Exam 3

A client is to have hemodialysis. What must the nurse do before this treatment? 1: Obtain a urine specimen to evaluate kidney function. 2: Weigh the client to establish a baseline for later comparison. 3: Administer medications that are scheduled to be given within the next hour. 4: Explain that the peritoneum serves as a semipermeable membrane to remove wastes

2. A baseline weight must be obtained to be able to determine the net fluid loss from dialysis. Obtaining a urine specimen to evaluate kidney function is not necessary; clients with advanced kidney disease may not produce urine. Medications often are delayed until after dialysis to prevent them from being filtered into the dialysate. Explaining that the peritoneum serves as a semipermeable membrane to remove wastes applies to peritoneal dialysis, not hemodialysis.

A client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client's wife indicates that further teaching is required? 1: "I must touch the shunt several times a day to feel for the bruit." 2: "I have to take his blood pressure every day in the arm with the fistula." 3: "He will have to be very careful at night not to lie on the arm with the fistula." 4: "We really should check the fistula every day for signs of redness and swelling."

2. Taking the blood pressure in the affected arm may injure the fistula. The presence of a bruit indicates that the circulation is not obstructed by a thrombus. Hemorrhage can occur in a matter of minutes if the cannula is dislodged. Redness and swelling are signs of infection, which is a complication of cannulization.

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy should the nurse assess this client? Select all that apply. 1: Mental confusion 2: Increased cholesterol 3: Brown-colored stools 4: Flapping hand tremors 5: Musty, sweet breath odor

1., 4. & 5. An accumulation of nitrogenous wastes affects the central nervous system, causing mental confusion. An accumulation of nitrogenous wastes in hepatic encephalopathy affects the nervous system. Flapping tremors and generalized twitching occur in the second and third stages, respectively. Fetor hepaticus is the musty, sweet odor of the client's breath. Increased cholesterol levels are not necessarily present. Stool is often clay-colored because of lack of bile caused by biliary obstruction.

A nurse is caring for a client with end-stage kidney disease who is about to receive a transplant. When the client returns from the postanesthesia care unit after a kidney transplant, how often should the nurse measure the client's urinary output? 1: 1 hour 2: 2 hours 3: 15 minutes 4: 30 minutes

1. Hourly output is critical in assessing kidney function; decreasing urinary output is a sign of rejection. Every 2 hours is too infrequent for monitoring output immediately after a kidney transplant; it is essential to monitor output more frequently to evaluate whether the new kidney is working or being rejected. It is not necessary to monitor every 15 or 30 minutes.

A client is diagnosed with acute kidney failure secondary to dehydration. An intravenous (IV) infusion of 50% glucose with regular insulin is prescribed. What does the nurse recognize as the primary purpose of the IV insulin for this client? 1: Correct hyperkalemia 2: Increase urinary output 3: Prevent respiratory acidosis 4: Increase serum calcium levels

1. The 50% glucose and regular insulin infusion treats the hyperkalemia associated with kidney failure; it moves potassium from the intravascular compartment into the intracellular compartment. Insulin will not increase urinary output. Insulin is not a treatment for respiratory acidosis. Insulin and glucose do not increase serum calcium levels.

A nurse is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing this client? Select all that apply. 1: Polyuria 2: Lethargy 3: Hypotension 4: Muscle twitching 5: Respiratory acidosis

2. & 4. Lethargy results from anemia, buildup of urea, and vitamin deficiencies. Muscle twitching results from excess nitrogenous wastes. Extensive nephron damage causes oliguria, not polyuria. Hypotension does not occur; the blood pressure is within the expected range or elevated as a result of increased total body fluid. Metabolic, not respiratory, acidosis occurs because of the kidneys' inability to excrete hydrogen and regulate sodium and bicarbonate levels.

