Week 3 - Alterations in Renal Function
The patient with end stage renal disease (ESRD) has decided to terminate dialysis treatments. Which is the best response by the nurse? 1. "I respect your decision. Would you like me to ask the health care provider for a palliative care consult?" 2. "I respect your decision, but believe you need to discuss options with your health care provider. Would you like me to page the health care provider to come speak with you?" 3. "You cannot stop now, you have so much to live for." 4. "Are you sure this is the right decision? How about if I ask a psychiatrist to come speak with you."
Answer: "I respect your decision, but believe you need to discuss options with your health care provider. Would you like me to page the health care provider to come speak with you?" The patient has the right to end treatment. This decision must be made with the health care provider. Telling the patient he or she has too much to live for may be giving false reassurance. The nurse has no right questioning the decision or calling a psychiatrist at this point. Text Reference - p. 1129
A patient has end-stage kidney disease and is receiving hemodialysis. During dialysis the patient complains of nausea and a headache and appears confused. On examination, the nurse finds that the blood pressure is very low. What should the nurse do? Select all that apply. 1. Decrease the volume of fluids being removed 2. Infuse 0.9% saline solution 3. Infuse hypertonic glucose solution 4. Avoid excess coagulation 5. Transfuse blood, as ordered
Answer: 1, 2 Hypotension is a complication of hemodialysis and may manifest as headache and nausea. The nurse should try to keep the intravascular volume adequate by decreasing the volume of fluids being removed and infusing 0.9% saline solution. Hypertonic glucose solutions are infused if the patient gets muscle cramps. Excess coagulation is avoided if the patient has blood loss. Blood is transfused if the patient has blood loss. Text Reference - p. 1122
A patient with end-stage kidney disease is receiving continuous ambulatory peritoneal dialysis. The patient has a fever and the nurse suspects that it is due to peritonitis. What are the other manifestations that the nurse should monitor the patient for? Select all that apply. 1. Vomiting 2. Abdominal pain 3. Bloody stools 4. Weight loss 5. Cloudly peritoneal effluent
Answer: 1, 2, 5 Peritonitis may manifest as vomiting due to the inflammatory process in the peritoneum. The patient may have pain in the abdomen due to peritoneal irritation caused by the inflammatory process in the peritoneum. The primary clinical manifestations of peritonitis are abdominal pain and cloudy peritoneal effluent with a white blood cell (WBC) count greater than 100 cells/μL (more than 50% neutrophils). An activated immune response may attract WBCs, and an elevated level of WBC in the peritoneal fluid indicates peritonitis. Bloody stool or weight loss is not associated with peritonitis. Peritonitis may not cause hemorrhage; therefore, bloody stools may not be present. Weight loss is usually caused by malnutrition or fluid loss and therefore may not be seen in peritonitis; weight gain may occur due to fluid retention Text Reference - p. 1119
The nurse just received an urgent laboratory value on a patient in renal failure. The potassium level is 6.3. The telemetry monitor is showing peaked T waves. Which prescription from the primary health care provider should be implemented first? 1. Administer regular insulin intravenously (IV) 2. Restrict dietary potassium intake to 40 meq daily 3. Administer kayexalate enema 4. Educate the patient on dietary restriction of potassium
Answer: 1. Administer regular insulin intravenously (IV) This patient is showing signs of hyperkalemia, which could be fatal and lead to myocardial damage. Regular insulin IV is needed to quickly force potassium into the cells. The kayexalate enema will take too long to excrete the potassium. Restricting oral intake and educating the patient will be needed when the crisis has resolved. Text Reference - p. 1112
The nurse caring for a patient with heart failure notes the patient has decreased urine output of 200 mL/day. Which laboratory finding aids in the diagnosis of prerenal azotemia in this patient? 1. Elevated blood urea nitrogen (BUN) 2. Normal creatinine level 3. Decreased sodium level 4. Decreased potassium level
