NCLEX Review: Renal/Urinary

A 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?

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.

A nurse is preparing to care for a client receiving peritoneal dialysis. Which should be included in the nursing plan of care to prevent the major complication associated with peritoneal dialysis?

Maintain strict aseptic technique. The major complication of peritoneal dialysis is peritonitis. Strict aseptic technique is required in caring for the client receiving this treatment.

A client newly diagnosed with chronic kidney disease has just been started on peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is most appropriate?

Explain that the pain will subside after the first few exchanges. Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, the pain usually disappears after 1 to 2 weeks of treatment.

A cystectomy is performed for a client with a diagnosis of bladder cancer, and a Kock pouch is created for urinary diversion. In preparing a discharge teaching plan for the client, the nurse should include which instruction in the plan?

Technique of catheterization Kock's pouch is a continent internal ileal reservoir. The nurse instructs the client about the technique of catheterization.

A client who is performing peritoneal dialysis at home calls the clinic and reports that the outflow from the dialysis catheter seems to be decreasing in amount. The clinic nurse should ask which question first?

"Have you been constipated recently?" Reduced outflow from the dialysis catheter may be caused by the catheter position, infection, or constipation. Constipation may contribute to a reduced outflow because peristalsis seems to aid in drainage.

A client is having difficulty coughing and deep breathing because of pain after a nephrectomy. Which action by the nurse is least helpful in promoting optimal respiratory function?

Administering pain medication only before ambulation The client who has had a nephrectomy may have pain with coughing and deep breathing and other respiratory exercises because the location of the incision is so close to the diaphragm. The nurse assists the client by administering opioid analgesics, encouraging incentive spirometer use, and assisting the client to splint the incision during coughing. If the client takes pain medication only before ambulation, control of pain may be insufficient, which will not promote optimal respiratory function (pain medication should be offered 30 to 45 minutes before the client ambulates).

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?

Altered body appearance related to change in 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.

The nurse is collecting data from a client who has a history of benign prostatic hyperplasia. To determine whether the client currently is experiencing this condition, the nurse should ask the client about the presence of which early symptom?

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.

The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder, if noted on the client's record, would the nurse identify as a risk factor for this disorder?

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.

A client is experiencing a decrease in renal perfusion. The nurse plans care, knowing that the client could benefit from greater endogenous production of which substance that dilates the renal arteries?

Dopamine 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 to improve urine output by increasing blood flow through the kidneys.

A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder?

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

The nurse has a prescription to obtain a urinalysis specimen from a client with an indwelling urinary catheter. Which actions should the nurse include in performing this procedure? Select all that apply.

Explaining the procedure to the client Clamping the tubing of the drainage bag Aspirating a sample from the port on the drainage bag Wiping the port with an alcohol swab before inserting the syringe A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag, so its properties do not necessarily reflect current client status. In addition, it may become contaminated with bacteria from opening the system. The remaining options are correct interventions for obtaining the specimen.

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?

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

A nurse is providing instructions to a client who is scheduled for cystoscopy and possible biopsy and will be receiving general anesthesia. Which instruction should the nurse provide to the client?

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.

A nurse has administered a dose of furosemide (Lasix) to a client with diminished urine output. The nurse expects the urine output to increase once the medication has had time to exert an effect on which part of the nephron?

Loop of Henle Furosemide works by acting to excrete sodium, potassium, and chloride in the ascending limb of the loop of Henle

A nurse is developing a plan of care for a client with a diagnosis of nephrotic syndrome whose glomerular filtration rate (GFR) is normal. Which interventions should be appropriate components of the care plan? Select all that apply.

Monitor daily weight. Maintain sodium restrictions. Monitor intake and output (I&O). 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 intake and output 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.

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 a necessity. The nurse should plan to use which information in discussions with the client to alleviate anxiety?

One kidney is adequate to meet the needs of the body so long as it has normal function. Fears about having only one 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, so long as it has normal function.

A client is diagnosed with epididymitis. The nurse checks the health care provider's prescriptions and expects that which options will be prescribed? Select all that apply.

Sits bath Antibiotics Scrotal elevation Bed rest with bathroom privileges 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 an arteriovenous fistula in the left arm and who is undergoing hemodialysis is at risk for infection. Which should the nurse formulate as the best outcome goal for this client problem?

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.

A nurse is caring for an older client. When evaluating the client's renal function, the nurse recalls that which change takes place as part of the normal aging process?

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.