A nurse is caring for a client with acute kidney injury. Which findings should the nurse anticipate when reviewing the laboratory report of the client's blood level of calcium, potassium, and creatinine? Select all that apply. 1: Calcium: 7.6 mg/dL (1.9 mmol/L) 2: Calcium: 10.5 mg/dL (2.6 mmol/L) 3: Potassium 6.0 mEq/L (6.0 mmol/L) 4: Potassium 3.5 mEq/L (3.5 mmol/L) 5: Creatinine: 3.2 mg/dL (194 mcmol/L) 6: Creatinine: 1.1 mg/dL (90 mcmol/L)

1., 3., & 5. A client with acute kidney injury will have a low calcium level, a high potassium level, and an elevated creatinine level.

A nurse is caring for a client with end-stage kidney disease after a kidney transplant. Which finding indicates the transplant is successful? 1: Increased specific gravity 2: Correction of hypotension 3: Elevated serum potassium 4: Decreasing serum creatinine

4. As the transplanted organ functions, nitrogenous wastes are eliminated, lowering the serum creatinine. As more urine is produced by the transplanted kidney, the specific gravity and concentration of the urine will decrease. With end-stage kidney disease, fluid retention causes hypertension; there should be a correction of hypertension, not hypotension. After the transplant, the serum potassium should correct to within expected limits for an adult.

A nurse is providing discharge instructions to a client diagnosed with cirrhosis and varices. Which information should the nurse include in the teaching session? Select all that apply. 1: Adhering to a low-carbohydrate diet 2: Avoiding aspirin and aspirin-containing products 3: Limiting alcohol consumption to two drinks weekly 4: Avoiding acetaminophen and products containing acetaminophen 5: Avoiding coughing, sneezing, and straining to have a bowel movement

2., 4. & 5. Aspirin can damage the gastric mucosa and precipitate hemorrhage when esophageal or gastric varices are present. Acetaminophen is hepatotoxic and should not be used by the client with cirrhosis. The client with cirrhosis should avoid coughing, sneezing, and straining to have a bowel movement. These activities increase pressure in the portal venous system and increase the client's risk of variceal hemorrhage. A high-carbohydrate diet is encouraged as the diseased liver's ability to synthesize and store glucose is diminished. To decrease the risk of complications, the client must abstain from alcohol.

The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings? 1: Azotemia 2: Hypokalemia 3: Metabolic alkalosis 4: Respiratory alkalosis

1. The BUN is greater than the expected value of 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Urea nitrogen is the major nitrogenous end product of protein and amino acid catabolism; azotemia is the accumulation of excessive nitrogenous compounds, such as BUN and creatinine, in the blood. The client has hyperkalemia; the expected value for potassium is 3.5 to 5.5 mEq/L (3.5 to 5.5 mmol/L). Although the client does have a metabolic acid-base imbalance, it is acidosis, not alkalosis, because the pH is less than the expected range of 7.35 to 7.45. The PO2 is within the expected range of 80 to 100 mm Hg, which indicates that the problem is metabolic, not respiratory.

What is the action of the vasopressin hormone released from the client's posterior pituitary? 1: Helps produce concentrated urine 2: Causes tubular secretion of sodium 3: Promotes potassium secretion in the collecting duct 4: Enhances sodium reabsorption in the distal convoluted tubule

1. The action of the hormone vasopressin released from the posterior pituitary is to make the distal convoluted tubule and collecting duct permeable to water so as to maximize reabsorption and produce concentrated urine. The natriuretic hormones produced from cardiac ventricles cause tubular secretion of sodium. Aldosterone released from the adrenal cortex promotes potassium secretion and sodium reabsorption in the distal convoluted tubules and collecting duct.

A client with cirrhosis of the liver and ascites is scheduled to have a paracentesis. What should the nurse do to prepare the client for the procedure? 1: Instruct the client to void. 2: Tell the client not to eat for four hours. 3: Give the client an analgesic. 4: Have the client turn to the lateral position.

