Chapter 47: Alterations in Renal Function
A patient with chronic kidney disease is advised to undergo peritoneal dialysis (PD). What advantages of PD over hemodialysis should the nurse explain to the patient? Select all that apply. 1 It is a simple procedure. 2 It is home-based. 3 It requires special water systems. 4 It needs a vascular access device. 5 Equipment setup is simple.
1, 2, 5 PD has many advantages over hemodialysis. The procedure is simple and home-based, with easy equipment setup. The patient can himself perform peritoneal dialysis. Because the dialysis is done through the peritoneal membrane, PD does not require a special water system or a vascular access device, as in hemodialysis. Text Reference - p. 1120
Which assessment finding of a patient with chronic kidney disease indicates to the nurse that hemodialysis is having the desired effect? 1. Decreased hematocrit and diuresis 2. Decreased serum creatinine and weight loss 3. Increased potassium level and improved appetite 4. Decreased white blood cell count and diaphoresis
2. Decreased serum creatinine and weight loss One of the main purposes of hemodialysis is removal of creatinine, other waste products, and water. Fluid loss may be measured by weighing the patient before and after the dialysis treatment and also by measuring the serum creatinine. The other answer options are inaccurate and/or incomplete. Hemodialysis will decrease potassium. It may also increase hematocrit and improve appetite. Hemodialysis will not produce diuresis, and has no direct effect on WBC count or diaphoresis. Text Reference - p. 1120
A 24-year-old female donated a kidney via a laparoscopic donor nephrectomy to a nonrelated recipient. The patient is experiencing a lot of pain and refuses to get up to walk. How should the nurse handle this situation? 1. Have the transplant psychologist convince her to walk. 2. Encourage even a short walk to avoid complications of surgery. 3. Tell the patient that no other patients have ever refused to walk. 4. Tell the patient she is lucky she did not have an open nephrectomy.
2. Encourage even a short walk to avoid complications of surgery Because ambulating will improve bowel, lung, and kidney function with improved circulation, even a short walk with assistance should be encouraged after pain medication. The transplant psychologist or social worker's role is to determine if the patient is emotionally stable enough to handle donating a kidney, while postoperative care is the nurse's role. Trying to shame the patient into walking by telling her that other patients have not refused and telling the patient she is lucky she did not have an open nephrectomy (implying how much more pain she would be having if it had been open) will not be beneficial to the patient or her postoperative recovery. Text Reference - p. 1127
A nurse planning care for a patient with acute renal failure recognizes that the interventions of highest priority are directly related to: 1. Ineffective coping 2. Excess fluid volume 3. Impaired gas exchange 4. Imbalanced nutrition: less than body requirements
2. Excess fluid volume The issue of excess fluid volume is the primary problem of acute renal failure and the highest priority for the nurse in this situation. The major problem with acute renal failure is altered fluid and electrolyte balance, which, if not managed, can lead to permanent renal damage, cardiac complications, and death. The nursing diagnosis of Ineffective Coping is due to the acute severity of the illness. The nursing diagnosis of Impaired Gas Exchange is related to Excess Fluid Volume, such as in the development of pulmonary edema. The nursing diagnosis of Imbalanced Nutrition, less than body requirements, is due to a decrease in appetite as a result of the acute renal failure. Text Reference - p. 1106
Which assessment finding is a consequence of the oliguric phase of acute kidney injury (AKI)? 1. Hypovolemia 2. Hyperkalemia 3. Hypernatremia 4. Thrombocytopenia
2. Hyperkalemia In AKI the serum potassium levels increase because the normal ability of the kidneys to excrete potassium is impaired. Sodium levels are typically normal or diminished, whereas fluid volume is normally increased because of decreased urine output. Thrombocytopenia is not a consequence of AKI, although altered platelet function may occur in AKI. Text Reference - p. 1104
The nurse recognizes which laboratory data as the most significant indicator that a patient is responding positively to peritoneal dialysis? 1. Creatinine of 7 mg/dL 2. Potassium of 4.1 mEq/L 3. A below-normal calcium level 4. Increased level of blood urea nitrogen
2. Potassium of 4.1 mEq/L The serum potassium level will return to a normal value of 3. 5 to 5.0 mEq/L when peritoneal dialysis (PD) is effective. Additionally, serum creatinine will decrease to a normal range of 0.2 to 1. 0 mg/dL. Blood urea nitrogen (BUN) will also decrease to a normal range of 10 to 30 mg/dL. When PD is effective, creatinine and BUN will decrease. The serum calcium level is affected by the renal disease process itself, not by the PD. Normal serum calcium levels are 9 to 11 mg/dL. Text Reference - p. 1120
The nurse is caring for a patient with severe burns in the emergency department. His laboratory values reveal serum creatinine level of 5 mg/dL, and the glomerular filtration rate (GFR) has decreased by 75%. What stage of acute kidney failure is this patient exhibiting? 1. Risk 2. Injury 3. Failure 4. Loss
3. Failure As per the RIFLE (Risk, Injury, Failure, Loss, and End-stage) classification for staging acute kidney injury, this patient is at the Failure stage. When the GFR has decreased by 25%, the patient is at the Risk stage. The patient with a GFR that has decreased by 50% is at the Injury stage. The patient with persistent acute kidney failure experiences a complete loss of kidney function and is at the Loss stage. Text Reference - p. 1103
A patient with chronic kidney disease has an arteriovenous (AV) graft in the right forearm. What is the nurse's priority in determining the patency of the graft? 1. Determine the range of motion of the right arm and shoulder 2. Observe for clubbing of the fingers on the right hand of the AV graft site 3. Compare radial pulses by checking the right and left pulses simultaneously 4. Check for a bruit by listening over the right arm AV graft site with a stethoscope
4 The arteriovenous (AV) graft is an artificial connection between an artery and vein to provide access for hemodialysis. Thrombosis may occur; therefore the need to determine patency is an essential assessment. Palpation of the site should indicate a thrill, which also indicates that the graft is patent. Listening over the AV graft should reveal a bruit sound, indicating patency. A bruit sounds similar to the impulse beat heard when measuring blood pressure. The arm that has the AV graft site should not be put through range-of-motion movements or exercises. Clubbing is not a complication observed in the fingers of a patient with an AV graft. Comparing the left radial pulse with the pulse on the AV graft site is not an accurate patency assessment procedure.
