Chapter 54: Management of Patients With Renal Disorders NCLEX
A (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.)
A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? a) Risk for infection b) Impaired urinary elimination c) Toileting self-care deficit d) Activity intolerance
A (During the second phase, the oliguric phase, oliguria occurs. Diuresis occurs during the third or diuretic phase. Acute tubular necrosis (ATN) occurs during the first, or initiation, phase in which reduced blood flow to the nephrons leads to ATN. Restoration of glomerular function, if it occurs, occurs during the fourth, or recovery, phase.)
A group of students are reviewing the phases of acute renal failure. The students demonstrate understanding of the material when they identify which of the following as occurring during the second phase? a) Oliguria b) Acute tubular necrosis c) Diuresis d) Restored glomerular function
A, B, D (Decreased calcium, increased potassium, and increased phosphate levels are associated with ESKD, along with the signs and symptoms associated with these serum values. Decreased magnesium and chloride levels are not associated with ESKD.)
The nurse is caring for a patient with a medical history of untreated CKD that has progressed to ESKD. Which of the following serum values and associated signs and symptoms will the nurse expect the patient to exhibit? Select all that apply. a) Phosphate 5.0 mg/dL; tachycardia and nausea and emesis b) Calcium 7.5 mg/dL; hypotension and irritability c) Chloride 90 mEq/L; irritability and seizures d) Potassium 6.4 mEq/L; dysrhythmias and abdominal distention e) Magnesium 1.5 mg/dL; mood changes and insomnia
C (Foods and fluids containing potassium or phosphorus (e.g., bananas, citrus fruits and juices, coffee) are restricted.)
The nurse is educating a patient who is required to restrict potassium intake. What foods would the nurse suggest the patient eliminate that are rich in potassium? a) Cooked white rice b) Salad oils c) Citrus fruits d) Butter
C (It is important to keep the dialysis supplies in a clean area, away from children and pets, because the supplies may be dangerous for them. A mask is generally worn only while performing exchanges, especially when a patient has an upper respiratory infection. The catheter insertion site should be cleaned daily with an antiseptic such as povidone-iodine (Betadine), not with soap. In addition, the catheter should be stabilized to the abdomen above the belt line, not below the belt line, to avoid constant rubbing.)
The nurse is helping a patient to correctly perform peritoneal dialysis at home. The nurse must educate the patient about the procedure. Which educational information should the nurse provide to the patient? a) Keep the catheter stabilized to the abdomen, below the belt line b) Wear a mask while handling any dialysate solutions c) Keep the dialysis supplies in a clean area, away from children and pets d) Clean the catheter insertion site daily with soap
D (No rationale available)
The nurse is passing out medications on a medical-surgical unit. A male patient is preparing for hemodialysis. The patient is ordered to receive numerous medications including antihypertensives. Which of the following is the best action for the nurse to take? a) Administer the medications as ordered. b) Ask the patient if he wants to take his medications. c) Check with the dialysis nurse about the medications. d) Hold the medications until after dialysis.
A (Uremia is the buildup of nitrogenous wastes in the blood, evidenced by an elevated blood urea nitrogen and creatine levels. Uremia, anemia, and acidosis are consistent clinical manifestations of chronic renal failure. Metabolic acidosis results from the inability to excrete hydrogen ions. Anemia results from a lack of erythropoietin. Hypertension (from fluid overload) may or may not be present in chronic renal failure. Hypotension, metabolic alkalosis, and polycythemia aren't present in renal failure.)
Which clinical finding should a nurse look for in a client with chronic renal failure? a) Uremia b) Polycythemia c) Hypotension d) Metabolic alkalosis
C (The intrarenal category of acute renal failure encompasses an increased BUN, increased creatinine, a low specific gravity of urine, and increased urine sodium.)
Which of the following is a characteristic of the intrarenal category of acute renal failure? a) Decreased creatinine b) High specific gravity c) Increased BUN d) Decreased urine sodium
A, C, E (Disorders or conditions that cause decreased urine specific gravity (ie, dilute urine) include diabetes insipidus, glomerulonephritis, and severe renal damage that may cause a fixed specific gravity of 1.010. Etiologies associated with increased urine specific gravity include diabetes mellitus, patients who have recently received high density radiopaque dyes, and fluid deficit.)
