restriction and fluid restriction and are based on the client's symptoms. Bed rest is prescribed to promote diuresis when edema is severe.
The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication?
2 Hyperglycemia An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis. Peritonitis is a risk associated with breaks in aseptic technique. Hyperphosphatemia is an electrolyte imbalance that occurs with renal dysfunction. Disequilibrium syndrome is a complication associated with hemodialysis and results in neurological deterioration because of rapid fluid shifting.
A client with glomerulonephritis has developed acute kidney injury (AKI) as a complication. The nurse should expect to note which abnormal finding documented on the client's medical record?
2 Hypertension AKI caused by glomerulonephritis is classified as an intrinsic or intrarenal cause of renal failure. It is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. AKI from a prerenal cause is characterized by decreased blood pressure, tachycardia, decreased cardiac output, and decreased central venous pressure. Bradycardia is not part of the clinical picture for any form of kidney failure.
The nurse is reviewing the 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 should base the response on knowing that which is the action of the glucose in the solution?
3 Increases osmotic pressure to produce ultrafiltration Increasing the glucose concentration makes the solution more hypertonic. The more hypertonic the solution, the higher the osmotic pressure for ultrafiltration and thus the greater the amount of fluid removed from the client during an exchange. The remaining options do not identify the purpose of the glucose.
The nurse checks the serum myoglobin level for a client with a crush injury to the right lower leg because the client is at risk for developing which type of acute kidney injury?
3 Intrarenal Serum myoglobin levels increase in crush injuries when large amounts of myoglobin and hemoglobin are released from damaged muscle and blood cells. The accumulation may cause acute tubular necrosis, an intrarenal cause of renal failure. Prerenal causes are conditions that interfere with the perfusion of blood to the kidney. Postrenal causes include conditions that cause urinary obstruction distal to the kidney. The cause and the type of renal failure may determine the interventions used in treatment.
The nurse is creating a plan of care for a client with chronic kidney disease and uremia. The nurse is developing interventions to assist in promoting an increased dietary intake while at the same time maintaining necessary dietary restrictions. Which action should the nurse include in the plan of care?
3 Maintain a diet high in calories with frequent snacks. Uremia usually is accompanied by nausea, anorexia, and an unpleasant taste in the mouth. Most clients experience more nausea and vomiting in the morning. Therefore, to maintain optimal nutrition, it is best for these clients to eat a diet that is high in calories with frequent snacks and a light breakfast in the morning and larger meals later in the day. Dietary management usually is aimed at restricting protein, sodium, and potassium
A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 38.5° C (101.2° F). Which nursing action is most appropriate?
3 Notify the primary health care provider. A temperature of 101.2° F (38.5° C) is significantly elevated and may indicate infection. The nurse should notify the primary health care provider (PHCP). Dialysis clients cannot have fluid intake encouraged. Vital signs and the shunt site should be monitored, but the PHCP should be notified first.
A client with urolithiasis (struvite stones) has a history of chronic urinary tract infections. What should the nurse plan to teach the client to avoid?
3 Wearing synthetic underwear and pantyhose Urolithiasis (struvite stones) can result from chronic infections. They form in urine that is alkaline and rich in ammonia, such as with a urinary tract infection. Teaching should focus on preventing infections and ingesting foods to make the urine more acidic. Foods such as currants, blueberries, and cranberries are acidic. The client should wear cotton, not synthetic, underclothing to prevent the accumulation of moisture and to prevent irritation of the perineal area, which can lead to infection. Antibiotics are not associated with chronic urinary tract infections.
The nurse is teaching a client with renal cancer who is scheduled for a renal artery embolization about the procedure. Which statement by the client indicates that the educational session was effective?
4 "This will decrease the size of the tumor because its blood supply will be removed after placement of an absorbable gelatin sponge." Renal artery embolization may be done instead of radiation therapy to shrink the kidney tumor by cutting off its blood supply and impairing its overall vascularity. A secondary benefit is that it reduces the risk of hemorrhage during surgery. This procedure can be accomplished in a number of ways, including placement of an absorbable gelatin sponge, a balloon, a metal coil, or any of various other substances.
A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication?
4 Decongestants In the client with benign prostatic hyperplasia, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. These medications lessen the voluntary ability to contract the bladder. The client should be questioned about the use of these medications if he has urinary retention. Diuretics increase urine output. Antibiotics and antilipemics do not affect ability to urinate.
The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?
4 Notify the primary health care provider (PHCP). Disequilibrium syndrome may be caused by rapid removal of solutes from the body during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs and symptoms of disequilibrium syndrome, and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The PHCP must be notified. Monitoring the client, elevating the head of the bed, and assessing the fistula site are correct actions, but the priority action is to notify the PHCP.
The nurse is giving general instructions to a client receiving hemodialysis. Which statement would be most appropriate for the nurse to include?
4 Several types of medications should be withheld on the day of dialysis until after the procedure." Many medications are dialyzable, which means that they are extracted from the bloodstream during dialysis. Therefore, many medications may be withheld on the day of dialysis until after the procedure. It is not typical for medications to be double-dosed because there is no way to be certain how much of each medication is cleared by dialysis. Clients receiving hemodialysis are not routinely taught that it is acceptable to disregard dietary and fluid restrictions.
A client with an arteriovenous fistula in the left arm who is undergoing hemodialysis is at risk for infection. Which should the nurse formulate as the best outcome goal for this client problem
4 The client's white blood cell (WBC) count remains within normal limits. General indicators that the client is not experiencing infection include a temperature and WBC count within normal limits. The client also should use proper hand-washing technique as a general preventive measure. Hand washing once per day is insufficient. It is true that the client should avoid BP measurement in the affected arm; however, this would relate more closely to the problem of risk for injury.
The nurse is caring for an older client. Which finding should the nurse expect to note in this client while evaluating renal function?