The nurse has administered a dose of meperidine hydrochloride (Demerol), 100 mg, to a client with renal colic as treatment for pain. The nurse carefully monitors this client for which side effect of this medication?

Urinary retention Meperidine hydrochloride is an opioid analgesic. Side effects of meperidine hydrochloride include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urinary retention.

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 the client understands the instructions if the client verbalizes that they will take which action?

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 for comfort. Antimicrobial therapy is always continued until the prescription is finished.

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?

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. 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

A client with glomerulonephritis has developed acute kidney injury (AKI) as a complication. The nurse would expect to note which abnormal finding documented on the client's medical record?

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.

The nurse is giving general instructions to a client receiving hemodialysis. Which statement would be most appropriate for the nurse to include?

"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.

The nurse is working on a medical-surgical nursing unit and is caring for several clients with chronic kidney disease. The nurse interprets that which client is best suited for peritoneal dialysis as a treatment option?

A client with severe heart failure Peritoneal dialysis may be the treatment option of choice for clients with severe cardiovascular disease. Severe cardiac disease can be worsened by the rapid shifts in fluid, electrolytes, urea, and glucose that occur with hemodialysis. For the same reason, peritoneal dialysis may be indicated for the client with diabetes mellitus. Contraindications to peritoneal dialysis include diseases of the abdomen such as ruptured diverticula or malignancies; extensive abdominal surgeries; history of peritonitis; obesity; and a history of back problems, which could be aggravated by the fluid weight of the dialysate. Severe disease of the vascular system also may be a relative contraindication.

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. The nurse would give the best response using which piece of information?

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 health care provider preference. This is done primarily to prevent infection because a loop of bowel will be used to create the urinary diversion.

A week after kidney transplantation, a client develops a temperature of 101° F, the blood pressure is elevated, and the kidney is tender. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse suspects which complication?

Acute rejection Acute rejection most often occurs in the first 2 weeks after transplantation. Clinical manifestations include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, and manifestations of deteriorating renal function. Chronic rejection occurs gradually over a period of months to years.

A patient with kidney failure reports dyspnea. The patient's pulse oximeter reading is 95% on room air, but the patient is visibly distressed with a respiratory rate of 32 breaths/min. What would be the priority intervention?

Administer oxygen by nasal cannula. Patients with kidney failure are anemic because they cannot produce the hormone erythropoietin. A high oxygen saturation in an anemic patient who is showing signs of respiratory distress may still be hypoxemic. Administering oxygen is necessary.

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?

Aluminum intoxication Aluminum intoxication can occur when there is 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 nurse is working with a client newly diagnosed with chronic kidney disease (CKD) to set up a schedule for hemodialysis. The client states, "This is impossible! How can I even think about leading a normal life again if this is what I'm going to have to do?" The nurse determines that the client is exhibiting which problem?

Anger Psychosocial reactions to CKD and hemodialysis are varied and may include anger. Other reactions include personality changes, emotional lability, withdrawal, and depression. The individual client's response may vary depending on the client's personality and support systems.

A client is being evaluated as a potential kidney donor for a family member. The client asks the nurse why separate teams are evaluating donor and recipient. In formulating a response, what should the nurse understand about this approach?

Avoids a conflict of interest between the team evaluating the recipient and those 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 two clients.

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 health care provider (HCP)?

Blood pressure, 90/50 mm Hg; pulse, 130 beats/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. Bladder spasms are expected to occur following surgery. A rapid pulse with a low blood pressure is a potential sign of excessive blood loss. The HCP should be notified.

A client who has had a prostatectomy has been instructed in perineal exercises to gain control of the urinary sphincter. The nurse determines that the client demonstrates a need for further instruction when he states that he will perform which movement as part of these exercises?

Bearing down as if having a bowel movement The Valsalva maneuver (bearing down) is avoided after prostatectomy because it increases the risk of bleeding in the postoperative period.

The patient with which condition is more likely to experience renal compromise (decreased urine production)?

Blood pressure of 92/46 mm Hg for 12 hours The ability of the kidneys to self-regulate renal blood pressure and renal blood flow keeps the glomerular filtration rate (GFR) constant. A blood pressure of 92/48 mm Hg is a mean arterial pressure of 62 mm Hg. The kidney has a difficult time regulating GFR with a mean arterial blood pressure less than 65 mm Hg

A client who is performing 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?

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.

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?

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.

The client with a 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 should immediately take?

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.