In which of the following renal disorders would one suspect a decreased urine specific gravity? Select all that apply a) Glomerulonephritis b) Diabetes c) Severe renal damage d) Fluid deficits e) Diabetes insipidus
A, B, D, E (The nurse teaches the patient with fistulae or grafts to check daily for a thrill and bruit. Further teaching includes avoiding compression of the site; not permitting blood to be drawn, an IV to be inserted, or blood pressure to be taken on the extremity with the dialysis access; not to wear tight clothing, carry bags or pocketbooks on that side, and not lie on or sleep on the area. The site is not cleansed unless it is being accessed for hemodialysis.)
Patient education regarding a fistulae or graft includes which of the following? Select all that apply. a) Check daily for thrill and bruit. b) No IV or blood pressure taken on extremity with dialysis access. c) Cleanse site b.i.d. d) Avoid compression of the site. e) No tight clothing.
A (ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is characterized by a urine output of 250 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn't diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn't result from this disorder.)
A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. I.V. fluid is being infused at 150 ml/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)? a) Urine output of 250 ml/24 hours b) Temperature of 100.2° F (37.8° C) c) Serum creatinine level of 1.2 mg/dl d) Blood urea nitrogen (BUN) level of 22 mg/dl
A (Hyperkalemia is the life-threatening effect of renal failure. The client can become apathetic; confused; and have abdominal cramping, dysrhythmias, nausea, muscle weakness, and numbness of the extremities. Symptoms of hypocalcemia are muscle twitching, irritability, and tetany. Elevation in urea levels can result in azotemia, which can be exhibited in fluid and electrolyte and/or acid-base imbalance. Elevation of WBCs is not indicated.)
A client in chronic renal failure becomes confused and complains of abdominal cramping, and numbness of the extremities. The nurse relates these symptoms to which of the following lab values? a) Hyperkalemia b) Elevated white blood cells c) Hypocalcemia d) Elevated urea levels
A (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.)
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) Assess the AV fistula for a bruit and thrill. b) Keep the AV fistula site dry. c) Take the client's blood pressure in the left arm. d) Keep the AV fistula wrapped in gauze.
B (Dialysis equilibrium syndrome causes confusion, a decreasing level of consciousness, headache, and seizures. These findings, which may last several days, probably result from a relative excess of interstitial or intracellular solutes caused by rapid solute removal from the blood. The resultant organ swelling interferes with normal physiological functions. To prevent this syndrome, many dialysis centers keep first-time sessions short and use a reduced blood flow rate. Acute bone pain and confusion are associated with aluminum intoxication, another potential complication of dialysis. Weakness, tingling, and cardiac arrhythmias suggest hyperkalemia, which is associated with renal failure. Hypotension, tachycardia, and tachypnea signal hemorrhage, another dialysis complication.)
A client with acute renal failure is undergoing dialysis for the first time. The nurse monitors the client closely for dialysis equilibrium syndrome, a complication that's most common during the first few dialysis sessions. Typically, dialysis equilibrium syndrome causes: a) acute bone pain and confusion. b) confusion, headache, and seizures. c) weakness, tingling, and cardiac arrhythmias. d) hypotension, tachycardia, and tachypnea.
D (Even a perfect match does not guarantee that a transplanted organ will not be rejected. Immunosuppressive drugs are used in all organ transplants to decrease incidence of organ rejection. To provide the client with the information needed to provide informed consent, the treatment plan is reviewed and discussed prior to transplant.)
A client with end-stage renal disease is scheduled to undergo a kidney transplant using a sibling donated kidney. The client asks if immunosuppressive drugs can be avoided. Which is the best response by the nurse? a) "Let's wait until after the surgery to discuss your treatment plan." b) "The doctor may decide to delay the use of immunosuppressant drugs." c) "Immunosuppressive drugs guarantee organ success." d) "Even a perfect match does not guarantee organ rejection."
D (Urine output less than 50 ml in 24 hours is called anuria. Urine output of less than 400 ml in 24 hours is called oliguria. Polyuria is excessive urination. Hematuria is the presence of blood in the urine.)
A nurse is caring for a client diagnosed with acute renal failure. The nurse notes on the intake and output record that the total urine output for the previous 24 hours was 35 ml. Urine output that's less than 50 ml in 24 hours is known as: a) oliguria. b) hematuria. c) polyuria. d) anuria.
C (Hemodialysis requires the creation of an arterio-venous access site. The absence of a palpable thrill suggests the AV site is blocked or clotted.)
