Chapter 36: Management of Clients with Renal Failure Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 36: Management of Clients with Renal Failure

MULTIPLE CHOICE

1. The nurse caring for a client in the diuretic phase of acute renal failure (ARF) should assess for manifestations of

a.

dehydration.

b.

hypertension.

c.

hypokalemia.

d.

metabolic acidosis.

ANS: A

A gradual or abrupt return to glomerular filtration and leveling of blood urea nitrogen (BUN) level signal the diuretic phase. Urine output may be 1000 ml/day, which may lead to dehydration.

DIF: Application/Applying REF: p. 810 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

2. A client with ARF is allowed a specific amount of fluid by mouth during 24 hours in order to

a.

compensate for insensible and measured fluid losses during the previous 24 hours.

b.

equal the expected urine output for the next 24 hours.

c.

prevent hyperkalemia, which could lead to serious cardiac dysrhythmia.

d.

prevent the development of complicating hypostatic pneumonia.

ANS: A

Fluid replacement volumes are usually calculated on the basis of some fraction of the previous days urine output plus an amount (e.g., 400 ml) to account for the usual insensible loss that occurs during a 24-hour period.

DIF: Knowledge/Remembering REF: p. 811 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

3. The nurse explains that a cation exchange resin such as Kayexalate will

a.

decrease diastolic blood pressure.

b.

stimulate diuresis by osmosis.

c.

increase appetite by decreasing insulin degradation.

d.

increase gastrointestinal potassium excretion.

ANS: D

Hyperkalemia is probably the most dangerous imbalance because of its contribution to cardiac dysrhythmias and arrest. Cation exchange resins such as sodium polystyrene sulfonate (Kayexalate) may be administered orally or rectally to facilitate excretion of potassium from the gastrointestinal (GI) tract.

DIF: Comprehension REF: p. 813 OBJ: Intervention

MSC: Physiological Integrity

4. A client with oliguric ARF would exhibit

a.

a BUN/creatinine ratio of 30:1.

b.

hematuria.

c.

proteinuria.

d.

a urine specific gravity of 1.001.

ANS: A

In oliguric ARF, urine production usually falls below 400 ml/day. The BUN/creatinine ratio is significantly elevated, reaching levels of 10:1 to 40:1.

DIF: Knowledge/Remembering REF: p. 810 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

5. The nurse explains to a clients family that the most common overall manifestation of ARF is that

a.

expected urine output is altered.

b.

the clients breath develops a fruity odor.

c.

urine specific gravity is greater than 1.040.

d.

urine develops a root beer color.

ANS: A

The most common overall manifestation of ARF is alteration in the expected urine output. Usually this is oliguria or anuria, although polyuric ARF accounts for 30% of cases.

DIF: Comprehension/Understanding REF: p. 810 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

6. A client has been on dialysis for 6 weeks. The family is complaining that instead of feeling grateful at this second chance at life, the client has become irritable with them and seems depressed. The most helpful response by the nurse would be

a.

Depression is very common at this time; it is hard to adapt to the losses s/he feels.

b.

I am surprised that your loved one doesnt feel happier about being alive.

c.

This must be very hard on you for your loved one to be so unappreciative.

d.

We can arrange a psychiatric consultation if you think it will help.

ANS: A

Clients are often happy and grateful as they start dialysis and begin to feel well for the first time in a long time. But as the time goes by and the implication of the permanent change to their lives becomes apparent, it is common for them to have psychosocial difficulties, including depression. In fact, the suicide rate for dialysis clients is estimated to be 100 times that of the general public. The other three options not only do not give helpful information about what is happening but also are poor examples of therapeutic communication.

DIF: Application/Applying REF: p. 829 OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Grief and Loss

7. While caring for a client in the oliguric phase of ARF, the nurses plan of care should include

a.

encouraging fluid intake to prevent dehydration.

b.

increasing the clients protein intake to prevent muscle wasting.

c.

maintaining reverse isolation to prevent infection.

d.

meticulous skin care to prevent skin breakdown.

ANS: D

The poor systemic nutrition and edema accompanying renal failure may cause skin breakdown. Meticulous skin care, frequent turning, and special mattresses are very important. Clients may well be on fluid restrictions. They do not need reverse isolation. Protein is often restricted as well.

DIF: Application/Applying REF: p. 815 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

8. The nurse assesses the client for the electrolyte imbalance that tends to occur in the earlier stages of chronic renal failure, which is

a.

hypercalcemia.

b.

hypocalcemia.

c.

hypokalemia.

d.

hyponatremia.

