Chapter 71: Care of Patients with Acute Kidney Injury and Chronic Kidney Disease Nursing School Test Banks

Chapter 71: Care of Patients with Acute Kidney Injury and Chronic Kidney Disease

Test Bank

MULTIPLE CHOICE

1. Which client is most at risk for developing postrenal kidney failure?

a.

Client diagnosed with renal calculi

b.

Client with congestive heart failure

c.

Client taking NSAIDs for arthritis pain

d.

Client recovering from glomerulonephritis

ANS: A

Causes of postrenal kidney failure include disorders that obstruct the flow of urine, such as renal calculi. Heart failure can lead to prerenal failure, which is due to decreased blood flow to the kidneys. Both NSAIDs and glomerulonephritis can damage the kidney, leading to intrarenal failure.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1538

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. A client is admitted to the hospital with a serum creatinine level of 2 mg/dL. When taking the clients history, which question does the nurse ask first?

a.

Do you take any nonprescription medications?

b.

Does anyone in your family have kidney disease?

c.

Do you have yearly blood work done?

d.

Is your diet low in protein?

ANS: A

Acute renal failure can be caused by certain medications considered to have a nephrotoxic effect, such as NSAIDs and acetaminophen. Asking the client whether he or she takes any nonprescription drugs can help determine which medication(s) might have contributed to the problem. A family history is important but is not as vital as assessing for nephrotoxic agents that the client may have ingested. Yearly blood work might reveal a trend in kidney function, but again would not be as important. A diet low in protein would not be an important factor to assess.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

3. A client with a decreased glomerular filtration rate asks how to prevent further damage to the kidneys. Which is the nurses best response?

a.

The diuretics you are taking will prevent further damage.

b.

Kidney damage is inevitable as you age.

c.

Avoid taking NSAIDs.

d.

You will need to follow a high-protein diet.

ANS: C

Kidney failure causes many problems, including decreased glomerular filtration rate. Nephrotoxins can worsen renal failure, especially in someone who already has some loss of kidney function.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1539

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

4. A client who has chronic kidney disease is being discharged from the hospital after receiving treatment for a hip fracture. Which information is most important for the nurse to provide to the client before discharge?

a.

Increase your intake of foods with protein.

b.

Monitor your daily intake and output.

c.

Maintain bedrest until the fracture is healed.

d.

Take your aluminum hydroxide (Nephrox) with meals.

ANS: D

Aluminum hydroxide lowers serum phosphate levels by binding phosphorus present in food. High blood phosphate levels cause hypocalcemia and osteodystrophy; this makes a client prone to fracture. Increasing protein may not be feasible for a client with chronic kidney disease and would not help prevent fracture. Intake and output will not be helpful for orthopedic problems. Bedrest will promote complications.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Teaching/Learning

5. Which intervention is most important for the nurse to implement in a client after kidney transplant surgery?

a.

Promote acceptance of new body image.

b.

Monitor magnesium levels daily.

c.

Place the client on protective isolation.

d.

Remove the indwelling (Foley) catheter as soon as possible.

ANS: D

Because of increased risk for infection related to immune suppressive drugs given to prevent rejection, the catheter is removed as soon as possible to avoid infection, usually 3 to 7 days after surgery. The client may need assistance with changes in body image, but this is not the priority. The client does not require protective precautions. Laboratory values will be monitored frequently in a post-transplant client, but this is not as important as preventing a complication by removing the catheter.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

6. During a hot summer day, an older adult client tells the clinic nurse, I am not drinking or voiding that much these days. The nurse notes a heart rate of 100 beats/min and a blood pressure of 90/60 mm Hg. Which action does the nurse take first?

a.

Give the client something to drink.

b.

Insert an intravenous catheter.

c.

Teach the client to drink 2 to 3 liters a day.

d.

Perform a bladder scan to assess urine volume.

ANS: A

Severe blood volume depletion can lead to kidney failure, even in those who have no kidney problem. The client is showing signs of mild volume depletion. The first action the nurse should take is to give the client something to drink. After that, the nurse should teach the client to avoid dehydration by drinking at least 2 to 3 L of fluid daily. The client does not need an IV at this time. Performing a bladder scan will not help prevent or reverse the clients problem.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems)

MSC: Integrated Process: Nursing Process (Implementation)

7. A client is taking furosemide (Lasix). To detect a common adverse effect, the nurse obtains which assessment as a priority?

a.