1. The bladder must be emptied to avoid trauma during insertion of the trocar. Giving the client an analgesic is not necessary. Systemic analgesics may mask the symptoms of shock, a potential complication. The semi-Fowler position is used to allow fluid to accumulate in the lower abdominal cavity so that it can be accessed by the trocar. Test-Taking Tip: Prepare for exams when and where you are most alert and able to concentrate. If you are most alert at night, study at night. If you are most alert at 2 am, study in the early morning hours. Study where you can focus your attention and avoid distractions. This may be in the library or in a quiet corner of your home. The key point is to keep on doing what is working for you. If you are distracted or falling asleep, you may want to change when and where you are studying.

A client with a long history of alcohol abuse develops cirrhosis of the liver. The client exhibits the presence of ascites. What does the nurse conclude is the most likely cause of this client's ascites? 1: Impaired portal venous return 2: Impaired thoracic lymph channels 3: Excess production of serum albumin 4: Enhanced hepatic deactivation of aldosterone secretion

1. The congested liver impairs venous return, leading to increased portal vein hydrostatic pressure and an accumulation of fluid in the abdominal cavity. Although lymph channels in the abdomen become congested, facilitating the leakage of plasma into the peritoneal cavity, it is primarily the increased portal vein hydrostatic pressure that causes the accumulation of fluid in the abdominal cavity. Increased serum albumin causes hypervolemia, not ascites. As fluid is trapped in the peritoneal cavity, circulating blood volume drops and aldosterone secretion increases, not decreases; aldosterone secretion is related to the renin-angiotensin system. STUDY TIP: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add points to your test scores that you have lost in the past.

After reviewing the urinalysis reports of a client with a renal disorder, the nurse concludes that the client may have a urinary tract infection. Which urinary laboratory findings enabled the nurse to make this conclusion? Select all that apply. 1; pH: 8.5 2: Specific gravity: 1.010 3: Red blood cells: 3/hpf 4: Osmolality: 1500 mOsm/kg (1500 mmol/kg) 5: White blood cells: 6/hpf

1. & 5. The client may have a urinary tract infection, as the urinalysis reports show the presence of pH as 8.5 and white blood cells as 6/hpf in the urine. A pH above 8.0 indicates a urinary tract infection; client's is 8.5. The normal level of white blood cells (WBC) in urine should be less than 5/hpf; therefore, the WBC level of 6/hpf indicates urinary tract infection. The specific gravity of 1.010 indicates a normal finding. The normal level of red blood cells (RBC) is less than 4/hpf; therefore, the RBC levels of 3/hpf indicates normal finding. Osmolality of 1500 mOsm/kg (1500 mmol/kg) indicates tubular dysfunction. Test-Taking Tip: The laboratory results are mentioned. You need to recollect the ranges to determine which finding is associated with urinary tract infection.

A nurse is caring for a client with orders for furosemide daily, a 2-gram sodium diet, and an oral fluid restriction of 1200 mL daily. The most recent laboratory results are blood urea nitrogen (BUN) 42 mg/dL (15.2 mmol/L) and creatinine 1.1 mg/dL (97 mcmol/L). Considering the assessment findings, which is the most appropriate intervention by the nurse? 1: Sending the client's urine for analysis 2: Requesting an increase in the oral fluid intake 3: Placing the client on strict intake and output measurements 4: Notifying a nutritionist/dietitian so that sodium can be restricted further

2. Diuretics such as furosemide can cause dehydration. This is evidenced in this scenario by an elevation in the BUN and a normal creatinine. Increasing fluid intake will result in improved hydration status and a decrease in the BUN level. Although sending the client's urine for analysis should be done, it will not change the client's hydration status. Although the client should be on strict intake and output, it will not change the client's hydration status. Sodium restriction will not lower the BUN level; in addition, nutritionists only make suggestions to the primary healthcare provider regarding interventions. The primary healthcare provider is the professional legally responsible for prescribing a sodium-restricted diet.

