Ch 63 - Concepts of Care for Patients with Acute Kidney Injury and Chronic Kidney Disease (rationale)

A client comes into the emergency department with a serum creatinine of 2.2 mg/dL (1944 mcmol/L) and a blood urea nitrogen (BUN) of 24 mL/dL (8.57 mmol/L). What question would the nurse ask first when taking this client's history?

"Have you been taking any aspirin, ibuprofen, or naproxen recently?" There are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the patient since both the serum creatinine and BUN are elevated, indicating some renal problems. A diet high in protein could be a factor in an increased BUN.

The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates that more teaching is needed?

"I am thrilled that I can continue to eat fast food." Fast-food restaurants usually serve food that is high in sodium. This statement indicates that more teaching needs to occur. The other statements show a correct understanding of the teaching.

A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.)

"I need to ask for an antibiotic when scheduling a dental appointment." "I'll need to check my blood sugar often to prevent hypoglycemia." "The dose of my pain medication may have to be adjusted." "I should watch for bleeding when taking my anticoagulants." In discharge teaching, the nurse must emphasize that the client needs to have an antibiotic prophylactically before dental procedures to prevent infection. There may be a need for dose reduction in medications if the kidney is not excreting them properly (antacids with magnesium, antibiotics, antidiabetic drugs, insulin, opioids, and anticoagulants).

The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the client demonstrates a correct understanding of the teaching?

"I should take a stool softener every morning to avoid constipation." Inflow and outflow problems of the dialysate are best controlled by preventing constipation. A daily stool softener is the best option for the client. The drainage bag should be below the level of the abdomen. Flushing the tubing will not help with the flow. A diet high in fiber will also help with a constipation problem.

A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are correct regarding PD? (Select all that apply.)

"You will not need vascular access to perform PD." "There is less restriction of protein and fluids." "You have flexible scheduling for the exchanges." PD is based on exchanges of waste, fluid, and electrolytes in the peritoneal cavity. There is no need for vascular access. Protein is lost in the exchange, which allows for more protein and fluid in the diet. There is flexibility in the time for exchanges, but the treatment takes a longer period of time compared to hemodialysis. There still is risk for infection with PD, especially peritonitis.

The nurse is teaching assistive personnel (AP) about fluid restriction for a client who has acute kidney injury (AKI). The client's 24-hour urinary output is 120 mL. How much fluid would the client be allowed to have over the next 24 hours?

620 mL. The general principle for fluid restriction for clients is that they may have a daily fluid intake of 500 mL plus the amount of their urinary output. In this case, 120 mL urinary output plus 500 mL equals 620 mL fluid allowance.

A client is undergoing hemodialysis. The client's blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions would the nurse perform to maintain blood pressure? (Select all that apply.)

Adjust the rate of extracorporeal blood flow. Place the patient in the Trendelenburg position. Administer a 250-mL bolus of normal saline. Hypotension occurs often during hemodialysis treatments as a result of vasodilation from the warmed dialysate. Modest decreases in blood pressure, as is the case with this client, can be maintained with rate adjustment, Trendelenburg positioning, and a fluid bolus. If the blood pressure drops considerably after two boluses and cooling dialysate, the hemodialysis can be stopped and the primary health care provider contacted.

The charge nurse is orienting a new nurse about care for an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe?

Administering intravenous fluids through the AV fistula. The nurse would not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula. The AV fistula would be monitored by auscultating or palpating the access site. Checking the distal pulse would be an appropriate assessment.

A 70-kg adult client with chronic kidney disease (CKD) is on a 40-g protein diet. The patient has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would be of most concern to the nurse?

Albumin level of 2.5 g/dL (3.63 mcmol/L). Protein restriction is necessary with CKD due to the buildup of waste products from protein breakdown. The nurse would be concerned with the low albumin level since this indicates that the protein in the diet is not enough for the client's metabolic needs. The electrolyte values are not related to the protein-restricted diet.