The nurse performs an admission assessment of a patient with acute renal failure. For which common complication does the nurse assess the patient? 1. Polyphagia 2. Hypernatremia 3. Hypotensive shock 4. Cardiac dysrhythmias
4. Cardiac dysrhythmias Because the kidneys are not effectively removing waste products, including electrolytes, an increased potassium level (hyperkalemia) of more than 5.0 mEq/L is common in acute renal failure and places the patient at risk for cardiac arrhythmias. Patients usually experience anorexia, not an increase in hunger. Acute renal failure will likely manifest as hyponatremia. Hypotensive shock may be the result of a severe cardiac arrhythmia that is not treated. Text Reference - p. 1105
The nurse reviews a plan of care for a patient with diagnosis of chronic kidney disease who is undergoing hemodialysis. Which part of the plan should the nurse question? 1. 2-g sodium diet 2. Oxygen via nasal cannula at 4 L/min 3. Furosemide (Lasix) 40 mg PO twice a day 4. IV of 0.9% sodium chloride at 125 mL/hour
4. IV of 0.9% sodium chloride at 125 mL/hour A patient with chronic kidney disease (CKD) should receive limited fluids because the kidneys are unable to remove excessive water. An IV solution of 0.9% sodium chloride at a rate of 125 mL/hr places this patient at high risk for complications such as fluid overload, electrolyte imbalance, and hypertension. A 2-g sodium diet, oxygen, and furosemide (Lasix) would be appropriate if prescribed for a patient with CKD. Text Reference - p. 1115
End-stage kidney disease
Complete loss of kidney function >3 mo
Stages of Chronic Kidney disease: stage 2
Kidney damage with mild ↓ GFR GFR 60-89 mL/min/1.73 m2
Stages of Chronic Kidney disease: stage 1
Kidney damage with normal or ↑ GFR GFR ≥90 mL/min/1.73 m2
Stages of Chronic Kidnsy Disease: stage 5
Kidney failure GFR less than 15 mL/min/1.73 m2 or dialysis
Stages of Chronic Kidney disease: stage 3
Moderate ↓ GFR GFR 30-59 ml/min/1.73 m2
RIFLE CLASSIFICATION FOR STAGING ACUTE KIDNEY INJURY: Loss Stage
Persistent acute kidney failure; complete loss of kidney function >4 wk
Stages of Chronic Kidney disease: stage 4
Severe ↓ GFR GFR 15-29 mL/min/1.73 m2
The nurse just received an urgent laboratory value on a patient in renal failure. The potassium level is 6.3. The telemetry monitor is showing peaked T waves. Which prescription from the primary health care provider should be implemented first? 1 Administer regular insulin intravenously (IV) 2 Restrict dietary potassium intake to 40 meq daily 3 Administer kayexalate enema 4 Educate the patient on dietary restriction of potassium
1 Administer regular insulin intravenously (IV) This patient is showing signs of hyperkalemia, which could be fatal and lead to myocardial damage. Regular insulin IV is needed to quickly force potassium into the cells. The kayexalate enema will take too long to excrete the potassium. Restricting oral intake and educating the patient will be needed when the crisis has resolved. Text Reference - p. 1112
RIFLE CLASSIFICATION FOR STAGING ACUTE KIDNEY INJURY: Risk Stage
Serum creatinine increased × 1.5 OR GFR decreased by 25% Urine output <0.5 mL/kg/hr for 6 hr
RIFLE CLASSIFICATION FOR STAGING ACUTE KIDNEY INJURY: Injury stage
Serum creatinine increased × 2 OR GFR decreased by 50% Urine output <0.5 mL/kg/hr for 12 hr
RIFLE CLASSIFICATION FOR STAGING ACUTE KIDNEY INJURY: Failure Stage
Serum creatinine increased × 3 OR GFR decreased by 75% OR Serum creatinine >4 mg/dL with acute rise ≥0.5 mg/dL Urine output <0.3 mL/kg/hr for 24 hr (oliguria) OR Anuria for 12 hr
The nurse is planning an education program on chronic kidney disease. Which ethnic group would the nurse target for promoting this event? 1 African Americans 2 Asian descent 3 Caucasian males 4 Hispanics
1. African Americans
The nurse is attending to a patient who receives regular hemodialysis. When teaching the patient about nutritional therapy during hemodialysis, which food items should the nurse tell the patient to avoid? Select all that apply. 1. Pasta 2. Cereal 3. Bananas 4. Pickled tuna 5. Barbecued red meat
