Honan-Chapter 27: Nursing Management: Patients With Renal Disorders

The nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure? A. Dehydration B. Hyperkalemia C .Crackles D. Hypertension

A. Dehydration RATIONALE: The diuretic phase of acute renal failure is characterized by increased urine output, hypotension, and dehydration.

When caring for the patient with kidney failure, the nurse teaches the patient to manage his diet by avoiding which foods? A. Green leafy vegetables and citrus B. Apples and pears C. Proteins of high biologic value D. Oat, wheat, and rye-containing products

A. Green leafy vegetables and citrus RATIONALE Patients should avoid potassium-containing foods such as greens, citrus, banana, tomato, and cantaloupe. Apples and pears are permitted on a renal diet as are proteins of high biologic value and carbohydrates such as grains.

When planning care for the patient with kidney trauma, the nurse notifies the physician immediately for which of these findings? A. Laboratory reports microscopic hematuria. B. Tachycardia and hypotension C. Patient is upset and crying D. Scar noted on patient's left flank

B. Tachycardia and hypotension RATIONALE While hematuria may be present in renal trauma, tachycardia and hypotension are clear symptoms of hemorrhagic shock and must be addressed immediately. The professional nurse has the skills to assist a patient who is upset. A scar on the flank represents an old wound; this is not an immediate concern.

The nurse performs acute intermittent peritoneal dialysis (PD) on a client who is experiencing uremic signs and symptoms. The peritoneal fluid is not draining as expected. What is the best response by the nurse? A. Notify the health care provider. B. Turn the client from side to side. C. Lower the head of the bed. D. Push the catheter further into the abdomen.

B. Turn the client from side to side. RATIONALE If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by turning the client from side to side or raising the head of the bed. The catheter should never be pushed further into the peritoneal cavity. Other measures to promote drainage include checking the patency of the catheter by inspecting for kinks, closed clamps, or an air lock.

The nurse recognizes the patient comprehends the signs and symptoms of renal transplant rejection when the patient states he will monitor for which of these signs and symptoms? Select all that apply. A. Thrill and bruit over the fistula B. Weight gain and fever C. Palpitations and thirst D. Flank pain and pyuria E. Swelling of the ankles and around the eyes

B. Weight gain and fever E. Swelling of the ankles and around the eyes RATIONALE Symptoms of transplant rejection include fever, edema, weight gain, leukocytosis, tenderness over the graft site, and returning symptoms of uremia. Thrill and bruit over the fistula indicate a positive outcome for the fistula. Palpitations and thirst may be symptoms of fluid volume deficit, which is not found in the renal failure patient. Flank pain and pyuria are symptoms of pyelonephritis.

A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF? A. Increased pH with decreased hydrogen ions B. Increased serum levels of potassium, magnesium, and calcium C. Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL D. Uric acid analysis 3.5 mg/dL and phenolsulfonphthalein (PSP) excretion 75%

C. Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL RATIONALE The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. A BUN level of 100 mg/dl and a serum creatinine of 6.5 mg/dl are abnormally elevated results, reflecting CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls within the normal range of 60% to 75%.

The nurse is receiving report on a client with AKI. What should the nurse follow up on first? A. Potassium value of 5.0 mEq/L B. Patient refused fingerstick blood glucose C. Crackles throughout lung fields D. Patient reports itching skin

C. Crackles throughout lung fields RATIONALE Crackles in the lungs is suggestive of heart failure or pulmonary edema, a life threatening complication of fluid overload from oliguria or anuria of kidney failure. This requires immediate evaluation. Potassium of 5.0 mEq/L is a normal value. The client who refuses a fingerstick is not unstable in this situation and will not require immediate attention. Uremic waste products on the skin causing itching is an expected finding in patients with kidney failure; this does not require immediate follow up.

