Chapter 48: Management of Patients with Kidney Disorders

Question 1

1. The nurse is assessing a client suspected of having developed acute
   glomerulonephritis. The nurse should expect to address what clinical manifestation that
   is characteristic of this health problem?
   A. Hematuria
   B. Precipitous decrease in serum creatinine levels
   C. Hypotension unresolved by fluid administration
   D. Glucosuria

Answer 1

ANS: A
Rationale: The primary presenting feature of acute glomerulonephritis is hematuria
(blood in the urine), which may be microscopic (identifiable through microscopic examination) or macroscopic or gross (visible to the eye). Proteinuria, primarily albumin, which is present, is due to increased permeability of the glomerular membrane. Blood urea nitrogen (BUN) and serum creatinine levels may rise as urine output drops. Glucosuria does not normally accompany glomerulonephritis, and hypertension is much more likely than hypotension.

Question 2

2. The nurse is caring for an acutely ill client. What assessment finding should prompt the
   nurse to inform the health care provider that the client may be exhibiting signs of acute
   kidney injury (AKI)?
   A. An inability to initiate voiding for 2 days.
   B. The urine is cloudy and has visible sediment with a foul odor.
   C. Average urine output has been 10 mL/hr for several hours.
   D. Client reports left-sided flank pain.

Answer 2

ANS: C
Rationale: Oliguria (<400 mL/day of urine or 0.5 mL/kg an hour over 6 hours) is the
most common clinical situation seen in AKI. The client’s inability to void and/or urine
hesitancy is typically seen with kidney stones, prostate problems, and/or a urinary tract infection (UTI). Urine that has visible sediment and is cloudy and foul smelling is more suggestive of a UTI. Acute flank pain is sometimes seen in AKI. Generally, flank pain has some connection to a variety of kidney diseases like acute glomerular inflammation and polycystic kidney disease.

Question 3

3. The nurse is caring for a client with a history of systemic lupus erythematosus who has
   been recently diagnosed with end-stage kidney disease (ESKD). The client has an
   elevated phosphorus level and has been prescribed calcium acetate to bind the
   phosphorus. The nurse should teach the client to take the prescribed medication at what
   time?
   A. Only when needed
   B. Daily at bedtime
   C. First thing in the morning
   D. With each meal

Answer 3

ANS: D
Rationale: Both calcium carbonate and calcium acetate are medications that bind with the phosphate and assist in excreting the phosphate from the body, in turn lowering the phosphate levels. Phosphate-binding medications must be given with food to be effective.

Question 4

4. The nurse is working on the renal transplant unit. To reduce the risk of infection in a
   client with a transplanted kidney, it is imperative for the nurse to take what action?
   A. Wash hands carefully and frequently.
   B. Ensure immediate function of the donated kidney.
   C. Instruct the client to wear a face mask.
   D. Bar visitors from the client’s room.

Answer 4

ANS: A
Rationale: The nurse ensures that the client is protected from exposure to infection by
hospital staff, visitors, and other clients with active infections. Careful handwashing is
imperative; face masks may be worn by hospital staff and visitors to reduce the risk for transmitting infectious agents while the client is receiving high doses of
immunosuppressants. Visitors may be limited, but are not normally barred outright. Ensuring kidney function is vital, but does not prevent infection.

Question 5

5. The nurse is caring for a client receiving hemodialysis three times weekly. The client
   has had surgery to form an arteriovenous fistula. What is most important for the nurse
   to be aware of when providing care for this client?
   A. Using a stethoscope for auscultating the fistula is contraindicated
   B. The client feels best immediately after the dialysis treatment
   C. Taking a BP reading on the affected arm can damage the fistula
   D. The client should not feel pain during initiation of dialysis

Answer 5

ANS: C
Rationale: When blood flow is reduced through the access for any reason (hypotension, application of BP cuff/tourniquet), the access site can clot. Auscultation of a bruit in the fistula is one way to determine patency. Typically, clients feel fatigued immediately after hemodialysis because of the rapid change in fluid and electrolyte status. Although the area over the fistula may have some decreased sensation, a needle stick is still painful.