Answer: 1. Elevated blood urea nitrogen (BUN) The patient with heart failure has a decreased circulating blood volume. This causes autoregulatory mechanisms to preserve blood flow to essential organs. Laboratory data for this patient will likely demonstrate an elevation in BUN, creatinine, and potassium. Prerenal azotemia results in a reduction in the excretion of sodium, increased sodium and water retention, and decreased urine output. Text Reference - p. 1102
The patient has a form of glomerular inflammation that is progressing rapidly. The patient is gaining weight and the urine output is declining steadily. What is the priority nursing intervention? 1. Monitor the patient's cardiac status 2. Teach the patient about hand washing 3. Obtain a serum specimen for electrolytes 4. Increase direct observation of the patient
Answer: 1. Monitor the patient's cardiac status The nurse's priority is to monitor the patient's cardiac status. With the rapidly progressing glomerulonephritis, renal function begins to fail and fluid, potassium, and hydrogen retention lead to hypervolemia, hyperkalemia, and metabolic acidosis. Excess fluid increases the workload of the heart and hyperkalemia can lead to life-threatening dysrhythmias. Teaching about hand washing and observation of the patient are important nursing interventions, but are not the priority . Electrolyte measurement is a collaborative intervention that will be done as prescribed by the health care provider. Text Reference - p. 1110
A patient is scheduled to undergo peritoneal dialysis. What is the highest-priority action that the nurse should perform before starting dialysis? 1. Obtain the patient's weight 2. Administer pain medication to the patient 3. Place the patient in a high Fowler's position 4. Place the patient in the Tredenlenburg position
Answer: 1. Obtain the patient's weight The nurse must check the patient's weight before and after peritoneal dialysis (PD) to determine how much fluid has been removed. The patient should assume a position of comfort, such as a low Fowler's, unless there is difficulty with removing the effluent, in which case the nurse will position the patient to facilitate drainage. Administering pain medication is not a priority in regard to PD. There is no indication that the patient is experiencing pain. Placing the patient in a high Fowler's or Trendelenburg position is not recommended for patients during PD. Text Reference - p. 110
A patient who has been on hemodialysis for several weeks asks the nurse what substances are being removed by the dialysis. What substances should the nurse tell the patient are passing through the membrane during hemodialysis? Select all that apply. 1. RBC 2. Creatinine 3. Glucose 4. Bacteria 5. Sodium
Answer: 2, 5 Creatinine, urea, uric acid, and electrolytes such as sodium and potassium are filtered by the semipermeable membrane during hemodialysis. RBCs do not pass through the semipermeable membrane during hemodialysis because of their molecular weight. Glucose does not pass through the semipermeable membrane during hemodialysis due to the osmotic difference of the dialysate. Bacteria do not pass through the semipermeable membrane during hemodialysis due to their high molecular weight. Text Reference - p. 1117
A patient with a history of end-stage kidney disease secondary to diabetes mellitus has presented to the outpatient dialysis unit for the scheduled hemodialysis. Which assessments should the nurse prioritize before, during, and after the treatment? 1. Level of consciousness 2. Blood pressure and fluid balance 3. Temperature, heart rate, and blood pressure 4. Assessment for signs and symptoms of infection
Answer: 2. Blood pressure and fluid balance Although monitoring level of consciousness, temperature, heart rate, and blood pressure and assessing for signs of infection are relevant to the care of a patient receiving hemodialysis , the nature of the procedure indicates a particular need to monitor the patient's blood pressure and fluid balance. Text Reference - p. 1122
Which assessment finding of a patient with chronic kidney disease indicates to the nurse that hemodialysis is having the desired effect?' 1. Decreased hematocrit and diuresis 2. Decreased serum creatinine and weight loss 3. Increased potassium level and improved appetite 4. Decreased white blood cell count and diaphoresis
Answer: 2. Decreased serum creatinine and weight loss One of the main purposes of hemodialysis is removal of creatinine, other waste products, and water. Fluid loss may be measured by weighing the patient before and after the dialysis treatment and also by measuring the serum creatinine. The other answer options are inaccurate and/or incomplete. Hemodialysis will decrease potassium. It may also increase hematocrit and improve appetite. Hemodialysis will not produce diuresis, and has no direct effect on WBC count or diaphoresis. Text Reference - p. 1120