ANS: C

The tubular salt-wasting properties of some failing kidneys, in addition to vomiting and diarrhea, may cause hyponatremia. Late in the disease the problem becomes hypernatremia.

DIF: Application/Applying REF: p. 817 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Fluid and Electrolyte Imbalances

9. The client with chronic renal failure who would not be a candidate for peritoneal dialysis is a client

a.

who has diabetes mellitus.

b.

who is a 10-year-old child.

c.

with severe cardiovascular disease.

d.

with severe respiratory disease.

ANS: D

Relative contraindications to peritoneal dialysis include obesity, history of ruptured diverticuli, abdominal disease, respiratory disease, recurrent episodes of peritonitis, abdominal malignancies, severe vascular disease, and extensive abdominal surgery with drains or tubes, which may increase risk of infection.

DIF: Knowledge/Remembering REF: p. 823 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Illness Management

10. During peritoneal dialysis the clients dialysate white blood cell count is 150/mm3 and neutrophils are 60%. This would indicate that the client has developed

a.

anemia.

b.

bowel perforation.

c.

peritonitis.

d.

pyelonephritis.

ANS: C

Peritonitis is diagnosed when the dialysate white blood cell count is greater than 100/mm3 and neutrophils are greater than 50%.

DIF: Knowledge/Remembering REF: p. 825 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Laboratory Values

11. The nurse notes in the first few exchanges during peritoneal dialysis of a client that the effluent is tinged pink. The nurses most appropriate action is to

a.

continue the dialysis.

b.

notify the physician.

c.

send a specimen for culture.

d.

stop the dialysis immediately.

ANS: A

Bloody effluent is usually insignificant and disappears spontaneously.

DIF: Application/Applying REF: p. 825 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

12. The nurse explains to a client with chronic renal failure that the rationale for receiving calcium carbonate is that it

a.

binds with phosphorus to eliminate it from the body.

b.

binds with potassium to eliminate it from the body.

c.

helps prevent constipation.

d.

helps prevent ulcer formation.

ANS: A

To improve excretion of phosphorus, the client with chronic renal failure is given calcium-based phosphate binders, such as calcium acetate or calcium carbonate.

DIF: Comprehension/Understanding REF: p. 829 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

13. In caring for a chronic dialysis patient with an arteriovenous fistula, the nurse would

a.

avoid getting the fistula site wet during the clients bath.

b.

irrigate the fistula with heparin to prevent clotting.

c.

not use the arm with the fistula when taking the clients BP.

d.

perform dressing changes to prevent infection.

ANS: C

Blood pressure should not be measured on or blood drawn from the limb containing the access. Between dialysis periods the skin over the fistula or graft requires only routine care with soap and water. The graft does not need heparin injections.

DIF: Application/Applying REF: p. 834 OBJ: Intervention

KEY: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

14. During a clients first dialysis treatment, the client complains of a severe headache and appears somewhat confused. The priority action by the nurses is to

a.

administer oxygen by nasal cannula.

b.

encourage the client to drink fluids.

c.

notify the physician immediately.

d.

slow the rate of the dialysis.

ANS: C

Dialysis equilibrium syndrome can occur after dialysis, particularly during the clients first few dialysis episodes. The syndrome is characterized by mental confusion, deterioration in level of consciousness, headache, and seizures and may last for several days. The frequency or strength of the dialysate may need to be altered. The priority action by the nurse is to notify the physician; the nurse should not independently slow the dialysis rate or encourage the client to drink fluids as fluids may be restricted. Oxygen will not help the situation.

DIF: Application/Applying REF: p. 828 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

15. A client has been found to be an acceptable candidate for a kidney transplant. The nurse counsels the client and family that the client now faces the greatest impediment to renal transplantation, which is

a.

high potential for rejection.

b.

high risk for infection.

c.

insufficient financial resources.

d.

lack of sufficient donor organs.

ANS: D

The primary factor limiting the number of transplants done is the availability of kidneys.

DIF: Comprehension/Understanding REF: p. 835 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

16. Three months after a kidney transplant, a client develops fever, graft tenderness, malaise, and elevated white blood cell count. The nurse conducts further assessments based on understanding that the likely cause of these manifestations is

a.

graft rejection.

b.

influenza.

c.

pyelonephritis.

d.

urinary tract infection.

ANS: A

Clinical manifestations of renal transplant rejection include fever, graft tenderness, anemia, and malaise.