A client has end-stage renal failure. Which of the following should the nurse include when teaching the client about nutrition to limit the effects of azotemia? A. Increase fat intake and limit carbohydrates. B. Eliminate fat intake and increase protein intake. C. Increase carbohydrates and limit protein intake. D. Increase protein, carbohydrates, and fat intake.

C. Increase carbohydrates and limit protein intake. RATIONALE: Calories are supplied by carbohydrates and fat to prevent wasting. Protein is restricted because the breakdown products of dietary and tissue protein (urea, uric acid, and organic acids) accumulate quickly in the blood.

A client with a history of chronic renal failure receives hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which intervention should the nurse include in the care plan? A. Keep the AV fistula site dry. B. Keep the AV fistula wrapped in gauze. C. Take the client's blood pressure in the left arm. D. Assess the AV fistula for a bruit and thrill.

D. Assess the AV fistula for a bruit and thrill. RATIONALE The nurse needs to assess the AV fistula for a bruit and thrill because if these findings aren't present, the fistula isn't functioning. The AV fistula may get wet when the client isn't being dialyzed. Immediately after a dialysis treatment, the access site should be covered with adhesive bandages, not gauze. Blood pressure readings or venipunctures shouldn't be taken in the arm with the AV fistula.

Nursing assessment for the patient receiving peritoneal dialysis would include which of the following to detect the most serious complication of this procedure? A. Palpate the abdominal wall for rebound tenderness. B. Inspect the catheter site for leakage of dialysate. C. Observe for evidence of bleeding. D. Measure fluid drainage to estimate incomplete recovery of fluid.

A. Palpate the abdominal wall for rebound tenderness. RATIONALE Peritonitis is the most serious complication of peritoneal dialysis. To detect rebound tenderness, the nurse presses one hand firmly into the abdominal wall and quickly withdraws the hand. Rebound tenderness exists when pain occurs upon removal; this pain is associated with inflammation of the peritoneal cavity.

What is used to decrease potassium level seen in acute renal failure? A. Sodium polystyrene sulfonate B. Sorbitol C. IV dextrose 50% D. Calcium supplements

A. Sodium polystyrene sulfonate RATIONALE: The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.

Hyperkalemia is a serious side effect of acute renal failure. Identify the electrocardiogram (ECG) tracing that is diagnostic for hyperkalemia. A. Tall, peaked T waves B. Shortened QRS complex C. Multiple spiked P waves D. Prolonged ST segment

A. Tall, peaked T waves RATIONALE Characteristic ECG signs of hyperkalemia are tall, tented, or peaked T waves, absent P waves, and a widened QRS complex.

A patient with end-stage renal disease (ESRD) is scheduled for his first hemodialysis treatment. The patient asks the nurse what common complications may occur from the treatment. What would be the nurse's best reply? A. "High blood sugar levels and low protein levels may occur." B. "Bleeding and double vision may occur." C. "Confusion and diarrhea may occur." D. "Low blood pressure and cramping sometimes occur."

D. "Low blood pressure and cramping sometimes occur." RATIONALE: The most common side effects associated with hemodialysis are hypotension and cramping. Confusion is an uncommon complication related to dialysis disequilibrium syndrome, and this condition is not frequently observed with advancing hemodialysis technology. Diarrhea is not a complication related to hemodialysis. High blood sugar levels and low protein levels are complications associated with peritoneal dialysis. Blood loss is a complication related to hemodialysis, but excessive bleeding is not a common complication related to advanced technology and equipment monitors. Double vision is not associated with hemodialysis, but blurry vision may be a manifestation of hypotension.

A patient admitted with nephrotic syndrome is being cared for on a medical unit. When writing this patient's care plan, what nursing diagnoses should the nurse prioritize? A. Constipation related to immobility B. Risk for injury related to altered thought processes C. Hyperthermia related to the inflammatory process D. Excess fluid volume related to excessive protein losses in the urine

D. Excess fluid volume related to excessive protein losses in the urine RATIONALE The major clinical manifestations of nephrotic syndrome include edema, so an appropriate nursing diagnosis is excess fluid volume related to generalized edema. Edema is usually soft, pitting, and commonly occurs around the eyes, in dependent areas, and in the abdomen. The other options are incorrect nursing diagnoses for this patient.