Which assessment finding is a consequence of the oliguric phase of acute kidney injury (AKI)? 1. Hypovolemia 2. Hyperkalemia 3. Hypernatremeia 4. Thrombocytopenia
Answer: 2. Hyperkalemia In AKI the serum potassium levels increase because the normal ability of the kidneys to excrete potassium is impaired. Sodium levels are typically normal or diminished, whereas fluid volume is normally increased because of decreased urine output. Thrombocytopenia is not a consequence of AKI, although altered platelet function may occur in AKI. Text Reference - p. 1104
During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do for the patient? 1. Administer hypertonic saline 2. Administer a blood transfusion 3. Decrease the rate of fluid removal 4. Administer antiemetic medications
Answer: Decrease the rate of fluid removal The patient is experiencing hypotension from a rapid removal of vascular volume. The rate and volume of fluid removal will be decreased and 0.9% saline solution may be infused. Hypertonic saline is not used because of the high sodium load. A blood transfusion is not indicated. Antiemetic medications may help the nausea, but would not help the hypovolemia. Text Reference - p. 1122
The nurse is caring for a patient with chronic kidney disease who is undergoing hemodialysis. What is an appropriate diet for this patient? 1. High protein and low calcium 2. Low protein and low potassium 3. High protein and high potassium 4. Low protein and high phosphorus
Answer: 2. Low protein and low potassium Patients with chronic kidney disease undergoing hemodialysis should consume a diet low in protein and potassium. Calcium needs to be maintained in the diet to help prevent hyperphosphatemia. High protein should be avoided because it causes uremic toxicity. High potassium in the diet needs to be avoided because the increased serum potassium level can result in cardiac disturbances. Text Reference - p. 1130
The nurse is planning an educational course on risk factors for chronic kidney disease. Which factors should the nurse identify as nonmodifiable risk factors? Select all that apply. 1. Hypertension 2. Type II diabetes 3. Family history of chronic kidney disease (CKD) 4. Age > 60 5. Exposure to nephrotoxic drugs
Answer: 3, 4 Family history of chronic kidney disease and age greater than 60 are risk factors out of the patient's control. The patient can make lifestyle changes to reduce high blood pressure and decrease blood glucose. The patient has a choice to take the drugs that are considered to be nephrotoxic. Text Reference - p. 1112
A nurse is explaining the warning signs of organ rejection to a patient who had a kidney transplant. What are the signs of rejection that the nurse should explain to the patient? Select all that apply. 1. Weight loss 2. Subnormal temperature 3. Elevated BP 4. Reduction in the amount of urine 5. Pain over the transplant site
Answer: 3, 4, 5 Hypertension is caused by hypervolemia because of the failure of the new kidney. A reduction in the amount of urine produced indicates ineffective functioning of the kidney. Pain in the site of transplant could be caused by any underlying kidney pathology, which could be a result of rejection. Weight gain, not loss, occurs with a rejection of the kidney because of fluid retention. The patient will have an elevated temperature exceeding 100°F with kidney rejection. Text Reference - p. 1127
When assessing the mental status of a patient in acute renal failure, the nurse recognizes that abnormal findings are most likely caused by: 1. Anger related to denial of chronic illness 2. Delirium related to hypoxia of brain cells 3. Confusion related to an increased urea level 4. Aggression related to possible underlying comorbidities
Answer: 3. Confusion related to an increased urea level In renal disease, urea is not filtered out of the blood by the kidneys and therefore accumulates in the blood. This results in toxicity to brain tissue, causing confusion. Anger is a possible emotional reaction, but it does not manifest as a change of mental status. Delirium related to hypoxia of brain cells is not a complication seen with acute renal failure. Aggression is not necessarily related to acute renal failure. Text Reference - p. 1108