An expected outcome for the hemodialysis client is: a) The client identifies signs and symptoms of rejection. b) The client demonstrates how to administer the dialysate by gravity. c) The client explains how to assess the venous access site. d) The client verbalizes the dwell time for the dialysate.
B (Many clients with glomerulonephritis have no symptoms. Early symptoms may be so slight that the client does not seek medical attention.)
As an inflammatory response in the glomerular capillary membrane, the renal filtration system is disrupted. Although diagnostic urinalysis can reveal glomerulonephritis, many of those suffering with glomerulonephritis exhibit what symptoms? a) Fever b) No symptoms c) Polyuria d) Headache
A, C, D, E (Common tests of renal function include BUN, serum creatinine, creatinine clearance, and renal concentration tests. Arterial blood gas analysis is a test of respiratory function.)
Common tests of renal function include which of the following? Select all that apply. a) Serum creatinine b) Arterial blood gas analysis c) Blood urea nitrogen (BUN) d) Creatinine clearance e) Renal concentration test
C (The Risk for Ineffective Breathing Pattern is often a challenge in caring for clients postnephrectomy due to location of incision. Nursing interventions should be directed to improve and maintain SpO2 levels at 90% or greater and keep lungs clear of adventitious sounds. Intake and output is monitored to maintain a urine output of greater than 30 mL/hour. Pain control is important and should allow for movement, deep breathing, and rest. Blood-tinged drainage from the JP tube is expected in the initial postoperative period.)
Following a nephrectomy, which assessment finding is most important in determining nursing care for the client? a) Blood tinged drainage in Jackson-Pratt drainage tube b) Urine output of 35 to 40 mL/hour c) SpO2 at 90% with fine crackles in the lung bases d) Pain of 3 out of 10, 1 hour after analgesic administration
B (During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain.)
For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important? a) Providing pain-relief measures b) Limiting fluid intake c) Encouraging coughing and deep breathing d) Promoting carbohydrate intake
A, C, D (Lethargy, muscle cramps, and bleeding of the oral mucous membranes are some of the signs and symptoms of chronic renal failure. With chronic renal failure, mental processes progressively slow as electrolyte imbalances become marked and nitrogenous wastes accumulate.)
Mr. Jarvis's renal failure has become chronic. You are seeing him in clinic and he discusses the various signs and symptoms he is experiencing. Select all of the following which you know to be associated with chronic renal failure. a) Muscle cramps b) Enhanced cognition c) Bleeding of the oral mucous membranes d) Lethargy
A (Clinical manifestations of acute glomerulonephritis include cola-colored urine, hematuria, edema, azotemia, and proteinuria.)
The client is admitted to the hospital with a diagnosis of acute glomerulonephritis. Which clinical manifestation would the nurse expect to find? a) Cola-colored urine b) Hyperalbuminemia c) Peripheral neuropathy d) Hypotension
A (As glomerular filtration decreases, the serum creatinine and BUN levels increase and the creatinine clearance decreases. Serum creatinine is the more sensitive indicator of renal function because of its constant production in the body. The BUN is affected not only by renal disease but also by protein intake in the diet, tissue catabolism, fluid intake, parenteral nutrition, and medications such as corticosteroids.)
The laboratory results for a patient with renal failure, accompanied by decreased glomerular filtration, would be evaluated frequently. Which of the following is the most sensitive indicator of renal function? a) Serum creatinine of 1.5 mg/dL b) Creatinine clearance of 90 mL/min c) Urinary protein level of 150 mg/24h. d) BUN of 20 mg/dLb
A (If bleeding goes undetected or is not detected promptly, the patient may lose significant amounts of blood and may experience hypoxemia. In addition to hypovolemic shock due to hemorrhage, this type of blood loss may precipitate a myocardial infarction or transient ischemic attack.)
The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for? a) Hypovolemic shock caused by hemorrhage b) Abdominal distention owing to reflex cessation of intestinal peristalsis c) Paralytic ileus caused by manipulation of the colon during surgery d) Pneumonia caused by shallow breathing because of severe incisional pain
D (Anemia, hyperkalemia, metabolic acidosis, and hyperphosphatemia occur in chronic glomerulonephritis.)
The nurse is caring for a patient diagnosed with chronic glomerulonephritis. The nurse will observe the patient for the development of which of the following? a) Metabolic alkalosis b) Hypophosphatemia c) Hypokalemia d) Anemia
A, B, E (The primary presenting features of an acute glomerular inflammation are hematuria, edema, azotemia (an abnormal concentration of nitrogenous wastes in the blood), and proteinuria (excess protein in the urine) (Porth & Matfin, 2009). The urine may appear cola colored because of red blood cells (RBCs) and protein plugs or casts; RBC casts indicate glomerular injury.)