A client is admitted to the hospital for acute gastritis and ascites secondary to alcoholism and cirrhosis. For which condition is it most important for the nurse to assess this client? 1: Nausea 2: Blood in the stool 3: Food intolerances 4: Hourly urinary output

2. Erosion of blood vessels may lead to hemorrhage, a life-threatening situation further complicated by decreased prothrombin production, which occurs with cirrhosis. Although food intolerances should be identified, there is no immediate threat to life. Although increased intraabdominal pressure because of ascites may precipitate nausea, there is no immediate threat to life. Hourly urine output measurements are unnecessary.

A client is diagnosed with acute tubular necrosis after sustaining a kidney trauma. Which laboratory result should the nurse anticipate while the client is in the oliguric phase? 1: Hypophosphatemia 2: Hyperkalemia 3: Hypomagnesemia 4: Hypernatremia

2. Hyperkalemia is the laboratory result that the nurse should anticipate while the client is in the oliguric phase of acute tubular necrosis (ATN). Hypernatremia, hypophosphatemia, and hypomagnesemia do not occur during this phase. The kidney is unable to reabsorb sodium in the ATN oliguric phase, so serum sodium is lost in the concentrated urine produced. Potassium, magnesium, and phosphorus are retained in the blood as urine levels of these electrolytes diminish. Also, hyperkalemia and metabolic acidosis occur together because the kidneys also cannot excrete hydrogen ions. As hydrogen ions shift into cells to compensate for the rising acidosis, they displace potassium ions out of cells and into serum, which worsens hyperkalemia. Hyperkalemia poses the greatest threat to life because its lethal range is relatively close to its maximum normal range, often indicating a need for dialysis.

A client with acute kidney injury moves into the diuretic phase after 1 week of therapy. For which clinical indicators during this phase should the nurse assess the client? Select all that apply. 1: Skin rash 2: Dehydration 3: Hypovolemia 4: Hyperkalemia 5: Metabolic acidosis

2. & 3. In the diuretic phase, fluid retained during the oliguric phase is excreted and may reach 3 to 5 L daily; dehydration and hypovolemia may occur unless fluids are replaced. Skin rash is not associated with the diuretic phase. Hyperkalemia develops in the oliguric phase when glomerular filtration is inadequate. Metabolic acidosis occurs in the oliguric, not diuretic, phase.

The registered nurse discusses normal renal function with the client. Which statements made by the client are correct regarding regulatory functions of the kidney? Select all that apply. 1: "They play a role in erythropoiesis." 2: "They play a role in acid-base balance." 3: "They play a role in vitamin D activation." 4: "They play a role in blood pressure regulation." 5: "They play a role in fluid and electrolyte balance."

2. & 5. Maintaining the acid-base balance of the body by selectively reabsorbing and secreting certain substances from the blood is a regulatory function of the kidneys. The kidneys also perform the regulatory function of electrolyte balance by regulating the reabsorption of certain electrolytes while eliminating others depending on their levels in the serum. The kidneys perform hormonal function by secreting a hormone called erythropoietin that aids in synthesis of red blood cells (erythropoiesis). Activation of vitamin D is a hormonal function of the kidneys. The kidneys perform hormonal function by secreting the hormone renin that assists in blood pressure control.

A nurse is caring for a client with hepatic encephalopathy and ascites. Which elements are important to include in this client's diet? Select all that apply. 1: High fat 2: Low sodium 3: High vitamins 4: Moderate protein 5: Low carbohydrates

2., 3. & 4. A low sodium intake controls fluid retention and edema and, consequently, ascites. Vitamins help to repair long-standing nutritional deficits associated with cirrhosis of the liver. A moderate-protein diet reduces formation of ammonia, which must be degraded by the liver. High fat intake is avoided because of related cardiovascular risks and the demand for bile that the liver may not be capable of meeting. High, not low, carbohydrate intake is necessary to meet energy requirements for tissue regeneration.