3, 4, 5 Pasta and cereal have a good amount of carbohydrates and hence should be encouraged. Bananas are high in potassium, pickled tuna is high in protein and sodium, and barbecued red meat is high in protein, sodium, and potassium. Therefore, these foods are to be avoided in this patient. Text Reference - p. 1115
A patient has end-stage kidney disease and is receiving hemodialysis. During dialysis the patient complains of nausea and a headache and appears confused. On examination, the nurse finds that the blood pressure is very low. What should the nurse do? Select all that apply. 1 Decrease the volume of fluids being removed. 2 Infuse 0.9% saline solution. 3 Infuse hypertonic glucose solution. 4 Avoid excess coagulation. 5 Transfuse blood, as ordered.
1 and 2 Hypotension is a complication of hemodialysis and may manifest as headache and nausea. The nurse should try to keep the intravascular volume adequate by decreasing the volume of fluids being removed and infusing 0.9% saline solution. Hypertonic glucose solutions are infused if the patient gets muscle cramps. Excess coagulation is avoided if the patient has blood loss. Blood is transfused if the patient has blood loss. Text Reference - p. 1122
The nurse is attending to a patient who is undergoing peritoneal dialysis. The dialysate solution is being infused to the patient. The nurse finds that the patient is developing symptoms of respiratory distress. What nursing interventions are necessary to prevent further respiratory complications? Select all that apply. 1. Auscultate the lungs. 2. Frequently reposition the patient. 3. Promote deep-breathing exercises. 4. Increase the rate of infusion of the dialysate. 5. Place the patient in a low Fowler's position.
1, 2, 3 Auscultation is very important to find the cause of respiratory distress. Decreased areas of ventilation suggest the presence of atelectasis, whereas adventitious sounds may suggest fluid overload, retained secretions, or infection. Frequent positioning will promote equal ventilation to all parts of the lungs. Deep-breathing exercises could help to promote proper expansion of lungs. Rapid infusion would cause more pressure on the diaphragm. The patient should be placed in the semi-Fowler's position for peritoneal dialysis; this allows inflow of fluid while not impinging on the thoracic cavity. Text Reference - p. 1119
A patient with end-stage kidney disease is receiving continuous ambulatory peritoneal dialysis. The patient has a fever and the nurse suspects that it is due to peritonitis. What are the other manifestations that the nurse should monitor the patient for? Select all that apply. 1. Vomiting 2. Abdominal pain 3. Bloody stools 4. Weight loss 5. Cloudy peritoneal effluent
1, 2, 5 Peritonitis may manifest as vomiting due to the inflammatory process in the peritoneum. The patient may have pain in the abdomen due to peritoneal irritation caused by the inflammatory process in the peritoneum. The primary clinical manifestations of peritonitis are abdominal pain and cloudy peritoneal effluent with a white blood cell (WBC) count greater than 100 cells/μL (more than 50% neutrophils). An activated immune response may attract WBCs, and an elevated level of WBC in the peritoneal fluid indicates peritonitis. Bloody stool or weight loss is not associated with peritonitis. Peritonitis may not cause hemorrhage; therefore, bloody stools may not be present. Weight loss is usually caused by malnutrition or fluid loss and therefore may not be seen in peritonitis; weight gain may occur due to fluid retention. Text Reference - p. 1119
A patient with end-stage kidney disease is to begin continuous ambulatory peritoneal dialysis (CAPD). What are the preparations to be done by the nurse before starting the catheter insertion for this patient? Select all that apply. 1. Ask patient to empty the bladder and bowel. 2. Note the patient's weight. 3. Obtain a signed consent form. 4. Monitor for abnormal cardiac signs and symptoms. 5. Monitor for abnormal respiratory signs and symptoms.