4 The glomerular filtration rate (GFR) diminishes As part of the normal aging process, the GFR decreases, along with each of the other functional abilities of the kidney. Tubular reabsorption and urine-concentrating ability also decrease. The kidneys have decreased ability to metabolize medications.
Which finding noted in the client on continuous ambulatory peritoneal dialysis (CAPD) should be reported to the primary health care provider (PHCP)?
1 Cloudy yellow dialysate output
The nurse is assessing the renal function of a client at risk for acute kidney injury. After noting the amount of urine output and urine characteristics, the nurse proceeds to assess which as the best indirect indicator of renal status?
1 Blood pressure The kidneys normally receive 20% to 25% of the cardiac output, even under conditions of rest. For kidney function to be optimal, adequate renal perfusion is necessary. Perfusion can best be estimated by the blood pressure, which is an indirect reflection of the adequacy of cardiac output. The heart rate affects the cardiac output but can be altered by factors unrelated to kidney function. Jugular vein distention and level of consciousness are unrelated items.
The client with chronic kidney disease has an indwelling abdominal catheter for peritoneal dialysis. The client spills water on the catheter dressing while bathing. Which action should the nurse immediately take?
1 Change the dressing. Clients with peritoneal dialysis catheters are at high risk for infection. A wet dressing is a conduit for bacteria to reach the catheter insertion site. The nurse ensures that the dressing is kept dry at all times. Reinforcing the dressing is not a safe practice to prevent infection in this circumstance. Flushing the catheter is not indicated. Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnection of peritoneal dialysis.
A client is about to begin hemodialysis. Which measures should the nurse employ in the care of the client? Select all that apply.
1. Using sterile technique for needle insertion 2.Using standard precautions in the care of the client 3.Giving the client a mask to wear during connection to the machine 4.Wearing full protective clothing such as goggles, mask, gloves, and apron Infection is a major concern with hemodialysis. For that reason, the use of sterile technique and the application of a face mask for both nurse and client are extremely important. It also is imperative that standard precautions be followed, which includes the use of goggles, mask, gloves, and apron. The connection site should not be covered; it should be visible so that the nurse can assess for bleeding, ischemia, and infection at the site during the hemodialysis procedure.
A client recently diagnosed with chronic kidney disease requiring hemodialysis has an arteriovenous fistula for access. The client asks the nurse what complications can occur with the access site. What complications should the nurse inform the client about? Select all that apply
1.Hepatitis 2.Infection Complications directly related to the access site for hemodialysis include hepatitis or infection as a result of poor infection control practices, as well as post-treatment blood loss from certain dialysis procedure practices and the removal of needles following the procedure. In addition, heparin is often given to prevent clotting of the access site; this can potentiate postdialysis bleeding. Hypotension from rapid removal of vascular volume can occur, as can muscle cramps from fluid shifting; however, these complications are not directly related to the access site.
The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder, if noted on the client's record, should the nurse identify as a risk factor for this disorder?
2 Diabetes mellitus Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities of the urinary tract, presence of urinary stones, and presence of an indwelling urinary catheter or frequent catheterization. The conditions noted in the remaining options are not associated risk factors.
The nurse is planning discharge teaching for a client newly diagnosed with chronic kidney disease (CKD). Which factor will enhance the educational process?
3 Presence of family The client with CKD may have several barriers to learning. The presence of family members is helpful because they need to understand the disease and treatment and may help reinforce information with the client after the formal teaching session is over. Anxiety about the disease and its ramifications frequently interferes with learning. Physiological effects of the disease process also impair the client's mental functioning. Specifically, the client may exhibit a short attention span and have memory deficits. Mental functioning usually improves once hemodialysis has begun.
The nurse is caring for a client whose urine output was 25 mL per hour for 2 consecutive hours. The nurse reviews the primary health care provider's prescriptions and plans care, knowing that which client-related factor would increase the amount of blood flow to the kidneys?
3 Release of low levels of dopamine The release of low levels of dopamine exerts a vasodilating effect on the renal arteries, increasing urinary output. The other options cause renal vasoconstriction.
A client is experiencing the syndrome of inappropriate antidiuretic hormone (ADH) secretion. When explaining this disorder to the client and family, the nurse recalls that ADH works to reabsorb water in which parts of the nephron?
3 The distal tubule and the collecting duct The distal tubule and the collecting duct of the nephron require the presence of ADH for water reabsorption. The hormone increases the permeability of the membranes to allow water to flow more easily along the concentration gradient. The glomerulus filters but does not reabsorb. The calices are responsible for collecting the urine. The proximal tubule and the loop of Henle reabsorb water without the assistance of ADH.
The nurse is preparing to perform a discharge teaching with a client who is started on hemodialysis. Which information should the nurse provide regarding the hemodialysis schedule?
3. 3 to 4 hours of treatment, 3 days per week The typical schedule for hemodialysis is 3 to 4 hours of treatment, 3 days per week. Individual adjustments are made according to variables such as the size of the client, type of dialyzer, rate of blood flow, personal client preferences, and other factors.
A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the primary health care provider (PHCP)?
4 Blood pressure, 100/50 mm Hg; pulse, 130 beats per minute Frank bleeding (arterial or venous) may occur during the first day after surgery. Some hematuria is usual for several days after surgery. A urinary output of 200 mL more than intake is adequate. A client pain rating of 2 on a 0 to 10 scale indicates adequate pain control. A rapid pulse with a low blood pressure is a potential sign of excessive blood loss. The PHCP should be notified.
The nurse has provided instructions regarding home care measures for a client with acute pyelonephritis. Which statement by the client indicates a need for further teaching?