Breath sounds

b.

Heart sounds

c.

Intake and output

d.

Nutritional patterns

ANS: C

Lasix is a diuretic that causes increased urine output. If too much urine output occurs, the client may be at risk for hypovolemia, which is a cause of prerenal kidney failure. A marked change in fluid balance seen in the intake and output measurement can help identify the client who may be at risk for hypovolemia. Heart sounds and breath sounds would be more important to assess if the client was receiving Lasix for fluid overload conditions, such as heart failure. Nutrition assessment is important to ensure that the client gets enough potassium, but dehydration is more common and needs more vigorous assessment.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

8. A client with acute kidney failure and on dialysis asks how much fluid will be permitted each day. Which is the nurses best response?

a.

This is based on the amount of damage to your kidneys.

b.

You can drink an amount equal to your urine output, plus 700 mL.

c.

It is based on your body weight and changes daily.

d.

You can drink approximately 2 liters of fluid each day.

ANS: B

For clients on dialysis, fluid intake is generally calculated to equal the amount of urine excreted plus 500 to 700 mL.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1556

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Teaching/Learning

9. Which statement by a client who has undergone kidney transplantation indicates a need for more teaching?

a.

I will need to continue to take insulin for my diabetes.

b.

I will have to take my cyclosporine for the rest of my life.

c.

I will take the antibiotics three times daily until the medication is finished.

d.

My new kidney is working fine. I do not need to take medications any longer.

ANS: D

A crucial role of the nurse in long-term follow-up of the kidney transplantation client involves maintenance of prescribed drug therapy. Such clients will need to take immune suppressants for the rest of their lives to prevent rejection of the kidney.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

10. Which staff member does the charge nurse assign to care for a client newly diagnosed with chronic kidney disease?

a.

Licensed practical nurse who usually works on the unit

b.

Registered nurse floated from the hemodialysis unit

c.

Registered nurse who has taken care of this client before

d.

Registered nurse with the most years of experience

ANS: C

Provide continuity of care, whenever possible, by using a consistent nurse-client relationship to decrease anxiety and promote discussion of concerns.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Support Systems)

MSC: Integrated Process: Nursing Process (Implementation)

11. A client has been missing some scheduled hemodialysis sessions. Which intervention is most important for the nurse to implement?

a.

Discussing with the client his or her acceptance of the disease

b.

Discussing with the client the option of peritoneal dialysis

c.

Rescheduling the sessions to another day or another time

d.

Stressing to the client the importance of going to the sessions

ANS: A

Some people on dialysis retreat into complete or partial denial of the disease and the need for treatment. They may deny the need for dialysis and/or may not adhere to drug therapy and diet restrictions. Providing support as the client struggles to accept the disease is an important step in ensuring compliance with the dialysis regimen. The nurse should explore scheduling options, but missing so many sessions cues the nurse that a bigger problem than just scheduling is involved. The nurse should provide education, but simply stressing the need for dialysis will not help the client accept it. Peritoneal dialysis, with its technical demands on the client and partner, probably is not an option for a client who appears noncompliant with hemodialysis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Nursing Process (Implementation)

12. Assessment findings reveal that a client with chronic kidney disease is refusing to take prescribed medications because of the cost. The client also is having difficulty performing activities of daily living and prefers to sleep most of the day. To which health care team member does the nurse refer the client?

a.

Home health aide

b.

Physical therapist

c.

Psychiatric nurse practitioner

d.

Physician

ANS: C

Professionals from many disciplines are resources for the client with renal failure. A psychiatric evaluation may be needed if depressive symptoms are present. Refusing treatment, having difficulty performing activities of daily living, and excessive sleeping could be signs of depression.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Collaboration with Interdisciplinary Team) MSC: Integrated Process: Nursing Process (Planning)

13. A client has a serum creatinine level of 2 mg/dL and a urine output of 1000 mL/day. How does the nurse categorize the clients kidney injury?

a.

Intrarenal

b.

Nonoliguric

c.

Prerenal

d.

Postrenal

ANS: B

Some clients have a nonoliguric form of acute renal failure (ARF), in which urine output remains near-normal but creatinine rises. The other categories relate to the cause of acute kidney injury.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

14. A client has a serum creatinine level of 2.5 mg/dL, a serum potassium level of 6 mmol/L, an arterial pH of 7.32, and a urine output of 250 mL/day. Which phase of acute kidney failure is the client experiencing?

a.

