UWorld Urinary/Renal

Place the nursing actions for performing a renal system physical assessment in the correct order. All options must be used. 1. Advise client to empty the bladder completely 2. Auscultate the renal arteries in right and left upper quadrants 3. Document the assessment of renal system function 4. Observe skin and contour of abdomen and lower back 5. Percuss and palpate both the right and left kidneys

1. Advise client to empty the bladder completely 4. Observe skin and contour of abdomen and lower back 2. Auscultate the renal arteries in right and left upper quadrants 5. Percuss and palpate both the right and left kidneys 3. Document the assessment of renal system function Examination of the urinary system requires an abdominal assessment. Therefore, assessment techniques must be reordered to optimize the examination. The steps for a renal system assessment are: 1. Empty the bladder to avoid discomfort during percussion and palpation and to provide a clean-catch sample (if prescribed) (Option 1) 2. Inspect the abdomen and lower back for color, contour, symmetry, distension, and movements (eg, visible peristalsis). Inspection is always done first during physical examination (Option 4). 3. The nurse should auscultate immediately after inspection as percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation. Listen for renal artery bruits in the right and left upper abdominal quadrants (Option 2). 4. Percuss for kidney borders, costovertebral angle tenderness, and bladder distension. A dull percussion sound indicates solid structures or fluid-filled cavities (eg, distended bladder). Palpate for bladder distension, masses, and tenderness. A distended bladder may be palpated at any point from the symphysis pubis to the umbilicus and is felt as a firm, rounded organ. A normal kidney is not usually palpable; a palpable kidney may indicate hydronephrosis or polycystic kidney disease (Option 5). 5. Document all renal assessment findings immediately after the examination (Option 3). Educational objective: Physical assessment of the renal system includes the techniques of inspection, auscultation, percussion, and palpation, in that order. Allow the client to empty the bladder before beginning the assessment and auscultate immediately after inspection as percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation. Always document the findings. Reduction of Risk Potential

A client had a percutaneous nephrolithotripsy 3 hours ago to remove left renal calculi. Since then, the indwelling urethral catheter has drained 125 mL of urine and the nephrostomy tube has drained 0 mL. The client now reports left flank pain radiating to the left groin along with severe nausea. What is the appropriate nursing intervention? 1. Assess the urethral catheter for kinks and obstruction 2. Irrigate the nephrostomy tube with sterile normal saline as prescribed 3. Irrigate the urethral catheter with sterile normal saline as prescribed 4. Place the client in the prone position to facilitate urine drainage

2 Percutaneous nephrolithotripsy involves the insertion of a needle and sheath through the skin into the pelvis of the kidney. A nephroscope is inserted through the sheath to break and remove kidney stones too large to remove with other methods. Post procedure, a temporary percutaneous nephrostomy tube may be placed to prevent obstruction by stone fragments and to promote healing of injured tissue; maintaining tube patency is critical. This client is experiencing left flank pain and has no drainage from the nephrostomy tube, which may indicate obstruction to urine flow in the left kidney that can lead to kidney injury (pressure atrophy). Gentle irrigation of the nephrostomy tube with a small volume of sterile normal saline (as prescribed or per protocol) using aseptic technique is the appropriate intervention. If tube patency cannot be established after irrigation, the health care provider is notified (Option 2). (Options 1 and 3) The indwelling urethral catheter is appropriately draining 42 mL/hr, so it is not likely kinked or obstructed. The urine flow is likely coming from a normal-functioning right kidney. (Option 4) The client is placed in the prone position for the procedure, but this does not facilitate drainage. Educational objective: A percutaneous nephrolithotripsy is a procedure to remove large kidney stones from the renal pelvis. Post procedure, a nephrostomy tube may be placed to prevent obstruction by stone fragments and to promote healing of injured tissue. Gentle irrigation of the nephrostomy tube with sterile normal saline may be necessary to maintain tube patency. 42% Physiological Adaptation

The charge nurse is making rounds and should immediately intervene when making which observation? 1. A new nurse is using gentle pressure to flush a kidney pelvis catheter with 5 mL of fluid 2. A nursing assistant is hanging a urinary drainage bag on the back of a wheelchair when transporting a client 3. Indwelling urinary catheter is taped to a male client's inner thigh 4. Total oral fluid intake in 24 hours for a client with a urinary diversion device is 2,800 mL

2 The flow of urine is dependent on gravity. In order to maintain gravity flow, the drainage bag should be hung below the level of the bladder. Impaired urine flow can lead to urinary retention and distension of the bladder. (Option 1) Catheters placed in the kidney pelvis are irrigated using gentle pressure and small amounts of sterile saline solution (≤5 mL at one time) to avoid damaging renal tissues. (Option 3) Securing an indwelling urinary catheter by taping it to a client's leg is acceptable to maintain gravity flow and prevent kinks and occlusions. Also, Velcro securement devices may be available at certain facilities. (Option 4) Fluid intake of 3,000 mL per day should be encouraged in clients after surgery involving the urinary system. Increased fluid intake ensures the maintenance of a high urinary output, reducing the risk for infection. Dilute urine is less irritating to the skin surrounding the stoma site. Electrolyte reabsorption from reservoirs may increase risk for calculi. However, high fluid intake and urine output reduce this risk. Educational objective: The flow of urine is dependent on gravity. The drainage bag should be hung below the level of the bladder to maintain gravity flow. Reduction of Risk Potential

A clinic nurse receives messages on 4 clients. Which client should the nurse call back first? 1. Client with celiac disease reporting diarrhea and foul-smelling stools 2. Client with chronic kidney disease reporting nausea, vomiting, and headache 3. Client with nausea and diarrhea after taking amoxicillin-clavulanate 4. Client with nausea, vomiting, and diarrhea after eating egg salad

2 The kidneys regulate fluid volume and blood pressure. Because renal damage often results in elevated blood pressure, clients with chronic kidney disease are at risk for uncontrolled hypertension and hypertensive emergencies. Hypertensive encephalopathy is a type of hypertensive crisis characterized by nausea, vomiting, and headache (Option 2). Treatment is urgent (ie, within 1 hour) to prevent damage to the heart, kidney, and brain. The client should check blood pressure at home, if possible, and then proceed to the emergency department for further assessment and treatment (eg, titration of antihypertensive medication). (Option 1) Celiac disease is an autoimmune disorder that interferes with the digestion of gluten. Diarrhea and foul-smelling stools are expected findings for this client, especially if noncompliant with a gluten-free diet. (Option 3) Nausea and diarrhea are possible side effects of many antibiotics. The nurse should inquire about fever and frequency of diarrhea, as antibiotic use could also cause Clostridium difficile infection. However, this does not take priority over a client with a potentially life-threatening hypertensive crisis. (Option 4) Nausea, vomiting, and diarrhea are signs of acute gastroenteritis (ie, food poisoning). Most symptoms of food poisoning resolve spontaneously in several hours to days and are usually not life-threatening. Encouraging adequate oral hydration is important. Educational objective: The kidneys regulate fluid volume and blood pressure. Renal damage causes high blood pressure. Nausea, vomiting, and headache could be signs of a hypertensive crisis and require immediate further assessment. Management of Care

Which nursing instruction is the highest priority when teaching a 38-year-old female client newly diagnosed with stress incontinence? 1. Coaching related to Kegel exercises 2. Importance of voiding every 2 hours 3. Minimizing caffeine and alcohol 4. Use of incontinence pads and pessary

2 The nursing care plan for a client experiencing stress incontinence includes pelvic floor exercises, bladder training, incontinence products, and lifestyle modifications. - The highest priority for a client newly diagnosed with stress incontinence is preventing skin breakdown and urinary tract infections through bladder training. Teaching the client to empty the bladder every 2 hours when awake and every 4 hours at night reduces these risks (Option 2). - Pelvic floor exercises (eg, Kegel exercises), which strengthen the sphincter and structural supports of the bladder, are an essential part of the teaching plan but are not the priority for this client (Option 1). It will take approximately 6 weeks for pelvic floor muscle strength to improve. - Natural bladder irritants (eg, smoking, caffeine, alcohol) increase incontinence and should be eliminated but are not the priority in this client (Option 3). - Pessaries relieve minor pelvic organ prolapse and may be used in some clients when initial conservative measures fail. This client should receive initial instruction on the importance of emptying the bladder often (Option 4). Educational objective: Nursing interventions related to stress incontinence include bladder training (eg, voiding every 2 hours), pelvic floor exercises (eg, Kegel exercises), lifestyle modifications (weight loss, reduction of dietary bladder irritants, smoking cessation), and incontinence products. Basic Care and Comfort

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy. Which of the following interventions are appropriate? Select all that apply. 1. Decrease fluid intake to 1 glass with each meal and at bedtime 2. Encourage the client to bear down while attempting to void 3. Inspect the perineal area for evidence of skin breakdown 4. Measure postvoid residual volumes as prescribed 5. Tell the client to wait 30 seconds after voiding and then attempt to void again

2, 3, 4, 5 Overflow urinary incontinence occurs due to compression of the urethra (eg, uterine prolapse, prostate enlargement) or impairment of the bladder muscle (eg, spinal cord injury, diabetic neuropathy, anticholinergic medications). Both types involve incomplete bladder emptying and urinary retention, which lead to overdistension and overfilling of the bladder and frequent involuntary dribbling of urine. When caring for clients with overflow incontinence, the nurse should: - Implement a fixed voiding schedule (eg, every 2 hours) to prevent bladder overfilling. - Instruct the client to use the Valsalva maneuver (ie, "bearing down") and Credé maneuver (ie, gently applying pressure to the lower abdomen) to help facilitate bladder emptying (Option 2). - Assess the perineal area for skin breakdown related to incontinence (Option 3). - Measure postvoid residual volumes as prescribed to ensure that the client is not retaining large amounts of urine (Option 4). - Instruct the client to wait 20-30 seconds after voiding and then attempt to void a second time (ie, double voiding) to help empty residual urine (Option 5). (Option 1) Fluid restriction can lead to dehydration with concentrated urine, which irritates the bladder and increases the risk for urinary tract infection. Dehydration also contributes to constipation, which worsens incontinence by compressing the bladder. Educational objective: When caring for clients with overflow incontinence, the nurse should implement a fixed voiding schedule, teach the client techniques that assist with bladder emptying (eg, Valsalva maneuver, Credé maneuver, double voiding), monitor for perineal skin breakdown, and measure postvoid residual volumes as prescribed. Basic Care and Comfort