1, 2, and 3 Preparation of the patient for catheter insertion includes emptying the bladder and bowel, weighing the patient, and obtaining a signed consent form. The bladder should be emptied to prevent accidental puncture of the bladder by the needle. Weighing the patient before and after the procedure is important to determine the effectiveness of dialysis. Because it is an invasive procedure, the nurse should explain about the risks and benefits, and informed consent should be obtained. Other factors are not contraindications for CAPD. Monitoring of cardiac and respiratory signs is essential but does not directly affect the procedure. Text Reference - p. 1118
Hemodialysis is planned for a patient who has end-stage kidney disease. The patient is scheduled for the creation of an internal arteriovenous fistula and the placement of an external arteriovenous shunt to be used until the fistula heals. What postoperative nursing care is appropriate for this patient? Select all that apply. 1. Regularly check the positioning of the external shunt. 2. Check for signs and symptoms of respiratory complications. 3. Ensure that intravenous fluids are not infused in the arm with the shunt. 4. Cover the ends of the shunt cannula with a dressing. 5. Do not take blood pressure on the extremity with the shunt.
1, 3, 5 The external shunt may come apart, external temperatures make clotting a potential hazard, and frequent handling increases the risk of infection. Infusions should not be in the extremity with the shunt or the fistula to avoid pressure from the tourniquet and to lessen the chance of phlebitis. Blood pressure readings should not be obtained in the extremity that has a shunt or fistula because of the pressure exerted on the circulatory system during the procedure. There are no respiratory complications of this procedure. The ends of the shunt cannula should be left exposed for rapid reconnection in the event of disruption. Text Reference - p. 1120
The nurse is attending to a patient who is receiving hemodialysis for chronic kidney disease. The nurse understands that hemodialysis is associated with complications. Which complications should the nurse be observant for in the patient? Select all that apply. 1. Hypotension 2. Renal calculi 3. Hepatitis type B 4. Bladder infection 5. Muscle cramps
1, 3, 5 The patient on hemodialysis may have decreased blood pressure due to rapid removal of blood. Hepatitis type B is a blood-borne infection, and hemodialysis poses a high risk for transmission of hepatitis B. Muscle cramps are a common complication of hemodialysis. Factors associated with the development of muscle cramps in hemodialysis include hypotension, hypovolemia, a high ultrafiltration rate (large interdialytic weight gain), and low-sodium dialysis solution. Hemodialysis does not increase the risk of development of renal calculi; people who are on bed rest or have low urine output may be at risk. Bladder infection is not related to dialysis. Text Reference - p. 1122
The nurse preparing to administer a dose of calcium acetate (PhosLo) to a patient with chronic kidney disease (CKD) should know that this medication should have a beneficial effect on which laboratory value? 1. Sodium 2. Potassium 3. Magnesium 4. Phosphorus
4. Phosphorus Phosphorus and calcium have inverse or reciprocal relationships, meaning that when phosphorus levels are high, calcium levels tend to be low. Therefore, administration of calcium should help to reduce a patient's abnormally high phosphorus level, as seen with CKD. PhosLo will not have an effect on sodium, potassium, or magnesium levels. Text Reference - p. 1113
A nurse is delivering a lecture on organ donation. She is explaining about the selection criteria for kidney donors. What are the donor characteristics that the nurse should discuss with the group? Select all that apply. 1 Donors should not have diabetes. 2 Donors should be a first-degree relative of a recipient. 3 Donors should be approximately the same body size as the recipient. 4 Donors must have ABO compatibility with the recipient. 5 The donor and recipient should have matching leukocyte antigen complexes.
1, 4, 5 Diabetes is a major predisposing factor for development of kidney disease; hence, the donor should not be a diabetic. ABO compatibility is necessary for being a donor, although the exact blood type is not necessary. Human leukocyte antigen compatibility provides the most specific predictions of the body's tendency to accept or reject foreign tissue. Being a member of the same family is unsafe unless the family member has matching leukocyte antigen complexes. Being a member of the same family may increase the possibility of a match, but there is no guarantee that a family member will match. Differences in body size do not cause problems. Text Reference - p. 1124
The health care provider informs the nurse that the patient who had been admitted a week ago is in the diuretic phase of acute kidney injury, and the interventions have to be changed accordingly. The nurse explains the present condition of the patient to the caregivers. Which information is appropriate regarding the condition of the patient? Select all that apply. 1. Urine output of the patient is increased. 2. The kidney has become fully functional. 3. The electrolyte imbalance will be normalized. 4. The patient will be in this phase for no more than 3 weeks. 5. There is a possibility that the fluid volume will be reduced in the body.
1, 4, 5 During the diuretic phase of acute kidney injury, daily urine output is usually around 1 to 3 L but may reach 5 L or more. Hypovolemia and hypotension can occur from massive fluid losses. The diuretic phase may last 1 to 3 weeks. Near the end of this phase, the patient's acid-base, electrolyte, and waste product (blood urea nitrogen, creatinine) values begin to normalize. Although urine output is increasing, the nephrons are still not fully functional. The high urine volume is caused by osmotic diuresis from the high urea concentration in the glomerular filtrate and the inability of the tubules to concentrate the urine. In this phase the kidneys have recovered their ability to excrete wastes, but not to concentrate the urine. Because of the large losses of fluid and electrolytes, the patient must be monitored for hyponatremia, hypokalemia, and dehydration. Text Reference - p. 1104
Which statement by the nurse regarding continuous ambulatory peritoneal dialysis (CAPD) would be of highest priority when teaching a patient new to this procedure? 1. "It is essential that you maintain aseptic technique to prevent peritonitis." 2. "You will be allowed a more liberal protein diet once you complete CAPD." 3. "It is important for you to maintain a daily written record of blood pressure and weight." 4. "You will need to continue regular medical and nursing follow-up visits while performing CAPD."
