IGGY Renal System

A 48-year-old African-American man is newly diagnosed with hypertension and Stage 1 chronic kidney disease (CKD). His primary health care provider has prescribed a thiazide diuretic. The client reports that he has increased his activity and changed his diet, which resulted in a 10 lbs (4.5 kg) in the past 2 months. The client says he feels well and does not want to take any drugs. What is the nurse's best response? a. "Reducing your blood pressure may slow or prevent progression of your chronic kidney disease." b. "Your provider prescribed the diuretic because it will reverse the damage caused by kidney disease." c. "Taking medications is a personal decision, and you have the right to decline this prescription." d. "Because your lifestyle changes have resulted in weight loss, this intervention is all that is needed to reduce your risk for progression of kidney disease."

ANS: A African Americans have greater risk for hypertension, CKD, and complications from both conditions. Blood pressure control is critical in the treatment of patients with CKD - lowering the blood pressure reduces the risk of stroke, MI, and progression of CKD. Stage 1 CKD already indicates some irreversible damage. Management of blood pressure at this stage of CKD can greatly slow its progression. A diuretic does not improve kidney function or reverse CKD damage. It does not alter the course of CKD progression. It does improve elimination of fluid, and fluid overload can contribute to hypertension. While personal values and preferences are essential decision points in determining a plan of care for each adult, it is also important that the client be well informed about the consequences of decisions. His risk for progression of CKD is not low and his blood pressure has not achieved a target goal, despite weight loss. It is time to consider additional interventions such as drug prescription. While this client has had a good outcome from diet and lifestyle, it has not been sufficient to meet targeted blood pressure goals and cannot slow progression of CKD.

A client with diabetes has all of the following changes after a percutaneous nephrolithotomy procedure. Which change is most important for the nurse to immediately report to the health care provider? a. Difficulty breathing and an oxygen saturation of 88% on 2 L of oxygen by nasal cannula b. A point-of-care blood glucose of 150 mg/dL and client report of thirst c. A decreased hematocrit by 1% (compared with preoperative values and hematuria) d. An oral temperature of 38C (101F) and cloudiness of urine draining from the nephrostomy tube right after IV administration of a broad-spectrum antibiotic

ANS: A All changes are somewhat abnormal but the only one that raises the level of concern to a point at which it should be immediately is the difficulty breathing and drop in oxygen saturation. This is NOT an expected problem associated with the procedure and is potentially life-threatening. The blood glucose elevation, thirst, temperature elevation, cloudiness of the urine, and slight decrease in hematocrit are expected and do not pose an immediate threat.

1. Which client being managed for dehydration does the nurse consider at greatest risk for possible reduced kidney function? a. An 80-year-old man who has benign prostatic hyperplasia b. A 62-year-old woman with a known allergy to contrast media c. A 48-year-old woman with established urinary incontinence d. A 45-year-old man receiving oral and intravenous fluid therapy

ANS: A Older adults have fewer nephrons and about half of the glomerular filtration rate of younger adults. This change increases their risk for kidney dysfunction more profoundly and persistently after dehydration of other conditions that can impair the renal system. Although an allergy to contrast media can cause problems, the adult must be exposed to it first. Tests requiring contrast media are not used to diagnose or manage dehydration. Urinary incontinence can lead to poor quality of life and skin problems but does not reduce kidney function. The client receiving hydration therapy with both oral and intravenous fluids is at risk for overhydration (fluid overload), not dehydration-induced kidney damage.

Which statement made by a client newly diagnosed with polycystic kidney disease (PKD) in the hyperfiltration stage indicates to the nurse that additional teaching for self-management is needed? a. "I will need to decrease my daily water intake." b. "I need to make certain my brothers and sisters know about this disease." c. "Probably the best time of day to take my lisinopril each day is with breakfast." d. "Regular low-impact exercise may help me feel better, as well as help prevent constipation."