A sexually active female client has had 3 urinary tract infections (UTIs) in 12 months. Which instructions should the nurse include in teaching the client how to prevent UTI recurrence? Select all that apply. 1. Douche with a water and vinegar solution after intercourse 2. Increase daily intake of fluids 3. Use a spermicidal contraceptive jelly 4. Use fragrance-free perineal deodorant products 5. Void immediately after intercourse 6. Wear underwear with a cotton crotch

2, 5, 6 The nurse should encourage a sexually active female client to implement the following interventions to help prevent recurrent UTIs: - Take all antibiotics as prescribed even if symptoms have improved as bacteria may still be present - Increase fluid intake; this dilutes the urine (minimizing bladder irritation), promotes frequent urination, and prevents urinary stasis. The client should void at least every 2-4 hours. Some health care providers recommend drinking cranberry juice as it inhibits bacterial attachment to the bladder wall, but there is no clinical evidence to support its effectiveness in preventing UTIs (Option 2). - Wipe from front to back to prevent introducing bacteria from the vagina and anus into the urethra - Avoid synthetic fabrics as these materials (eg, nylon, spandex) seal in moisture and create an environment conducive to bacterial proliferation; cotton underwear is recommended instead (Option 6). - Void after sexual intercourse to flush out bacteria that may have entered the urethra (Option 5). (Options 1 and 4) Avoid douching and using feminine perineal products (eg, deodorants, powders, sprays), as they can alter the vaginal pH and normal flora, increasing the risk for infection. Take showers instead of baths as bath products (eg, bubble bath, oils) and bacteria in bath water can irritate the urethra and increase the risk of infection. (Option 3) Avoid spermicidal contraceptive jelly as it can suppress the production of protective vaginal flora. Discontinue diaphragm use temporarily (until symptoms subside and antibiotic course is completed); a diaphragm increases pressure on the urethra and bladder neck, which may inhibit complete bladder emptying. Educational objective: Interventions to help prevent recurrent UTIs in sexually active female clients include avoiding use of feminine perineal products, vaginal douches, and spermicidal contraceptive jelly. Protective factors include wearing cotton underwear, increasing water intake, and voiding immediately after sexual intercourse. Health Promotion and Maintenance

A client underwent a transurethral resection of the prostate (TURP) today and has a 3-way Foley urinary catheter with continuous bladder irrigation (CBI). The client reports lower abdominal pain rated as an 8 on a scale of 0-10. What action should the nurse carry out first? 1. Administer prescribed belladonna-opium suppositories prn 2. Administer prescribed morphine intravenous push prn 3. Check amount and characteristics of urine output 4. Check when the client had the last flatus or bowel movement

3 Blood and mucus can obstruct the Foley catheter if the CBI is not infused at a sufficient rate. Bladder pain will result from distention if the flow is obstructed. The nurse should ensure that there is adequate urinary drainage and no blockage from blood clots before treating the pain. If the urinary flow is obstructed, manual irrigation with sterile normal saline should be performed until there are no clots or the urine is clear/pink. (Options 1 and 2) Belladonna-opium suppositories or antispasmodics (eg, oxybutynin) are used for bladder spasms, an expected complication of the TURP procedure. Clients should be instructed not to urinate around the catheter as this would increase bladder pressure and spasms. Narcotics can be used for postoperative pain. If the urinary flow is adequate, a description of the pain would help to determine whether to give the client a narcotic or an antispasmodic. Before treating the resulting pain, the possibility of a physiological etiology for procedure-related pain (eg, blockage of urinary flow from blood clots) should be ruled out first. (Option 4) Large intestine peristalsis does not usually return for at least 24 hours. Intestinal pain is usually related to the presence of flatus. It is too soon for this to be the primary cause. An etiology related to the procedure should be ruled out first. Educational objective: Causes of postoperative pain from TURP with a CBI include a kinked blocked catheter, bladder spasms, and general postoperative pain. The nurse should ensure first that urinary flow is intact prior to treating the pain with analgesics. Reduction of Risk Potential

A client has been given instructions about collecting a urine specimen to test creatinine clearance. The client indicates correct understanding of the specimen collection procedure by making which statement? 1. "A catheter is placed temporarily then removed after I void." 2. "I must provide a midstream sample in a sterile container." 3. "I will need to collect all my urine in a container for 24 hours." 4. "The first AM specimen is best as it is more concentrated."

3 Creatinine clearance is a measure of glomerular function and is a sensitive indicator of renal disease progression. A 24-hour urine collection is needed for the test. When the test begins, the first urine specimen is discarded and the time is noted. All other voided urine for the next 24 hours is collected in a container and kept cool. At the end of the 24 hours, the client should void one last time and add the specimen to the container. Blood is drawn to measure serum creatinine level in addition to urine creatinine. (Option 1) An in-and-out catheter (straight catheter) is used for any test requiring a urine specimen when the client is unable to urinate or unable to follow the specimen collection procedure. A catheter is also used for a cystourethrogram or a residual urine test. (Option 2) Clean catch or midstream urine samples are collected for urinalysis or urine culture and sensitivity testing. For a creatinine clearance test, all urine for the 24-hour period must be collected or the test must be started again. (Option 4) The first AM void is preferable for a urinalysis or urine culture and sensitivity as an overnight specimen is more concentrated. Educational objective: Creatinine clearance is a measure of the glomerular filtration rate. The test requires a 24-hour urine specimen and a blood specimen. When the test begins, the first urine specimen is discarded and the time is noted. Reduction of Risk Potential

A client returns to the unit after receiving hemodialysis for the first time. The client vomits once, reports headache, and appears restless and disoriented. What is the priority intervention? 1. Administer antihypertensives that were held prior to dialysis 2. Administer PRN ondansetron to relieve nausea 3. Contact the health care provider 4. Place client in Trendelenburg position

3 Dialysis disequilibrium syndrome (DDS) is a rare but potentially life-threatening complication that can occur in clients during the initial stages of hemodialysis (HD); it can be prevented by slowing the rate of dialysis. During HD, solutes (ie, urea) are removed more quickly from the blood than from the brain cells and cerebrospinal fluid, creating a concentration gradient that can lead to excess fluid in the brain cells and increased intracranial pressure. Characteristic neurologic manifestations include nausea and vomiting, headache, restlessness, change in mentation, and seizure activity. If DDS is suspected, the health care provider should be contacted immediately (Option 3). If severe, DDS can progress to coma and death. If DDS is identified during treatment, the rate of dialysis should be slowed or stopped. Treatment focuses on interventions to decrease cerebral edema and manage symptoms. (Option 1) Antihypertensives are withheld prior to HD to minimize the risk for hypotension. If the client is not hypotensive after HD, prescribed antihypertensives should be administered but are not the priority intervention for a client with DDS. (Option 2) Antiemetics should be administered to treat nausea associated with DDS, but they are not the priority intervention. (Option 4) Trendelenburg position may increase cerebral edema and would be inappropriate for a client with DDS. Educational objective: Dialysis disequilibrium syndrome (DDS) is a potentially life-threatening condition associated with cerebral edema. Characteristic neurologic manifestations include nausea and vomiting, headache, restlessness, change in mentation, and seizure activity. If DDS is suspected, the health care provider should be contacted immediately and dialysis should be slowed or stopped. 49% Physiological Adaptation

The nurse assesses a client during the dwell time of a peritoneal dialysis cycle. Which assessment would require immediate intervention? 1. Blood pressure of 168/88 mm Hg and pulse of 72/min 2. Client experiencing intermittent nausea 3. Crackles present in the left and right lung bases 4. Presence of 1+ pitting edema in ankles and feet bilaterally

3 During peritoneal dialysis, dialysate is infused into the abdominal cavity and the tubing is then clamped to allow the fluid to dwell for a specified period. After the dwell time, the catheter is unclamped and the fluid drains out via gravity. During the instillation and dwell portions of the cycle, clients are monitored closely for indications of respiratory distress (eg, difficulty breathing, rapid respirations, crackles) that can result from instilling the dialysate too rapidly, overfilling of the abdomen, or fluid entering the thoracic cavity (Option 3). Crackles can also occur if over time there is more dialysate infused than is removed (fluid gain). (Option 1) Clients receive peritoneal dialysis due to chronic kidney failure. The client's blood pressure is likely elevated secondary to the renal failure. This assessment is important to monitor, but crackles in the lungs are the priority. (Option 2) Clients with renal failure typically have electrolyte abnormalities (eg, acidosis) that lead to nausea. This is not a priority. (Option 4) Edema in the extremities can also indicate volume overload. However, this could be due to many other factors (eg, blood pressure medications such as amlodipine) or fluid overload from kidney disease. It is not a priority over crackles, which indicate direct seeping of excess peritoneal cavity fluid into the thorax through diaphragmatic channels. Educational objective: Clients receiving peritoneal dialysis should be monitored carefully for signs and symptoms of respiratory compromise, including difficulty breathing, rapid respirations, and crackles. Physiological Adaptation

The nurse is conducting a pain assessment on a client with dysuria. Which pain description is most likely associated with pyelonephritis? 1. Constant; increased by pressure over the suprapubic area 2. Dull and continuous; occasional spasms over the suprapubic area 3. Dull flank pain; extending toward the umbilicus 4. Excruciating; sharp flank pain radiating to the groin