Intrarenal

b.

Nonoliguric

c.

Oliguric

d.

Postrenal

ANS: C

The oliguric phase of acute kidney failure is characterized by the accumulation of nitrogenous wastes, resulting in increasing levels of serum creatinine and potassium, bicarbonate deficit, and decreased or no urine output.Intrarenal and postrenal refer to causes of kidney injury. Nonoliguric is not a classification.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

15. A client has been diagnosed with acute postrenal kidney injury. Which assessment finding does the nurse assess most carefully for?

a.

Blood urea nitrogen (BUN), 35 mg/dL

b.

Creatinine, 2.5 mg/dL

c.

Feeling of urgency

d.

Weight gain and edema

ANS: C

Postrenal kidney failure is identified by focusing on urinary obstructive problems. Symptoms include changes in the urine stream or difficulty starting urination. All the other distractors can be seen with prerenal and intrarenal kidney injury.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

16. A client with chronic hypertension is seen in the clinic. Which assessment indicates that the clients hypertension is not under control?

a.

Heart rate of 55 beats/min

b.

Serum creatinine level of 1.9 mg/dL

c.

Blood glucose level of 128 mg/dL

d.

Irregular heart sounds

ANS: B

Increased blood pressure damages the delicate capillaries in the glomerulus and eventually results in acute kidney injury. An elevated serum creatinine level is a manifestation of this. Heart rate, blood glucose level, and irregular heart sounds are not correlated with acute kidney injury.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Evaluation)

17. A client is scheduled to have dialysis in 30 minutes and is due for the following medications: vitamin C, B-complex vitamin, and cimetidine (Tagamet). Which action by the nurse is best?

a.

Give medications with a small sip of water.

b.

Hold all medications until after dialysis.

c.

Give the supplements, but hold the Tagamet.

d.

Give the Tagamet, but hold the supplements.

ANS: B

All three medications are dialyzable, meaning that they will be removed by the dialysis. They should be given after the treatment is over.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Analysis)

18. When evaluating the effects of a low-protein diet in a client with chronic kidney disease, the nurse is most concerned with which result?

a.

Albumin level of 2 g/dL

b.

Calcium level of 8.0 mg/dL

c.

Potassium level of 5.2 mmol/L

d.

Magnesium level of 3 mEq/L

ANS: A

Clients with chronic kidney disease are placed on a low-protein diet. However, decreased serum albumin levels indicate that the protein they are taking in is not enough for their metabolic needs. The electrolyte levels in the other options are not related to protein.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Evaluation)

19. A client with acute kidney injury is placed on a fluid restriction. To determine whether outcomes related to fluid balance are being met, the nurse assesses for which finding?

a.

Absence of lung crackles

b.

Decreased serum creatinine level

c.

Decreased serum potassium level

d.

Increased muscle strength

ANS: A

The client with chronic kidney disease is expected to achieve and maintain an acceptable fluid balance. Fluid restriction helps with this outcome. Absence of lung crackles can indicate that the client is not fluid overloaded. The other options are not related to fluid balance.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

20. A client with chronic kidney disease is scheduled to be given the following medications: digoxin (Lanoxin) and epoetin alfa (Epogen). The client reports nausea and vomiting and wishes to wait to take the medications. Which action by the nurse is most appropriate?

a.

Administer both medications with soda crackers.

b.

Allow the client to wait an hour before taking the medications.

c.

Review todays potassium level and notify the health care provider.

d.

Call the health care provider to get an order for anti-nausea medication.

ANS: C

Clients with kidney failure are particularly at risk for digoxin toxicity because the drug is excreted by the kidneys. When caring for clients with chronic kidney disease (CKD) who are receiving digoxin, monitor for signs of toxicity, such as nausea and vomiting. Potassium imbalances can alter digoxin levels as well. The nurse should hold the dose, check the current potassium level, and notify the provider. Giving the digoxin could be dangerous, so the nurse should not administer it with crackers, give it later, or ask for an anti-nausea medication.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Analysis)

21. A client is receiving continuous arteriovenous hemofiltration (CAVH). Which laboratory value does the nurse monitor most closely?

a.

Hemoglobin

b.

Glomerular filtration rate

c.

Sodium

d.