A home health nurse is planning to make a home visit to a client who has undergone surgical creation of an ileal conduit. The nurse plans to include which consideration in ostomy care in discussions with the client?

Cleanse the skin around the stoma, using gentle soap and water, and then rinse and dry well. The skin around the stoma is cleansed at each appliance change using a gentle, nonresidue soap and water. The skin is rinsed and then dried thoroughly. The appliance should be changed early in the morning because urine production is slowest from no fluid intake during sleep. The appliance is cut so that the opening is not more than 3 mm larger than the stoma. An opening smaller than the stoma will prevent application of the appliance. Generous fluid intake is encouraged to dilute the urine, decreasing the intensity of odor.

In performing a physical assessment of a client with chronic kidney disease (CKD), which finding should the nurse anticipate to note?

Crackles auscultated in lungs Chronic kidney disease 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 kidney's 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.

A nurse is reviewing the assessment findings for a client with a diagnosis of nephrotic syndrome. Which would the nurse expect to note in this client?

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 client with an external arteriovenous shunt in place for hemodialysis is at risk for bleeding. Which intervention is the priority nursing action?

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 two 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.

A client with a bladder injury has had surgical repair of the injured area with placement of a suprapubic catheter. The nurse plans to take which action to prevent complications of this procedure?

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.

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations?

Headache, deteriorating level of consciousness, and twitching Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing increased intracranial pressure and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.

A patient with a history of kidney disease is admitted with acute shoulder pain. Which order should the nurse question?

Ibuprofen 600 mg by mouth every 8 hours as needed for pain High-dose or long-term use of NSAIDs can seriously reduce kidney function. Explore the past and current use of over-the-counter (OTC) drugs or agents, including dietary supplements, vitamins and minerals, herbal agents, laxatives, analgesics, acetaminophen, and NSAIDs.

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?

Intake 1800 mL, output 1750 mL For the client taking 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.

A nurse is planning teaching for a female client diagnosed with urethritis caused by chlamydial infection. Which point should the nurse plan to include in the teaching session?

Keep follow-up appointments for repeat cultures in 4 to 7 days. Follow-up cultures are typically done in 4 to 7 days to evaluate the effectiveness of the medication. Using a spermicide does not change the perineal pH. The infection can be prevented by the use of latex condoms. Chlamydial infection is treated with antibiotics and, which are not discontinued until the prescribed course is completed. All sexual partners during the 30 days before diagnosis should be notified, examined, and treated as necessary.

The nurse is caring for a client with acute kidney injury (AKI). When performing an assessment, the nurse would expect to note which breathing pattern?

Kussmaul's respirations Clinical manifestations associated with AKI occur as a result of metabolic acidosis. The nurse would expect to note Kussmaul's respirations as a result of the metabolic acidosis because the bodily response is to exhale excess carbon dioxide.

A client has just had a Foley catheter removed and is to be started on a bladder retraining program. Which intervention will provide the most useful information about the client's ability to empty the bladder?

Measuring post-void residual using a bladder scan Measuring post-void residual gives specific information about the ability of the bladder to empty completely. Recording intake and output and assisting the client to the bathroom are general interventions but do not provide information about the client's ability to empty the bladder.

A client being discharged home after renal transplantation has a risk for infection related to immunosuppressive medication therapy. The nurse determines that the client needs further instruction on measures to prevent and control infection if the client states that it is necessary to take which action?

Monitor urine character and output at least 1 day each week The client receiving immunosuppressive medication therapy must learn and use infection-control methods for use at home. The client self-monitors urine output and its characteristics on a daily basis. The client must learn proper hand washing technique and should take the temperature daily to detect early infection. This is especially important because the client also takes corticosteroids, which mask signs and symptoms of infection. All medications should be taken exactly as prescribed.

When reading the product literature for a medication, the nurse notes that the medication is nephrotoxic. The nurse plans care, knowing that this medication could cause damage to which structure of the kidney?

Nephron The nephron is the functional unit of the kidney that is responsible for clearance of excess fluid and waste products of metabolism.

The nurse is preparing to care for a client after a renal scan. Which intervention should the nurse include in the postprocedure plan of care?

No special precautions are necessary except the wearing of gloves by persons who may have contact with the client's urine. No specific precautions are necessary after a renal scan. Urination into a commode is acceptable without risk from the small amount of radioactive material to be excreted. The nurse wears gloves to maintain body secretion precautions.