3 Urinary tract infections (UTIs) can occur in the kidneys (pyelonephritis), bladder (cystitis), and/or urethra (urethritis). Pyelonephritis (inflammation of the kidney parenchyma) causes flank pain that is experienced in the back at the costovertebral angle (the angle between the lower ribs and adjacent vertebrae) and may spread toward the umbilicus. Cystitis alone does not cause nausea/vomiting or chills. Presence of these, fever, and signs and symptoms of a lower UTI (dysuria, urgency, and frequency) indicate pyelonephritis. (Option 1) The client with a distended bladder experiences constant pain increased by any pressure over the bladder. Bladder distension is found through palpation (firmness, pain, urgency) and percussion (dullness) over the suprapubic area. (Option 2) Bladder and urethral pain is usually dull and continuous and may be experienced as spasms. The detrusor muscle of the bladder may spasm if cystitis is present. (Option 4) Renal colic pain (in response to renal calculi) is excruciating, sharp, and stabbing; the client would be tossing in the bed unable to find a comfortable position. Pain radiates down to the groin area as the stone travels down the ureter. Educational objective: Pain in pyelonephritis is dull, constant, and maximal at the costovertebral angle area. Pain from renal stones is excruciating, sharp, and often radiates toward the groin from the flank. Suprapubic pain indicates bladder distension or cystitis. Spasms can be seen with infection (cystitis) or manipulation of the bladder. Reduction of Risk Potential

The nurse provides post-procedure teaching for a female client who had a cystoscopy as an outpatient. Which client statement indicates the need for additional instruction? 1. "I can expect pink-tinged urine for at least 24 hours." 2. "I can take a warm bath and acetaminophen if I have discomfort or bladder spasms." 3. "I should expect frequency and burning when I urinate." 4. "I should expect to see blood clots in my urine for up to 24 hours."

4 A cystoscopy is a procedure that uses a flexible fiber-optic scope inserted through the urethra into the urinary bladder with the client in the lithotomy position. Complications associated with cystoscopy include urinary retention, hemorrhage, and infection. Therefore, clients are instructed to notify the health care provider (HCP) immediately if they have bright red blood when urinating, blood clots, inability to urinate, fever >100.4 F (38 C) and chills, or abdominal pain unrelieved by analgesia. These conditions necessitate evaluation by the HCP and may require antibiotic therapy or the insertion of a urinary catheter to irrigate the bladder, remove clots, or drain the bladder (Option 4). (Options 1 and 3) Pink-tinged urine, frequency, and dysuria are expected for up to 48 hours following a cystoscopy. Clients are instructed to increase fluids, drink 4-6 glasses of water daily to help dilute the urine, and avoid alcohol and caffeine for 24-48 hours as these can irritate the bladder. (Option 2) Abdominal discomfort and bladder spasms may occur for up to 48 hours following the procedure. Clients are taught to take a mild analgesic (eg, acetaminophen, ibuprofen) and a warm tub/sitz bath (except with recurrent urinary tract infections) for pain relief. Educational objective: Clients can expect pink-tinged urine, frequency, dysuria, and abdominal discomfort for up to 48 hours after cystoscopy. They are instructed to increase fluid intake, avoid alcohol and caffeine, take a mild analgesic and tub/sitz bath to relieve discomfort, and notify the HCP immediately of inability to void, gross hematuria, blood clots, fever, chills, or severe pain. Reduction of Risk Potential

The nurse cares for a client scheduled for a percutaneous left kidney biopsy as an outpatient. Which intervention should the nurse include in the client's post-procedure care plan? 1. Compare pre- and post-procedure BUN and creatinine levels 2. Insert and maintain the patency of an indwelling urinary catheter 3. Maintain prone position for at least 30 minutes 4. Monitor vital signs every 15 minutes for the first hour

4 A kidney biopsy involves obtaining a tissue sample for pathological evaluation to determine the cause of certain kidney diseases (eg, nephritis, transplant rejection). The kidney has extensive vasculature (similar to the liver); therefore, bleeding from the biopsy site is the major complication following a percutaneous kidney biopsy. Before the procedure, the client must give informed consent and discontinue all anticoagulants (eg, heparin, warfarin, rivaroxaban) and antiplatelet agents (eg, aspirin, clopidogrel, nonsteroidal anti-inflammatory drugs) for at least one week. The client should be typed and crossmatched for blood (although the need for a transfusion is rare). Blood pressure should be well-controlled. After the procedure, the nurse should monitor vital signs at least every 15 minutes for the first hour as tachycardia, tachypnea, and hypotension can indicate blood loss. The nurse should also assess the puncture site dressing for bleeding (Option 4). (Option 1) Blood urea nitrogen (BUN) and creatinine levels would not change significantly within 30-60 minutes. These are usually measured once every 24 hours and rarely every 12 hours. (Option 2) Insertion of an indwelling urinary catheter is not necessary to perform a kidney biopsy and is not part of the usual protocol. (Option 3) Post-procedure, the client should be positioned on the affected (left) side for 30-60 minutes to provide pressure and help prevent bleeding. The client is usually placed in the prone position during the procedure to facilitate access to the kidney. Educational objective: Bleeding is a complication following a kidney biopsy. For assessment and prevention of this complication the nurse should monitor vital signs frequently, assess the biopsy site and dressing, and have the client positioned on the affected side for 30-60 minutes and on bed rest for 24 hours. Reduction of Risk Potential

The nurse is caring for a 72-year-old client with a history of renal calculi and diabetes mellitus who was admitted for acute pyelonephritis. The nurse assesses shaking chills, temperature of 101.2 F (38.4 C), and flank pain. Which of the following is the priority nursing intervention? 1. Administer intravenous antibiotics 2. Check baseline serum creatinine level 3. Have the client strain all urine 4. Obtain blood and urine cultures

4 Acute pyelonephritis is an infection of the kidney usually caused by an extension of infection from the lower urinary tract (bladder). Chills and fever, vomiting, flank pain, and costovertebral tenderness are characteristic. Blood and urine cultures should be obtained prior to initiation of antibiotic therapy whenever possible to identify the causative microorganisms and determine the most effective antibiotics (Option 4). Given this client's age and underlying diabetes, sepsis can occur quickly. Therefore, antibiotics should be given immediately after cultures are obtained (Option 1). (Option 2) The nurse should check the client's baseline renal function and complete blood count tests to compare subsequent findings. This is not the priority nursing intervention. (Option 3) The client has a history of renal calculi. Straining all urine is not the priority nursing intervention. Educational objective: The priority of care for acute pyelonephritis is to obtain blood and urine cultures before initiating antibiotic therapy whenever possible. Management of Care

The nurse is caring for a client with an ileal conduit. While assisting the client in removing the external pouch, the nurse observes that the stoma appears bluish grey. What is the nurse's best action? 1. Administer an antibacterial agent and assess for further signs of infection 2. Document the findings and continue to monitor for changes 3. Measure the stoma and apply a larger pouching device 4. Report the findings to the health care provider (HCP) immediately

4 An ileal conduit is a surgical technique that uses an excised piece of the client's ileum to create an incontinent urinary diversion. The client's ureters are connected to the ileal conduit, which is used to create an abdominal stoma that allows the passage of urine. A healthy stoma should be pink to brick-red and moist, indicating vascularity and viability. If the stoma is dusky or any shade of blue, the nurse should suspect impaired perfusion and contact the HCP immediately. This finding is considered a medical emergency (Option 4). (Option 1) Infection is a potential complication; signs and symptoms of infection may include fever, elevated white blood cell count, odor, and delayed healing. A bluish grey color indicates impaired perfusion, not infection. (Option 2) Although the nurse will document the findings and monitor for changes, lack of perfusion to the stoma is an emergency that must be reported immediately. (Option 3) Applying an appropriate-size pouching system (approximately 0.1 in [0.25 cm] larger than the stoma) prevents decreased perfusion and skin irritation. Using a larger drainage bag, especially at night, prevents urine backflow through the stoma and reduces the risk for infection. These are important concepts of stoma care but are not the priority at this time. Educational objective: Stoma care involves frequent nursing assessment for signs of potential complications such as impaired perfusion, infection, and wound dehiscence. The stoma should be pink to brick-red and moist. Suspected impaired perfusion is considered a surgical emergency and should be reported immediately. Reduction of Risk Potential

The nurse prepares to instill dialysate for a client receiving peritoneal dialysis. Which nursing action is the priority? 1. Ensuring that the drainage collection bag is below the level of the abdomen 2. Placing the client in the semi-Fowler position 3. Recording the characteristics of output dialysate 4. Using sterile technique when spiking and attaching the bag of dialysate

4 In peritoneal dialysis (PD), the abdominal lining (peritoneum) is used as a semipermeable membrane to dialyze clients with decreased kidney function. A catheter is placed in the peritoneal cavity for infusing and draining dialysate (dialysis fluid). Dialysate is infused and dwells in the abdomen, which allows waste products and electrolytes to cross the peritoneum into the dialysate for removal. After the prescribed dwell time, the dialysate, electrolytes, and wastes are drained via gravity. When administering PD, it is essential to use sterile technique when spiking and attaching bags of dialysate to the client's PD catheter to prevent contamination and infection (Option 4). Bacterial peritonitis, an infection of the peritoneum, is a potential complication of PD that may lead to sepsis. Signs of peritonitis should be reported to the health care provider. (Options 1 and 2) Proper positioning of the catheter drainage bag (ie, below the abdomen) and the client (eg, Fowler or semi-Fowler position) promotes effluent outflow but is not a priority over infection prevention. (Option 3) Cloudy effluent may indicate infection, whereas bloody or brown effluent may indicate bowel perforation. Documenting effluent characteristics is important but not a priority over maintaining asepsis. Educational objective: Peritoneal dialysis (PD) uses the peritoneum as a semipermeable membrane to dialyze clients with decreased kidney function. Bacterial peritonitis is a potential complication of PD. Using sterile technique when spiking or changing bags of dialysate is a priority to avoid contamination and reduce the risk of peritonitis. Physiological Adaptation