ANS: A Water restriction is avoided with a diagnosis of polycystic kidney disease (PKD) until the client transitions to dialysis. A liberal water intake can reduce the harm from reduced blood flow to the kidney, including decreasing the stimulus for vasopressin release, a hormone that decreases kidney perfusion. Once daily ACE inhibitors are first line drugs for management of hypertension in clients with PKD and developing a routine for daily administration is a good self-management approach. Complementary approaches to pain management that the client can initiate will increase in benefit from practice (rehearsal) and regular use. PKD is a genetic disorder. This client's brothers and sisters also have a risk for inheriting the disorder, and early diagnosis can help ensure the correct management options are used. Thus, informing siblings is an important and ethical action in this situation. Constipation is a frequent problem for clients with PKD. Fluid intake and exercise can help ameliorate this problem.

When providing care to a client who has undergone a nephrostomy for hydronephrosis, which observation alerts the nurse to a possible complication? (Select all that apply.) a. Urine output of 15 mL for the first hour and then diminishes b. Tenderness at the surgical site c. Pink-tinged urine draining from the nephrostomy d. A hematocrit value 3% lower than the preoperative value e. Sudden onset of abdominal pain that worsens after abdominal palpation f. Blood pressure of 180/90 that persists despite administration of pain medication g. The presence of a few small (less that 0.5 cm) clots with irrigation of the nephrostomy h. Bright red drainage through the nephrostomy tube 12 hours after the procedure

ANS: A, D, E, F, H Low output is concerning immediately after nephrostomy placement; most clients have a diuresis. After nephrostomy placement, most clients have bloody urine (red- or pink-tinged) for several hours. Irrigation may be required to maintain patency and clots may be dislodged with irrigation and this helps maintain nephrostomy patency. Clots interfere with patency. The presence of small clots in the returned irrigation fluid is not a concern. There is pain and tenderness at the surgical site but bleeding at the site is not common. New onset of abdominal pain with rebound tenderness may indicate a perforation, an uncommon but potentially life-threatening complication of manipulating the needles during nephrostomy placement. Similarly, blood loss either through the nephrostomy or surgical site can be related to a clinical important decrease in hematocrit; diuresis means that the change in hematocrit is unlikely to be from hemodilution. Inform the provider whenever this change occurs post-operatively. Hypertension can contribute to bleeding risk and occurrence; generally as will most post-operative or post-interventional procedures, a reasonable blood pressure goal is 120-140/80-90.

Which actions/interventions are most important for the nurse to perform when caring for a 70-year-old client who is scheduled for a contrast-medium enhanced CT scan? (Select all that apply.) a. Assess for co-existing conditions of pre-existing diabetes, heart failure, and established CKD. b. Assess the hourly urine output for at least 6 hours prior to the procedure. c. Assess creatinine clearance using a 24-hour urine collection test. d. Alert the provider to a serum creatinine that has increased from 0.2 to 0.4 mg/dL (20 to 40 mcmol/L) in the previous 24 hours. e. Alert the provider to a glomerular filtration rate (GFR) <60 mL/min/1.73 m2. f. Assess for hypovolemia, including evaluation of the mean arterial pressure (MAP). g. Collaborate with the provider to determine whether isotonic IV fluids should be infused before the test. h. Discuss with the provider about whether the client's prescribed diuretic should be held immediately before the test.

ANS: A, E, F, G, H

The client is a 62-year-old admitted 2 days ago with traumatic injuries and hypovolemic shock from a car crash. The nurse reviewing the client's daily laboratory test results notices the following values. Which result is most important to report to the health care provider immediately? a. Serum sodium 132 mEq/L (mmol/L) b. Serum potassium 6.9 mEq/L (mmol/L) c. Blood urea nitrogen 24 mg/dL (mmol/L) d. Hematocrit 32% (0.32 volume fraction); hemoglobin 9.2 g/dL (92 g/L)

ANS: B All listed laboratory values are out of the normal range. However, the only value that has reached or is approaching a critical level is the serum potassium, which shows hyperkalemia. This problem must be addressed immediately.

Which question does the nurse ask the client who has a urinary tract infection to assess the risk for possible pyelonephritis? a. What drugs do you take for asthma? b. How long have you had diabetes? c. How much fluid do you drink daily? d. Do you take your antihypertensive drugs at night or in the morning?