White blood cells

ANS: C

CAVH is used for clients who have fluid volume overload. It continuously removes large quantities of plasma, water, waste, and electrolytes, such as sodium. Fluid removal can also affect the serum sodium level.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1546

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Assessment)

22. A client who is 2 days postfemoral vein cannulation begins to have difficulty with outflow of blood during dialysis. For which complication does the nurse assess?

a.

Hematoma at cannula insertion site

b.

Infection

c.

Oliguria

d.

Skin necrosis at cannula insertion site

ANS: A

The puncture site of the femoral vein is prone to hematoma formation because positioning the extremity can cause movement of the cannula and subsequent bleeding at the site. The hematoma can compress the cannula, decreasing flow through it. The other complications would not diminish outflow.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Assessment)

23. A client is admitted with a 3-day history of vomiting and diarrhea. The clients vital signs are blood pressure, 85/60 mm Hg; and heart rate, 105 beats/min. Which intervention by the nurse takes priority?

a.

Obtain blood and urine cultures.

b.

Start an IV of normal saline as ordered.

c.

Administer antiemetic medications.

d.

Assess the clients recent travel history.

ANS: B

Many types of problems can reduce kidney function. Severe hypotension from shock or dehydration reduces renal blood flow and leads to prerenal acute renal failure (ARF). Volume depletion leading to prerenal azotemia is the most common cause of ARF and usually is reversible with prompt intervention. The nurse should first initiate the ordered IV fluids. Obtaining cultures will help identify a possible cause of the clients symptoms and should be done quickly after the IV has been started. Attending to the clients discomfort would be next. Assessing for travel history, although important, can wait until after the other interventions have been accomplished.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Planning)

24. Which response by a client indicates an understanding of measures to facilitate the flow of peritoneal dialysate fluid?

a.

I will take my stool softeners every day.

b.

I will keep the drainage bag at the level of my abdomen.

c.

Flushing the catheter is needed with each exchange.

d.

Warmed dialysate infusion increases the speed of flow.

ANS: A

Constipation is the primary cause of inflow and outflow problems. To prevent constipation, clients are placed on a bowel regimen before placement of a peritoneal catheter. The drainage bag should be lower than the abdomen. Warming the fluid helps prevent discomfort during the procedure. Flushing the catheter will not facilitate the flow of dialysate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Evaluation)

25. When providing care for a client receiving peritoneal dialysis, the nurse notices that the effluent is cloudy. Which intervention is most important for the nurse to carry out?

a.

Irrigate the peritoneal catheter with saline.

b.

Send a specimen for culture and sensitivity.

c.

Document the finding in the clients chart.

d.

Change the dialysate solution and catheter tubing.

ANS: B

Cloudy or opaque effluent is the earliest sign of peritonitis. The health care provider should be notified, and a sample of the outflow should be sent for culture and sensitivity. Irrigating the catheter or changing the solution and tubing will not help reveal the cause of the problem so that appropriate treatment can be started. Documentation is important but is not the priority.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

26. During hemodialysis, a client with chronic kidney disease develops headache, nausea, vomiting, and restlessness. After notifying the health care provider, which action by the nurse is most appropriate?

a.

Administer a bolus of dextrose solution.

b.

Draw blood for sodium and potassium.

c.

Order a blood urea nitrogen level stat.

d.

Prepare to administer phenytoin (Dilantin),

ANS: D

Headache, nausea, vomiting, and restlessness may be signs of dialysis disequilibrium syndrome. Rapid decreases in fluid and in blood urea nitrogen (BUN) level can cause cerebral edema and increased intracranial pressure (ICP). Early recognition and treatment of this syndrome are essential for preventing a life-threatening situation. Treatment includes administration of anticonvulsants (Dilantin) or barbiturates. Dextrose is not used to treat disequilibrium syndrome, and sodium and potassium levels are not helpful because the symptoms are related to changes in urea levels and increased intracranial pressure. Obtaining the BUN would provide useful information; however, it is more important to treat the problem.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

27. A clients temperature after dialysis is 99 F (37.2 C) and was normal before dialysis. Which is the nurses best action?

a.

Continue to monitor the temperature.

b.

Encourage the client to drink fluids.

c.

Obtain a white blood cell count.

d.

Prepare to culture the fistula site.