The nurse assesses a client diagnosed with chronic kidney disease who had an internal arteriovenous fistula performed on the left arm yesterday. Which assessment finding would require immediate follow-up? 1. A bruit cannot be auscultated over the fistula site 2. Capillary refill of 2 seconds is assessed on the left hand 3. Client reports squeezing a rubber ball with the left hand several times daily 4. Incision is dry with no redness and has sterile skin closures in place

1 An arteriovenous fistula is a surgical connection of an artery to a vein created to provide vascular access for hemodialysis therapy in clients with kidney disease. Arterial blood flowing through this vein causes it to engorge and thicken (mature) over a period of several weeks, after which it can sustain frequent access by 2 large-bore needles required for dialysis. Maturing of the fistula is aided by having the client perform hand exercises, such as squeezing a rubber ball, that increase blood flow through the vein. Following fistula placement, it is important to monitor for patency. A palpable thrill (vibration) over the fistula or an auscultated bruit (blowing or swooshing sound caused by turbulent blood flow) indicates a patent fistula. Absence of the thrill or bruit can indicate potential clot formation in the fistula. Client reports of numbness or tingling as well as decreased capillary refill can also signal potential clotting. (Option 2) Capillary refill of <3 seconds is considered normal and indicates acceptable blood flow to the area. (Option 3) Daily hand exercises such as squeezing handgrips or a rubber ball are performed to help properly mature the fistula. (Option 4) A dry surgical incision without redness, warmth, and induration is an optimal finding. Sterile skin closures (eg, Steri-Strips) are used to help hold the incision together as it heals. Educational objective: Following placement of an arteriovenous fistula, it is imperative to monitor for signs of potential clotting of the fistula such as absence of a bruit, absence of a thrill, decreased capillary refill, and coolness of the extremity below the fistula. Reduction of Risk Potential

The nurse assesses a client with benign prostatic hyperplasia. Which client statement requires further assessment? 1. "I have a burning sensation when I urinate." 2. "I have been having some dribbling after I finish urinating." 3. "I missed 3 days of finasteride while on a trip last week." 4. "I was awakened 3 times last night by the need to urinate."

1 Benign prostatic hyperplasia (BPH) is an abnormal prostate enlargement that most commonly affects male clients age >50. The prostate gradually enlarges and compresses the urethra, causing voiding problems. Symptoms include urinary urgency, frequency, and hesitancy, dribbling urine after voiding, nighttime frequency (nocturia), and urinary retention. Treatment includes lifestyle changes and medications that shrink or slow growth of the prostate, and symptom management interventions (eg, voiding schedule, avoidance of caffeine and antihistamines). Surgical prostate resection may be required. Clients with BPH have increased risk for urinary tract infection (UTI) because of incomplete bladder emptying and urine retention. Symptoms of UTI are often similar to those of BPH; however, burning sensation with urination and cloudy/foul-smelling urine are specific UTI symptoms that require further assessment and treatment (Option 1). (Options 2 and 4) Dribbling after urination and nocturia are expected findings with BPH. (Option 3) Finasteride (Proscar) is a medication that inhibits further growth of the prostate. Appreciable differences in prostate size are noticed only after several months of therapy. Missing three doses would not cause immediate or long-term adverse effects. Educational objective: Clients with benign prostatic hyperplasia (BPH) have increased risk for urinary tract infections (UTI) due to incomplete bladder emptying and urine retention. Symptoms of UTI that differ from those of BPH include burning sensation with urination and cloudy/foul-smelling urine. Reduction of Risk Potential

A client with chronic kidney disease has blood laboratory results as shown in the exhibit. What is the best afternoon snack to provide to this client? Click on the exhibit button for additional information. Lab Results: Sodium 150 mEq/L Potassium 6.0 mEq/L Chloride 100 mEq/L Calcium 9.0 mg/dL Magnesium 2.0 mg/dL Phosphorus 5.8 mg/dL 1. Apple slices with caramel dip 2. Chips and avocado dip 3. Nonfat yogurt with orange slices 4. Vanilla pudding with strawberries

1 Clients with chronic kidney disease (CKD) have decreased glomerular filtration, resulting in retention of fluid, potassium, and phosphorus. Fluid retention is initially treated with sodium restriction and diuretic therapy. Dietary adjustments should also be made to reduce serum potassium and phosphorus. Laboratory values are key to determining allowable foods. Dairy products (eg, milk, yogurt) and certain fruits (eg, bananas, oranges, coconuts, watermelons, and avocados) contain high potassium levels. Dairy products also contain high phosphorus levels. Examples of allowable foods for CKD clients include apples, pears, grapes, pineapple, blackberries, blueberries, and plums. (Option 2) Avocados are high in potassium; the chips may be high in sodium. (Options 3 and 4) Pudding and yogurt contain dairy products and are high in phosphorous and potassium. Oranges are high in potassium. Educational objective: The diet for a client with chronic kidney disease may need to be restricted in fluids, sodium, potassium, and phosphorus. Dairy products (eg, milk, yogurt) and certain fruits (eg, bananas, oranges, coconuts, watermelons, and avocados) contain high potassium levels. Dairy products are also high in phosphorus. 28% Physiological Adaptation

The nurse is caring for a 78-year-old client with a urinary tract infection (UTI). Which assessment finding would be most concerning and require immediate follow-up by the nurse? 1. Confusion 2. Presbyopia 3. Temperature 100.2 F (37.8 C) 4. White blood cell (WBC) count 12,000/mm3

1 Confusion is a common clinical manifestation of urinary tract infections in the elderly but still should be cause for concern and requires follow-up to rule out other possible causes. Confusion is not a normal finding in the elderly adult client. Some causes of confusion in the elderly include dehydration, lack of blood flow to the brain (stroke), decreased ability to metabolize medications, and concurrent infections. (Option 2) Presbyopia is the decrease in ability to see objects close up. This is common in clients over age 40. (Option 3) The elderly tend to have a lower body temperature, so 100.2 F (37.8 C) is considered febrile. This elevation is probably a result of the UTI and the nurse should follow up after further assessing the confusion. (Option 4) An elevated WBC count would be expected in the presence of a current infection. Educational objective: Confusion is a common clinical manifestation of UTI in the elderly; however, it is still a cause for concern and should be evaluated further by the nurse. Physiological Adaptation

The evening shift nurse reviews the preoperative checklist and latest serum laboratory values for an elderly client with a ruptured diverticulum who is scheduled for surgery in the early morning. Which laboratory value is most important for the nurse to report to the health care provider? 1. Creatinine level 2.5 mg/dL (221 µmol/L) 2. Potassium level 3.5 mEq/L (3.5 mmol/L) 3. Sodium level 134 mEq/L (134 mmol/L) 4. White blood cell count 16,000/mm3 (16.0 × 109/L)

1 Creatinine level of 2.5 mg/dL (221 µmol/L) is the most important abnormal value (normal 0.6-1.3 mg/dL [53-115 µmol/L]) for the nurse to report to the health care provider. An elevated creatinine level increases the risk for intra- and postoperative complications. Nothing-by-mouth (NPO) status preoperatively, dehydration (ie, fluid shift from peritonitis), intraoperative fluid losses, antibiotic therapy, and advanced age affect renal function and increase the risk for postoperative exacerbation of kidney injury in this client. (Option 2) Potassium level 3.5 mEq/L (3.5 mmol/L) is within normal limits (3.5-5.0 mEq/L [3.5-5.0 mmol/L]). (Option 3) Sodium level 134 mEq/L (134 mmol/L) is decreased (normal 135-145 mEq/L [135-145 mmol/L]) but is most likely related to NPO status and fluid shift from peritonitis. (Option 4) Elevated White blood cell count (normal 4,000-11,000/mm3 [4.0-11.0 ×109/L]) is an expected finding related to ruptured diverticulum and peritonitis. Educational objective: NPO status preoperatively, dehydration, intraoperative fluid losses, antibiotic therapy, and advanced age can negatively affect renal function. An elevated serum creatinine level preoperatively increases the risk for postoperative kidney injury. Reduction of Risk Potential

A 65-year-old client with end-stage renal disease comes to the emergency department after missing 5 hemodialysis sessions. Serum potassium level is 7.5 mEq/L (7.5 mmol/L) and ECG shows tall, peaked T waves. Which prescription will immediately protect the client from experiencing dysrhythmias associated with hyperkalemia? 1. Intravenous calcium gluconate 2. Intravenous regular insulin with dextrose 3. Oral sodium polystyrene sulfonate 4. Transport to hemodialysis unit

1 Hyperkalemia can be asymptomatic but may cause fatigue, generalized weakness, or in severe cases muscle paralysis and/or dysrhythmias. Management includes preventing life-threatening dysrhythmias and correcting serum potassium levels. Intravenous calcium gluconate is administered to hyperkalemic clients with ECG changes (eg, peaked T waves). Calcium gluconate itself does not decrease the serum potassium level but temporarily stabilizes the myocardium by raising the threshold for dysrhythmia occurrence. Once the nurse stabilizes the client by administering calcium gluconate, other prescriptions may then be implemented to decrease serum potassium level (eg, intravenous regular insulin with dextrose, sodium polystyrene sulfonate, hemodialysis) (Option 1). (Option 2) Intravenous regular insulin temporarily corrects hyperkalemia by shifting potassium into the cells. Dextrose is administered concurrently to prevent hypoglycemia. Although intravenous regular insulin will effectively decrease serum potassium levels, calcium gluconate will provide immediate protection from dysrhythmias. (Option 3) Sodium polystyrene sulfonate causes excretion of potassium from the body via the gastrointestinal tract. Although this will effectively decrease serum potassium levels, calcium gluconate will provide immediate protection from dysrhythmias. (Option 4) Although hemodialysis will effectively decrease serum potassium levels, calcium gluconate will provide immediate protection from dysrhythmias. Educational objective: The priority in treatment of hyperkalemia with ECG changes (eg, peaked T waves) is administration of intravenous calcium gluconate to prevent life-threatening dysrhythmias. Once calcium gluconate is administered, prescriptions to correct serum potassium (eg, intravenous regular insulin with dextrose, sodium polystyrene sulfonate, hemodialysis) may be implemented. Physiological Adaptation