A client is admitted to the emergency department following a fall from a horse and the health care provider (HCP) prescribes insertion of a Foley catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action?

Notify the HCP. The presence of blood at the urinary meatus may indicate urethral trauma or disruption. The nurse notifies the HCP, knowing that the client should not be catheterized until the cause of the bleeding is determined by diagnostic testing.

A client with a chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). When should the nurse plan to administer this medication?

On return from dialysis Antihypertensive medications such as enalapril (Vasotec) 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.

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess the client for which manifestations of this complication?

Pallor, diminished pulse, and pain in the left hand Steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and a diminished pulse distal to the fistula. The client also complains of pain distal to the fistula, caused by tissue ischemia. Warmth and redness probably would characterize a problem with infection.

A nurse is reviewing the urinalysis results for a client with glomerulonephritis. Which findings would the nurse expect to note? Select all that apply.

Proteinuria Hematuria A dark and smoky appearance of the urine In the client with glomerulonephritis, characteristic findings in the urinalysis report are gross proteinuria and hematuria. The specific gravity is elevated, and the urine may appear dark and smoky. Positive ketones are not associated with this condition but may indicate a secondary problem.

A health care provider writes prescriptions for a client with chronic kidney disease (CKD). Which prescription should the nurse question?

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 by-products of protein metabolism, so monitoring of 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 kidney's 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 one 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.

The nurse has provided instructions to a client with a urinary tract infection regarding foods and fluids to consume that will acidify the urine. Which fluids should the nurse include in the client's teaching plan that will aid in acidifying the urine? Select all that apply.

Prune juice Apricot juice Cranberry juice Acidification of the urine inhibits multiplication of bacteria. Fluids that acidify the urine include prune, apricot, cranberry, and plum juice. Carbonated drinks should be avoided because they increase urine alkalinity. Two glasses of milk a day can make the urine more alkaline, which could aid in the development of kidney stones.

The nurse is analyzing the post-hemodialysis 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?

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 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.

Reposition the client. Make sure the peritoneal catheter is not kinked. Check that the drainage bag is lower than the client's abdomen. Assess the stool history, and institute elimination measures if the client is constipated. 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 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 one 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.

A client with chlamydial infection has received instructions on self-care and prevention of further infection. The nurse determines that the client needs further teaching if the client states that he or she will take which action?

Take an antibiotic so as to prophylactically prevent symptoms of Chlamydia. Antibiotics are not taken prophylactically to prevent acquisition of chlamydial infection. The risk of reinfection can be reduced by limiting the number of sexual partners and the use of condoms. In some cases follow-up culture is requested in 4 to 7 days to confirm a cure.

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?

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.

A client is scheduled for surgical creation of an internal arteriovenous (AV) fistula on the following day. The client says to the nurse, "I'll be so happy when the fistula is made tomorrow. This means I can have that other hemodialysis catheter pulled right out." Which interpretation should the nurse make based on the client's statement?

The client does not understand that the site needs to mature or develop for 1 to 2 weeks before use. An AV fistula is the internal creation of an arterial-to-venous anastomosis. This causes engorgement of the vein, allowing both the artery and the vein to be easily cannulated for hemodialysis. Fistulas take 1 to 2 weeks to mature (engorgement) or develop before they can be used for dialysis, so the current method of access must remain in place to be used during that time period

A nurse is caring for a client who has just returned from having a cystoscopy. The nurse should recognize which as an abnormal assessment finding for this client?

The client reports bright red urine. The main purpose of a cystoscopy is to inspect the interior of the bladder with a tubular lighted scope (cystoscope). Pink-tinged urine is a normal finding after this procedure, but bright red urine indicates hemorrhaging and is not a normal finding.

A client with a chronic kidney disease has completed a hemodialysis treatment. The nurse should use which standard indicators to evaluate the client's status after dialysis?

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.

The registered nurse is instructing a new nursing graduate about hemodialysis. Which statement, if made by the new nursing graduate, would indicate an understanding of the procedure for hemodialysis? Select all that apply.

"Heparin sodium is administered during dialysis." "Dialysis cleanses the blood of accumulated waste products." "Warming the dialysate increases the efficiency of diffusion." Heparin sodium is used during dialysis, and it inhibits the tendency of blood to clot when it comes in contact with foreign substances. The dialysate is warmed to approximately 100° F to increase the efficiency of diffusion and to prevent a decrease in the client's blood temperature. Dialysate is made from clear water and chemicals and is free from any metabolic waste products or medications. Bacteria and other microorganisms are too large to pass through the membrane; therefore the dialysate does not need to be sterile.