The nurse is caring for a client with a new diagnosis of chronic kidney disease. Which priority complications would the nurse anticipate? (Select all that apply.)

Anemia. Hypertension. Dysrhythmias. Heart failure. The client who has CKD has fluid overload and electrolyte imbalances, especially hyperkalemia, that can cause hypertension, heart failure, and dysrhythmias. Anemia results because erythropoietin production by the kidneys is decreased.

A client is started on continuous venovenous hemofiltration (CVVH). Which finding would require immediate action by the nurse?

Blood pressure of 76/58 mm Hg. Hypotension can be a problem with CVVH if replacement fluid does not provide enough volume to maintain blood pressure. The nurse needs to monitor for ongoing fluid and electrolyte replacement. The sodium level is normal and the potassium level is slightly elevated, which could be normal findings for someone with acute kidney injury. A pulse rate of 88 beats/min is within usual limits.

A client with chronic kidney disease (CKD) has an elevated serum phosphorus level. What drug would the nurse anticipate to be prescribed for this client?

Calcium acetate. The client with CKD often has a high phosphorus level which tends to lower the calcium level in an inverse relationship, and causes osteodystrophy. To prevent this bone disease, the client needs to take a drug that can bind with phosphorus for elimination via the GI tract. When phosphorus is lowered to within normal limits, normal calcium levels may be restored.

The nurse is caring for four clients with chronic kidney disease (CKD). Which client would the nurse assess first upon initial rounding?

Client with Kussmaul respirations. Kussmaul respirations indicate that the client has metabolic acidosis which is a complication of CKD. The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs to lower serum pH. Hypertension is common in most patients with CKD, and skin itching increases with calcium-phosphate imbalances and elevations of nitrogenous wastes, another common finding in CKD. Uremia from CKD causes ammonia to be formed, resulting in the common findings of halitosis and stomatitis.

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for postrenal acute kidney injury (AKI)? (Select all that apply.)

Client with prostate cancer. Client with blood clots in the urinary tract. Client with ureterolithiasis. Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and kidney stones (ureterolithiasis), causes postrenal AKI. Severe burns would be a prerenal cause. Lupus would be an intrarenal cause for AKI.

A client with acute kidney injury (AKI) has a blood pressure of 76/55 mm Hg. The primaryhealth care provider prescribed 1000 mL of nor mal saline to be infused over 1 hour to maintain perfusion. The client starts to develop shortness of breath. What is the nurse's priority action?

Decrease the rate of the IV infusion. The nurse would assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the client's hemodynamic status, but this would not be the initial or priority action by the nurse. Vital signs are also important after adjusting the intravenous infusion.

The nurse is assessing a client with a diagnosis of prerenal acute kidney injury (AKI). Which condition would the nurse expect to find in the patient's recent history?

Dehydration. Prerenal causes of AKI are related to a decrease in perfusion, such as in clients who have prolonged dehydration. Pyelonephritis is an intrinsic or intrarenal cause of AKI related to kidney damage. Bladder cancer and kidney stones are postrenal causes of AKI related to urine flow obstruction.

A client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse?

Discuss what the treatment regimen means to the client. The initial action for the nurse is to assess anxiety, coping styles, and the client's acceptance of the required treatment for CKD. The client may be in denial of the diagnosis. While rescheduling hemodialysis appointments may help, and referral to a mental health practitioner and the possibility of peritoneal dialysis are all viable options, assessment of the client's acceptance of the treatment would come first.

A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this patient's care?

Electrolyte and fluid imbalance. This client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance are essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the client's cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated.

A marathon runner comes into the clinic and states "I have not urinated very much in the last few days." The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is most appropriate?

Give the client a bottle of water immediately. This athlete is mildly dehydrated as evidenced by the higher heart rate and lower blood pressure. The nurse can start hydrating the client with a bottle of water first, followed by teaching the patient to drink 2 to 3 L of water each day. An intravenous line may be needed later, after the patient's degree of dehydration is assessed. An electrocardiogram is not necessary at this time.