ANS: B Pyelonephritis risk is increased in the client who has diabetes and a urinary tract infection (UTI). While it is important to know all the drugs that a client takes, neither asthma drugs nor asthma itself increases the risk for pyelonephritis. (An exception would be high-dose systemic corticosteroids; however, these are rarely recommended in current asthma therapy). Although insufficient fluid intake may make a UTI worse, it does not increase the risk for pyelonephritis. Antihypertensives are not a risk factor for pyelonephritis.

1. The charge nurse is preparing assignments on a busy medical unit. For this shift, there are two LPNs, two RNs, and one nursing assistant. Which client assignments are most appropriate? (Select all that apply.) a. An LPN is assigned to a client who is receiving the first dose of an oral immunomodulating agent to manage acute glomerulonephritis. b. An RN is assigned to the client who is receiving an IV corticosteroid twice daily to manage systemic lupus erythematous that has resulted in chronic glomerulonephritis. c. An LPN is assigned to replace a urinary catheter (in place >2 weeks) in a client with a fever who requires a chronic urinary catheter to assist healing from a genitourinary fistula. d. An RN is assigned to administer IV antibiotics to a client admitted with pyelonephritis. e. A nursing assistant is assigned to do all the morning baths. f. LPNs are assigned to clients who have oral drugs prescribed and will perform the vital signs for those clients. g. An RN is assigned to the client who is being discharged with a new diagnosis of diabetic nephropathy that is serious (stage 3 CKD).

ANS: B, C, D, E, F, G Consider which tasks are within the scope of practice for the RN, LPN, and NA. Giving a bath is within the scope of NA practice - this assignment is OK. LPNs may administer oral drugs and do vital signs - this assignment is also OK. In some states, LPNs can administer intravenous drugs after the first dose has already been given and the client's responses documented. RNs administer IV drugs, especially the first dose, and assess client responses. An LPN can insert a urinary catheter, and urinary catheters should be replaced in patients who have catheters longer than 2 weeks and appear to be symptomatic (fever) with UTI - this assignment is OK. An RN provides discharge teaching, particularly with complex or new diagnoses and interventions - this assignment is OK. Client teaching around new drug administration is reserved to the RN scope of practice - assignment to an LPN is not an assignment within the LPN scope of practice.

1. Which adverse drug effects does the nurse assess for a client who is hospitalized for an acute problem and is also prescribed an anticholinergic drug to manage incontinence? (Select all that apply.) a. Insomnia b. Blurred vision c. Constipation d. Dry mouth e. Loss of sphincter control f. Increased sweating g. Worsening mental function h. Hypotension

ANS: B, C, D, G Anticholinergic drugs tend to block the parasympathetic nervous system and mimic the sympathetic nervous system responses. In addition to reducing urinary output, these commonly include dry mouth, reduced gastric motility, constipation, blurred vision, hypertension, increasing confusion, dizziness, and sleepiness.

1. When obtaining a health history from a 22-year-old female client who has new onset urinary incontinence, which findings or factors does the nurse consider significant? (Select all that apply.) a. Chemical exposure in the workplace b. A burning sensation occurring on urination c. Urinating 10 times daily although fluid intake remains unchanged d. A recent change in the client's oral contraceptive prescription e. A new inability to hold urine (urgency) f. A "stinky" odor from the urine

ANS: B, C, E, F Burning on urination, frequent urination without increasing fluid intake, urgency, and malodorous urine are concerning changes in urine elimination. Although chemical exposure in the workplace may cause kidney damage, it is not associated with new onset incontinence in a young adult. Oral contraceptives do not contribute to problems with urination.

1. The nurse is admitting a client who has type 2 diabetes (T2D) and is scheduled for surgery. Which laboratory findings from this client's admission panel does the nurse report as indicating possible abnormal kidney function? (Select all that apply.) a. Presence of ammonia in the urine b. Urine microalbumin 240 mcg/24 hour (0.240 g/24 hour) c. Urine specific gravity of 1.028 d. Blood urea nitrogen of 38 mg/dL (13.5 mmol/L) f. Serum creatinine 2.2 mg/dL (294.3 mcmol/L) g. Blood osmolarity 290 mOsm/kg (290 mmol/kg)

ANS: B, D, E Urine normally has a small amount of ammonia in it as a breakdown product of nitrogen. Other normal values include the urine specific gravity (normal range of 1.005 to 1.030) and the blood osmolarity (280 to 300 mOsm/kg; 280 to 300 mmol/kg). The urine microalbumin is much higher than the normal levels (30 to 80 mcg/24 hour; 0.03 to 0.08 g/24 hour) and indicates abnormal kidney function. Blood urea nitrogen is high (normal ranges 10 to 120 mg/dL; 3.6 to 7.1 mmol/L) as is the serum creatinine (normal ranges 0.5 to 1.2 mg/dL; 44 to 106 mcmol/L). Both of these values indicate abnormal kidney function.