A nurse has provided instructions regarding home care measures for a client with acute pyelonephritis. Which statement by the client indicates a need for further instruction?

"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.

A client with renal cancer is being treated preoperatively with radiation therapy. What statement by the client demonstrates understanding of proper care of the skin over the treatment field?

"I need to avoid skin exposure to direct sunlight and chlorinated water." The client undergoing radiation therapy should avoid washing the site until instructed to do so. The client should then wash, using mild soap and warm or cool water, and pat the area dry. No lotions, creams, alcohol, or deodorants should be placed on the skin over the treatment site. Lines or ink marks that are placed on the skin to guide the radiation therapy should be left in place. The affected skin should be protected from temperature extremes, direct sunlight, and chlorinated water (as from swimming pools).

The nurse has given instructions to a woman with a cystocele about Kegel exercises. The nurse determines that the woman needs further instructions if she makes which statement?

"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 three or four times a day. Residual urine should not be held in the bladder for long periods because this could promote urinary tract infection.

A nurse provides home care instructions to a client undergoing hemodialysis with regard to care of a newly created arteriovenous (AV) fistula. Which client statement would indicate understanding of the instructions?

"I should check the fistula every day by feeling it for a vibration." An AV fistula provides access to the client's bloodstream for the dialysis procedure. The client is instructed to monitor fistula patency daily by palpating for a thrill (vibration feeling). The client is instructed to avoid compressing the fistula with tight clothing or when sleeping, and that blood pressure measurements and blood draws should not be performed on the arm with the fistula. The client also is instructed to assess the fistula for signs and symptoms of infection, including pain, redness, swelling, and excessive warmth.

A client has chronic kidney disease (CKD) that does yet not require dialysis. Which comment to the nurse, if made by the client, indicates the need for further teaching?

"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.

An ambulatory care nurse is providing instructions to a client after a cystoscopy. Which statement by the client indicates a need for further instruction?

"If I noticed any pink-tinged urine, I should contact the 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.

The nurse instructs a client about continuous ambulatory peritoneal dialysis (CAPD). Which statement, if made by the client, indicates an accurate understanding of CAPD?

"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.

A nurse instructor is evaluating a nursing student for knowledge regarding care of a client with acute kidney injury. Which statement by the student demonstrates the need for further education about the diuretic phase of acute kidney injury?

"The diuretic phase is characterized by an increase in urine output of about 500 mL in a 24-hour period." The diuretic phase of acute kidney injury is characterized by an increase in urine output of more than 1000 mL in a 24 hour period. This increase in urine output indicates the return of some renal function; however, BUN and creatinine levels continue to rise during the first few days of diuresis. The diuretic phase develops about 14 days after the initial insult and lasts about 10 days.

A nurse measures the cardiac output of a client and finds it to be 6 L/min. Which amount should the nurse calculate is the amount of blood circulating to the kidneys?

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, then the kidneys receive 1.2 to 1.5 L/min, which is equal to 1200 to 1500 mL/min.

The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination?

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. Epididymitis needs to be distinguished correctly from testicular torsion.

A 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 sign/symptom is not a cause for concern?

A blood pressure of 105/68 mm Hg 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. The client with polycystic kidney disease should report any signs/symptoms of urinary tract infection (burning on urination/temp of 100.6) so that treatment may begin promptly.

Which client is most at risk for developing a Candida urinary tract infection (UTI)?

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 providing instructions regarding the complications of peritoneal dialysis. The nurse emphasizes that onset of peritonitis, a serious complication, is most likely to be associated with which clinical manifestation?

Fever The signs of peritonitis include fever, nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output. Fatigue may be associated with peritonitis, but fever is the most likely sign. Leaking around the catheter site is not an indication of peritonitis.

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.

Check the level of the drainage bag. Reposition the client to his or her side Place the client in good body alignment. Check the peritoneal dialysis system for kinks. 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.

Which findings noted in a client on continuous ambulatory peritoneal dialysis (CAPD) should be reported to the health care provider (HCP)?