DIF: Application/Applying REF: p. 835 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

17. A client with renal failure has an order to infuse dopamine (Intropin) to activate the dopamine receptors in the kidney. The nurse would set the infusion rate for

a.

21 to 25 mg/kg/minute.

b.

11 to 20 mg/kg/minute.

c.

6 to 10 mg/kg/minute.

d.

1 to 5 mg/kg/minute.

ANS: D

Low doses (1 to 5 mg/kg/minute) of dopamine hydrochloride (Intropin) may be given to activate dopamine receptors in the kidney.

DIF: Analysis/Analyzing REF: p. 813 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

18. For the nurse trying to assist a client with renal failure to stay within the prescribed fluid restriction, the least helpful strategy would be to

a.

give medication at mealtime.

b.

provide frequent oral hygiene.

c.

put allotted water into a spray bottle.

d.

use ice chips liberally instead of fluids.

ANS: D

The nurse helps the client stay within the prescribed fluid restriction with careful oral hygiene and judicious use of ice chips, lip ointments, and appropriate diversionary activities. Placing the allotted water in a spray bottle may help to spread out the amount taken. To conserve fluids for the client with renal failure, medications are administered with meals, if possible.

DIF: Application/Applying REF: p. 831 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

19. The nurse teaching a client about continuous ambulatory peritoneal dialysis (CAPD) would include the information that

a.

a small, lightweight pump must be carried in a pocket or on a belt.

b.

CAPD eliminates the need for strict aseptic technique when handling the catheter.

c.

the procedure involves instilling 250 to 500 ml of fluid at a time.

d.

there are four daily cycles with an 8-hour dwell for one cycle during the night.

ANS: D

CAPD usually uses four dialysis cycles every 24 hours, including an 8-hour dwell overnight. There is still the need for asepsis.

DIF: Comprehension/Understanding REF: p. 824 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

20. The nurse performing intermittent peritoneal dialysis notes that the medical record shows the client has not had a bowel movement for 3 days. The nurse would be careful to assess the client for

a.

cloudy dialysate output.

b.

fluid leakage.

c.

increased thirst.

d.

reduced catheter outflow.

ANS: D

Constipation can reduce catheter flow, possibly because peristalsis facilitates outflow.

DIF: Application/Applying REF: p. 825 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

21. To help the peritoneal dialysis client who is complaining of low back pain associated with increased weight in the abdomen, the nurse would suggest

a.

lying down as much as possible.

b.

performing specified exercises.

c.

reducing voluntary fluid intake.

d.

walking on surfaces with gradual inclines.

ANS: D

Low back pain may develop with continuous dialysis procedures because the abdominal weight affects posture. Appropriate exercises may help relieve this problem.

DIF: Application/Applying REF: p. 825 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

22. To assess the effect of epoetin alfa on a client with chronic renal failure, the nurse would monitor

a.

blood urea nitrogen level.

b.

hematocrit level.

c.

leukocyte count.

d.

serum creatinine level.

ANS: B

Anemia in clients with chronic renal failure is treated primarily with erythropoietin, a hormone produced in the kidney that stimulates red blood cell production.

DIF: Application/Applying REF: p. 822 OBJ: Assessment

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

23. The nurse is conducting peritoneal dialysis for a client with renal failure and finds the drainage tubing has no outflow. The priority action that the nurse would take is to

a.

apply a 5-pound sandbag to the abdomen.

b.

check the tubing for kinks or obstruction.

c.

notify the physician about the problem.

d.

try a more concentrated dialysate solution.

ANS: B

If fluid does not drain properly during peritoneal dialysis, the nurse should check the system for kinks or other obstructions. If there is no obvious problem, then the nurse should notify the physician. The other two options are not related.

DIF: Application/Applying REF: p. 831 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

24. For a client with chronic renal failure who is experiencing insomnia, the least helpful strategy would be

a.

establishing a pre-sleep quiet time.

b.

planning on a standard time to go to bed.

c.

setting up a bedtime routine.

d.

taking an over-the-counter sedative drug.

ANS: D

Hypnotics and sedatives must be used cautiously because these drugs may alter mentation and may not be adequately cleared by the failing kidneys.

DIF: Application/Applying REF: p. 832 OBJ: Intervention

MSC: Physiological Integrity Basic Care and Comfort-Rest and Sleep

25. A client is complaining about the decrease in quality of life experienced since the client started dialysis. Using recent research to guide suggestions, the nurse counsels the client to

a.

become more active in care planning.

b.

engage in regular exercise.

c.

start attending church if not already going.

d.

try to stay active in the community.