The nurse is caring for a patient with severe burns in the emergency department. His laboratory values reveal serum creatinine level of 5 mg/dL, and the glomerular filtration rate (GFR) has decreased by 75%. What stage of acute kidney failure is this patient exhibiting? 1. Risk 2. Injury 3. Failure 4. Loss
Answer: 3. Failure As per the RIFLE (Risk, Injury, Failure, Loss, and End-stage) classification for staging acute kidney injury, this patient is at the Failure stage. When the GFR has decreased by 25%, the patient is at the Risk stage. The patient with a GFR that has decreased by 50% is at the Injury stage. The patient with persistent acute kidney failure experiences a complete loss of kidney function and is at the Loss stage. Text Reference - p. 1103
A patient with chronic kidney disease has an arteriovenous (AV) graft in the right forearm. What is the nurse's priority in determining the patency of the graft? 1. Determine the range of motion of the right arm and shoulder 2. Observe for clubbing of the fingers on the right hand of the AV graft site 3. Compare radial pulses by checking the right and left pulses simultaneously 4. Check for a bruit by listening over the right arm AV graft site with a stethoscope
Answer: 4. Check for a bruit by listening over the right arm AV graft site with a stethoscope The arteriovenous (AV) graft is an artificial connection between an artery and vein to provide access for hemodialysis. Thrombosis may occur; therefore the need to determine patency is an essential assessment. Palpation of the site should indicate a thrill, which also indicates that the graft is patent. Listening over the AV graft should reveal a bruit sound, indicating patency. A bruit sounds similar to the impulse beat heard when measuring blood pressure. The arm that has the AV graft site should not be put through range-of-motion movements or exercises. Clubbing is not a complication observed in the fingers of a patient with an AV graft. Comparing the left radial pulse with the pulse on the AV graft site is not an accurate patency assessment procedure. Text Reference - p. 1120
The nurse preparing to administer a dose of calcium acetate (PhosLo) to a patient with chronic kidney disease (CKD) should know that this medication should have a beneficial effect on which laboratory value? 1. Sodium 2. Potassium 3. Magnesium 4. Phosphorus
Answer: 4. Phosphorus Phosphorus and calcium have inverse or reciprocal relationships, meaning that when phosphorus levels are high, calcium levels tend to be low. Therefore, administration of calcium should help to reduce a patient's abnormally high phosphorus level, as seen with CKD. PhosLo will not have an effect on sodium, potassium, or magnesium levels. Text Reference - p. 1113
The nurse is planning an education program on chronic kidney disease. Which ethnic group would the nurse target for promoting this event? 1. African Americans 2. Asian descent 3. Caucasian males 4. Hispanics
Answer: African Americans African Americans are at the greatest risk for develop kidney disease. Those of Asian descent, Caucasian males, and Hispanics are not at as great a risk. Text Reference - p. 1108
The nurse reviews lab tests that have been prescribed for a patient in acute renal failure. Which is the best indicator of renal function? 1. Potassium 2. Creatinine 3. BUN (Blood urea nitrogen) 4. ALT (alanine aminotransferase)
Answer: Creatinine Creatinine is the best indicator of renal function. Creatinine is a waste product of the skeletal muscles and is excreted through the kidneys. In renal failure, the kidneys are unable to excrete creatinine, leading to a serum level greater than the normal range of 0.2 to 1. 0 ml/dL. Potassium excretion and regulation is impaired in acute renal failure, and potassium may therefore be increased. However, potassium may be increased for reasons other than renal disease, whereas increased creatinine is specific to renal disease. Blood urea nitrogen (BUN) is also used to measure kidney function, but other disorders such as dehydration may cause an increase in BUN. Alanine aminotransferase (ALT) is related to liver dysfunction, not renal dysfunction. Text Reference - p. 1104
A nurse planning care for a patient with acute renal failure recognizes that the interventions of highest priority are directly related to: 1. Ineffective coping 2. Excess fluid volume 3. Impaired gas exchange 4. Imbalance nutrition: less than body requirements