4 "I need to avoid alcohol and highly spiced foods but may continue to drink my coffee every day." Clients with acute pyelonephritis should be instructed to try to maintain an acid ash diet, which may be of some benefit. Also, they should increase fluid intake to 3 L per day; this helps relieve dysuria and flushes bacteria out of the bladder. However, for clients with chronic pyelonephritis and renal dysfunction, an increase in fluid intake may be contraindicated. Medications such as vitamin C help acidify the urine. Juices such as cranberry, plum, and prune juice will leave an acid ash in the urine. Caffeine, alcohol, chocolate, and highly spiced foods are avoided to prevent potential bladder irritation.
The nurse has given instructions about Kegel exercises to a female client with a cystocele. The nurse determines that the client needs further instruction if she makes which statement?
4 "I should begin voiding and then stop the stream, holding residual urine for an hour." Kegel muscles strengthen the perineal floor and are useful in the prevention and management of cystocele, rectocele, and enterocele. Several ways to perform Kegel exercises are acceptable. One method entails starting and stopping the flow of urine during a single voiding for about 5 seconds. Also, these exercises may be done by holding perineal muscles taut for up to 10 seconds several times a day or for 5 minutes, 3 or 4 times a day. Residual urine should not be held in the bladder for long periods because this could promote urinary tract infection.
The graduate nurse is caring for a client with decreased renal perfusion. The registered nurse determines that the graduate nurse demonstrates understanding of why this is occurring if which statement is made?
4 "It may be a consequence of decreased dopaminergic receptor stimulation." Dopaminergic receptors are found in the renal blood vessels and in the nerves. When stimulated, they dilate renal arteries and help modulate release of the neurotransmitter dopamine. Renal artery dilation helps improve urine output by increasing blood flow through the kidneys. Serotonin is a local hormone that is released from platelets after an injury; it constricts arterioles but dilates capillaries. Dehydration, not overhydration, would decrease renal perfusion. A hemoglobin of 13.2 g/dL (132 mmol/L) is a normal value.
A client with chronic kidney disease (CKD) has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now presents with mental cloudiness, dementia, and complaints of bone pain. The nurse determines that these assessment data are compatible with which condition?
4 Aluminum intoxication Aluminum hydroxide may be prescribed as a phosphate-binding agent. Aluminum intoxication can occur when there is an accumulation of aluminum, an ingredient in many phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. It can be treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum. The data in the question are not specifically associated with the other conditions noted in the options.
The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action
4 Notify the primary health care provider (PHCP) Disequilibrium syndrome may be caused by rapid removal of solutes from the body during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs and symptoms of disequilibrium syndrome, and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The PHCP must be notified. Monitoring the client, elevating the head of the bed, and assessing the fistula site are correct actions, but the priority action is to notify the PHCP.
A client with epididymitis is upset about the extent of scrotal edema. Attempts to reassure the client that this condition is temporary have not been effective. The nurse should plan to address which client problem?
4Altered body appearance related to change in the appearance of the scrotum Altered body appearance is a problem when the client has either a verbal or a nonverbal response to a change in the structure or the function of a body part. Pain may apply but does not correlate with the information in the question. There are no data in the question that uneasiness, inability to reduce scrotal swelling, or sterility is a client concern.
The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply.
1 Check the level of the drainage bag. 2.Reposition the client to his or her side. 3.Place the client in good body alignment. 4.Check the peritoneal dialysis system for kinks Peritoneal dialysis is a treatment that uses the peritoneum as a filter along with a dialysate solution to remove waste products. If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing and peritoneal dialysis system are also checked for kinks or twisting, and the clamps on the system are checked to ensure that they are open. There is no reason to contact the PHCP. Increasing the flow rate should not be done and also is not associated with the amount of outflow solution.
A client with chronic kidney disease (CKD) has been taking aluminum hydroxide gel. On the basis of this information, the nurse determines that the client is most at risk for which problem?
1 Constipation The client with CKD is almost certain to have a problem with constipation as a result of factors such as fluid restriction, fatigue that limits exercise, and dietary restrictions. In addition, phosphate-binding antacids such as aluminum hydroxide gel cause constipation as a side effect. The other problems listed are unrelated to the information in the question.
A client has been diagnosed with pyelonephritis. The nurse interprets that which health problem has placed the client at risk for this disorder
1 Diabetes mellitus Pyelonephritis is most commonly caused by entry of bacteria, obstruction, or reflux. Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, overuse of analgesics, structural abnormalities of the urinary tract, presence of urinary stones, and indwelling or frequent urinary catheterization.
The nurse is reviewing a client's record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?
1 Elevated creatinine level The creatinine level is the most specific laboratory test to determine renal function. The creatinine level increases when at least 50% of renal function is lost. A decreased hemoglobin level and red blood cell count are associated with anemia or blood loss and not specifically with decreased renal function. Increased white blood cells in the urine are noted with urinary tract infection.
Before providing care for a client in the late stages of chronic kidney disease (CKD), the nurse should review the results of which most relevant laboratory studies?
1 serum potassium, serum calcium Because of the potentially life-threatening outcomes associated with hyperkalemia and hypocalcemia, they are the most relevant to nursing management of the client with CKD. The diagnostic tests in the remaining options may be helpful in diagnosing CKD or in monitoring treatment but are not the most relevant. Additionally, decreased hematocrit and hemoglobin occur in CKD because of the decreased level of erythropoietin. However, a decrease in hematocrit and hemoglobin may be reflective of various health alterations.
The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply.
1,2,3,4 If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing and peritoneal dialysis system are also checked for kinks or twisting, and the clamps on the system are checked to ensure that they are open. There is no reason to contact the PHCP. Increasing the flow rate should not be done and also is not associated with the amount of outflow solution.
A client is diagnosed with epididymitis. The nurse checks the primary health care provider's prescriptions and expects that which measures will be prescribed? Select all that apply
1,2,3,5 Common interventions used in the treatment of epididymitis include bed rest with bathroom privileges, elevation of the scrotum, ice packs, sitz baths, analgesics, and antibiotics. A heating pad would not be used because direct application of heat would enhance blood flow to the area, thereby increasing the swelling.