Question 6

6. A client has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m2. Based on this
   GFR, the nurse interprets that the client’s chronic kidney disease is at what stage?
   A. Stage 1
   B. Stage 2
   C. Stage 3
   D. Stage 4

Answer 6

ANS: C
Rationale: Stages of chronic kidney disease are based on the GFR. Stage 3 is defined by
a GFR in the range of 30 to 59 mL/min/1.73 m2. This is considered a moderate decrease
in GFR.

Question 7

7. An inpatient client with acute kidney injury (AKI) has moderate edema to both legs.
   What resulting skin conditions would increase the client’s likelihood of skin breakdown?
   Select all that apply.
   A. Atopic dermatitis
   B. Pruritus
   C. Psoriasis
   D. Urticaria
   E. Excoriation

Answer 7

ANS: B, E
Rationale: The skin may be dry or susceptible to breakdown as a result of edema. Excoriation and itching (pruritus) may result from the deposits of irritating toxins in the client’s tissue due to AKI. Prevention recommendations include bathing in cool water, assisting or encouraging frequent turning and repositioning as well as keeping the skin clean and moisturized. Clients should be instructed to keep nails trimmed to help prevent scratches. Atopic dermatitis or eczema has strong genetic links and is commonly associated with asthma and hay fever. Eczema results in red, dry, and itchy patches of skin. Urticaria or hives are raised, red welts that suddenly appear on the skin and are usually caused by an allergic reaction. Psoriasis is a chronic skin condition characterized by thick red patches or plaques of skin covered with white or silvery scales. Psoriasis is usually linked to an autoimmune response.

Question 8

8. A client admitted with nephrotic syndrome is being cared for on the medical unit. When
   writing this client’s care plan, based on the major clinical manifestation of nephrotic
   syndrome, what nursing diagnosis should the nurse include?
   A. Constipation related to immobility
   B. Risk for injury related to altered thought processes
   C. Hyperthermia related to the inflammatory process
   D. Excess fluid volume related to generalized edema

Answer 8

ANS: D
Rationale: The major clinical manifestation of nephrotic syndrome is edema, so the
appropriate nursing diagnosis is “Excess fluid volume related to generalized edema.”
Edema is usually soft, pitting, and commonly occurs around the eyes, in dependent areas, and in the abdomen.

Question 9

9. The nurse coming on shift on the medical unit is taking a report on four clients. What
   client does the nurse know is at the greatest risk of developing ESKD?
   A. A client with a history of polycystic kidney disease
   B. A client with diabetes mellitus and poorly controlled hypertension
   C. A client who is morbidly obese with a history of vascular disorders
   D. A client with severe chronic obstructive pulmonary disease

Answer 9

ANS: B
Rationale: Systemic diseases, such as diabetes mellitus (leading cause); hypertension; chronic glomerulonephritis; pyelonephritis; obstruction of the urinary tract; hereditary lesions, such as in polycystic kidney disease; vascular disorders; infections; medications;
or toxic agents may cause ESKD. A client with more than one of these risk factors is at the greatest risk for developing ESKD. Therefore, the client with diabetes and hypertension is likely at highest risk for ESKD.

Question 10

10. The nurse is caring for a client postoperative day 4 following a kidney transplant.
    When assessing for potential signs and symptoms of rejection, what assessment should
    the nurse prioritize?
    A. Assessment of the quantity of the client’s urine output
    B. Assessment of the client’s incision
    C. Assessment of the client’s abdominal girth
    D. Assessment for flank or abdominal pain

Answer 10

ANS: A
Rationale: After kidney transplantation, the nurse should perform all of the listed
assessments. However, oliguria is considered to be more suggestive of rejection than changes to the client’s abdomen or incision.

Question 11

11. The nurse is caring for a client in acute kidney injury (AKI). Which complication would
    most clearly warrant the administration of polystyrene sulfonate?
    A. Hypernatremia
    B. Hypomagnesemia
    C. Hyperkalemia
    D. Hypercalcemia

Answer 11

ANS: C
Rationale: Hyperkalemia (high potassium) is a common complication of AKI. If the
client’s potassium is elevated but does not cause ECG (electrocardiography) changes,
then polystyrene sulfonate may be administered since it reduces serum potassium levels. It is not recommended for emergency treatment since it takes more than 6 hours to work. Polystyrene sulfonate does not treat low (hypo) magnesium, high sodium (hypernatremia), or high calcium (hypercalcemia).