The nurse is reviewing a patient's laboratory results. What findings does the nurse assess that are consistent with acute glomerulonephritis? (Select all that apply.) a) Red blood cells in the urine b) Proteinuria c) Polyuria d) Hemoglobin of 12.8 g/dL e) White cell casts in the urine
D (The physician does not need to be contacted as blood-tinged urine is an expected finding following cystoscopy due to trauma of the procedure. The nurse should document the finding and continue to monitor the client. The client should be encouraged to increase fluid intake to help flush the urinary tract of microorganisms. The urinary meatus does not need to be inspected.)
The nurse notes that the client's urine is blood-tinged following cystoscopy. Which of the following nursing actions should the nurse do next? a) Instruct the client to increase fluid intake. b) Inspect the client's urinary meatus. c) Notify the physician of the finding. d) Document the finding in the health record.
C (The normal BUN:Cr ratio is less than 15. Prerenal azotemia is caused by hypoperfusion of the kidneys due to a nonrenal cause. Over time, higher than normal blood levels of urea or other nitrogen-containing compounds will develop.)
The presence of prerenal azotemia is a probable indicator for hospitalization for CAP. Which of the following is an initial laboratory result that would alert a nurse to this condition? a) BUN of 18 mg/dL. b) Glomerular filtration rate (GFR) of 100 mL/min. c) Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20. d) Serum creatinine of 1.2 mg/dL.
B (Tea-colored urine is a typical symptom of glomerulonephritis. Flank pain on the affected side, not left upper quadrant pain, would be present. Pyuria is a symptom of pyelonephritis, not glomerulonephritis. Blood pressure typically elevates in glomerulonephritis.)
When caring for the patient with acute glomerulonephritis, which of the following assessment findings should the nurse anticipate? a) Low blood pressure b) Tea-colored urine c) Left upper quadrant pain d) Pyuria
D (Fever is an indicator of infection or transplant rejection.)
Which nursing assessment finding indicates that the client who has undergone renal transplant has not met expected outcomes? a) Weight loss b) Absence of pain c) Diuresis d) Fever
D (The nurse should strain all urine following lithotripsy. Stone fragments are sent to the laboratory for chemical analysis.)
Which of the following nursing actions is most important in caring for the client following lithotripsy? a) Administer allopurinol (Zyloprim). b) Notify the physician of hematuria. c) Monitor the continuous bladder irrigation. d) Strain the urine carefully for stone fragments.
B (Because CRF causes loss of renal function, the client with this disorder retains fluid. Hemodialysis removes this fluid, causing weight loss. Hematuria is unlikely to follow hemodialysis because the client with CRF usually forms little or no urine. Hemodialysis doesn't increase urine output because it doesn't correct the loss of kidney function, which severely decreases urine production in this disorder. By removing fluids, hemodialysis decreases rather than increases the blood pressure.)
A client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, the nurse knows that the client is most likely to experience: a) increased urine output. b) weight loss. c) increased blood pressure. d) hematuria.
A (When a client with urinary calculi complains of excruciating pain, the client should be encouraged to ambulate. This is because the supine position increases colic, while ambulation relieves it. Also, adequate fluid intake should be suggested to promote the passage of stones and to prevent urinary stasis, or the formation of new stones. The client should be encouraged to void when there is a risk of infection related to urinary stasis. The suggestion for restricting sodium intake is offered to a client with chronic glomerulonephritis, not urinary calculi. The nurse should promote deep-breathing exercises to provide relief to a client recovering from surgery who has an ineffective breathing pattern.)
A male client who is admitted with the diagnosis of urinary calculi complains of excruciating pain. The pain is suspected to be caused by increased pressure in the renal pelvis. Which measure would be most appropriate to provide pain relief? a) Encourage frequent ambulation. b) Encourage deep-breathing exercises. c) Encourage the client to void every 2 to 3 hours. d) Restrict the client's sodium intake.
A (There is no cure for polycystic kidney disease. Medical management includes therapies to control blood pressure, urinary tract infections, and pain. Renal replacement therapy is indicated as the kidneys fail.)
