Exam 3 - Renal

Question 1

The nurse is discussing the prevention of urinary tract infections with a female client. What would be important to include in the discussion?

1. Decrease fluid intake to decrease burning on urination.
2. Take warm sitz baths with a mild bubble bath.
3. Avoid spermicides with nonoxynol-9.
4. Drink only acidic fluids such as orange juice.

Answer 1

3

The use of nonoxynol-9 spermicides can be irritating to the urinary tract and lead to infections. UTIs in women can be prevented by urination before and after sexual intercourse. Fluid intake should be increased, and no soap should be added to the sitz bath.

Question 2

A client with acute kidney injury develops severe hyperkalemia. What prescription would the nurse anticipate?

1. Furosemide (Lasix)
2. Calcium carbonate (Caltrate)
3. 50% glucose and regular insulin
4. Epoietin (Procrit)

Answer 2

3

Hyperkalemia can develop into an emergency situation (cardiac arrest). It is important to quickly move the potassium back into the cells by administering 50% glucose and regular insulin, usually in conjunction with some type of base to correct the acidosis, such as sodium bicarbonate or calcium gluconate given intravenously. Insulin assists in the movement of potassium into the cells and helps to reduce the serum potassium level. Calcium carbonate is used for the treatment of hyperphosphatemia that occurs with chronic kidney disease. Procrit is used for treatment of anemia caused by a decrease in erythropoietin production by the kidneys. A diuretic, such as Lasix, may lead to a loss of potassium, but the rate is too low.

Question 3

The nurse is evaluating a client’s response to hemodialysis. Which laboratory values will indicate the dialysis was effective? Select all that apply.

1. Serum potassium level decreases from 5.4 to 4.5 mEq/L
2. Serum creatinine level decreases from 1.6 to 0.8 mg/dL
3. Hemoglobin increases from 10 to 12 g/dL
4. White blood cells increase from 5000 to 8000/mm3
5. BUN decreases from 110 to 90 mg/dL

Answer 3

1, 2, 5 (serum potassium 5.4 to 4.5; serum creatinine 1.6 to 0.8; BUN 110 to 90)

Primary action of hemodialysis is to clear nitrogenous waste products. The creatinine and BUN provide a measure of how effective the dialysate was in removing the waste products. Electrolytes are altered with a decrease in potassium. Hemoglobin, white blood cells, sedimentation rate are not affected, these cells are too large to diffuse through the pores of the dialysate membrane.

Question 4

Nephrotic syndrome

Pathology and clinical manifestations

Answer 4

• Problem with the glomerular permeability to plasma proteins results in massive urinary protein loss.
• Characterized by massive proteinuria (≥3.5 g/day in adults) and lipiduria (e.g., free fat, oval bodies, fatty casts), along with an associated hypoalbuminemia (<3 g/dL), generalized edema, and hyperlipidemia
• Not a specific glomerular disease, but a constellation of clinical findings that result from an increase in glomerular permeability and loss of plasma proteins in the urine

Question 5

Acute glomerulonephritis

Pathology and clinical manifestations

Answer 5

• Post-streptococcal infection, inflammation of glomerulus
• 2-3 weeks after streptococcal infection
• Decreased GFR
• Inflammation of glomerulus, caused by immunological reaction
• Clinical manifestations: hematuria (smoky brown-tinged urine), proteinuria (edema, low serum albumin), eventual oliguria

Question 6

Chronic glomerulonephritis

Pathology and clinical manifestations

Answer 6

• Often silent first few years, can come years after an acute attack
• Develops after acute phase or slowly over time
• Chronic kidney function
• Often silent

Question 7

Pyelonephritis

Pathology and clinical manifestations

Answer 7

• ASCENDING INFECTION – starts somewhere lower in the urinary tract (such as bladder), moves up the ureters, up towards kidneys
• Rapid onset infection of the ureter, renal pelvis, and/or renal parenchyma
• Contributing factors:
  o Cystitis UTI
  o Urinary tract obstruction with reflux infection
  o Women 5 times more likely to develop

Clinical manifestation:

• Flank pain
• Fever
• Chills
• Costovertebral angle tenderness (CVAT)
• Purulent urine

Question 8

Nephrolithiasis

Pathology, clinical manifestations and most common type

Answer 8

• Kidney stones formed in renal parenchyma
• Calcium build-up and crystals
• S/S: excruciating intermittent pain radiating from flank to groin or genital and inner thigh

Most common type of stone – calcium

Question 9

Medications that cause nephrotoxicity

Answer 9

• Antibiotics
• Chronic laxative use
• NSAIDs
• ACE inhibitors
• Chemotherapy drugs

Question 10

Urinary tract infections/cystitis

Pathophysiology

What is most common causative?

Client teaching on how to prevent?