Question 12

12. The nurse is caring for a client whose acute kidney injury (AKI) resulted from a
    prerenal cause. Which condition most likely caused this client’s health problem?
    A. Burns
    B. Glomerulonephritis
    C. Ureterolithiasis
    D. Pregnancy

Answer 12

ANS: A
Rationale: AKI has categories that identify causation. These are prerenal, intrarenal, and postrenal. Prerenal AKI results from hypoperfusion of the kidney caused by volume depletion. Common causes are burns, hemorrhage, gastrointestinal losses, sepsis, and shock. Glomerulonephritis and ureterolithiasis (kidney stones) are associated with intrarenal causes. Pregnancy is linked to postrenal AKI (obstructions distal to the
kidney).

Question 13

13. A client with diabetic nephropathy has end-stage renal disease and is starting
    dialysis. What should the nurse teach the client about hemodialysis?
    A. “Hemodialysis is a treatment option that is usually required three times a week.”
    B. “Hemodialysis is a program that will require you to commit to daily treatment.”
    C. “This will require you to have surgery and a catheter will need to be inserted into
    your abdomen.”
    D. “Hemodialysis is a treatment that is used for a few months until your kidney
    heals and starts to produce urine again.”

Answer 13

ANS: A
Rationale: Hemodialysis is the most commonly used method of dialysis. Clients receiving hemodialysis must undergo treatment for the rest of their lives or until they undergo successful kidney transplantation. Treatment usually occurs three times a week for at least 3 to 4 hours per treatment. Peritoneal dialysis, not hemodialysis, requires placement of a catheter inserted into the abdomen.

Question 14

14. A client with end-stage renal disease receives continuous ambulatory peritoneal
    dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the
    nurse’s most appropriate action?
    A. Inform the health care provider and assess the client for signs of infection.
    B. Flush the peritoneal catheter with normal saline.
    C. Remove the catheter promptly and have the catheter tip cultured.
    D. Administer a bolus of IV normal saline as prescribed.

Answer 14

ANS: A
Rationale: Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate drainage fluid, so prompt reporting to the primary provider and rapid assessment for other signs of infection are warranted. Administration of an IV bolus is not necessary or appropriate and the health care provider would determine whether removal of the catheter is required. Flushing the catheter does not address the risk for infection.

Question 15

15. The nurse is planning client teaching for a client with end-stage kidney disease who
    is scheduled for the creation of a fistula. The nurse should teach the client what
    information about the fistula?
    A. “A vein and an artery in your arm will be attached surgically.”
    B. “The arm should be immobilized for 4 to 6 days.”
    C. “One needle will be inserted into the fistula for each dialysis treatment.”
    D. “The fistula can be used 5 to 7 days after the surgery for dialysis treatment.”

Answer 15

ANS: A
Rationale: The fistula joins an artery and a vein, either side-to-side or end-to-end. This
access will need several weeks to “mature” before it can be used. The client is
encouraged to perform exercises to increase the size of the affected vessels (e.g., squeezing a rubber ball for forearm fistulas). Two needles will be inserted into the fistula for each dialysis treatment.

Question 16

16. A client with end-stage kidney disease is scheduled to begin hemodialysis. The nurse
    is working with the client to adapt the client’s diet to maximize the therapeutic effect and
    minimize the risks of complications. The client’s diet should include which of the following
    modifications? Select all that apply.
    A. Decreased protein intake
    B. Decreased sodium intake
    C. Increased potassium intake
    D. Fluid restriction
    E. Vitamin D supplementation

Answer 16

ANS: A, B, D
Rationale: Restricting dietary protein decreases the accumulation of nitrogenous wastes, reduces uremic symptoms, and may even postpone the initiation of dialysis for a few months. Restriction of fluid is also part of the dietary prescription because fluid
accumulation may occur. As well, sodium is usually restricted to 2 to 3 g/day. Potassium
intake is usually limited, not increased, and there is no particular need for vitamin D
supplementation.

Question 17

17. A client is scheduled for a CT scan of the abdomen with contrast. The client has a
    baseline creatinine level of 2.3 mg/dL (203 mol/L). In preparing this client for the
    procedure, the nurse anticipates what orders?
    A. Monitor the client’s electrolyte values every hour before the procedure.
    B. Provide adequate hydration before the procedure
    C. Start hemodialysis immediately prior to the CT scan
    D. Obtain a creatinine clearance by collecting a 24-hour urine specimen.