The nurse administers epoetin alfa to a client who has chronic kidney disease (CKD). Which laboratory test value would the nurse monitor to determine this drug's effectiveness?

Hemoglobin. The purpose of giving epoetin alfa to a client with CKD is to manage anemia by stimulating the bone marrow to produce more red blood cells. Therefore, monitoring the client's hemoglobin, hematocrit, and red blood cell count would indicate if the drug was effective.

A nurse reviews the laboratory values of a client who returned from kidney transplantation 12 hours ago: Sodium: 136 mEq/L Potassium: 5 mEq/L BUN: 44 mg/dL Creatinine: 2.5 mg/dL What initial intervention would the nurse anticipate?

Increase the dose of immunosuppression. The client may need a higher dose of immunosuppressive medication as evidenced by the elevated BUN and serum creatinine levels. This increased dose may reverse the possible acute rejection of the transplanted kidney. The client does not need hemodialysis, peritoneal dialysis, or further surgery at this point.

A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the client's spouse about the renal-specific formulation for the enteral solution compared to standard formulas. What components would be discussed in the teaching plan? (Select all that apply.)

Lower sodium. Lower potassium. Higher calories. Many clients with AKI are too ill to meet caloric goals and require tube feedings with renal-specific formulas that are lower in sodium, potassium, and phosphorus, and higher in calories than are standard formulas.

A client is placed on fluid restriction because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the client's fluid balance is stable at this time?

No adventitious sounds in the lungs. The absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the client's body. Decreased calcium levels and increased phosphorus levels are common findings with CKD. Edema would indicate a fluid imbalance.

A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse?

Obtain a sample of the effluent and send to the laboratory. An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse. Checking the catheter for obstruction is a viable option but will not treat the peritonitis.

A client is taking furosemide 40 mg/day for management of early chronic kidney disease (CKD). To assess the therapeutic effect of the medication, what action of the nurse is best?

Obtain daily weights of the client. Furosemide is a loop diuretic that helps reduce fluid overload and hypertension in patients with early stages of CKD. One kilogram of weight equals about 1 L of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication. Heart and breath sounds would be assessed if there is fluid retention, as in heart failure. Palpation of the client's abdomen is not necessary, but the nurse would check for edema. The diet history of the client would be helpful to assess electrolyte replacement since potassium is lost with this diuretic, but this does not assess the effectiveness of the medication.

A client has a serum potassium level of 6.5 mEq/L (6.5 mmol/L), a serum creatinine level of 2 mg/dL (176 mcmol/L), and a urine output of 350 mL/day. What is the best action by the nurse?

Place the client on a cardiac monitor immediately. The best action by the nurse would be to check the cardiac status with a monitor. High-potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.

A client with diabetes mellitus type 2 has been well controlled with metformin. The client is scheduled for magnetic resonance imaging (MRI) scan with contrast. What priority would the nurse take at this time?

Tell the client to withhold metformin for 24 hours before the MRI. Contrast media can be nephrotoxic (damaging to the kidneys). Metformin can also be nephrotoxic and the client should not be exposed to two agents. Clients who have diabetes are already at risk for renal damage.

A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse would prompt immediate action to prevent acute kidney injury? (Select all that apply.)

Urine output of 100 mL in 4 hours. Large amount of sediment in the urine. Blood pressure of 90/60 mmHg. The low urine output, sediment, and blood pressure would be reported to the primary health care provider. Postoperatively, the nurse would measure intake and output, check the characteristics of the urine, and report sediment, hematuria, and urine output of less than 0.5 mL/kg/hr for 3 to 4 hours. A urine output of 100 mL is low, but a urine output of 500 mL in 12 hours would be within normal limits. Perfusion to the kidneys is compromised with low blood pressure. The amber odorless urine is normal.