A client with chronic kidney disease (CKD) is being managed by continuous ambulatory peritoneal dialysis (CAPD). During outflow, the nurse notes that only half of the 2-L dialysate has returned, and the flow has stopped. Which interventions should the nurse take to enhance the outflow? Select all that apply.
1,3,5,6 CAPD is a method of peritoneal dialysis in which the client infuses dialysate into the abdomen through a special peritoneal catheter and then lets it dwell for a period of hours. After a specified time, the client drains the dialysate out of the abdomen by gravity and then instills another 1.5 to 3 L of dialysate into the peritoneal cavity. During the dwell time, substances are exchanged across the peritoneal membrane through the process of diffusion. It is important for the nurse to make sure that all of the dialysate in each treatment is removed to ensure proper waste and fluid removal. The distal end of the peritoneal catheter hangs loosely within the abdomen cavity, so if the nurse encourages the client to change position, placement of the catheter also could be changed, potentially increasing outflow. Because the peritoneal catheter and the tubing to the drainage bag are long and flexible, either could get kinked. Correcting this is an easy solution to the outflow problem. The peritoneal catheter is surgically placed in the abdomen, and the skin grows around the cuff. With peritoneal dialysis, gravity is the process whereby dialysate is removed from the peritoneal cavity. Keeping the bag lower than the abdomen enhances gravity. Constipation is 1 of the primary causes of poor outflow. Assessing and intervening for constipation and encouraging a high-fiber diet are important actions to include in the care of a client on peritoneal dialysis. The catheter cannot be physically manipulated. In addition, this is not an action that would be within the focus of a nursing responsibility.
A client with benign prostatic hyperplasia undergoes a transurethral resection of the prostate. Postoperatively the client is receiving continuous bladder irrigations. The nurse assesses the client for manifestations of transurethral resection syndrome. Which assessment data would indicate the onset of this syndrome?
2 Bradycardia and confusion Transurethral resection syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure, such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting.
A client who is to have a cystectomy with creation of an ileal conduit asks the nurse why the bowel needs to be cleansed before surgery if the bladder is being removed. Which response by the nurse is the most appropriate?
3 "A portion of the bowel will be used to create the conduit for urinary diversion." The client scheduled for surgical creation of either an ileal conduit or a reservoir undergoes bowel preparation the night before the procedure. Preparation can include intake of copious clear liquids, laxatives, enemas, and antibiotics, depending on primary health care provider preference. This is done primarily to prevent infection because a loop of bowel will be used to create the urinary diversion.
The nurse measures the cardiac output of a client and finds it to be 6 L/min. Which amount of kidney perfusion should the nurse anticipate?
3 1200 to 1500 mL/min The kidneys normally receive about 20% to 25% of the cardiac output when the client is at rest. If the cardiac output is 6 L/min, the kidneys receive 1.2 to 1.5 L/min, which is equal to 1200 to 1500 mL/min.
A client is being evaluated as a potential kidney donor for a family member. The client asks the nurse why separate teams are evaluating the donor and recipient. What is the most appropriate response by the nurse?
3 Avoids a conflict of interest between the team evaluating the recipient and the team evaluating the donor Both the kidney donor and the kidney recipient need thorough medical and psychological evaluation before transplant surgery. Separate teams evaluate the donor and the recipient to avoid a conflict of interest in providing care for the 2 clients. Options 1, 2, and 4 are not related to the purpose of this approach.
The primary health care provider writes prescriptions for a client with chronic kidney disease (CKD). Which prescription should the nurse question?
3 Provide a high-protein diet. When a client experiences CKD, the blood urea nitrogen (BUN) and serum creatinine levels rise. The client also experiences increased potassium, increased phosphates, and decreased calcium. BUN and creatinine are the byproducts of protein metabolism, so monitoring protein intake is important, with care taken to include proteins of high biological value. Clients with CKD will have protein restricted early in the disease to preserve kidney function. In end-stage disease, protein is restricted according to the client's weight, the type of dialysis, and protein loss. With CKD, the nurse is concerned about fluid volume overload and accumulation of waste products. Because of the kidneys' inability to excrete fluid, it is important for the nurse to prevent, as well as assess for early signs of, fluid volume excess. Infusing an intravenous (IV) solution into a client with CKD significantly increases the risk for overload. If an IV access is needed, it usually involves only a saline lock. Obtaining the client's daily weight is 1 of the most important assessment tools for evaluating changes in fluid volume. The kidneys also are responsible for removing waste products. The client also receives phosphate binders, calcium supplements, and vitamin D to prevent bone demineralization (osteodystrophy) from chronically elevated phosphate levels.
A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition?
3 Trauma to the bladder or abdomen Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria. Glomerulonephritis and pyelonephritis would be accompanied by fever and are thus not applicable to the client described in this question. Renal cancer would not cause pain that is felt in the low abdomen; rather, the pain would be in the flank area.
A client has urinary calculi composed of uric acid. The nurse is teaching the client dietary measures to prevent further development of uric acid calculi. The nurse should inform the client that it is acceptable to consume which item?
4 Cottage cheese With a uric acid stone, the client should limit intake of foods high in purines. Organ meats, sardines, herring, and other high-purine foods are eliminated from the diet. Intake of foods with moderate levels of purines, such as red and white meats and some seafood, also is limited. Avoiding the consumption of milk and dairy products is a recommended dietary change for calculi composed of calcium stones but is acceptable for the client with a uric acid stone.
A client undergoing hemodialysis begins to experience muscle cramping. What is the best action by the hemodialysis nurse in this situation?