Answer: Excess fluid volume The issue of excess fluid volume is the primary problem of acute renal failure and the highest priority for the nurse in this situation. The major problem with acute renal failure is altered fluid and electrolyte balance, which, if not managed, can lead to permanent renal damage, cardiac complications, and death. The nursing diagnosis of Ineffective Coping is due to the acute severity of the illness. The nursing diagnosis of Impaired Gas Exchange is related to Excess Fluid Volume, such as in the development of pulmonary edema. The nursing diagnosis of Imbalanced Nutrition, less than body requirements, is due to a decrease in appetite as a result of the acute renal failure. Text Reference - p. 1106
A patient has renal failure. The nurse, reviewing the lab results, recognizes which finding as indicative of the diminished renal function associated with the diagnosis? 1. Hypokalemia 2. Increased serum urea and serum creatinine 3. Anemia and decreased blood urea nitrogen 4. Increased serum albumin and hyperkalemia
Answer: Increased serum urea and serum creatinine Renal failure, whether acute or chronic, causes an increase in serum urea, creatinine, and blood urea nitrogen. Renal failure may also cause hyperkalemia and anemia and decrease serum albumin. However, it does not cause decreased blood urea nitrogen or increased serum albumin. Text Reference - p. 1102
The nurse is caring for a patient who had a surgery for an arteriovenous fistula (AVF) in preparation for hemodialysis. What precautionary step should the nurse follow when caring for this patient? 1. Perform venipuncture in the extremity only after 3 months 2. Allow insertion of IV lines in the extremity only after 6 months 3. Never take blood pressure measurements in the extremity 4. Initiate hemodialysis after 4 weeks.
Answer: Never take blood pressure measurements in the extremity. The nurse should inform the patient to never take blood pressure measurements, insert IV lines, or perform venipuncture in the extremity with vascular access. These special precautions are taken to prevent infection and clotting of the vascular access site. Maturation may take 6 weeks to months. Arteriovenous fistula (AVF) should be placed at least 3 months before initiating hemodialysis. Text Reference - p. 1120
Which continuous renal replacement therapy requires no fluid replacement? 1. Slow continous ultrafiltration 2. Continuous venovenous hemodialysis 3. Continuous venovenous hemofiltration 4. Continuous venovenous hemodiafiltration
Answer: Slow continuous ultrafiltration Slow continuous ultrafiltration is a simplified version of continuous venovenous hemofiltration. No fluid replacement is required in this process. Continuous venovenous hemodialysis removes both fluids and solutes and requires both dialysate and replacement fluid. Continuous venovenous hemofiltration removes both fluids and solutes and requires replacement fluid. Continuous venovenous hemodiafiltration removes both fluids and solutes and requires both dialysate and replacement fluid. Text Reference - p. 1123
Which patient is most likely to develop chronic kidney disease (CKD) and should be taught preventive measures by the nurse? 1. A 5o-year-old white female with hypertension 2. A 61-year-old Native-American male with diabetes 3. A 4o-year-old Hispanic female with cardiovascular disease 4. A 28-year-old African-American female with a urinary tract infection
It is especially important that the nurse should teach CKD prevention to the 61-year-old Native American with diabetes. This patient is at highest risk because diabetes causes about 50% of CKD. This patient is the oldest and Native Americans with diabetes develop CKD six times more frequently than other ethnic groups. Hypertension causes about 25% of CKD. Hispanics have CKD about 1.5 times more than non-Hispanics. African Americans have the highest rate of CKD because hypertension is increased significantly in African Americans. A urinary tract infection (UTI) will not cause CKD unless it is not treated or occurs recurrently. Text Reference - p. 1112
The nurse is caring for a patient with sepsis who was just initiated on continuous renal replacement therapy (CRRT). In which order should the nurse perform the following actions? (Place the options in the order in which they should be performed. All options must be used.)
The patient on CRRT is hemodynamically unstable. Therefore, frequent vital signs should be assessed. Intake and output should be next, followed by obtaining a weight with assistance from an unlicensed assistive personnel (UAP). Document all laboratory values after the patient has been determined to be stable. Text Reference - p. 1123