Answer 17

ANS: B
Rationale: Radiocontrast-induced nephropathy is a major cause of hospital-acquired acute kidney injury. Baseline levels of creatinine greater than 2 mg/dL (177 mol/L) identify the client as being at high risk. Preprocedure hydration the day prior to the test is effective in prevention. The nurse would not monitor the client’s electrolytes every hour pre-procedure because this would not change the client’s risk factors. To decrease this risk factor, an intervention is needed. Nothing in the scenario indicates the need for hemodialysis. A creatinine clearance is not necessary prior to a CT scan with contrast.

Question 18

18. A client is admitted to the ICU after a motor vehicle accident. On the second day of
    the hospital admission, the client develops acute kidney injury. The client is
    hemodynamically unstable, and renal replacement therapy is needed to manage the
    client’s hypervolemia and hyperkalemia. Which of the following therapies will the client’s
    hemodynamic status best tolerate?
    A. Hemodialysis
    B. Peritoneal dialysis
    C. Continuous venovenous hemodialysis (CVVHD)
    D. Plasmapheresis

Answer 18

ANS: C
Rationale: CVVHD facilitates the removal of uremic toxins and fluid. The hemodynamic
effects of CVVHD are usually mild in comparison to hemodialysis, so CVVHD is best tolerated by an unstable client. Peritoneal dialysis is not the best choice, as the client may have sustained abdominal injuries during the accident and catheter placement would be risky. Plasmapheresis does not achieve fluid removal and electrolyte balance.

Question 19

19. A client has presented with signs and symptoms that are characteristic of acute
    kidney injury, but preliminary assessment reveals no obvious risk factors for this health
    problem. The nurse should recognize the need to interview the client about what priority
    topic?
    A. Typical diet
    B. Allergy status
    C. Psychosocial stressors
    D. Current medication use

Answer 19

ANS: D
Rationale: The kidneys are susceptible to the adverse effects of medications because
they are repeatedly exposed to substances in the blood. Nephrotoxic medications are a
more likely cause of AKI than diet, allergies, or stress.

Question 20

20. An older adult client diagnosed with cancer is admitted to the oncology unit for
    surgical treatment. The client has been on chemotherapeutic agents to decrease tumor
    size prior to the planned surgery. The nurse caring for the client is aware that what
    precipitating factors in this client may contribute to acute kidney injury (AKI)? Select all
    that apply.
    A. Anxiety and agitation
    B. Low body mass index (BMI)
    C. Age-related physiologic changes
    D. Chronic systemic disease
    E. Nothing by mouth (NPO) status

Answer 20

ANS: C, D, E
Rationale: Changes in kidney function with normal aging increase the susceptibility of
older clients to kidney dysfunction and kidney injury. In addition, the presence of chronic, systemic diseases increases the risk of AKI. This client was on chemotherapeutic agents that frequently cause nausea and vomiting, which contribute to dehydration. Older adult clients taking medications may cause alterations in renal flow and clearance. The client was made NPO prior to surgery, making them more susceptible to AKI even with parenteral fluids. A low BMI and anxiety are not risk factors for acute renal disease.

Question 21

21. A client is being treated for AKI and the client daily weights have been ordered. The
    nurse notes a weight gain of 3 pounds (1.4 kg) over the past 48 hours. What nursing
    diagnosis is suggested by this assessment finding?
    A. Imbalanced nutrition: More than body requirements
    B. Excess fluid volume
    C. Sedentary lifestyle
    D. Adult failure to thrive

Answer 21

ANS: B
Rationale: If the client with AKI gains or does not lose weight, fluid retention should be
suspected. Short-term weight gain is not associated with excessive caloric intake or a
sedentary lifestyle. Failure to thrive is not associated with weight gain.

Question 22

22. A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious
    glomerular disease. The nurse should recognize that this form of kidney disease may
    have been precipitated by what event?
    A. Psychosocial stress
    B. Hypersensitivity to an immunization
    C. Menarche
    D. Streptococcal infection

Answer 22

ANS: D
Rationale: Postinfectious causes of postinfectious glomerular disease are group A beta-hemolytic streptococcal infection of the throat that precedes the onset of
glomerulonephritis by 2 to 3 weeks. Menarche, stress, and hypersensitivity are not typical causes.