4 Decrease the ultrafiltration rate. Muscle cramps during hemodialysis result from either too rapid removal of water and sodium or neuromuscular hypersensitivity. The nurse corrects this situation by either slowing down the ultrafiltration rate on the hemodialyzer or administering hypertonic or isotonic normal saline. Magnesium sulfate is not prescribed to correct this occurrence.
The nurse is analyzing the posthemodialysis laboratory test results for a client with chronic kidney disease. The nurse interprets that the dialysis is having an expected but nontherapeutic effect if which value is decreased?
4 Red blood cell (RBC) count Hemodialysis typically lowers the amounts of fluid, sodium, potassium, urea nitrogen, creatinine, uric acid, magnesium, and phosphate levels in the blood. Hemodialysis also worsens anemia because RBCs are lost during dialysis from blood sampling and anticoagulation and from residual blood left in the dialyzer. Although all of these results are expected, only the lowered RBC count is nontherapeutic and worsens the anemia already caused by the disease process.
A client with nephrolithiasis arrives at the clinic for a follow-up visit. Laboratory analysis of the stone that the client passed 1 week earlier indicates that the stone is composed of calcium oxalate. Based on these data, what food item does the nurse instruct the client to avoid?
4 Spinach Many kidney stones are composed of calcium oxalate. Foods that raise urinary oxalate excretion include spinach, rhubarb, strawberries, chocolate, wheat bran, nuts, beets, and tea. Pasta, lentils, and lettuce are acceptable to consume.
The spouse of a client with acute kidney injury secondary to heart failure asks the nurse how a heart problem can affect the kidneys. The nurse should formulate a response using what fact about the kidneys?
4 The kidneys generally require and receive about 20% to 25% of the resting cardiac output. Heart failure is referred to as a prerenal cause of acute kidney injury because heart failure results in decreased blood flow to the kidneys. The kidneys normally receive about 20% to 25% of the cardiac output and require adequate perfusion to function properly. With a significant or prolonged decrease in blood supply, the kidneys can fail. Options 1 and 3 are incorrect. As for option 2, large doses of furosemide resulting in severe dehydration may lead to decreased kidney perfusion, but moderate doses of furosemide do not cause prerenal acute kidney injury, and furosemide may be used to treat acute kidney injury.
The nurse is caring for a client with a bladder infection. The nurse plans care understanding that the primary risk factor for spread of infection in this client is dysfunction of which structure?
4 Ureterovesical junction The ureterovesical junction is the point at which the ureters enter the bladder. At this juncture, the ureter runs obliquely for 1.5 to 2 cm through the bladder wall before opening into the bladder. This anatomical pathway prevents reflux of urine back into the ureter and, in essence, acts as a valve to prevent urine from traveling back into the ureter and up to the kidney.
A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder?
4 tender, indurated prostate gland that is warm to the touch The client with bacterial prostatitis has a swollen and tender prostate gland that is also warm to the touch, firm, and indurated. Systemic symptoms include fever with chills, perineal and low back pain, and signs of urinary tract infection, which often accompany the disorder.
The nurse is reviewing a client's record and notes that the primary health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding?
1 Elevated creatinine level The creatinine level is the most specific laboratory test to determine renal function. The creatinine level increases when at least 50% of renal function is lost. A decreased hemoglobin level and red blood cell count are associated with anemia or blood loss and not specifically with decreased renal function. Increased white blood cells in the urine are noted with urinary tract infection.
The nurse has taught the client with polycystic kidney disease about management of the disorder and prevention and recognition of complications. The nurse should determine that the client understands the instructions if the client states that which should be reported to the primary health care provider (PHCP)? Select all that apply.
1 Frequent urination 2.Burning on urination 3.A temperature of 100.6º F (38.1º C) 4.New-onset shortness of breath The client with polycystic kidney disease should report any signs and symptoms of urinary tract infection, such as frequent urination, burning on urination, and elevated temperature so that treatment may begin promptly. Lowered blood pressure is not a complication of polycystic kidney disease, and it is an expected effect of antihypertensive therapy. The client would be concerned about increases in blood pressure because control of hypertension is essential. The client may experience heart failure as a result of hypertension, and thus any symptoms of heart failure, such as shortness of breath, are also a concern.
A client has chronic kidney disease (CKD) that does not yet require dialysis. Which client statement indicates the need for further teaching?
1 I will reduce the sodium in my diet, and I can use salt substitutes to spice my food." CKD is a condition in which the kidneys have progressive problems in their ability to clear nitrogenous waste products and control fluid and electrolyte balance within the body. Conservative treatment of CKD slows progression of the disease and includes reducing the protein, sodium, potassium, and phosphorus in the diet, and controlling the blood pressure. It is important to reduce the sodium in the diet. Salt substitutes usually are potassium-based and should not be used by a client with CKD because of the risk of hyperkalemia. The client should alter the fluid intake in relation to urine output. Obtaining a daily weight is an important measurement that indicates fluid volume. The client should also monitor for signs and symptoms of fluid overload, which could include an increase in weight, edema, and fluid collection in the lungs.
The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? Select all that apply.
1 Nocturia 2.Incontinence 3.Enlarged prostate Nocturia, incontinence, and an enlarged prostate are characteristics of BPH and need to be assessed for in all male clients over 50 years of age. Nocturnal emissions are commonly associated with prepubescent males. Low testosterone levels (not BPH) may be associated with a decreased desire for sexual intercourse.
A client is admitted to the emergency department following a fall from a horse, and the primary health care provider (PHCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action?
1 Notify the PHCP before performing the catheterization. The presence of blood at the urinary meatus may indicate urethral trauma or disruption. The nurse notifies the PHCP, knowing that the client should not be catheterized until the cause of the bleeding is determined by diagnostic testing. The other options include performing the catheterization procedure and therefore are incorrect.