A client with advanced kidney disease has serum potassium of 7.1 mEq/L (7.1 mmol/L) and creatinine of 4.5 mg/dL (398 µmol/L). What is the priority prescribed intervention? 1. Administer IV 50% dextrose and regular insulin 2. Administer IV furosemide 3. Administer oral sodium polystyrene sulfonate 4. Prepare the client for hemodialysis catheter placement

1 Severe hyperkalemia (potassium >7.0 mEq/L [7.0 mmol/L]) requires urgent treatment because cardiac muscle cannot tolerate very high potassium levels. Severe hyperkalemia increases the risk for life-threatening ventricular dysrhythmias (eg, ventricular tachycardia and fibrillation, asystole). IV administration of 50 mL 50% dextrose with 10 units of regular insulin is the priority intervention as it is most effective in reducing the potassium level quickly. The insulin temporarily shifts the potassium from the extracellular fluid back into the intracellular fluid. The dextrose prevents hypoglycemia associated with the increase of insulin in the body and can be eliminated if the client has hyperglycemia (Option 1). If the client has ECG changes (eg, tall peaked T waves), calcium gluconate should be given before insulin/dextrose. This will stabilize the cardiac muscle until the potassium level can be reduced with insulin/dextrose. (Option 2) Furosemide (Lasix) increases the renal excretion of potassium and is usually prescribed for clients with fluid overload. However, administration of furosemide would take time to be effective and is not the priority. (Option 3) Sodium polystyrene sulfonate (Kayexalate) is administered by mouth or enema to remove potassium from the body by exchanging sodium for potassium ions in the intestines; these are then excreted in feces. This is not the priority due to the delayed onset of potassium removal. (Option 4) Hemodialysis is an invasive procedure that can be initiated if more conservative, noninvasive therapies are ineffective in reducing the potassium level. Placement of the catheter will delay treatment. Educational objective: Administration of IV 50% dextrose and regular insulin rapidly corrects an elevated serum potassium level by shifting potassium intracellularly. If the client has ECG changes from hyperkalemia, calcium gluconate should be given first to stabilize cardiac muscle. Physiological Adaptation

The nurse caring for multiple clients who underwent renal system diagnostic testing should report which post-procedure finding to the health care provider? 1. 150 mL residual urine on bladder scan 2. Burning sensation when voiding after cystoscopy 3. Increased urinary output after arteriogram 4. Less than 10,000 organisms/mL on urine culture

1 Various diagnostic tests, including bladder scans, urine cultures, cystoscopy, renal arteriograms, and renal scans, assess the renal system. It is necessary to understand the purpose and procedures for each examination when evaluating complications arising from these assessments. Portable ultrasonic bladder scanners are used at the bedside to determine the amount of residual urine in the bladder. Amounts >100 mL should be reported as the client may be experiencing urinary retention (Option 1). (Option 2) A cystoscope is inserted through the urethra to directly visualize the bladder wall and urethra. Irritation of the urethral and bladder lining from the insertion and manipulation of the cystoscope may cause a slight burning sensation with voiding for a day or two. (Option 3) Renal arteriogram is a radiologic test performed to visualize renal blood vessels to detect abnormalities (renal artery stenosis or aneurysm). A contrast medium is injected into the femoral artery; therefore, the client should be taught to increase fluid intake after the procedure to flush the dye from the body. Increased output is an expected finding. (Option 4) Urine is sterile, but the urethra contains bacteria and a few white blood cells. Less than 10,000 organisms/mL is a normal value for urine culture. Values >10,000 organisms/mL indicate urinary tract infection (UTI). Educational objective: Residual urine volume of >100 mL on bladder scan may indicate urinary retention. Urine culture showing values >10,000 organisms/mL can suggest UTI. Burning sensation is common after cystoscopy. Renal arteriogram is performed with a contrast agent; excretion of the dye with oral and intravenous hydration is recommended to prevent kidney injury. Reduction of Risk Potential

The nurse evaluates the results of laboratory tests completed on a client admitted for a non-healing wound. Which of the following values would be a priority for the nurse? 1. Blood urea nitrogen 15 mg/dL (5.4 mmol/L) 2. Serum albumin 3.7 g/dL (37 g/L) 3. Serum potassium 4.5 mEq/L (4.5 mmol/L) 4. Serum sodium 153 mEq/L (153 mmol/L)

4 Nutritional deficiencies (eg, zinc, protein, vitamin C) and dehydration can impair wound healing. Dehydration (loss of free water) can increase serum sodium levels. The normal value for serum sodium is 135-145 mEq/L (135-145 mmol/L). The value listed, 153 mEq/L (153 mmol/L), is high. Increased serum sodium level (hypernatremia) has an osmotic action that causes water to be pulled from the interstitial spaces into the vascular system. Remember that "water goes where salt is." This action decreases wound healing at a cellular level, reducing the nutrients cells need for repair. (Option 1) Normal blood urea nitrogen (BUN) values are 6-20 mg/dL (2.1-7.1 mmol/L). Elevated BUN may indicate dehydration and could impair wound healing. (Option 2) Malnutrition can impair wound healing. Serum albumin and prealbumin levels are obtained to assess nutritional status. The normal value for albumin is 3.5-5.0 g/dL (35-50 g/L). (Option 3) The normal value for serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). Educational objective: Nutritional deficiencies (eg, zinc, protein, vitamin C) and dehydration (hypernatremia, elevated BUN) can impair wound healing. Reduction of Risk Potential

A client taking morphine sulfate for acute pain has not voided in 6 hours. The nurse suspects the client has developed urinary retention. What is the priority nursing intervention? 1. Ask if the client needs to use the bedpan 2. Assess the client's fluid intake 3. Assess the client's skin turgor 4. Palpate the client's suprapubic area

4 Opioids (eg, morphine sulfate), anticholinergic medications, and tricyclic antidepressants can cause urinary retention; they increase bladder sphincter tone and/or relax bladder muscle. The nurse should assess the client's suprapubic area to determine if the client has urinary retention. If the area is distended and dull to percussion, the nurse should proceed with interventions. (Option 1) While asking if a bedpan is needed is an important nursing intervention, it does not aid in the assessment of urinary retention. (Option 2) Gathering assessment data indicating the presence of urinary retention is necessary prior to other interventions. The nurse should assess for fluid intake after assessing bladder distension. (Option 3) The client's skin turgor is assessed after the nurse checks for urinary retention and fluid intake. There is no need to assess skin turgor until other indicators of adequate fluid intake are reviewed. Educational objective: Assessing the client's suprapubic area is the priority nursing action when urinary retention is suspected. Interventions are performed after a problem is identified and its cause is determined. Urinary retention is an expected side effect of opioid medications. Pharmacological and Parenteral Therapies

The nurse reinforces teaching about self-management strategies for a client with urge incontinence. Which of the following statements indicate that teaching has been effective? Select all that apply. 1. "I am going to join a walking program to lose excess weight." 2. "I may have dry mouth as a side effect from the oxybutynin." 3. "I really need caffeine to get myself going in the morning." 4. "I should perform Kegel exercises several times daily." 5. "I will void every 2 hours until I am having fewer accidents."

1, 2, 4, 5 Urge incontinence (UI), also known as overactive bladder, occurs when the bladder contracts randomly, causing a strong, sudden urge to urinate that is followed by urine leakage. UI may occur without cause or may result from spinal cord injury and impairment of the bladder (eg, interstitial cystitis) or neurological system (eg, Parkinson disease, stroke). Interventions for clients with UI include: - Loss of excess weight to reduce pressure on the pelvic floor (Option 1). - Anticholinergic medications (eg, oxybutynin, tolterodine) to decrease bladder spasms. Dry mouth (xerostomia) is a frequent adverse effect (Option 2). - Avoidance of bladder irritants (eg, artificial sweeteners, caffeine, citrus juices, alcohol, carbonated drinks, nicotine) (Option 3). - Pelvic floor exercises (eg, Kegel) to strengthen the muscles and help prevent urinary leakage (Option 4). - Bladder training (eg, voiding every 2 hours while awake) and gradually lengthening intervals between voiding (Option 5). Educational objective: Management of urge incontinence includes loss of excess weight, anticholinergic medications (eg, oxybutynin), avoidance of bladder irritants, pelvic floor exercises, and bladder training. Dry mouth is a common adverse effect of anticholinergic medications. Basic Care and Comfort

After reviewing the urinalysis report data on a client, which question is most appropriate for the nurse to ask? Click on the exhibit button for additional information. Urinalysis Specimen type: Midstream Color: Amber Specific gravity: 1.031 Red blood cells - None White blood cells - Rare Protein - None Glucose - Absent 1. "Do you have a family history of diabetes?" 2. "Do you have any burning or difficulty urinating?" 3. "Have you suffered any recent kidney trauma?" 4. "What has your fluid intake been for the last 24 hours?"

