HEMODIALYSIS/PERITONEAL DIALYSIS

A client with chronic renal failure has completed a hemodialysis treatment. The nurse would use which of the following standard indicators to evaluate the client's status after dialysis? a. Vital signs and weight. b. Potassium level and weight. c. Vital signs and BUN. d. BUN and creatinine levels.

A Following dialysis, the client's vital signs are monitored to determine whether the client is remaining hemodynamically stable. Weight is measured and compared with the client's predialysis weight to determine effectiveness of fluid extraction. Laboratory studies are done as per protocol but are not necessarily done after the hemodialysis treatment has ended.

The nurse has completed client teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse determines that the client best understands the information if the client states to record daily the: a. Amount of activity. b. Pulse and respiratory rate. c. Intake and output and weight. d. Blood urea nitrogen and creatinine levels.

A If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, notify the physician, and administer oxygen as needed. Options 2, 3, and 4 are incorrect.

A nurse is giving general instructions to a client receiving hemodialysis. Which of the following statements would be appropriate for the nurse to include? a. Several types of medications should be withheld on the day of dialysis until after the procedure. b. Medications should be double-dosed on the morning of hemodialysis to prevent loss. c. It's acceptable to exceed the fluid restriction on the day before hemodialysis. d. It's acceptable to eat whatever you want on the day before hemodialysis.

A Many medications are dialyzable, which means they are extracted from the bloodstream during dialysis. Therefore, many medications may be withheld on the day of dialysis until after the procedure. It is not typical for medications to be "double-dosed," because there is no way to be certain how much of each medication is cleared by dialysis. Clients receiving hemodialysis are not routinely taught that it is acceptable to disregard dietary and fluid restrictions.

A patient receiving peritoneal dialysis using 2 L of dialysate per exchange has an outflow of 1200 ml. Which action should the nurse take first? a. Infuse 1200 ml of dialysate during the inflow. b. Assist the patient in changing position. c. Administer a laxative to the patient. d. Notify the health care provider about the outflow problem.

Answer: B Rationale: Outflow problems may occur because the peritoneal catheter is collapsed by a portion of the intestine, and repositioning the patient will move the catheter and allow outflow to occur. If less than the ordered 2 L of dialysate is infused, the dialysis will be less effective. Administration of a laxative may also help if the patient's colon is full, but this should be tried after repositioning the patient. If the problem with outflow persists after the patient is repositioned, the health care provider should be notified.

The client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious. The nurse suspects air embolism. The priority action for the nurse is to: a. Discontinue dialysis and notify the physician. b. Monitor vital signs every 15 minutes for the next hour. c. Continue dialysis at a slower rate after checking the lines for air. d. Bolus the client with 500 mL of normal saline to break up the embolus. A

A If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, notify the physician, and administer oxygen as needed. Options 2, 3, and 4 are incorrect.

A nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? a. Palpation of a thrill over the fistula. b. Presence of a radial pulse in the left wrist. c. Absence of a bruit on auscultation of the fistula. d. Capillary refill less than 3 seconds in the nail beds of the fingers of the left hand.

A The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and bruit indicate patency of the fistula. Although the presence of a radial pulse in the left wrist and capillary refill shorter than 3 seconds in the nail beds of the fingers on the left hand are normal findings, they do not assess fistula patency.

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which of the following is the most appropriate nursing action? a. Monitor the client. b. Notify the physician. c. Elevate the head of the bed. d. Medicate the client for nausea.

B Disequilibrium syndrome may be caused by the rapid decreases in the blood urea nitrogen level during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs of disequilibrium syndrome and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The physician must be notified.

The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse assesses the client during dialysis for: a. Hypertension, tachycardia, and fever. b. Hypotension, bradycardia, and hypothermia. c. Restlessness, irritability, and generalized weakness. d. Headache, deteriorating level of consciousness, and twitching.

D Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.

The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication: a. during dialysis b. just before dialysis c. the day after dialysis d. on return form dialysis D on return form dialysis The client with chronic renal failure is on chronic hemodialysis. Which of the following indicate improvement of the client's condition due to hemodialysis? Select all that apply a) the client's BP is 130/90 b) the client's serum potassium is 4.8 mEq/L c) the client's hemoglobin level is 10 g/dL d) the client's serum calcium is 7.7 mg/dL e) the client's serum sodium is 140 mEg/L f) the client's serum magnesium is 4 mEq/L g) the client's weight has increased from 60 kg to 63 kg

a) the client's BP is 130/90 b) the client's serum potassium is 4.8 mEq/L e) the client's serum sodium is 140 mEg/L

A client newly diagnosed with renal failure has just been started on peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is appropriate? 1. Stop the dialysis. 2. Slow the infusion. 3. Decrease the amount to be infused. 4. Explain that the pain will subside after the first few exchanges.

4. Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, the pain usually disappears after 1 to 2 weeks of treatment. The infusion amount should not be decreased, and the infusion should not be slowed or stopped.

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of: 1. Infection. 2. Hyperglycemia. 3. Hypophosphatemia. 4. Disequilibrium syndrome.

2. An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis.

A client has an arteriovenous (AV) fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which of the following measures should the nurse implement to promote client safely? a. take blood pressures only on the right arm to ensure accuracy b. use the fistula for all venipunctures and intravenous infusions c. ensure that small clamps are attached to the AV fistula dressing d. assess the fistula for the presence of a bruit and thrill every 4 hours

D assess the fistula for the presence of a bruit and thrill every 4 hours

A registered nurse is instructing a new nursing graduate about hemodialysis. Which statement if made by the new nursing graduate would indicate an inaccurate understanding of the procedure for hemodialysis? a. Sterile dialysate must be used. b. Warming the dialysate increases the efficiency of diffusion. c. Heparin sodium is administered during dialysis. d. Dialysis cleanses the blood from accumulated waste products.