The nurse is monitoring the urine output of a client with a low serum protein level and urinary output less than 30 mL in the last hour. Based on these data, the nurse understands that low urinary output is caused by which force within the kidneys?
1 Oncotic pressure The pulling pressure within the capillaries that is exerted by the plasma proteins is referred to as the oncotic pressure. Osmotic pressure is the movement of water along a pressure gradient. Filtration pressure is the pressure that is exerted with ultrafiltration, in which the pressure within the capillaries is greater than the pressure outside them; this results in fluids being pushed across the membrane into Bowman's capsule. Hydrostatic pressure in the capillaries allows fluid to be filtered out of the blood in the glomerulus.
The nurse is monitoring a client who has just returned from surgery after a transurethral resection of the prostate (TURP). The client has a 3-way Foley catheter in place for ongoing bladder irrigation. The nurse is observing the color of the client's urine and should expect which urine color during the immediate postoperative period?
1 Pale pink urine If the bladder irrigation is infusing at a sufficient rate, the urinary drainage through the Foley tubing should be pale pink. Dark pink urine indicates that the rate of the irrigation solution should be increased. Tea-colored urine is not seen after TURP but may be noted in a client with other renal disorders such as renal failure. Bright red bleeding and clots could indicate a complication, and if this is noted, it should be reported to the primary health care provider.
A client tells the nurse about a pattern of a strong urge to void, followed by incontinence before the client can get to the bathroom. Based on the data provided, which condition should the nurse suspect?
1 Urge incontinence Urge incontinence occurs when the client experiences involuntary loss of urine soon after experiencing urgency. Total incontinence occurs when loss of urine is unpredictable and continuous. Stress incontinence occurs when the client voids in increments of less than 50 mL under conditions of increased abdominal pressure. Reflex incontinence occurs at rather predictable times that correspond to when a certain bladder volume is attained.
A client with chronic kidney disease has completed a hemodialysis treatment. The nurse should use which standard indicators to evaluate the client's status after dialysis?
1 Vital signs 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 effectiveness of fluid extraction. Laboratory studies are done as per protocol but are not necessarily done after the hemodialysis treatment has ended.
The nurse is performing assessment on a client with acute kidney injury who is in the oliguric phase. Which should the nurse expect to note? Select all that apply.
1,2,3,5 During the oliguric phase of acute kidney injury, serum creatinine levels increase by approximately 1 mg/dL (88 mcmol/L) per day, and the BUN level increases by approximately 20 mg/dL (7.1 mmol/L) per day. The specific gravity of the urine is low and fixed, and the urine osmolarity approaches that of the client's serum level, or about 300 mOsm/kg (300 mmol/kg). Urine output is less than 100 mL in a 24-hour period.
The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply.
1,2,4 Polycystic kidney disease is a genetic familial disease in which the kidneys enlarge with cysts that rupture and scar the kidney, eventually resulting in end-stage renal disease. Treatment options include hemodialysis or kidney transplant. Clients usually undergo bilateral nephrectomy to remove the large, painful, cyst-filled kidneys. Peritoneal dialysis is not a treatment option due to the infected cysts. The condition does not respond to immunosuppression.
The nurse is caring for a client just after ureterolithotomy and is monitoring the drainage from the ureteral catheter hourly. Suddenly, the catheter stops draining. The nurse assesses the client and determines that which could be the cause of the problem? Select all that apply.
1,2,4,5 After ureterolithotomy, a ureteral catheter is put in place. Urine flows freely through it for the first 2 to 3 days. As ureteral edema diminishes, urine leaks around the ureteral catheter and drains directly into the bladder. At this point, drainage through the ureteral catheter diminishes. Immediately after surgery, absence of drainage usually is caused by blockage from blood clots, mucous shreds, chemical sediment, or catheter displacement.
The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply.
1,3,4 Polycystic kidney disease is a genetic familial disease in which the kidneys enlarge with cysts that rupture and scar the kidney, eventually resulting in end-stage renal disease. Treatment options include hemodialysis or kidney transplant. Clients usually undergo bilateral nephrectomy to remove the large, painful, cyst-filled kidneys. Peritoneal dialysis is not a treatment option due to the cysts. The condition does not respond to immunosuppression.
The nurse is performing an assessment on a client after a cystoscopy. Which assessment finding indicates a need to notify the primary health care provider (PHCP)?
2 Grossly bloody urine with clots Grossly bloody urine with clots following cystoscopy is always an abnormal finding and should be reported to the PHCP immediately. The client may have clear or blood-tinged urine after cystoscopy. If a contrast agent such as methylene blue is used, the urine may have an unusual bluish or green tinge. A blood pressure of 120/82 mm Hg and a temperature of 99.4º F (37.4º C) are not abnormal findings at this time.
The nursing student is caring for a client with benign prostatic hyperplasia (BPH). The nursing instructor asks the student to identify the clinical manifestations associated with this condition. The student needs further teaching if the student states that which finding is an early symptom of BPH?
2 Hematuria Hematuria is not an early sign of BPH. Nocturia, decreased force of urine stream, and difficulty initiating urine stream are all early signs of BPH.
The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication?
2 Hyperglycemia An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis. Peritonitis is a risk associated with breaks in aseptic technique. Hyperphosphatemia is an electrolyte imbalance that occurs with renal dysfunction. Disequilibrium syndrome is a complication associated with hemodialysis.
A client has developed acute kidney injury (AKI) as a complication of glomerulonephritis. Which should the nurse expect to observe in the client?
2 Hypertension AKI caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of AKI commonly manifests with hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. AKI from prerenal causes is characterized by decreased blood pressure or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for any form of renal failure.
The nurse provides discharge instructions to a client after prostatectomy. What is the priority discharge instruction for this client?