4 This client's urinalysis reveals that the client is most likely dehydrated. Amber color indicates concentrated urine. The specific gravity evaluates the ability of the kidneys to concentrate solutes in the urine. The normal urine specific gravity value ranges from 1.003 to 1.030. Causes of increased specific gravity include fluid deficit. (Option 1) Glucose should be absent in the urine. Its presence is suspicious for diabetes mellitus. (Option 2) Dysuria (burning or difficulty urinating) may be indicative of infection or inflammation. The number of white blood cells (WBCs) should be very few (0-5 per high power field), as seen in this client. Increased numbers indicate infection or inflammation. (Option 3) Hematuria is indicative of possible renal trauma. The normal range for red blood cells is 0-4 per high power field. None are present on this client's urinalysis results. Educational objective: The normal urine specific gravity value ranges from 1.003 to 1.030. Causes of increased specific gravity include fluid deficit. The presence of a few (0-5 per high power field) WBCs on urinalysis is normal. Reduction of Risk Potential

The nurse assesses a client receiving peritoneal dialysis. Which assessment findings are most important for the nurse to report to the health care provider? Select all that apply. 1. Cloudy outflow 2. Low-grade fever 3. Oliguria 4. Pruritus 5. Tachycardia

1, 2, 5 During peritoneal dialysis (PD), a catheter is placed into the peritoneal cavity to infuse dialysate (dialysis fluid); the tubing is then clamped to allow the fluid to dwell for a specified period. After the dwell time, the catheter is unclamped and the fluid (effluent) drains out via gravity. Cloudy outflow (effluent), tachycardia, and low-grade fever are signs of peritonitis, an infection of the peritoneal cavity and a major concern with PD. Bloody fluid can indicate intestinal perforation or that the client may be menstruating. Brown effluent can indicate fecal contamination from perforation. All these findings need to be reported to the health care provider. (Option 3) Oliguria (very low urine output) is associated with acute or chronic kidney failure and is the reason the client is receiving peritoneal dialysis. It does not indicate a complication of PD. (Option 4) Pruritus (itching) is a common finding in clients with kidney failure, and may occur due to dry skin, neuropathy, or skin deposits of waste products (eg, urea, calcium-phosphate) that are normally removed via the kidney. PD can help relieve this symptom of kidney failure by filtering waste products. Educational objective: Peritonitis is a major complication of peritoneal dialysis. Signs of developing peritonitis are low-grade fever, tachycardia, and cloudy outflow (effluent). Bloody effluent can indicate intestinal perforation or that the client may be menstruating. Physiological Adaptation

A client undergoes transurethral resection of the prostate for benign prostatic hyperplasia. The client has a 3-way Foley catheter with continuous bladder irrigation. Which assessment is the best indication that the bladder irrigation flow rate is productive? 1. Blood pressure 120/80 mm Hg, pulse 80/min 2. Client has no bladder spasms 3. Irrigation input 3,000 mL, Foley output 3,000 mL 4. Output urine is light pink in color

4 Transurethral resection of the prostate (TURP) involves the insertion of a scope to remove obstructing prostate tissue. Continuous bladder irrigation (CBI) with a 3-way Foley catheter is initiated after the procedure. The catheter balloon applies direct pressure to the bleeding tissue while the tubing allows the urine to drain. During the first 24 hours, the urine color changes from reddish-pink to pink. Small clots are also expected for up to 36 hours after surgery. However, the nurse should adjust the irrigation rate with these normal findings so that the urine remains light pink without clots (Option 4). (Option 1) Vital signs within normal limits indicate hemodynamic stability but will not reflect the patency of the draining catheter. (Option 2) Painful bladder spasms are expected after TURP and catheter placement. Spasms are typically treated with antispasmodics (eg, belladonna-opium suppositories, oxybutynin [Ditropan]). (Option 3) The total Foley output should be more than the CBI input, as the Foley output includes CBI fluid (not processed through the kidneys) plus the normal renal output of urine. An obstruction is indicated if the CBI input is equal to or greater than the Foley output. Educational objective: A 3-way Foley catheter with continuous bladder irrigation allows urine to drain after a transurethral resection of the prostate. During the first 24 hours, the urine color changes from reddish-pink to pink. Small clots may occur for up to 36 hours. However, the nurse adjusts the irrigation flow to keep the urine light pink without clots. Reduction of Risk Potential

The nurse is caring for a client with multiple renal calculi. Which nursing interventions should be included in the plan of care? Select all that apply. 1. Administer analgesics at regularly scheduled intervals 2. Encourage fluid intake of up to 3 L/day 3. Instruct client to stay on bed rest 4. Provide massage to the client's flank 5. Strain all urine for the presence of stones

1, 2, 5 The formation of renal calculi (ie, kidney stones) can be due to various factors (eg, family history, dietary imbalances, immobilization, dehydration). Manifestations include sudden, severe abdominal or flank pain and nausea/vomiting. Client management focuses on analgesics administered at regularly scheduled intervals, rehydration of up to 3 L/day unless contraindicated by other comorbidities, and ambulation to facilitate the passage of calculi (Options 1 and 2). To retrieve stones that the client may pass, the nurse should strain all urine obtained (Option 5). The collected stones are analyzed to determine their composition (eg, calcium oxalate, calcium phosphate, struvite, uric acid, cystine), which can then direct preventive measures, such as dietary and lifestyle changes, after discharge. (Option 3) Immobilization is a contributing cause of renal calculi formation and should be avoided. Ambulation and frequent mobilization are encouraged as tolerated to help facilitate the passage of calculi. (Option 4) Massage therapy to the flank should not be performed to prevent further instigation of renal colic. Other interventions, such as monitored heat therapy, would be acceptable. Educational objective: When caring for a client with renal calculi, the nurse should provide adequate analgesia for pain, encourage increased fluid intake, and assist with ambulation as tolerated to promote clearance of calculi. All urine should be strained to retrieve any stones for analysis to determine preventive measures. Physiological Adaptation

The nurse is caring for a client whose peritoneal dialysis is beginning to exhibit insufficient outflow. What actions should the nurse perform initially? Select all that apply. 1. Assess for abdominal distention and constipation 2. Contact the client's health care provider 3. Examine the catheter for kinks and obstructions 4. Flush the tubing with 100 mL of dialysate 5. Place the client in a side-lying position

1, 3, 5 Peritoneal dialysis uses the abdominal lining (ie, peritoneum) as a semipermeable membrane to dialyze a client with insufficient renal function. A catheter is placed into the peritoneal cavity, and dialysate (ie, dialysis fluid) is infused. The tubing is clamped to allow the fluid to remain in the cavity, usually for 20-30 minutes (dwell phase). The catheter is then unclamped to allow dialysate to drain via gravity. Insufficient outflow results most often from constipation when distended intestines block the catheter's holes. If outflow becomes sluggish, the nurse should assess the client's bowel patterns and administer appropriate prescribed medications (eg, stool softeners) (Option 1). The nurse should also check the tubing for kinks and reposition the client to a side-lying position or assist with ambulation (Options 3 and 5). The drainage bag should be maintained below the abdomen to promote gravity flow. The nurse should assess for fibrin clots and milk the tubing to dislodge or administer fibrinolytics (eg, alteplase) as prescribed. If these measures are ineffective, an x-ray may be needed to check the catheter location. (Options 2 and 4) The nurse should identify the problem before instilling additional fluids and perform routine assistive measures before contacting the health care provider. Educational objective: Insufficient outflow from peritoneal dialysis commonly results from constipation; bowel movements should be monitored and stool softeners administered as prescribed. Additional nursing measures include checking the tubing for kinks or clots; maintaining the drainage bag below the abdomen; and placing clients in a side-lying position or assisting with ambulation. Physiological Adaptation

The emergency department nurse cares for 5 clients. Which of the clients below are at risk for developing metabolic acidosis? Select all that apply. 1. 25-year-old client with claustrophobia who was stuck in an elevator for 2 hours 2. 36-year-old client with food poisoning and severe diarrhea for the past 3 days 3. 40-year-old client with 3-day history of chemotherapy-induced vomiting 4. 75-year-old client with pyelonephritis and hypotension 5. 82-year-old client due for hemodialysis with clotted arteriovenous shunt

2, 4, 5 Metabolic acidosis is due to an increase in the production or retention of acid or the depletion of bicarbonate via the kidneys or gastrointestinal (GI) tract. In metabolic acidosis there is a decrease in pH (<7.35) and HCO3- (<22 mEq [22 mmol/L]). Common causes of metabolic acidosis include: - GI bicarbonate losses (eg, diarrhea) (Option 2) - Ketoacidosis (eg, diabetes, alcoholism, starvation) - Lactic acidosis (eg, sepsis, hypoperfusion) (Option 4) - Renal failure (eg, hemodialysis with inaccessible arteriovenous shunt) (Option 5) - Salicylate toxicity (Option 1) A client with claustrophobia who was stuck in an elevator is at risk for an anxiety attack, which leads to hyperventilation and respiratory alkalosis (pH >7.45, PaCO2 <35 mm Hg [4.66 kPa]). (Option 3) A client with excessive vomiting is at risk for metabolic alkalosis due to loss of stomach acid. Educational objective: Conditions that increase acid production or retention (eg, ketoacidosis, lactic acidosis, renal failure) or bicarbonate depletion (eg, diarrhea) can put a client at risk for metabolic acidosis (pH <7.35, HCO3- <22 mEq/L [22 mmol/L]). Physiological Adaptation

When a client diagnosed with acute urinary retention is emergently catheterized, the nurse should initially assess for which priority manifestation that may occur as a result of the catheterization? 1. Dysuria 2. Hypotension 3. Infection 4. Tachycardia

2 Acute urinary retention is best treated with rapid, complete bladder decompression rather than the intermittent urine drainage that is limited to 500 to 1000 mL at a time. Rapid decompression can be associated with hematuria, hypotension, and postobstructive diuresis (Option 2). However, these are rarely clinically significant if appropriate supportive care is administered, whereas inability to relieve the obstruction can be associated with infection and kidney injury (Option 3). (Option 1) Dysuria from catheterization can be treated with analgesics or antispasmodic medications. Maintaining perfusion and adequate blood pressure is the priority concern. (Option 4) With sudden release of bladder obstruction, cardiovascular autonomic activity occurs and the blood pressure and heart rate are reduced due to the excitation of the parasympathetic system. Educational objective: Acute urinary retention is best treated with rapid complete bladder decompression. The nurse should carefully assess for hypotension and bradycardia, which are potential complications. Reduction of Risk Potential