1. "It is essential that you maintain aseptic technique to prevent peritonitis." Peritonitis is a potentially fatal complication of peritoneal dialysis, and thus it is imperative to teach the patient methods of preventing this from occurring by use of aseptic technique. Although the nurse will teach a patient he or she may be allowed more liberal protein, the importance of maintaining a weight and blood pressure record, and keeping follow-up appointments, these statements do not have the potential for morbidity and mortality as does peritonitis, thus making that statement of highest priority . Text Reference - p. 1119
A 78-year-old patient has Stage 3 chronic kidney disease (CKD) and is being taught about a low potassium diet. The nurse knows the patient understands the diet when the patient selects which foods to eat? 1 Apple, green beans, and a roast beef sandwich 2 Granola made with dried fruits, nuts, and seeds 3 Watermelon and ice cream with chocolate sauce 4 Bran cereal with ½ banana, milk, and orange juice
1. Apple, green beans, and roast beef sandwich When the patient selects an apple, green beans, and a roast beef sandwich, the patient demonstrates understanding of the low potassium diet. Granola, dried fruits, nuts and seeds, milk products, chocolate sauce, bran cereal, banana, and orange juice all have elevated levels of potassium, at or above 200 mg per 1/2 cup. Text Reference - p. 1114
Which process involves movement of fluid and molecules across a semipermeable membrane from one compartment to another? 1. Dialysis 2. Osmosis 3. Diffusion 4. Ultrafiltration
1. Dialysis Dialysis is the movement of fluid and molecules across a semipermeable membrane from one compartment to another. Substances move from the blood through a semipermeable membrane and into a dialysis solution in this process. Osmosis is the movement of fluid from an area of lesser concentration to an area of greater concentration of solutes. Diffusion is the movement of solutes from an area of greater concentration to an area of lesser concentration. Ultrafiltration occurs when there is a pressure gradient across the membrane. Text Reference - p. 1117
The nurse caring for a patient with heart failure notes the patient has decreased urine output of 200 mL/day. Which laboratory finding aids in the diagnosis of prerenal azotemia in this patient? 1. Elevated blood urea nitrogen (BUN) 2. Normal creatinine level 3. Decreased sodium level 4. Decreased potassium level
1. Elevated blood urea nitrogen (BUN) The patient with heart failure has a decreased circulating blood volume. This causes autoregulatory mechanisms to preserve blood flow to essential organs. Laboratory data for this patient will likely demonstrate an elevation in BUN, creatinine, and potassium. Prerenal azotemia results in a reduction in the excretion of sodium, increased sodium and water retention, and decreased urine output. Text Reference - p. 1102
When obtaining a health history for the patient with chronic kidney disease, the nurse notes the following medications on the patient's medication list. The patient will need further education on which medication? 1. Ibuprofen 2. Tylenol 3. Calcium supplements 4. PhosLo
1. Ibuprofen Ibuprofen, and other nonsteroidal anti-inflammatory drugs (NSAIDS), will cause further damage to the kidneys. Chronic kidney disease (CKD) patients should be taking Tylenol as prescribed for pain. CKD patients also could be consuming calcium supplements and PhosLo tablets as prescribed by the health care provider. Text Reference - p. 1107
When caring for a patient during the oliguric phase of acute kidney injury (AKI), what is an appropriate nursing intervention? 1 Weigh patient three times weekly 2 Increase dietary sodium and potassium 3 Provide a low-protein, high-carbohydrate diet 4 Restrict fluids according to previous daily loss
4. Restrict fluids according to previous daily loss
A patient is scheduled to undergo peritoneal dialysis. What is the highest-priority action that the nurse should perform before starting dialysis? 1. Obtain the patient's weight 2. Administer pain medication to the patient 3. Place the patient in a high Fowler's position 4. Place the patient in the Trendelenburg position
1. Obtain the patients weight The nurse must check the patient's weight before and after peritoneal dialysis (PD) to determine how much fluid has been removed. The patient should assume a position of comfort, such as a low Fowler's, unless there is difficulty with removing the effluent, in which case the nurse will position the patient to facilitate drainage. Administering pain medication is not a priority in regard to PD. There is no indication that the patient is experiencing pain. Placing the patient in a high Fowler's or Trendelenburg position is not recommended for patients during PD. Text Reference - p. 110
Which continuous renal replacement therapy requires no fluid replacement? 1 Slow continuous ultrafiltration 2 Continuous venovenous hemodialysis 3 Continuous venovenous hemofiltration 4 Continuous venovenous hemodiafiltration
1. Slow continuous ultrafiltration Slow continuous ultrafiltration is a simplified version of continuous venovenous hemofiltration. No fluid replacement is required in this process. Continuous venovenous hemodialysis removes both fluids and solutes and requires both dialysate and replacement fluid. Continuous venovenous hemofiltration removes both fluids and solutes and requires replacement fluid. Continuous venovenous hemodiafiltration removes both fluids and solutes and requires both dialysate and replacement fluid text Reference - p. 1123
The nurse is attending to a patient who has received a kidney transplant. What parameters would indicate a successful transplant? Select all that apply. 1 The specific gravity of urine increases. 2 High blood pressure is corrected. 3 Serum potassium levels are elevated. 4 Serum creatinine levels are decreased. 5 Blood sodium levels are decreased.