Question 23

23. A client on the medical unit has a documented history of polycystic kidney disease
    (PKD). What principle should guide the nurse’s care of this client?
    A. The disease is self-limiting and cysts usually resolve spontaneously in the fifth or
    sixth decade of life.
    B. The client’s disease is incurable and the nurse’s interventions will be supportive.
    C. The client will eventually require surgical removal of his or her renal cysts.
    D. The client is likely to respond favorably to lithotripsy treatment of the cysts.

Answer 23

ANS: B
Rationale: Nursing actions focus on support and symptom control. It is not self-limiting
and is not treated surgically or with lithotripsy.

Question 24

24. The nurse is providing a health education workshop to a group of adults focusing on
    cancer prevention. The nurse should emphasize what action in order to reduce
    participants’ risks of renal carcinoma?
    A. Avoiding heavy alcohol use
    B. Control of sodium intake
    C. Smoking cessation
    D. Adherence to recommended immunization schedules

Answer 24

ANS: C
Rationale: Tobacco use is a significant risk factor for renal cancer, surpassing the
significance of high alcohol and sodium intake. Immunizations do not address an
individual’s risk of renal cancer.

Question 25

25. The nurse performing the health interview of a client with a new onset of periorbital
    edema has completed a genogram, noting the health history of the client’s siblings,
    parents, and grandparents. This assessment addresses the client’s risk of what kidney
    disorder?
    A. Nephritic syndrome
    B. Acute glomerulonephritis
    C. Nephrotic syndrome
    D. Polycystic kidney disease (PKD)

Answer 25

ANS: D
Rationale: PKD is a genetic disorder characterized by the growth of numerous cysts in the kidneys. Nephritic syndrome, acute glomerulonephritis, and nephrotic syndrome are not genetic disorders.

Question 26

26. A client is brought to the renal unit from the PACU status postresection of a renal
    tumor. Which of the following nursing actions should the nurse prioritize in the care of
    this client?
    A. Increasing oral intake
    B. Managing postoperative pain
    C. Managing dialysis
    D. Increasing mobility

Answer 26

ANS: B
Rationale: The client requires frequent analgesia during the postoperative period and assistance with turning, coughing, use of incentive spirometry, and deep breathing to prevent atelectasis and other pulmonary complications. Increasing oral intake and
mobility are not priority nursing actions in the immediate postoperative care of this client. Dialysis is not necessary following kidney surgery.

Question 27

27. A nurse is caring for a client who is in the diuresis phase of acute kidney injury. The
    nurse should closely monitor the client for what complication during this phase?
    A. Hypokalemia
    B. Hypocalcemia
    C. Dehydration
    D. Acute flank pain

Answer 27

ANS: C
Rationale: The diuresis period is marked by a gradual increase in urine output, which
signals that glomerular filtration has started to recover. The client must be observed
closely for dehydration during this phase; if dehydration occurs, the uremic symptoms
are likely to increase. Excessive losses of potassium and calcium are not typical during this phase, and diuresis does not normally result in pain.

Question 28

28. The nurse is caring for a client’s status after a motor vehicle accident. The client has
    developed AKI. What are the nurse’s roles in caring for this client? Select all that apply.
    A. Providing emotional support for the family
    B. Monitoring for complications
    C. Participating in emergency treatment of fluid and electrolyte imbalances
    D. Providing nursing care for primary disorder (trauma)
    E. Directing nutritional interventions

Answer 28

ANS: A, B, C, D
Rationale: The nurse has an important role in caring for the client with AKI. The nurse
monitors for complications, participates in emergency treatment of fluid and electrolyte imbalances, assesses the client’s progress and response to treatment, and provides physical and emotional support. Additionally, the nurse keeps family members informed about the client’s condition, helps them understand the treatments, and provides psychological support. Although the development of AKI may be the most serious problem, the nurse continues to provide nursing care indicated for the primary disorder
(e.g., burns, shock, trauma, obstruction of the urinary tract). The nurse does not direct
the client’s nutritional status; the dietitian and the health care provider normally
collaborate on directing the client’s nutritional status.