A client is being cared for after a nephrectomy. Because of the incisional pain and restricted positioning, the client frequently suffers from breathing difficulty. Which measures should the nurse include in the care plan to relieve this distress? Select all that apply. A. Help the client to breathe deeply and cough every 2 hours. B. Provide firm support for the incision when the client coughs. C. Auscultate lung sounds once per shift. D. Administer antibiotic therapy as prescribed.

A. Help the client to breathe deeply and cough every 2 hours. B. Provide firm support for the incision when the client coughs. C. Auscultate lung sounds once per shift. RATIONALE: To monitor the client's respiratory status, the nurse would auscultate the lungs. The nurse also would provide assistance with deep breathing, coughing, and splinting. Antibiotic therapy administration would not relieve this acute distress.

A patient with chronic renal failure has frequent blood work ordered so that the care team can monitor the progression of his disease. The nurse has noted a consistent downward trend in the patient's levels of hemoglobin, hematocrit, and red blood cells (RBCs). The nurse understands that this is likely attributable to what pathophysiologic phenomenon? A. Inadequate metabolism of folic acid B. Increased hemolysis of red cells by the spleen C. Decreased synthesis and release of erythropoietin D. Aplastic anemia

C. Decreased synthesis and release of erythropoietin RATIONALE: Inadequate production of erythropoietin by the damaged kidney causes anemia. Erythropoietin, normally produced by the kidneys, stimulates bone marrow to produce RBCs. The anemia associated with CRF is not attributable to folic acid deficiency, hemolysis, or bone marrow dysfunction.

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? A. Impaired urinary elimination B. Toileting self-care deficit C .Risk for infection D. Activity intolerance

C. Risk for infection RATIONALE: The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection.

When caring for the patient with nephrotic syndrome, what is appropriate to include in the patient teaching plan to prevent long-term? A. Observe for dark urine and clay-colored stool. B. Void every 2 hours on schedule. C. Avoid driving at night. D. Minimize the intake of saturated fat.

D. Minimize the intake of saturated fat. RATIONALE The patient with nephrotic syndrome has hyperlipidemia and risk for cardiovascular disease as part of the constellation of symptoms. Minimizing saturated fats is a prudent means to prevent cardiovascular disease. Dark urine and clay colored stools are symptoms of gallbladder or hepatic disease. Voiding every 2 hours on a schedule is useful to prevent incontinence. There are no ocular complications of nephrotic syndrome that will prevent the client from driving at night.

The nurse earlier infused the prescribed quantity of dialysate into the peritoneal dialysis catheter of an adult patient and has now drained the fluid. Upon examination, the nurse observes that there is significantly less fluid removed than was earlier infused. How should the nurse follow up this observation? A. Adjust the quantity of dialysate used in the next scheduled dialysis treatment accordingly. B. Inform the care provider and arrange for peritoneal lavage. C. Inform the hemodialysis team and facilitate a hemodialysis treatment. D. Reposition the patient to facilitate drainage from the peritoneal cavity.

D. Reposition the patient to facilitate drainage from the peritoneal cavity. RATIONALE If the fluid drains slowly or the volume drained is less than the amount inserted, the nurse turns the patient from side to side, elevates the head of the bed, or repositions the patient to facilitate drainage. This event does not necessitate hemodialysis, a change in the next scheduled treatment, or lavage.

A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately? A. Serum potassium level of 4.9 mEq/L B. Serum sodium level of 135 mEq/L C. Temperature of 99.2° F (37.3° C) D. Urine output of 20 ml/hour

D. Urine output of 20 ml/hour RATIONALE Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. A serum potassium level of 4.9 mEq/L, a serum sodium level of 135 mEq/L, and a temperature of 99.2° F are normal assessment findings.