ANS: B

While all suggestions might help improve quality of life for the client undergoing dialysis, a recent research study with 226 participants identified exercise activity as the most important predictor of quality of life approximately 60 days after starting dialysis.

DIF: Analysis/Analyzing REF: p. 830 OBJ: Intervention

MSC: Psychosocial Integrity Psychosocial Adaptation-Quality of Life

26. A client had a kidney transplant and is doing well, except for being concerned that the spouse does not seem happy about it. The assessment by the nurse that would yield the most helpful information is to ask the

a.

client what hobbies and activities they enjoy together.

b.

client why he/she thinks the spouse is acting that way.

c.

spouse how he/she feels about the clients progress.

d.

spouse what his/her role was while the client was ill.

ANS: D

After a kidney transplant, the client must incorporate the new kidney and better functional status into his or her self-image. Family members must also adapt. For both client and family, role changes occur that require adaptation. Family members may no longer feel needed if they took care of the client. Asking the spouse what his/her role was during the clients illness will give the nurse information about the spouses role and the nurse can then start a discussion of role adaptation.

DIF: Analysis/Analyzing REF: p. 836 OBJ: Assessment

MSC: Psychosocial Integrity Coping and Adaptation-Situational Role Changes

27. A client had an episode of acute renal failure after heart surgery but seems to have recovered now. What is an important health promotion strategy the nurse could teach the client? The nurse should teach the client to

a.

avoid aminoglycosides and IVP dye in the future.

b.

drink lots of fluids on an ongoing basis.

c.

have a BUN and creatinine drawn every 6 months.

d.

monitor his/her temperature daily.

ANS: A

An important health promotion strategy to help prevent renal failure is to avoid nephrotoxic agents, including aminoglycosides and IVP dye.

DIF: Application/Applying REF: pp. 809-810, 813

OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

28. A nurse is planning care for a client who has chronic kidney disease. Which of the following interventions would help the client meet a priority outcome?

a.

Delegate monitoring vital signs during dialysis to the nurses aide.

b.

Instruct the client not to get out of bed without assistance.

c.

Place a sign on the door outlining the fluid allotment for each shift.

d.

Plan to weigh the client each morning on the same scale.

ANS: B

Almost 90% of clients with chronic kidney disease have renal osteodystrophy. This demineralization of the bones leaves them vulnerable to fracture with slight trauma. The client should have assistance when getting out of bed to avoid injury. Client safety is a TJC priority. Option a does not meet a client outcome; option c is a good idea, except then the client cannot see how fluids are divided over the day; option d is a good intervention to monitor fluid status, but does not address a safety need.

DIF: Application/Applying REF: p. 821 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

MULTIPLE RESPONSE

1. A client is at a follow-up appointment and confesses that s/he does not take medications as prescribed. When planning a teaching strategy to address this problem, the nurse understands that clients often do not adhere to self-care guidelines because (Select all that apply)

a.

a good understanding of the consequences leads them to skip meds.

b.

clients may believe they no longer need the medications.

c.

side effects may be disruptive and unpleasant.

d.

the economic costs are too high for them to absorb.

ANS: B, C, D

There are many reasons for noncompliance, including options b, c, and d. Failure to follow prescribed guidelines is a major problem and the nurses challenge is to collaborate on a plan to take medications as directed while fitting this activity into the clients lifestyle.

DIF: Comprehension/Understanding REF: p. 836 OBJ: Assessment

MSC: Health Maintenance and Promotion Prevention and/or Early Detection of Health Problems-Self Care

2. The nurse monitoring a client load for risks of acute renal failure (ARF) understands that older clients are more susceptible to ARF because (Select all that apply)

a.

cardiac contractile function and kidney perfusion diminish with age.

b.

medication use is generally lower in this age group.

c.

of a higher probability of pre-existing renal damage.

d.

older adults have more difficulty with fluid balance in general.

e.

the ability to retain sodium declines with age.

ANS: A, C, D, E

There are several reasons why older clients are at increased risk of ARF, including options a, c, d, and e. Older clients also have more difficulty concentrating urine. Elderly clients in general take more medications that do clients in other age groups.

DIF: Application/Applying REF: p. 816 OBJ: Assessment

MSC: Health Promotion and Maintenance Growth and Development Through the Lifespan-Age Related Differences

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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