The nurse is caring for a 68-year-old male client following a laparoscopic cholecystectomy 8 hours ago. The client has not urinated since surgery. Which would be the most appropriate initial intervention? 1. Conduct a bladder scan 2. Help the client out of bed 3. Insert an indwelling catheter using sterile technique 4. Obtain a prescription for intermittent catheterization

2 Urinary retention occurs frequently after surgery due to administration of opioids (eg, morphine) and anesthesia, and in older men, who often have an enlarged prostate gland or benign prostatic hyperplasia (BPH). Up to 50% of men over age 60 have an enlarged prostate. Body position can also contribute to urinary retention. Most men are used to urinating when standing up; therefore, the nurse or assistive personnel should help the client out of bed rather than offer a urinal for use in bed (Option 2). Providing privacy may also aid in relaxation and urination. (Option 1) The second intervention should be a bladder scan. If the client is unable to urinate, an ultrasound scan can be used to noninvasively assess the volume of urine in the bladder. It can also be used to determine the residual bladder volume after the client has urinated to assess the amount of retention. (Option 3) An indwelling catheter is not currently indicated for this client. Catheter-associated urinary tract infection (CAUTI) is a significant hospital-acquired infection. The risk of CAUTI can be reduced by using an indwelling catheter only when other interventions have failed to produce desired outcomes. (Option 4) Intermittent catheterization would be the third intervention if the client has been unable to urinate or has significant urinary retention (>300-400 mL). Educational objective: Urinary retention after surgery is common and often made worse by existing benign prostatic hyperplasia in older men. If a client has difficulty urinating, the nurse should first try noninvasive methods to help the client urinate in a normal position and provide privacy to help the client relax. 29% Basic Care and Comfort

A client who was discharged following a prostatectomy performed 6 days ago calls the clinic and reports passing some small blood clots and experiencing a decreased urinary stream. What is the nurse's best response? 1. "Please come to the clinic to be evaluated by the health care provider." 2. "Those symptoms are normal in the first week following surgery." 3. "Try to bear down as if having a bowel movement." 4. "You should increase your daily fluid intake."

1 A prostatectomy uses either minimally invasive or open surgical techniques to remove all or part of the prostate gland for clients with related disorders (eg, cancer, benign prostatic hyperplasia). For up to 36 hours after surgery, small blood clots may occur, although they should not impair the urine stream. Consistent passage of clots after this time could indicate a postoperative complication. Signs of such complications (eg, reduced urine stream, persistent bleeding/blood clots, urinary retention, fever, dysuria) after discharge should be evaluated by the health care provider for further treatment (Option 1). (Option 2) The presence of blood clots 6 days after surgery is not normal and may indicate bleeding from the prostatic fossa. This client requires further evaluation. (Option 3) Clients should avoid the Valsalva maneuver for up to 8 weeks after prostatectomy because the exerted pressure may injure the healing tissue, causing hematuria. (Option 4) Maintaining adequate fluid intake helps prevent blood clot formation. However, this client is reporting blood clots with a decreased urinary stream and needs further evaluation. Educational objective: Prostatectomy uses either minimally invasive or open surgical techniques to remove all or part of the prostate. Signs of complications (eg, reduced stream, persistent bleeding/blood clots, retention, fever, dysuria) after discharge should be evaluated by the health care provider for further treatment. Reduction of Risk Potential

The nurse is preparing to administer morning medications to a client with type 2 diabetes mellitus and end-stage renal disease who is scheduled for dialysis today. Which medication should the nurse hold for clarification prior to administration? Click the exhibit button for more information. Allergies: None Medications + Time: Atenolol 50 mg by mouth daily, 0900 Calcium acetate 667 mg by mouth, With each meal Insulin lispro, high-dose sliding-scale SQ injection with meals and before bedtime, 0730 Vitamin E 400 IU by mouth daily, 0900 1. Atenolol 2. Calcium acetate 3. Insulin lispro 4. Vitamin E

1 Medication administration may require modification on days that clients are scheduled to receive dialysis. The nurse should consider whether the medication will be dialyzed out of the client's system or may create adverse effects during dialysis. Fluid is removed during dialysis, which may cause hypotension. Typically, antihypertensives are held before dialysis to prevent hypotension. In addition, some medications are dialyzed out of the client's system and should therefore be held until after dialysis. Commonly held medications are water-soluble vitamins (eg, vitamins B and C), antibiotics, and digoxin. (Option 2) Clients with chronic kidney disease have high phosphorus levels as the kidney is unable to filter the phosphate from the body; dialysis also does not filter it. Therefore, the client should still take phosphate binders prior to dialysis. Phosphate binders (eg, calcium containing [calcium carbonate and calcium acetate]) and non-calcium containing [sevelamer and lanthanum]) block absorption of ingested phosphate from the intestine and excrete it through feces. (Option 3) Lispro is a fast-acting insulin that should be given 15-30 minutes before meals. It is appropriate to give scheduled lispro with breakfast prior to dialysis. (Option 4) Vitamin E is a fat-soluble vitamin that is not affected by dialysis. It is given to some clients to prevent leg cramps that can be experienced by dialysis clients. Educational objective: Unless otherwise indicated by the health care provider, antihypertensives and other blood pressure-lowering medications (eg, furosemide), antibiotics, digoxin, and water-soluble vitamins (B, C, and folic acid) should be held prior to dialysis. Pharmacological and Parenteral Therapies

The nurse gathers a health history from a 58-year-old male client with acute urinary retention. Which of the following questions should the nurse ask to aid in assessing for benign prostatic hyperplasia? Select all that apply. 1. "Do you feel the need to urinate again immediately after urinating?" 2. "Do you have to strain to begin your stream of urine?" 3. "How often do you engage in sexual intercourse?" 4. "How often do you wake at night with the urge to urinate?" 5. "Is your stream of urine weak or intermittent?"

1, 2, 4, 5 With increasing age (typically age >50), male clients experience hormone changes that can lead to prostate enlargement, known as benign prostatic hyperplasia (BPH). BPH is often not diagnosed until it begins to compress the surrounding bladder and urethra, causing voiding difficulties and abnormalities. Clients with BPH exhibit the following signs and symptoms: - Urinary retention - Sensation of incomplete emptying and/or increased urgency to void (Option 1) - Straining or difficulty initiating voiding (hesitancy) (Option 2) - Weak and/or intermittent stream of urine during voiding (Option 5) - Frequent voiding patterns throughout the day (eg, urinating more than once in 2 hours) and night (nocturia) (Option 4) (Option 3) Frequency of sexual intercourse is unrelated to urinary retention and BPH in the male client. Educational objective: Benign prostatic hyperplasia (BPH) occurs with increasing age (usually in men age >50) and is often undiagnosed until voiding difficulties and abnormalities are observed. Typical BPH symptoms include acute urinary retention, voiding urgency, incomplete emptying, straining to void, weak urinary stream, urinary frequency, and nocturia. Physiological Adaptation

The nurse is caring for a client who received extracorporeal shock wave lithotripsy with ureteral stent placement for treatment of a kidney stone. Which discharge instructions provided by the nurse are appropriate? Select all that apply. 1. "Contact your health care provider if you develop a fever or chills." 2. "Except for using the bathroom, you should stay on bed rest for the next 48 hours." 3. "Increase your fluid intake to help flush out the kidney stone fragments." 4. "It is common to have some blood in the urine up to 24 hours after this procedure." 5. "You may develop some bruising on your back or on the side of your abdomen."

1, 3, 4, 5 Extracorporeal shock wave lithotripsy (ESWL) is a noninvasive procedure that uses high-energy acoustic shock waves to break up kidney stones into small fragments that can be excreted in the urine. The procedure is typically performed in an outpatient setting under general anesthesia. Temporary ureteral stents are often placed during the procedure to facilitate the passage of the stone fragments and prevent occlusion of the ureter. Stents are typically removed in 1-2 weeks. After an ESWL procedure, the client should be instructed to: - Increase fluid intake to help flush out the kidney stone fragments (Option 3). - Expect some bruising and pain of the back and/or flank of the affected side. Analgesics may be required (Option 5). - Expect to see blood in the urine (hematuria). Urine color should progress from bright red to pink-tinged during the first several hours. Hematuria is concerning if the urine remains bright red for a prolonged period (eg, >24 hours) (Option 4). - Report any symptoms of infection (eg, fever, chills) to the health care provider (Option 1). (Option 2) Ambulation is encouraged after ESWL to facilitate passage of the stone fragments. Educational objective: Following extracorporeal shock wave lithotripsy, the client should increase fluid intake and ambulate frequently to facilitate passage of the stone fragments. Expected side effects include hematuria as well as bruising and pain of the back and/or flank. Urine color should progress from bright red to pink-tinged during the first several hours. Reduction of Risk Potential

A client suffering from bladder prolapse and subsequent stress urinary incontinence has discussed treatment options with the health care provider (HCP). The nurse evaluates that the client understands support pessary use when the client makes which statement? 1. "After the pessary is surgically placed, I'll experience bladder discomfort for several weeks." 2. "I can remain sexually active while my pessary is in place." 3. "I need to schedule weekly appointments to have the pessary removed and replaced." 4. "I should report any vaginal discharge to my HCP immediately."