The nurse is providing care to a client with ascites secondary to liver failure. What is appropriate to include in this client's care? Select all that apply. 1: High protein diet 2: Low sodium diet 3: Daily abdominal girth measurements 4: Encourage increased by mouth fluid intake 5: Daily weights

2., 3. & 5. In the client with liver failure and ascites, the liver has lost its ability to synthesize proteins. This leads to hypoalbuminemia and decreased oncotic pressure in the vessels. This decrease in oncotic pressure leads to fluids leaking out of the vessels and into the interstitial spaces and peritoneum, causing edema and ascites. A low sodium and low protein diet is recommended. A high protein diet will worsen the symptoms, and often these clients are on a fluid restriction. Taking daily weights is the most reliable indicator of fluid retention.

A client is admitted to the hospital in the oliguric phase of acute kidney injury. The nurse estimates that the urine output for the last 12 hours is about 200 mL. The nurse reviews the plan of care and notes a prescription for 900 mL of water to be given orally over the next 24 hours. What does the nurse conclude about the amount of fluid prescribed? 1: It equals the expected urinary output for the next 24 hours. 2: It will prevent the development of pneumonia and a high fever. 3: It will compensate for both insensible and expected output over the next 24 hours. 4: It will reduce hyperkalemia, which can lead to life-threatening cardiac dysrhythmias.

3. Insensible losses are 500 to 1000 mL in 24 hours, with an average of about 600 mL; the measured output is about 400 mL in 24 hours based on the available history (about 200 mL in 12 hours). Based on the history, the expected urinary output should be about 400 mL in the next 24 hours, far less than 900 mL. More than 900 mL daily is necessary to help prevent pneumonia and its associated fever. Hyperkalemia in acute kidney injury is caused by inadequate glomerular filtration and is not related to fluid intake.

A nurse is notified that the latest potassium level for a client in acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action should the nurse take first? 1: Alert the cardiac arrest team. 2: Call the laboratory to repeat the test. 3: Take vital signs and notify the primary healthcare provider. 4: Obtain an electrocardiogram (ECG) strip and obtain an antiarrhythmic medication.

3. Vital signs monitor the cardiopulmonary status; the primary healthcare provider must treat this hyperkalemia [1] [2] to prevent cardiac dysrhythmias. The cardiac arrest team responds to a cardiac arrest; there is no sign of arrest in this client. A repeat laboratory test will take time and probably reaffirm the original results; the client needs medical attention. Although obtaining an ECG strip is appropriate, obtaining an antiarrhythmic is premature; vital signs and medical attention is needed first.

The nurse is administering lactulose to a client with a history of cirrhosis of the liver. The client asks the nurse why this medication is needed because the client is not constipated. How will the nurse respond? 1: "This medication helps you to stop drinking so much alcohol." 2: "This medication helps you relax and not feel anxious." 3: "This medication helps you lower the high ammonia level caused by your liver disease." 4: "This medication helps you keep your abdomen from being so distended."

3. actulose is a hyperosmotic laxative and ammonia detoxicant. It decreases serum ammonia concentration by preventing reabsorption of ammonia. Lactulose has been used to lower blood ammonia content in clients with portal hypertension and hepatic encephalopathy secondary to chronic liver disease. Lactulose has no effect on the craving for alcohol or anxiety and is not prescribed to reduce abdominal distension.

A client with cirrhosis of the liver develops ascites, and the health care provider prescribes spironolactone. What should the nurse monitor the client for? 1: Bruising 2: Tachycardia 3: Hyperkalemia 4: Hypoglycemia

3. Spironolactone is a potassium-sparing diuretic that is used to treat clients with ascites; therefore the nurse should monitor the client for signs and symptoms of hyperkalemia. Bruising and purpura are associated with cirrhosis, not with the administration of spironolactone. Spironolactone does not cause tachycardia. Spironolactone does not cause hypoglycemia. STUDY TIP: Determine whether you are a "lark" or an "owl." Larks, day people, do best getting up early and studying during daylight hours. Owls, night people, are more alert after dark and can remain up late at night studying, catching up on needed sleep during daylight hours. It is better to work with natural biorhythms than to try to conform to an arbitrary schedule. You will absorb material more quickly and retain it better if you use your most alert periods of each day for study. Of course, it is necessary to work around class and clinical schedules. Owls should attempt to register in afternoon or evening lectures and clinical sections; larks do better with morning lectures and day clinical sections.