Question 29

29. A 76-year-old client with ESKD has been told by the health care provider that it is
    time to consider hemodialysis until a transplant can be found. The client tells the nurse
    about feeling unsure about undergoing a kidney transplant. What would be an
    appropriate response for the nurse to make?
    A. “The decision is certainly yours to make, but be sure not to make a mistake.”
    B. “Kidney transplants in peoples your age are as successful as they are in younger
    clients.”
    C. “I understand your hesitancy to commit to a transplant surgery. Success is
    relatively rare.”
    D. “Have you talked this over with your family?”

Answer 29

ANS: B
Rationale: Although there is no specific age limitation for renal transplantation,
concomitant disorders (e.g., coronary artery disease, peripheral vascular disease) have
made it a less common treatment for the older adult. However, the success rate of the surgery is comparable to that for younger clients. The other listed options either belittle the client or give the client misinformation.

Question 30

30. The nurse has identified the nursing diagnosis of “Risk for Infection” in a client who
    undergoes peritoneal dialysis. What nursing action best addresses this risk?
    A. Maintain aseptic technique when administering dialysate.
    B. Wash the skin surrounding the catheter site with soap and water prior to each
    exchange.
    C. Add antibiotics to the dialysate as prescribed.
    D. Administer prophylactic antibiotics by mouth or IV as prescribed.

Answer 30

ANS: A
Rationale: Aseptic technique is used to prevent peritonitis and other infectious
complications of peritoneal dialysis. It is not necessary to cleanse the skin with soap and
water prior to each exchange. Antibiotics may be added to dialysate to treat infection, but they are not used to prevent infection.

Question 31

31. The nurse is caring for a client who has returned to the postsurgical suite after
    postanesthetic recovery from a nephrectomy. The nurse’s most recent assessment
    reveals increased sedation, shortness of breath, hypotension, and low urine output over
    the last 2 hours. What is the nurse’s best response?
    A. Assess the client for signs of bleeding and inform the primary provider.
    B. Perform a full neurological assessment and notify the primary care provider.
    C. Increase the frequency of taking vital signs, monitor urine output, and notify the
    provider.
    D. Palpate the client’s torso bilaterally for flank pain and notify the primary care
    provider.

Answer 31

ANS: A
Rationale: Bleeding is a major complication of kidney surgery, and if missed can lead to
hypovolemic (decreased volume of circulating blood) and hemorrhagic shock. Bleeding can be suspected when the client experiences fatigue, shortness of breath, and urine output of less than 400 mL within 24 hours. The postoperative client is monitored closely and these findings should be reported to the primary care provider. Ruling out the complication of the life-threatening condition of bleeding is the priority decision for this client. Performing a full neurological assessment will be warranted after the priority complications of surgery are ruled out. Increasing the monitoring of vital signs and urine output are just small parts of assessing the client for bleeding. Palpating the client’s torso
for flank pain may increase the client’s pain and does not (in itself) address the most
common cause of the client’s signs and symptoms.

Question 32

32. The critical care nurse is monitoring the client’s urine output and drains following
    renal surgery. What should the nurse promptly report to the primary care provider?
    A. Increased pain on movement
    B. Absence of drain output
    C. Increased urine output
    D. Blood-tinged serosanguineous drain output

Answer 32

ANS: B
Rationale: Urine output and drainage from tubes inserted during surgery are monitored for amount, color, and type or characteristics. Decreased or absent drainage is promptly reported because it may indicate obstruction that could cause pain, infection, and disruption of the suture lines. Reporting increased pain on movement has nothing to do with the scenario described. Increased urine output and serosanguineous drainage are
expected.

Question 33

33. The nurse is creating an education plan for a client who underwent a nephrectomy for
    the treatment of a renal tumor. What should the nurse include in the teaching plan?
    A. The importance of increased fluid intake
    B. Signs and symptoms of rejection
    C. Inspection and care of the incision
    D. Techniques for preventing metastasis

Answer 33

ANS: C
Rationale: The nurse teaches the client to inspect and care for the incision and perform other general postoperative care, including activity and lifting restrictions, driving a vehicle, and pain management. There would be no need to teach the signs or symptoms of rejection as there has been no transplant. Increased fluid intake is not normally recommended and the client has minimal control on the future risk for metastasis.