2 A pessary is a vaginal device that provides support for the bladder. Clients can remain sexually active while wearing a pessary. They are fitted for the proper type and size by an HCP in the office. Surgery is not required for pessary placement; clients who are able can insert and remove the pessary themselves (Option 1). If a pessary or other treatment (eg, pelvic muscle exercises, estrogen replacement therapy) is ineffective, reconstructive surgery may be indicated. (Option 3) Clients who are able to remove and reinsert the pessary on their own will have the choice to remove it weekly, possibly even nightly, for cleaning. Clients who are sexually active may prefer to remove the pessary prior to intercourse, although this is not necessary. When the client cannot remove the pessary regularly, removal by an HCP at 2- to 3-month intervals is recommended. (Option 4) Increased vaginal discharge is a common side effect. However, if an odor is present, the client should be instructed to notify the HCP to be treated for a possible infection. Educational objective: A pessary is a vaginal support device recommended for pelvic organ prolapse. Pessaries are fitted by an HCP; many clients can then remove, clean, and replace these themselves. Clients can remain sexually active with a pessary in place. Reduction of Risk Potential

The nurse is performing discharge teaching on nutritional therapy for a client with chronic kidney disease. Which statement indicates that further teaching is needed? 1. "Because I have chronic kidney disease, I should avoid canned soups and cold-cut sandwiches." 2. "I can use a salt substitute because I am required to restrict both sodium and potassium in my daily diet." 3. "I must avoid eating raw carrots and tomatoes on my salads because I take hemodialysis treatments." 4. "The popsicles I eat should be counted in my daily fluid intake because they become liquid at room temperature."

2 Clients with chronic kidney disease (CKD) are at risk for fluid overload and hyperkalemia. Clients should avoid salt substitutes, which typically contain potassium chloride and may contribute to hyperkalemia (Option 2). To avoid further complications and prevent progressive kidney damage, clients with CKD are advised to follow certain dietary restrictions, including: 1) Sodium restriction - Avoid high-sodium foods such as cured meats, pickled foods, canned soups, frankfurters, cold cuts, soy sauce, and salad dressings (Option 1). 2) Potassium restriction - Avoid high-potassium foods such as raw carrots, tomatoes, and orange juice (Option 3). 3) Fluid intake monitoring - Monitor fluid intake closely and accurately, being careful to include foods that are liquid-based (eg, popsicles, gelatin), because fluid is often restricted (Option 4). 4) Low-protein diet - Eat 0.6-0.8 g/kg/day of protein to help prevent progression of kidney disease. If the client is already on hemodialysis, increased protein intake is recommended to prevent malnutrition. 5) Low-phosphorus diet - Avoid foods high in phosphorus (eg, chicken, turkey, dairy). Educational objective: Clients with chronic kidney disease are at risk for fluid overload and hyperkalemia. An appropriate renal diet includes low sodium, low potassium, low phosphorus, and low protein. Basic Care and Comfort

A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. Which finding should the nurse report immediately to the health care provider? 1. 2+ pitting edema of the extremity with the arteriovenous fistula 2. Loud swooshing sound auscultated over the arteriovenous fistula 3. Pale skin of the hand of the arm with the arteriovenous fistula 4. Surgical site pain reported by the client as 3 on a scale of 0-10 during hand exercises

3 Arteriovenous fistula (AVF) is a permanent hemodialysis access surgically created by connecting an artery to a vein, typically in the forearm or upper arm. This anastomosis diverts arterial blood into the vein, which increases intravenous blood flow and causes the vein to thicken and expand (ie, "mature"). The matured AVF can then sustain frequent access by large-bore needles during hemodialysis. Arterial steal syndrome is an AVF complication that occurs when the anastomosed vein "steals" too much arterial blood, causing distal extremity ischemia. Symptoms occur distal to the AVF, including skin pallor, pain, numbness, tingling, diminished pulses, and poor capillary refill. Without prompt intervention, ischemia may lead to limb necrosis (Option 3). (Option 1) After AVF creation, edema may occur due to venous congestion but typically improves spontaneously. Extremity elevation helps reduce edema. Severe or prolonged edema (eg, >2 weeks) could indicate venous hypertension that may require surgery to prevent AVF failure. (Option 2) A loud swooshing sound (ie, bruit) auscultated over the AVF is expected due to turbulent blood flow at the arteriovenous anastomosis. (Option 4) Hand-grip exercises (eg, ball squeezing, hand flexing) are encouraged after AVF creation to promote fistula maturation. Postoperative surgical site pain is expected; however, pain distal to the AVF may indicate tissue ischemia. Educational objective: Arterial steal syndrome is a complication of arteriovenous fistula (AVF) creation that impairs distal extremity perfusion and may result in tissue ischemia and necrosis. Symptoms include skin pallor, pain, numbness, tingling, diminished pulses, and poor capillary refill distal to the AVF. Physiological Adaptation

Which health history information would be most important for the nurse to obtain when assessing a client with suspected bladder cancer who reports painless hematuria? 1. Family risk factors 2. Industrial chemical exposure 3. Tobacco use 4. Usual diet

3 The tell-tale symptom of bladder cancer, seen in >75% of cases, is painless hematuria; the client will report seeing blood in the urine with no associated pain. As with many other types of cancer, the primary cause of bladder cancer is cigarette smoking or other tobacco use (Option 3). Poorer outcomes are seen with increased length of time as a smoker and higher number of packs per day. (Option 1) Clients who have family members with bladder cancer have an increased risk of developing bladder cancer themselves; however, the primary risk factor is tobacco use. (Option 2) Occupational carcinogen exposure is the second most common risk factor. Occupational exposures include printing, iron and aluminum processing, industrial painting, metal work, machining, and mining. Clients are exposed to carcinogens through direct skin contact and inhalation (aerosols and vapors). (Option 4) Consuming a high-fat diet and using artificial sweeteners are risk factors for developing bladder cancer, but they are not the primary cause. Educational objective: Painless hematuria is the most common presenting symptom of bladder cancer. Cigarette smoking or other tobacco use is the primary risk factor. Health Promotion and Maintenance

A client diagnosed with end-stage renal disease comes to the dialysis clinic for treatment. Which actions should the nurse take to prepare the client for hemodialysis? Select all that apply. 1. Administer subcutaneous heparin to decrease clotting during dialysis 2. Administer the client's morning doses of carvedilol and lisinopril 3. Check the client's medical records to determine the last post-dialysis weight 4. Obtain a set of client vital signs and the client's current weight 5. Palpate the fistula in the client's arm for a thrill and auscultate for a bruit

3, 4, 5 Prior to dialysis treatment, the nurse should assess the client's fluid status (weight, blood pressure, peripheral edema, lung and heart sounds), vascular access (arteriovenous fistula, arteriovenous grafts), and vital signs (Option 4). The amount of fluid removed (ultrafiltration) is determined by calculating the difference between the last post-dialysis weight and the client's current pre-dialysis weight (Option 3). After the client is connected to the dialysis machine, IV heparin is added to the blood from the client to prevent clotting that can occur when blood contacts a foreign substance. Giving subcutaneous heparin prior to initiation is not necessary (Option 1). (Option 2) During dialysis, excess fluid is removed, making the client prone to hypotension. In addition, medications are removed from the blood during hemodialysis, making them ineffective. Many medications that are taken once daily can be held until after the dialysis treatment to prevent their removal. If blood pressure medications are given prior to dialysis, the client can develop hypotension during the dialysis and then uncontrolled hypertension (decreased drug concentrations). (Option 5) Arteriovenous fistulas are created by anastomosing an artery to a vein; a thrill can be felt when palpating the fistula, and a bruit can be heard during auscultation when the fistula is functioning properly. Educational objective: The nurse is responsible for assessing the client diagnosed with end-stage renal disease for risks associated with dialysis. These risks include medication removal, hemodialysis access dysfunction, hypotension, and fluid and electrolyte imbalances. Physiological Adaptation

A client with chronic kidney disease has a subcutaneous arteriovenous fistula (AVF) placed in the nondominant left wrist for hemodialysis. Which of the following statements indicate the client understands how to care for the fistula properly? Select all that apply. 1. "I don't need to call my health care provider (HCP) if I have numbness or tingling in my left arm." 2. "I will make sure I always have my blood pressure taken in my nondominant (left) arm." 3. "I will squeeze a small sponge with my left hand several times a day." 4. "I will touch the site and feel for a vibration several times a day." 5. "I will try not to sleep on my left arm."

3, 4, 5 The creation of an AVF for hemodialysis access involves an anastomosis between an artery and a vein (usually the cephalic or basilic vein). The fistula permits the arterial blood to flow through the vein, causing the vein to become larger in diameter and the walls to thicken, enabling blood to flow at high pressures. After the AVF is placed, it takes 2-4 months for it to mature to accommodate the repeated venipunctures necessary for hemodialysis access. The major complications of an AVF are infection (especially in end-stage kidney disease and diabetes), stenosis, thrombosis, and hemorrhage. Clients are taught the following preventive interventions: - Report numbness or tingling of the extremity to the HCP to prevent neuromuscular damage (Option 1) - Do not allow anyone (other than dialysis personnel) to draw blood or take blood pressure measurements on the extremity to prevent thrombosis (Option 2) - Avoid wearing restrictive clothing or jewelry to prevent thrombosis - Do not use the arm with vascular access to carry heavy objects (more than 5 lb [2.26 kg]); however, exercises to increase strength could include squeezing a soft ball or sponge several times a day (Option 3) - Check the function of the vascular access several times a day by feeling for vibration to assess for patency, stenosis, and clotting (Option 4) - Do not sleep on the arm with vascular access or use creams or lotions on the site (Option 5) - Monitor for signs of infection and bleeding after dialysis and report immediately - Keep the site clean to help prevent infection Educational objective: The creation of an AVF for hemodialysis access involves an anastomosis between an artery and a vein. Clients are taught interventions to help prevent the major complications associated with an AVF (infection, stenosis, thrombosis, and hemorrhage). Reduction of Risk Potential