Hinkle 48 Flashcards
Week 8
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
A
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.
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.
C
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.
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
D
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.
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.
A
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.
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
C
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.
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
C
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.
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
B, E
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.
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
D
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.
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
B
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.
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
A
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.
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
C
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).
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
A
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).
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.”
A
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.
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.
A
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.
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.”
A
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.
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
A, B, D
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.
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.
B
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.
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
C
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.
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
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.
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
C, D, E
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.
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
B
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.
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
D
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.
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.
B
Nursing actions focus on support and symptom control. It is not self-limiting and is not treated surgically or with lithotripsy.
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
C
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.