Cloudy yellow dialysate output CAPD is a form of peritoneal dialysis in which exchanges are completed four or five times daily. Peritonitis is a major complication of this type of dialysis. Peritonitis can be recognized by cloudy dialysate outflow, fever, abdominal guarding (board-like abdomen), abdominal pain, pain on inflow, malaise, nausea, and vomiting. The client has the right to refuse medications, but it also is important for the nurse to explain the importance of medications to the client. Typically the dwell time during the night is for the entire time that the client sleeps, which could be around 7 to 9 hours. The peritoneal site should have intact skin. The skin grows around the peritoneal catheter cuff, and this prevents tunnel (around catheter) infections.

The nurse is reviewing the medication record of a client diagnosed with chronic kidney disease (CKD). The nurse notes that the client is receiving aluminum hydroxide (ALternaGEL). The nurse plans care, knowing that which is the purpose of this medication?

Combines with phosphorus and helps eliminate phosphates from the body. Aluminum hydroxide 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 returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 100.2° F. Which nursing action is most appropriate?

Continue to monitor vital signs. The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. Therefore it is not necessary to notify the health care provider. If the temperature is elevated excessively and remains elevated, sepsis would be suspected and a blood sample would be obtained as prescribed for culture and sensitivity determinations. Encouraging fluids is an unsafe action for a client with chronic kidney disease.

A client has been diagnosed with pyelonephritis. The nurse interprets that which health problem has placed the client at risk for this disorder?

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.

A client has been diagnosed with polycystic kidney disease. On assessment of the client, the nurse will observe for which as the most common manifestation of this disorder?

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 diagnosed with benign prostatic hyperplasia (BPH) is scheduled for a transrectal ultrasound examination and a test to measure the level of prostate-specific antigen (PSA). The client says to the nurse, "I can't remember...can you tell me again why I need these tests to be done?" The nurse responds knowing that these tests are done for which purpose?

Help to rule out the possibility of cancer A transrectal ultrasound examination and PSA level determination help to rule out the possibility of prostate cancer.

The nurse provides discharge instructions to a client after a prostatectomy. What is the priority discharge instruction for this client?

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 pounds 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 HCP.

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?

Infrarenal 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.

A nurse has completed client teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse should determine that the client understands the information if the client states to record which parameters daily?

Intake and output and weight The client on hemodialysis should monitor fluid status between hemodialysis treatments by recording intake and output and measuring weight daily. Ideally the hemodialysis client should not gain more than 0.5 kg of weight per day.

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 most appropriate nursing action?

Notify the health care provider (HCP). Disequilibrium syndrome may be caused by the rapid decreases in the blood urea nitrogen level during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs/symptoms of disequilibrium syndrome and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The HCP must be notified.

A nurse is monitoring the urine output of a client whose Foley catheter has drained less than 30 mL in an hour. The nurse plans care, knowing that the client's low serum protein level could alter glomerular filtration because of which type of pulling pressure that plasma proteins exert?

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 urging a client to cough and deep breathe after nephrectomy. The client tells the nurse, "That's easy for you to say! You don't have to do this." The nurse interprets that the client's statement is most likely to be a result of which factor?

Pain that is intensified because of the location of the incision near the diaphragm After nephrectomy, the client may be in considerable pain. This is because of the size of the incision and its location near the diaphragm, which make coughing and deep breathing very uncomfortable. For this reason, opioids are used liberally and may be most effective when provided as patient-controlled analgesia or through epidural analgesia.

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, would indicate an adequate understanding of the treatment plan for this client?

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.

A nurse assessing the ureterostomy of a postoperative client interprets that the stoma has normal characteristics if which is observed?

Red and moist Following ureterostomy, the stoma should be red and moist. A dry stoma may indicate fluid volume deficit. A pale stoma may indicate an inadequate vascular supply. Any darkness or duskiness of the stoma may mean loss of vascular supply and must be corrected immediately to prevent necrosis.

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 additional teaching if the client states that which is included in the treatment plan?

Sodium restriction Individuals with polycystic kidney disease seem to waste rather than retain sodium. Unless the client has problems with uncontrolled hypertension, they need increased sodium and water intake. Antihypertensive medications are prescribed to control hypertension. Genetic counseling is advisable because of the hereditary nature of the disease.

A client with renal cancer is to undergo preoperative renal artery embolization. What should the nurse tell the client regarding the primary benefit of this procedure?

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 (Gelfoam), a balloon, a metal coil, or any of various other substances.

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?

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.

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 is the least likely cause of the problem?

Ureteral edema 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.

A client has been diagnosed with a bladder infection. The nurse plans care, knowing that the client will be at increased risk for extension of the infection to the kidneys if there is improper function of which area of the urinary system?

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.