2, 4, 5 The patient with end-stage kidney disease may have hypertension due to fluid retention; the hypertension is corrected after a successful transplant through adequate urine output. The serum creatinine levels decrease as the transplanted kidney starts eliminating the nitrogenous wastes. After the transplant, the sodium levels should be corrected as the fluid balance returns to normal. As more urine is produced by the transplanted kidney, the specific gravity and concentration of the urine will decrease. Following a transplant, the serum potassium levels are corrected as fluid balance is restored. Text Reference - p. 1127
The patient with end stage renal disease (ESRD) has decided to terminate dialysis treatments. Which is the best response by the nurse? 1. "I respect your decision. Would you like me to ask the health care provider for a palliative care consult?" 2. "I respect your decision, but believe you need to discuss options with your health care provider. Would you like me to page the health care provider to come speak with you?" 3. "You cannot stop now, you have so much to live for." 4. "Are you sure this is the right decision? How about if I ask a psychiatrist to come speak with you."
2. "I respect your decision, but believe you need to discuss options with your health care provider. Would you like me to page the health care provider to come speak with you?" The patient has the right to end treatment. This decision must be made with the health care provider. Telling the patient he or she has too much to live for may be giving false reassurance. The nurse has no right questioning the decision or calling a psychiatrist at this point. Text Reference - p. 1129
Which patient is most likely to develop chronic kidney disease (CKD) and should be taught preventive measures by the nurse? 1. A 50-year-old white female with hypertension 2. A 61-year-old Native-American male with diabetes 3. A 40-year-old Hispanic female with cardiovascular disease 4. A 28-year-old African-American female with a urinary tract infection
2. A 61-year-old Native-American male with diabetes It is especially important that the nurse should teach CKD prevention to the 61-year-old Native American with diabetes. This patient is at highest risk because diabetes causes about 50% of CKD. This patient is the oldest and Native Americans with diabetes develop CKD six times more frequently than other ethnic groups. Hypertension causes about 25% of CKD. Hispanics have CKD about 1.5 times more than non-Hispanics. African Americans have the highest rate of CKD because hypertension is increased significantly in African Americans. A urinary tract infection (UTI) will not cause CKD unless it is not treated or occurs recurrently. Text Reference - p. 1112
A patient with a history of end-stage kidney disease secondary to diabetes mellitus has presented to the outpatient dialysis unit for the scheduled hemodialysis. Which assessments should the nurse prioritize before, during, and after the treatment? 1. Level of consciousness 2. Blood pressure and fluid balance 3. Temperature, heart rate, and blood pressure 4. Assessment for signs and symptoms of infection
2. Blood pressure and fluid balance Although monitoring level of consciousness, temperature, heart rate, and blood pressure and assessing for signs of infection are relevant to the care of a patient receiving hemodialysis , the nature of the procedure indicates a particular need to monitor the patient's blood pressure and fluid balance. Text Reference - p. 1122
The nurse reviews lab tests that have been prescribed for a patient in acute renal failure. Which is the best indicator of renal function? 1. Potassium 2. Creatinine 3. BUN (blood urea nitrogen) 4. ALT (alanine aminotransferase)
2. Creatinine Creatinine is the best indicator of renal function. Creatinine is a waste product of the skeletal muscles and is excreted through the kidneys. In renal failure, the kidneys are unable to excrete creatinine, leading to a serum level greater than the normal range of 0.2 to 1. 0 ml/dL. Potassium excretion and regulation is impaired in acute renal failure, and potassium may therefore be increased. However, potassium may be increased for reasons other than renal disease, whereas increased creatinine is specific to renal disease. Blood urea nitrogen (BUN) is also used to measure kidney function, but other disorders such as dehydration may cause an increase in BUN. Alanine aminotransferase (ALT) is related to liver dysfunction, not renal dysfunction. Text Reference - p. 1104