A 70-year-old client is seeing his primary care provider for an annual examination. Which assessment finding alerts the nurse to an increased risk for bladder cancer? a. A 5-pack year history of smoking 45 years ago b. Difficulty starting and stopping the urine stream c. A 30-year occupation as a long-distance truck driver d. A recent colon cancer diagnosis in his 72-year-old brother

ANS: C Although cigarette smoking is a risk factor for bladder cancer, a 5-pack year history more than 45 years ago is not significant as a potential cause of cancer. Bladder cancer does not appear to have a familial or genetic predisposition. Difficulty starting or stopping urination is a symptom, usually of prostate issues, not a harbinger of bladder cancer. The latest research indicates exposure to gasoline and diesel fuel is a major risk factor for bladder cancer.

When assessing a client with acute glomerulonephritis, which question about self-management will the nurse ask to determine whether the client is currently following best practices to slow progression of kidney damage? a. "Have you increased your protein intake to promote healing of the damaged nephrons?" b. "Do you avoid contact sports while you are taking cyclosporine?" c. "How are you evaluating the amount of daily fluid you drink?" d. "Have you contacted anyone from our dialysis support services?"

ANS: C Protein intake may be increased early in Chronic Kidney Disease (CKD) and reduced late in CKD. Since you do not have information about the extent of CKF (stage), this question may be incorrect. Cyclosporine is a cytotoxic agent that reduces immune responses, which would require the client to avoid sick contacts. Because the client needs to find a balance between too much and too little fluid intake (both are harmful), this is a good question to see how the individual ensures adequate kidney blood flow (perhaps with systemic blood pressure assessment) while providing sufficient intake to eliminate waste (perhaps through urine volume or color or via staying within a target of fluid intake. A target fluid intake is generally 1.5 to 2 L daily if not receiving dialysis). The client may not progress to needing dialysis; this intervention is usually reserved until the last stage of CKD before dialysis occurs; there is no indication that CKD has been staged at this point.

A client who performs home continuous ambulatory peritoneal dialysis reports that the drainage (effluent) has become cloudy in the past 24 hours. What is the nurse's best first action? a. Remove the peritoneal catheter. b. Notify the health care provider immediately. c. Obtain a sample of effluent for culture and sensitivity. d. Explain to the client the need to keep the dialysate in the refrigerator to prevent bacterial overgrowth.

ANS: C The client most likely has beginning peritonitis. This problem needs to be confirmed and interventions started quickly. A culture is needed to identify that an infection is indeed present. Although the health care provider does need to be notified, obtaining the culture is performed first. The peritoneal catheter should not be removed at this time because it may be needed to instill intraperitoneal antibiotics. Also, removal of this catheter in not within the scope of practice for registered nurses in most states. Dialysate for peritoneal dialysis is sterile and does not need to be refrigerated.

A 25-year-old sexually active female client diagnosed with cystitis tells the nurse that she doesn't understand why she has these infections yearly because she tries to avoid them by drinking very little at work so she doesn't have to use the "dirty" public toilet. Which suggestions or actions by the nurse are most likely to help this client reduce her risk for cystitis? (Select all that apply.) a. Reinforce her choice to avoid using a public toilet b. Teach her to shower immediately after having sexual intercourse c. Suggest that she drink at least 2-3 L of fluid throughout the day d. Urge her to change her method of birth control from oral contraceptives to a barrier method e. Instruct her to always wipe her perineum from front to back after each toilet use f. Reinforce that she should complete the entire course of antibiotics as prescribed g. Instruct her to empty her bladder immediately before intercourse