The client with polycystic kidney disease asks the nurse, "Will my kidneys ever function normally again?" The best response by the nurse is: a) "As the disease progresses, you will most likely require renal replacement therapy." b) "Draining of the cysts and antibiotic therapy will cure your disease." c) "Dietary changes can reverse the damage that has occurred in your kidneys." d) "Genetic testing will determine the best treatment for your condition."
D (Hyperphosphatemia and hypocalcemia are treated with medications that bind dietary phosphorus in the GI tract. Binders such as calcium carbonate (Os-Cal) or calcium acetate (PhosLo) are prescribed, but there is a risk of hypercalcemia. The nurse administers phosphate binders with food for them to be effective.)
The nurse is administering calcium acetate (PhosLo) to a patient with ESKD. When is the best time for the nurse to administer this medication? a) 2 hours before meals b) 2 hours after meals c) At bedtime with 8 ounces of fluid d) With food
B (Hematuria may be caused by cancer of the genitourinary tract, acute glomerulonephritis, renal stones, renal tuberculosis, blood dyscrasias, trauma, extreme exercise, rheumatic fever, hemophilia, leukemia, or sickle cell trait or disease.)
A 32 year old female client has come to your clinic with a complaint of hematuria, or the presence of red blood cells in the urine. Of the following, which is not a cause of hematuria? a) Renal stones b) Lithium toxicity c) Extreme exercise d) Acute glomerulonephritis
C (As urine output decreases, the serum potassium level rises; if it rises sufficiently, hyperkalemia may occur, possibly triggering a cardiac arrhythmia. Hyperkalemia doesn't cause paresthesia (sensations of numbness and tingling). Dehydration doesn't occur during this oliguric phase of ARF, although typically it does arise during the diuretic phase. In the client with ARF, pruritus results from increased phosphates and isn't associated with hyperkalemia.)
A client develops acute renal failure (ARF) after receiving I.V. therapy with a nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 ml, the nurse suspects that the client is at risk for: a) dehydration. b) paresthesia. c) cardiac arrhythmia. d) pruritus.
D (Signs and symptoms of transplant rejection include abdominal pain, hypertension, weight gain, oliguria, edema, fever, increased serum creatinine levels, and swelling or tenderness over the transplanted kidney site.)
A client has undergone a renal transplant and returns to the healthcare agency for a follow-up evaluation. Which finding would lead to the suspicion that the client is experiencing rejection? a) Polyuria b) Hypotension c) Weight loss d) Abdominal pain
D (After a kidney transplant, rejection and failure can occur within 24 hours (hyperacute), within 3 to 14 days (acute), or after many years. A hyperacute rejection is caused by an immediate antibody-mediated reaction that leads to generalized glomerular capillary thrombosis and necrosis. The term "simple" is not used in the categorization of types of rejection of kidney transplants.)
The nurse is caring for a patient who underwent a kidney transplant. The nurse understands that rejection of a transplanted kidney within 24 hours after transplant is termed which of the following? a) Acute rejection b) Chronic rejection c) Simple rejection d) Hyperacute rejection
A (Renal cancers rarely cause symptoms in the early stage. Tumors can become quite large before causing symptoms. Painless, gross hematuria is often the first symptom in renal cancer and does not present until later stages of the disease. Adenocarcinomas are the most common renal cancer (about 80%),whereas squamous cell renal cancers are rare. It is not therapeutic to place doubt or blame for delayed diagnosis.)
A client with newly diagnosed renal cancer is questioning why detection was delayed. Which is the best response by the nurse? a) "Very few symptoms are associated with renal cancer." b) "You should have sought treatment earlier." c) "Squamous cell carcinomas do not present with detectable symptoms." d) "Painless gross hematuria is the first symptom in renal cancer."
D (The nurse should advise the client to wear a mask while performing exchanges. This prevents contamination of the dialysis catheter and tubing, and is usually advised to clients with upper respiratory infection. Auscultation of the lungs will not prevent contamination of the catheter or tubing. The client may also be advised to perform deep-breathing exercises to promote optimal lung expansion, but this will not prevent contamination. Clients with a fistula or graft in the arm should be advised against carrying heavy items.)
A male client has doubts about performing peritoneal dialysis at home. He informs the nurse about his existing upper respiratory infection. Which of the following suggestions can the nurse offer to the client while performing an at-home peritoneal dialysis? a) Avoid carrying heavy items. b) Auscultate the lungs frequently. c) Perform deep-breathing exercises vigorously. d) Wear a mask when performing exchanges.