A patient has renal failure. The nurse, reviewing the lab results, recognizes which finding as indicative of the diminished renal function associated with the diagnosis? 1. Hypokalemia 2. Increased serum urea and serum creatinine 3. Anemia and decreased blood urea nitrogen 4. Increased serum albumin and hyperkalemia
2. Increased serum urea and serum creatinine Renal failure, whether acute or chronic, causes an increase in serum urea, creatinine, and blood urea nitrogen. Renal failure may also cause hyperkalemia and anemia and decrease serum albumin. However, it does not cause decreased blood urea nitrogen or increased serum albumin. Text Reference - p. 1102
Diffusion, osmosis, and ultrafiltration occur in both hemodialysis and peritoneal dialysis. The nurse should know that ultrafiltration in peritoneal dialysis is achieved by which method? 1 Increasing the pressure gradient 2 Increasing osmolality of the dialysate 3 Decreasing the glucose in the dialysate 4 Decreasing the concentration of the dialysate
2. Increasing osmolarity of the dialysate Ultrafiltration in peritoneal dialysis is achieved by increasing the osmolality of the dialysate with additional glucose. In hemodialysis the increased pressure gradient from increased pressure in the blood compartment or decreased pressure in the dialysate compartment causes ultrafiltration. Decreasing the concentration of the dialysate in either peritoneal or hemodialysis will decrease the amount of fluid removed from the blood stream. Text Reference - p. 1118
The nurse is caring for a patient with chronic kidney disease who is undergoing hemodialysis. What is an appropriate diet for this patient? 1. High protein and low calcium 2. Low protein and low potassium 3. High protein and high potassium 4. Low protein and high phosphorus
2. Low protein and low potassium Patients with chronic kidney disease undergoing hemodialysis should consume a diet low in protein and potassium. Calcium needs to be maintained in the diet to help prevent hyperphosphatemia. High protein should be avoided because it causes uremic toxicity. High potassium in the diet needs to be avoided because the increased serum potassium level can result in cardiac disturbances.
The nurse has the following tasks to perform. Which is an appropriate task to delegate to the unlicensed assistive personnel (UAP)? 1. Document intake and output on the patient performing bedside peritoneal dialysis 2. Obtain a finger stick blood sugar on the patient receiving hemodialysis 3. Ambulate the patient who is postoperative day one following a right-sided nephrectomy 4. Report the patient's potassium level of 5.2 to the primary health care provider
2. Obtain a finger stick blood sugar on the patient receiving hemodialysis It is within the scope of practice of the UAP to obtain a finger stick blood glucose level. It is not within the UAP scope of practice to assess the intake and output during a peritoneal dialysis exchange. The patient postoperative day one will need a nursing assessment on his or her ability to ambulate, as well as a pain assessment. UAP do not report any results to health care providers. Text Reference - p. 1117
A patient with chronic kidney disease is prescribed regular peritoneal dialysis (PD). What should the nurse inform the patient while teaching about PD? 1 Avoid high-protein diets. 2 Take potassium supplements. 3 Restrict fluid intake, as in hemodialysis. 4 Avoid powdered breakfast drinks.
2. Take potassium supplements The patient undergoing regular peritoneal dialysis (PD) does not need to restrict potassium intake; instead, this patient may be prescribed oral potassium supplementation because of hypokalemia caused by dialysis. The patient need not restrict protein diet or fluid intake. The patient should include enough protein in diet to compensate for loss of protein in dialysate. The patient may even take liquid or powdered breakfast drinks in case of inadequate protein intake. Patients on hemodialysis have a more restricted fluid intake than patients receiving peritoneal dialysis (PD). Text Reference - p. 1118
The nurse is planning an educational course on risk factors for chronic kidney disease. Which factors should the nurse identify as nonmodifiable risk factors? Select all that apply. 1. Hypertension 2. Type II diabetes 3. Family history of chronic kidney disease (CKD) 4. Age > 60 5. Exposure to nephrotoxic drugs
3 and 4 Family history of chronic kidney disease and age greater than 60 are risk factors out of the patient's control. The patient can make lifestyle changes to reduce high blood pressure and decrease blood glucose. The patient has a choice to take the drugs that are considered to be nephrotoxic.