A client with the diagnosis of chronic kidney disease develops hypocalcemia. Which clinical manifestations should the nurse expect the client with hypocalcemia to exhibit? Select all that apply. 1: Acidosis 2: Lethargy 3: Fractures 4: Osteomalacia 5: Eye calcium deposits

3., 4. & 5. Because of calcium loss from the bone, fractures, osteomalacia, and eye calcium deposits occur. Acidosis decreases calcium that binds to albumin, resulting in more ionized calcium (free calcium) in the blood. Lethargy and weakness are associated with hypercalcemia.

A client with end-stage kidney disease is receiving continuous ambulatory peritoneal dialysis. The nurse should monitor the client for which peritoneal dialysis complications? Select all that apply. 1: Pruritus 2: Oliguria 3: Tachycardia 4: Cloudy outflow 5: Abdominal pain

3., 4. & 5. Tachycardia can be caused by peritonitis [1] [2], a complication of peritoneal dialysis; the heart rate increases to meet the metabolic demands associated with infection. Cloudy or opaque dialysate outflow (effluent) is the earliest sign of peritonitis; it is caused by the constituents associated with an infectious process. Abdominal pain is associated with peritonitis, a complication of peritoneal dialysis; pain results from peritoneal inflammation, abdominal distention, and involuntary muscle spasms. Severe itching (pruritus) is caused by metabolic waste products that are deposited in the skin; dialysis removes metabolic waste products, preventing this adaptation associated with kidney failure. The production of abnormally small amounts of urine (oliguria) is a sign of kidney failure, not a complication of peritoneal dialysis

A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the student nurse indicates to the primary nurse that the student nurse understands the purpose of this therapy? 1: "It provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration." 2: "It exchanges and cleanses blood by correction of electrolytes and excretion of creatinine." 3: "It decreases the need for immobility because it clears toxins in short and intermittent periods." 4: "It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion."

4. Diffusion [1] [2] moves particles from an area of greater concentration to an area of lesser concentration; osmosis moves fluid from an area of lesser to an area of greater concentration of particles, thereby removing waste products into the dialysate, which is then drained from the abdomen. The principle of ultrafiltration involves a pressure gradient, which is associated with hemodialysis, not peritoneal dialysis. Peritoneal dialysis uses the peritoneal membrane to indirectly cleanse the blood. Dialysate does not clear toxins in a short time; exchanges may occur four or five times a day.

For which clinical indicator associated with a complication of portal hypertension should the nurse assess the client? 1: Liver abscess 2: Intestinal obstruction 3: Perforation of the duodenum 4: Hemorrhage from esophageal varices

4. The increased pressure within the portal circulatory system causes increased pressure in areas of portal systemic collateral circulation (most important, in the distal esophagus and proximal stomach). Hemorrhage is a possible complication. Liver abscesses may occur as a complication of intestinal infections, not portal hypertension. Intestinal obstruction may be caused by manipulation of the bowel during surgery, peritonitis, neurologic disorders, or organic obstruction, not portal hypertension. Perforation of the duodenum usually is caused by peptic ulcers; it is not a direct result of portal hypertension or cirrhosis.

A nurse administers sodium polystyrene sulfonate to a client with chronic renal failure. Which finding provides evidence that the intervention is effective? 1: Frequent loose stools 2: Improved mental status 3: Sodium increases to 137 mEq/L (137 mmol/L) 4: Potassium decreases to 4.2 mEq/L (4.2 mmol/L)

4. This resin exchanges sodium ions for potassium in the large intestine to lower the serum potassium level; 4.2 mEq/L (4.2 mmol/L) is in the expected range for potassium. Constipation is a more common side effect. Mental status improvement is not a therapeutic effect of the drug. Sodium retention is an adverse effect; 137 mEq/L (137 mmol/L) is in the expected range for sodium.