Answer 10

Pathophysiology
- Inflammation of the urinary epithelium following invasion and colonization by some pathogen within the urinary tract

Causative micro-organisms

• Escherichia coli
• Staphylococcus saprophyticus
• Enterbacter sppWhich one is most common?
• E. coliClient teaching on how to prevent
• Wipe front to back
• Cotton underwear
• No tight pants
• Plenty of fluids

Question 11

Management of anemia of chronic renal failure

Answer 11

• (Erythropoietin produced in kidneys, controls RBC production)
• Recombinant human erythropoietin used to maintain 11-12 g/dL
• Iron supplements

Question 12

Nursing management of hyperkalemia in acute renal failure

Answer 12

• Low potassium diet
• Loop diuretics (if kidneys function)
• 50% dextrose, insulin
• Volume expansion dialysis (renal dysfunction)

Question 13

Nursing assessment & management of an AV fistula

Answer 13

• Swelling & edema
• Feel for thrill
• Should have (weak) pulse
• Assess depth & diameter
• Arm above head – should collapse, shows no obstruction
• Listening for bruits (continuous low-pitched – medical fistula is normal)

Question 14

Expected changes (directions) in lab values in renal disease

Answer 14

• Increased BUN (>120 mg/dL)
• Increased creatinine (10 mg/dL)
• <20% GFR
• Metabolic acidosis
• Hyperkalemia
• Hypernatremia
• Anemia

Question 15

Nursing management of hematuria (blood in urine)

Answer 15

• Promote fluid intake
• Monitor I/O
• Catheter indwelling
• Medications
• Culture/labs
• Vitals
• Monitor pain

Question 16

The client with acute renal failure has a serum potassium level of 6.0 mEq/L. The nurse would plan which of the following as a priority action?

1. Check the sodium level.
2. Place the client on a cardiac monitor.
3. Encourage increased vegetables in the diet.
4. Allow an extra 500 mL of fluid intake to dilute the electrolyte concentration.

Answer 16

2

The client with hyperkalemia is at risk of developing cardiac dysrhythmias and cardiac arrest. Because of this, the client should not be placed on a cardiac monitor. Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly. Vegetables are a natural source of potassium in the diet, and their use would not be increased. The nurse also may assess the sodium level because sodium is another electrolyte commonly measured with the potassium level. However, this is not a priority action of the nurse.

Question 17

The client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of:

1. Pyelonephritis
2. Glomerulonephritis
3. Trauma to the bladder or abdomen
4. Renal cancer in the client’s family

Answer 17

3

Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria. Glomerulonephritis and pyelonephritis would be accompanied by fever and are thus not applicable to the client described in this question. Renal cancer would not cause pain that is felt in the low abdomen, rather pain would be in the flank area.

Question 18

The client is admitted to the emergency department following a motor vehicle accident. The client was wearing a lap seat belt when the accident occurred and now the client has hematuria and lower abdominal pain. To assess further whether the pain is caused by bladder trauma, the nurse asks the client if the pain is referred to which of the following areas?

1. Hip
2. Shoulder
3. Umbilicus
4. Costovertebral angle

Answer 18

2

Bladder trauma or injury is characterized by lower abdominal pain that may radiate to one of the shoulders due to phrenic nerve irritation. Bladder injury does not radiate to the umbilicus, costovertebral angle, or hip.

Question 19

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 present?

1. Palpation of a thrill over the fistula
2. Presence of a radial pulse in the left wrist
3. Absence of a bruit on auscultation of the fistula
4. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand

Answer 19

1

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.

Question 20

The nurse is reviewing the client’s record and notes that the physician has documented that the client has a renal disorder. On review of the laboratory results, the nurse most likely would expect to note which of the following?

1. Decreased hemoglobin level
2. Elevated creatinine level
3. Decreased red blood cell count
4. Decreased white blood cell count

Answer 20

2

Measuring the creatinine level is a frequently used laboratory test to determine renal function. The creatinine level increases when at least 50% of renal function is lost. A decreased hemoglobin level and red blood cell count may be noted if bleeding from the urinary tract occurs or if erythropoietic function by the kidney is impaired. An increased white blood cell count is most likely to be noted in renal disease.

Question 21

A nurse is assigned to care for a child suspected to have glomerulonephritis. The nurse reviews the child’s record and notes that which finding is associated with the diagnosis of glomerulonephritis?

1. Hypotension
2. Brown-colored urine
3. Low urinary specific gravity
4. Low blood area nitrogen level

Answer 21

2

Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria, resulting in dark, smoky, cola-colored or brown-colored urine, is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis.

Question 22

A nurse is performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse understands that the most common characteristic associated with nephrotic syndrome is:

1. Hypertension
2. Generalized edema
3. Increased urinary output
4. Frank, bright red blood in the urine

Answer 22

2

Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema. Other manifestations include weight gain; periorbital and facial edema that is most prominent in the morning; leg, ankle, labial, or scrotal edema; decreased urine output and urine that is dark and frothy; abdominal swelling; and blood pressure that is normal or slightly decreased.

Question 23

A nurse interviews the parents of a child recently diagnosed with glomerulonephritis. The nurse understands that which information collected during the assessment most often is associated with the diagnosis of glomerulonephritis?

1. Child fell off bike onto the handlebars
2. Nausea and vomiting for the last 24 hours
3. Urticaria and itching for 1 week before diagnosis
4. Streptococcal throat infection 2 weeks before diagnosis

Answer 23

4

Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Group A beta-hemolytic streptococcal infection is a cause of glomerulonephritis. Often, a child becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks. The assessment data in options 1, 2, and 3 are unrelated to a diagnosis of glomerulonephritis.

Question 24

A nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. What assessment findings would the nurse expect to observe? (Select all that apply.)

1. Pallor
2. Edema
3. Anorexia
4. Proteinuria
5. Weight loss
6. Decreased serum lipids

Answer 24

1, 2, 3, 4

Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The child gains weight.