Question 34

34. A client with end stage renal disease (ESKD) is being treated for a right ankle fracture
    unrelated to a fall. The client’s lab values show high phosphate levels, low calcium levels,
    and low vitamin D levels. What is the most likely reason for this client’s fracture?
    A. Osteoporosis
    B. Codman triangle
    C. Hypertrophic osteoarthropathy
    D. Renal osteodystrophy

Answer 34

ANS: D
Rationale: An abnormality seen in ESKD is called renal osteodystrophy or uremic bone
disease. It is a disease that involves complex changes in calcium, phosphate, and
parathormone balances. Damage seen in ESKD results in an increase in phosphate and a decrease in calcium (reciprocal relationship), which causes increased production from the parathyroid. Clients with ESKD cannot handle these increases, effectively resulting in bone changes and bone disease. All of the other choices can cause fractures but are not typically suspected in a client with ESRD with the presented lab values. Osteoporosis,
where bone becomes brittle and fragile, is usually diagnosed with a bone density scan.
Codman triangle is a radiologic sign seen commonly on x-rays. It is usually an indication of bone tumors. Hypertrophic osteoarthropathy (HOA) is characterized by abnormal proliferation (growth) of skin and periosteal tissue involving the extremities. Diagnosis is typically from x-rays and physical findings.

Question 35

35. The nurse is caring for a client who has just returned to the postsurgical unit following
    renal surgery. When assessing the client’s output from surgical drains, the nurse should
    physically assess what parameter(s)? Select all that apply.
    A. Quantity of output
    B. Color of the output
    C. Visible characteristics of the output
    D. Specific gravity of the output
    E. Potential hydrogen (pH) of the output

Answer 35

ANS: A, B, C
Rationale: Urine output and drainage from tubes inserted during surgery are monitored for amount, color, and type or characteristics. Decreased or absent drainage from the surgical drains are reported and may indicate obstruction. Specific gravity and pH are not
normally assessed at the bedside but are sent to the lab if needed. Those two tests are not part of the recommendations.

Question 36

36. The nurse is caring for a client after kidney surgery. When assessing for bleeding,
    what assessment parameter should the nurse evaluate?
    A. Oral intake
    B. Pain intensity
    C. Level of consciousness
    D. Radiation of pain

Answer 36

ANS: C
Rationale: Bleeding is a major complication of kidney surgery. The nurse’s role is to
observe for these complications, to report their signs and symptoms, and to administer prescribed parenteral fluids and blood and blood components. Monitoring of vital signs, skin condition, the urinary drainage system, the surgical incision, and the level of consciousness is necessary to detect evidence of bleeding, decreased circulating blood, and fluid volume and cardiac output. Bleeding is not normally evidenced by changes in pain or oral intake.

Question 37

37. A nurse is providing education to the family of a client beginning peritoneal dialysis.
    The family ask questions concerning catheter placement and stabilization. Which
    information will the nurse provide about the cuffs? Select all that apply.
    A. The cuffs are constructed of Dacron polyester material.
    B. The cuffs will help stabilize the catheter.
    C. The cuffs prevent the dialysate from leaking.
    D. The cuffs provide a barrier against microorganisms.
    E. The cuffs will absorb the dialysate.

Answer 37

ANS: A, B, C, D
Rationale: Most catheters used for peritoneal dialysis have two cuffs, which are made of Dacron polyester. The cuffs stabilize the catheter, limit movement, prevent leaks, and provide a barrier against microorganisms. They do not absorb dialysate.

Question 38

38. A client with chronic kidney disease is completing an exchange during peritoneal
    dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the
    client’s abdomen is increasing in girth. What is the nurse’s most appropriate action?
    A. Advance the catheter 2 to 4 cm further into the peritoneal cavity.
    B. Reposition the client to facilitate drainage.
    C. Aspirate from the catheter using a 60-mL syringe.
    D. Infuse 50 mL of additional dialysate.

Answer 38

ANS: B
Rationale: If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by turning the client from side to side or raising the head of the bed. The catheter should never be pushed further into the peritoneal cavity. It would be unsafe to aspirate or to infuse more dialysate.