ANS: C, E, F, G A is incorrect because using a public toilet, even sitting on the seat, does not lead to cystitis or a UTI. Showering after intercourse does not affect the development of UTIs. Showering BEFORE intercourse can reduce the number of perineal organisms and reduce the risk for UTI. Oral contraceptives do not increase the risk for UTI; however, some barrier methods (especially a cervical cap or diaphragm) can increase because of the increased manipulation of tissues in the area. Drinking more fluids throughout the day dilute the urine and increase the frequency of urination, and both responses help reduce the number of organisms in the bladder. Wiping the perineum from front to back prevents organisms around the anus and vagina from being translocated to the area around the urethra. Completing the antibiotics prescribed for a current UTI helps eradicate the organism and prevent recurrence with resistant organisms. Emptying the bladder before intercourse decreases the risk for reflux from the bladder into the ureters from external pressure

When the nurse caring for a client with severe chronic kidney disease asks what dietary modifications he has made for the disease, he reports the following actions. Which action indicates to the nurse that additional client education is needed? a. Using a scale to measure protein weight b. Taking calcium and vitamin D supplements daily c. Eliminating bananas, citrus fruits, and avocados d. Using a salt-substitute instead of ordinary table salt

ANS: D Salt substitutes contain very little sodium, which is a good thing because sodium restriction is needed. However, the sodium is replaced with potassium. Clients with CKD must restrict their intake of potassium severely to avoid life-threatening cardiac dysrhythmias.

For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter? a. A 35-year-old woman who was admitted with a splenic laceration and femur fracture (closed repair completed) following a car crash b. A 48-year-old man who has established paraplegia and is admitted for pneumonia c. A 61-year-old woman who is admitted following a fall at home and has new-onset dysrhythmia d. A 74-year-old man who has lung cancer with brain metastasis and is bring transitioned to hospice for end-of-life care

ANS: D The man with advanced lung cancer and brain metastasis is dying and likely to be incontinent, in a lot of pain, and confused. An indwelling catheter can help provide comfort at this time by reducing the amount of manipulation needed to keep him and his bed dry. The other clients have no conditions for which use of a bedpan or intermittent catheterization would be contraindicated.

1. Which symptom(s) in a client during the first 12 hours after a kidney biopsy indicates to the nurse a possible complication from the procedure? a. The client experiences nausea and vomiting after drinking juice. b. The biopsy site is tender to light palpation. c. The abdomen is distended and the client reports abdominal discomfort. d. The heart rate is 118, blood pressure is 108/50, and peripheral pulses are thready.

ANS: D The most serious complication after a kidney biopsy is excessive bleeding. Nausea and vomiting are not signs of bleeding. Some discomfort at the biopsy site is expected and not considered a complication unless there is swelling and a large amount of bruising/discoloration in the flank area. The kidneys are not in the abdomen. Bleeding from the kidney would cause flank pain and swelling, not abdominal pain and swelling. The elevated pulse rate, thready peripheral pulses, and low diastolic blood pressure are consistent with excessive bleeding.

The nurse is preparing a client for discharge who experienced an acute kidney injury during coronary artery by-pass graft surgery. The nurse notices that the client has a serum creatinine of 1.2 mg/dL (106 mcmol/L) and a glomerular filtration rate (GFR) of 75 mL/kg/1.73 m2. Which is the priority nursing action? a. Reminding the client to remain hydrated by drinking 500 mL of an electrolyte-based solution daily. b. Encouraging the client to reduce protein intake to reduce creatinine production until the follow-up visit with the nephrologist occurs. c. Checking the remaining values on the metabolic panel and informing the primary care provider of all results before the client is discharged. d. Educating the client about the need for follow-up, including re-evaluation of serum creatinine with the primary care provider or nephrologist in 8 to 12 weeks.

ANS: D The serum creatinine is within normal limits but the GFR is reduced, indicating risk for CKD. Follow-up is needed but not urgently and follow-up should occur within the health care team members who are familiar with her hospital course and general health. Protein is an essential nutrient needed for wound healing after surgery. A normal creatinine typically does not require protein restriction to avoid progression of kidney problems. Water or electrolyte-free fluid is recommended for hydration unless there is an indication that electrolytes are being excreted in urine. Although the rest of the metabolic panel should be evaluated by the discharge nurse, the primary care provider need only be informed of critical values in an urgent manner.