A nurse is explaining the warning signs of organ rejection to a patient who had a kidney transplant. What are the signs of rejection that the nurse should explain to the patient? Select all that apply. 1. Weight loss 2. Subnormal temperature 3. Elevated blood pressure 4. Reduction in the amount of urine 5. Pain over the transplant site
3, 4, 5 Hypertension is caused by hypervolemia because of the failure of the new kidney. A reduction in the amount of urine produced indicates ineffective functioning of the kidney. Pain in the site of transplant could be caused by any underlying kidney pathology, which could be a result of rejection. Weight gain, not loss, occurs with a rejection of the kidney because of fluid retention. The patient will have an elevated temperature exceeding 100°F with kidney rejection. Text Reference - p. 1127
When assessing the mental status of a patient in acute renal failure, the nurse recognizes that abnormal findings are most likely caused by: 1. Anger related to denial of chronic illness 2. Delirium related to hypoxia of brain cells 3. Confusion related to an increased urea level 4. Aggression related to possible underlying comorbidities
3. Confusion related to an increased urea level In renal disease, urea is not filtered out of the blood by the kidneys and therefore accumulates in the blood. This results in toxicity to brain tissue, causing confusion. Anger is a possible emotional reaction, but it does not manifest as a change of mental status. Delirium related to hypoxia of brain cells is not a complication seen with acute renal failure. Aggression is not necessarily related to acute renal failure. Text Reference - p. 1108
The physician has decided to use renal replacement therapy to remove large volumes of fluid from a patient who is hemodynamically unstable in the intensive care unit. The nurse should expect which treatment to be used for this patient? 1 Hemodialysis (HD) three times per week 2 Automated peritoneal dialysis (APD) 3 Continuous venovenous hemofiltration (CVVH) 4 Continuous ambulatory peritoneal dialysis (CAPD)
3. Continuous venovenous hemofiltration (CAPD) CVVH removes large volumes of water and solutes from the patient over a longer period of time by using ultrafiltration and convection. HD three times per week would not be used for this patient because fluid and solutes build up and then are removed rapidly. With APD (used at night instead of during the day) fluid and solutes build up during the day and would not benefit this patient as much. CAPD will not remove as rapidly large amounts of fluid as CVVH can do. Text Reference - p. 1123
During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do for the patient? 1. Administer hypertonic saline 2. Administer a blood transfusion 3.Decrease the rate of fluid removal 4. Administer antiemetic medications
3. Decrease the rate of fluid removal The patient is experiencing hypotension from a rapid removal of vascular volume. The rate and volume of fluid removal will be decreased and 0.9% saline solution may be infused. Hypertonic saline is not used because of the high sodium load. A blood transfusion is not indicated. Antiemetic medications may help the nausea, but would not help the hypovolemia. Text Reference - p. 1122
The nurse is caring for a patient who had a surgery for an arteriovenous fistula (AVF) in preparation for hemodialysis. What precautionary step should the nurse follow when caring for this patient? 1. Perform venipuncture in the extremity only after 3 months. 2. Allow insertion of IV lines in the extremity only after 6 months. 3. Never take blood pressure measurements in the extremity. 4. Initiate hemodialysis after 4 weeks.
3. Never take blood pressure measurements in the extremity The nurse should inform the patient to never take blood pressure measurements, insert IV lines, or perform venipuncture in the extremity with vascular access. These special precautions are taken to prevent infection and clotting of the vascular access site. Maturation may take 6 weeks to months. Arteriovenous fistula (AVF) should be placed at least 3 months before initiating hemodialysis. Text Reference - p. 1120
The patient was diagnosed with prerenal acute kidney injury (AKI). The nurse should know that what is most likely the cause of the patient's diagnosis? 1 Intravenous (IV) tobramycin (Nebcin) 2 Incompatible blood transfusion 3 Poststreptococcal glomerulonephritis 4 Dissecting abdominal aortic aneurysm
4. Dissecting abdominal aortic aneurysm A dissecting abdominal aortic aneurysm is a prerenal cause of AKI because it can decrease renal artery perfusion and therefore the glomerular filtrate rate. Aminoglycoside antibiotic administration, a hemolytic blood transfusion reaction, and poststretpcoccal glomerulonephritis are intrarenal causes of AKI. Text Reference - p. 1102
Which clinical action plan is most appropriate for a patient in stage 3 of chronic kidney disease? 1 Diagnosis and treatment 2 Estimation of progression 3 Renal replacement therapy 4 Evaluation and treatment of complications
4. Evaluation and treatment of complications A patient in stage 3 of chronic kidney disease has a moderate decrease in the glomerular filtration rate (GFR). The most appropriate clinical action plan for this patient is evaluation and treatment of complications. Diagnosis and treatment is the clinical action plan for patients in stage 1 of chronic kidney disease. Estimation of progression is the clinical action plan for patients in stage 2 of chronic kidney disease, as this stage is associated with kidney damage with mild decrease in GFR. Renal replacement therapy is the clinical action plan for patients in stage 5, which is associated with kidney failure. Text Reference - p. 1108
The patient has had type 1 diabetes mellitus for 25 years and now is reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse finds that the patient has newly developed hypertension and difficulty with blood glucose control. The nurse should know that which diagnostic study will be most indicative of chronic kidney disease (CKD) in this patient? 1. Serum creatinine 2. Serum potassium 3. Microalbuminuria 4. Calculated glomerular filtration rate (GFR)
4. GFR The best study to determine kidney function or CKD that would be expected in the patient with diabetes is the calculated GFR that is obtained from the patient's age, gender, race, and serum creatinine. It would need to be abnormal for three months to establish a diagnosis of CKD. A creatinine clearance test done with a blood sample and a 24-hour urine collection is also important. Serum creatinine is not the best test for CKD because the level varies with different patients. Serum potassium levels could explain why the patient has an irregular heartbeat. The finding of microalbuminuria can alert the patient with diabetes about potential renal involvement and potentially failing kidneys. However, urine albumin levels are not used for diagnosis of CKD. Text Reference - p. 1107