2 Increase fluid intake to at least 2.5 L/day. A daily intake of 2.5 L of fluid should be maintained to limit clot formation and prevent infection. Driving a car and sitting for long periods are restricted for at least 3 weeks. The client should be instructed to avoid lifting objects heavier than 20 lb (9 kg) for at least 6 weeks. Passing small pieces of tissue or blood clots in the urine for up to 2 weeks after surgery is expected and does not necessitate contacting the PHCP.
The nurse is providing instructions to a client who is scheduled for cystoscopy and possible biopsy under general anesthesia. Which information should the nurse include?
2 Intravenous fluids may be started on the day of the procedure. Client preparation for cystoscopy and possible biopsy includes informing the client that intravenous fluids will be started the day of the procedure to ensure adequate hydration and flow of urine. The procedure will take approximately 30 minutes to 1 hour. An informed consent is obtained from the client, and preprocedure sedatives are administered as prescribed. If a general anesthetic is to be used, the client is told that fasting is necessary after midnight before the procedure.
The nurse is caring for a client with acute kidney injury (AKI) experiencing metabolic acidosis. When performing an assessment, the nurse should expect to note which breathing pattern?
2 Kussmaul respirations Clinical manifestations associated with AKI occur as a result of metabolic acidosis. The nurse would expect to note Kussmaul respirations as a result of the metabolic acidosis because the bodily response is to exhale excess carbon dioxide. The breathing patterns noted in options 1, 3, and 4 are not characteristic of AKI.
The nursing student is assigned to care for a client with a diagnosis of acute kidney injury (AKI), diuretic phase. The nursing instructor asks the student about the primary goal of the treatment plan for this client. Which goal, if stated by the nursing student, indicates an adequate understanding of the treatment plan for this client?
2 Prevent loss of electrolytes. In the diuretic phase, fluids and electrolytes are lost in the urine. As a result, the plan of care focuses on fluid and electrolyte replacement and monitoring. Options 1, 3, and 4 are not the primary concerns in this phase of AKI.
A client diagnosed with polycystic kidney disease has been taught about the treatment plan for this disease. The nurse should determine that the client needs further teaching if the client states that which is included in the treatment plan?
2 Sodium restriction Individuals with polycystic kidney disease seem to waste rather than retain sodium. Unless the client has problems with uncontrolled hypertension, increased sodium and water intake is needed. Antihypertensive medications are prescribed to control hypertension. Genetic counseling is advisable because of the hereditary nature of the disease.
A cystectomy is performed for a client with a diagnosis of bladder cancer, and a Kock pouch is created for urinary diversion. In creating a discharge teaching plan for the client, the nurse should include which instruction in the plan?
2 Technique of catheterization A Kock pouch is a continent internal ileal reservoir. The nurse instructs the client about the technique of catheterization. Dietary restrictions are not required. There is no external pouch. Antibiotics are not required unless an infection is present; also, antibiotics are prescribed by the health care provider.
A client who is undergoing peritoneal dialysis calls the nurse at the renal unit and reports the presence of severe abdominal pain and diarrhea. The client also informs the nurse that the peritoneal dialysis returns are brown-tinged in color. Which would the nurse suspect?
3 Bowel perforation Complications of a peritoneal catheter include infection, perforation of the bowel or bladder, and bleeding. Brown-tinged returns suggest bowel perforation, which usually is accompanied by severe abdominal pain and diarrhea. Cloudy or opaque returns suggest possible infection. Urine-colored returns suggest possible bladder perforation. An intact catheter is unrelated to the information provided in the question.
The nurse is providing dietary instructions to a client with an oxalate kidney stone. The nurse should instruct the client to avoid which food?
3 Chocolate Clients with oxalate stones should avoid foods high in oxalate, such as tea, instant coffee, cola drinks, beer, rhubarb, beans, asparagus, spinach, cabbage, chocolate, citrus fruits, apples, grapes, cranberries, and peanuts and peanut butter. Large doses of vitamin C may help increase oxalate excretion in the urine.
In performing a physical assessment of a client with chronic kidney disease (CKD), which finding should the nurse anticipate?
3 Crackles auscultated in the lungs CKD is a condition in which the kidneys have progressive problems in clearing nitrogenous waste products and controlling fluid and electrolyte balance within the body. Cardiovascular symptoms of heart failure and hypertension are caused by the fluid volume overload resulting from the kidneys' inability to excrete water. Signs and symptoms of heart failure include jugular venous distention, S3 heart sound, pedal edema, increased weight, shortness of breath, and crackles auscultated in the lungs. The typical signs and symptoms of CKD include proteinuria or hematuria, not glycosuria. The nurse would observe anorexia and nausea in this client, not polyphagia
The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination?
3 Fever, nausea, vomiting, and painful scrotal edema Typical signs and symptoms of epididymitis include scrotal pain and edema, which often are accompanied by fever, nausea and vomiting, and chills. Epididymitis most often is caused by infection, although sometimes it can be caused by trauma. The remaining options do not present all of the accurate manifestations.
A client has been diagnosed with polycystic kidney disease. On assessment of the client, the nurse should observe for which most common manifestation of this disorder?
3 Flank pain and hematuria The most common findings with polycystic kidney disease are hematuria and flank or lumbar pain that is either colicky in nature or dull and aching. Other common findings include proteinuria, calculi, uremia, and palpable kidney masses. Hypertension is another common finding and may be associated with cardiomegaly and heart failure. The client may complain of a headache, but this is not a specific assessment finding in polycystic kidney disease.
A client with prostatitis following kidney infection has received instructions on management of the condition at home and prevention of recurrence. The nurse determines that education was effective if the client makes which statement?
3 I should use warm tub baths and analgesics to increase comfort." Treatment of prostatitis includes medication with antibiotics, analgesics, and stool softeners. The nurse also teaches the client to rest, increase fluid intake, and use sitz baths or warm tub baths for comfort. Antimicrobial therapy is always continued until the prescription is finished.