A Dialysate is made from clear water and chemicals and is free from any metabolic waste products or medications. Bacteria and other microorganisms are too large to pass through the membrane; therefore, the dialysate does not need to be sterile. The dialysate is warmed to approximately 100° F to increase the efficiency of diffusion and to prevent a decrease in the client's blood temperature. Heparin sodium inhibits the tendency of blood to clot when it comes in contact with foreign substances. Option 4 is the purpose of dialysis.

A patient needing vascular access for hemodialysis asks the nurse what the differences are between an arteriovenous (AV) fistula and a graft. The nurse explains that one advantage of the fistula is that it a. can accommodate larger needles. b. increases patient mobility. c. is much less likely to clot. d. can be used sooner after surgery.

C Rationale: AV fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not impact on needle size or patient mobility.

The client with chronic renal failure is undergoing peritoneal dialysis. He asks why the nurse monitors his blood glucose levels. Which of the following will be the most appropriate response by the nurse? a) I have to check if you have diabetes mellitus b) the dialysate contains glucose c) the procedure may lower your blood glucose levels d) it is a routine procedure for every client who undergoes the treatment b) the dialysate contains glucose A client with end-stage renal disease is receiving continuous ambulatory peritoneal dialysis. The nurse is monitoring the client for signs of complications associated with peritoneal dialysis. Select all that apply. 1. Pruritus 2. Oliguria 3. Tachycardia 4. Cloudy outflow 5. Abdominal pain

Answer: 3, 4, 5 Rationale: Tachycardia can be caused by peritonitis, 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.

The client with chronic renal failure returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 100.2F. Which of the following is the appropriate nursing action? a. Encourage fluids. b. Notify the physician. c. Continue to monitor vital signs. d. Monitor the site of the shunt for infection.

C The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. If the temperature is elevated excessively and remains elevated, sepsis would be suspected and a blood sample would be obtained as prescribed for culture and sensitivity determinations.

The client with an external arteriovenous shunt in place for hemodialysis is at risk for bleeding. The priority nurse action would be to: a. Check the shunt for the presence of bruit and thrill. b. Observe the site once as time permits during the shift. c. Check the results of the prothrombin times as they are determined. d. Ensure that small clamps are attached to the arteriovenous shunt dressing.

D An arteriovenous shunt is a less common form of access site but carries a risk for bleeding when it is used because two ends of an external cannula are tunneled subcutaneously into an artery and a vein, and the ends of the cannula are joined. If accidental disconnection occurs, the client could lose blood rapidly. For this reason, small clamps are attached to the dressing that covers the insertion site for use if needed. The shunt site also should be assessed at least every 4 hours.

A patient with chronic kidney disease (CKD) is started on hemodialysis, and after the first treatment, the patient complains of nausea and a headache. The nurse notes mild jerking and twitching of the patient's extremities. The nurse will anticipate the need to a. increase the time for the next dialysis to remove wastes more completely. b. switch to continuous renal replacement therapy (CRRT) to improve dialysis efficiency. c. administer medications to control these symptoms before the next dialysis. d. slow the rate for the next dialysis to decrease the speed of solute removal.

D Rationale: The patient has symptoms of disequilibrium syndrome, which can be prevented by slowing the rate of dialysis so that fewer solutes are removed during the dialysis. Increasing the time of the dialysis to remove wastes more completely will increase the risk for disequilibrium syndrome. CRRT is a less efficient means of removing wastes and, because it is continuous, would not be used for a patient with CKD. Administration of medications to control the symptoms is not an appropriate action; rather, the disequilibrium syndrome should be avoided.

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) Perform deep-breathing exercises vigorously. b) Avoid carrying heavy items. c) Auscultate the lungs frequently. d) Wear a mask when performing exchanges.

D) Wear a mask when performing exchanges 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.

The nurse monitoring a client receiving peritoneal dialysis notes that the clietn's outflow is less than the inflow. Select all nursing actions in the situation that apply. 1. Contact the physician. 2. Check the level of the drainage bag. 3. Reposition the client to his or her side. 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks. 6. Increase the flow rate of the peritoneal dialysis solution.

2, 3, 4, 5. If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing and peritoneal dialysis system are also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician. Increasing the flow rate is an inappropriate action and is not associated with the amount of outflow solution.

The nurse is assessing a patient who is receiving peritoneal dialysis with 2-L inflows. Which information should be reported immediately to the health care provider? a. The patient complains of feeling bloated after the inflow. b. The patient's peritoneal effluent appears cloudy. c. The patient has abdominal pain during the inflow phase. d. The patient has an outflow volume of 1600 ml.

Answer: B Rationale: Cloudy-appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient.

The client with chronic renal failure is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication: a. During dialysis. b. Just before dialysis. c. The day after dialysis. d. On return from dialysis.

D Antihypertensive medications such as enalapril are given to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. No rationale exists for waiting an entire day to resume the medication. This would lead to ineffective control of the blood pressure.

A nurse is analyzing the posthemodialysis lab test results for a client with chronic renal failure (CRF). The nurse interprets that the dialysis is having an expected but nontherapeutic effect if the results indicate a decreased: a. Phosphorus. b. Creatinine. c. Potassium. d. Red blood cell count

D Hemodialysis typically lowers the amounts of fluid, sodium, potassium, urea nitrogen, creatinine, uric acid, magnesium, and phosphate levels in the blood. Hemodialysis also worsens anemia, because RBCs are lost in dialysis from blood sampling and anticoagulation during the procedure, and from residual blood that is left in the dialyzer. Although all of these results are expected, only the lowered RBC count is nontherapeutic and worsens the anemia already caused by the disease process.

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 Explanation: 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.