The nurse has completed teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse should determine that education was effective if the client states to record which parameters daily?
3 Intake and output (I&O) and weight The client on hemodialysis should monitor fluid status between hemodialysis treatments by recording I&O and measuring weight daily. Ideally, the hemodialysis client should not gain more than 0.5 kg of weight per day. It is not necessary to record the pulse and respiratory rate or the amount of activity and sleep; these parameters are not specifically related to hemodialysis. BUN and creatinine levels are not measured on a daily basis.
A client with renal cell carcinoma of the left kidney is scheduled for nephrectomy. The right kidney appears normal at this time. The client is anxious about whether dialysis will ultimately be needed. The nurse should plan to use which information in discussions with the client to alleviate anxiety?
3 One kidney is adequate to meet the needs of the body as long as it has normal function. Fears about having only 1 functioning kidney are common in clients who must undergo nephrectomy for renal cancer. These clients need emotional support and reassurance that the remaining kidney should be able to fully meet the body's metabolic needs, as long as it has normal function. Therefore, the remaining options are incorrect.
The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia?
4 Decreased force in the stream of urine Decreased force in the stream of urine is an early symptom of benign prostatic hyperplasia. The stream later becomes weak and dribbling. The client then may develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur. Constipation or scrotal edema is not associated with benign prostatic hyperplasia.
The nurse is reviewing the assessment findings for a client with a diagnosis of nephrotic syndrome. Which should the nurse expect to note in this client?
4 Decreased serum albumin levels Nephrotic syndrome describes a variety of signs and symptoms that accompany any condition that markedly impairs filtration by glomerular capillary membranes and results in increased permeability to protein. Hallmark signs and symptoms of this syndrome include increased serum lipids, edema, increased excretion of protein in the urine, and decreased serum albumin levels.
A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder?
4 Dysuria and penile discharge Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays. Hematuria is not associated with urethritis. Proteinuria is associated with kidney dysfunction.
A client with an external arteriovenous shunt in place for hemodialysis is at risk for bleeding. Which is the priority nursing intervention?
4 Ensure that small clamps are attached to the arteriovenous shunt dressing. An external arteriovenous shunt is a less common form of access site but carries a risk for bleeding when it is used because 2 ends of an external cannula are tunneled subcutaneously into an artery and a vein, and the ends of the cannula are joined. If accidental disconnection occurs, the client could lose blood rapidly. For this reason, small clamps are attached to the dressing that covers the insertion site for use if needed. The shunt site also should be assessed at least every 4 hours. Checking the shunt for the presence of bruit and thrill relates to patency of the shunt. Although checking the results of the prothrombin time is important, it is not the priority nursing action.
A client with a bladder injury has had surgical repair of the injured area with placement of a suprapubic catheter. Which is the most appropriate nursing action to prevent complications of this procedure?
4 Ensure that the catheter tubing is not kinked. A complication after surgical repair of the bladder is disruption of sutures, caused by tension on them from urine buildup. The nurse prevents this from happening by ensuring that the catheter is able to drain freely. This involves basic catheter care, including keeping the tubing free from kinks, maintaining the tubing at a level below the bladder, and monitoring the flow of urine frequently. Monitoring of urine output every shift is insufficient to detect decreased flow from catheter kinking. Measurement of urine specific gravity and an excessive intake of oral fluids do not prevent complications of bladder surgery.
The ambulatory care nurse is providing instructions to a client after a cystoscopy. Which statement by the client indicates a need for further teaching?
4 If I notice any pink-tinged urine, I should contact the primary health care provider." The client is instructed that pink-tinged urine and burning on urination are expected for 1 to 2 days after the procedure. Increased fluid intake is encouraged. Application of heat to the lower abdomen, administration of mild analgesics, and the use of sitz baths may relieve discomfort. The client also is advised to avoid alcoholic beverages for 2 days after the test.
A week after kidney transplantation, a client develops a temperature of 101º F (38.3º C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment?
4 Increased immunosuppression therapy Acute rejection most often occurs within 1 week after transplantation but can occur any time posttransplantation. Clinical manifestations include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, and manifestations of deteriorating renal function. Treatment consists of increasing immunosuppressive therapy. Antibiotics are used to treat infection. Peritoneal dialysis cannot be used with a newly transplanted kidney due to the recent surgery. Removal of the transplanted kidney is indicated with hyperacute rejection, which occurs within 48 hours of the transplant surgery.
A client with chronic kidney disease (CKD) is prescribed aluminum hydroxide. Which information should the nurse include while instructing the client regarding the action of this medication?
4 It combines with phosphorus and helps eliminate phosphates from the body. Aluminum hydroxide may be prescribed for a client with CKD. It binds with phosphate in the intestines for excretion in the feces, thus lowering phosphorus levels. It can cause constipation, and it does not promote the elimination of potassium. It may be used in the treatment of hyperacidity associated with gastric ulcers, but this is not the purpose of its use in the client with renal failure.
A client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril. When should the nurse plan to administer this medication?
4 On return from dialysis Antihypertensive medications such as enalapril are given to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and from having the medication removed from the bloodstream by dialysis. No rationale exists for waiting an entire day to resume the medication. This would lead to ineffective control of the blood pressure.
A client undergoing hemodialysis is at risk for bleeding from the heparin used during the hemodialysis treatment. The nurse assesses for this occurrence by periodically checking the results of which laboratory test?
4 Partial thromboplastin time (PTT) Heparin is the anticoagulant used most often during hemodialysis. The hemodialysis nurse monitors the extent of anticoagulation by checking the PTT, which is the appropriate measure of heparin effect. Thrombin and bleeding times are not used to measure the effect of heparin therapy, although they are useful in the diagnosis of other clotting abnormalities. The PT is a test used to monitor the effect of warfarin therapy.