ANS: A

The clients temperature may be elevated because the dialysis machine warms the blood slightly. An excessive temperature elevation from baseline can signal sepsis. The nurse should inform the provider and obtain blood cultures if this happens. The other actions are not needed.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

28. The RN has assigned a client with a newly placed arteriovenous (AV) fistula in the right arm to an LPN. Which information about the care of this client is most important for the RN to provide to the LPN?

a.

Avoid movement of the right extremity.

b.

Place gentle pressure over the fistula site after blood draws.

c.

Start any IV lines below the site of the fistula.

d.

Take blood pressure in the left arm.

ANS: D

Repeated compression of a fistula site can result in loss of vascular access. Therefore, avoid taking blood pressures and performing venipunctures or IV placement in the arm with the vascular access. The other statements are not appropriate.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1561

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Communication and Documentation

29. The nurse is providing dietary teaching to a client who was just started on peritoneal dialysis (PD). Which instruction does the nurse provide to this client regarding protein intake?

a.

Your protein needs will not change, but you may take more fluids.

b.

You will need more protein now because some protein is lost by dialysis.

c.

Your protein intake will be adjusted according to your predialysis weight.

d.

You no longer need to be on protein restriction.

ANS: B

When renal disease has progressed and requires treatment with dialysis, increased protein is required in the diet to compensate for protein losses through peritoneal dialysis. The other statements are inaccurate.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1556

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Teaching/Learning

30. A client was just admitted to the emergency department for new-onset confusion. As the nurse starts the IV line, the client says he just finished a hemodialysis session. The IV site is bleeding briskly. What action by the nurse takes priority?

a.

Assess for a bruit and thrill over the vascular access site.

b.

Draw blood for coagulation studies and white blood cell count.

c.

Prepare to administer protamine sulfate.

d.

Hold constant firm pressure with a gauze pad for 5 minutes.

ANS: C

To prevent blood clots from forming within the dialyzer or blood tubing, anticoagulation is needed during hemodialysis treatment. The drug used is heparin, which makes the client at risk for hemorrhage for the next 4 to 6 hours. Protamine sulfate is the antidote to heparin, and the nurse should prepare to administer it. Pressure may help, and someone else can apply it while the nurse is getting the medication. Laboratory studies are not needed because the client is at known risk for bleeding from heparin. Assessing the vascular access device does nothing to help the situation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Analysis)

31. A client with acute kidney injury had normal assessments 1 hour ago. Now the nurse finds that the clients respiration rate is 44 breaths/min and the client is restless. Which assessment does the nurse perform?

a.

Obtain an oxygen saturation level.

b.

Send blood for a creatinine level.

c.

Assess the client for dehydration.

d.

Perform a bedside blood glucose.

ANS: A

A complication of acute kidney injury is pulmonary edema. Manifestations of this include tachypnea; frothy, blood-tinged sputum; and tachycardia, anxiety, and crackles. The nurse needs to obtain an oxygen saturation, listen to the clients lungs, and notify the health care provider, so that treatment can be started. The other interventions are not helpful.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

32. A client has end-stage kidney disease (ESKD). Which food selection by the client demonstrates understanding of a low-sodium, low-potassium diet?

a.

Bananas

b.

Ham

c.

Herbs and spices

d.

Salt substitutes

ANS: C

Herbs and spices can be used in place of salt to enhance food flavor. Bananas are high in potassium. Ham is high in sodium. Many salt substitutes contain potassium chloride and should not be used.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Evaluation)

33. A client who is admitted to the hospital with a history of kidney disease begins to have difficulty breathing. Vital signs are as follows: blood pressure, 90/70 mm Hg; heart rate, difficult to feel peripheral pulses. His heart sounds are difficult to hear. Which intervention does the nurse prepare for?

a.

Administration of digoxin (Lanoxin)

b.

Draining of pericardial fluid with a needle

c.

Emergency hemodialysis

d.

Placement of a pacemaker

ANS: B

These signs and symptoms are of cardiac tamponade, an emergency situation in which fluid accumulates in the pericardial sac, making it difficult for the heart to pump normally. Treatment includes a pericardiocentesis, or withdrawing the fluid with a needle or catheter. The other interventions are not appropriate in this situation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

34. A client with chronic kidney disease states that he will be going to the dentist for a planned tooth extraction. Which is the nurses best response?

a.

Rinse your mouth with an antiseptic solution after the procedure.

b.

Kidney disease is probably what caused your dental decay.

c.

You should receive prophylactic antibiotics before any dental procedure.

d.

You may take any medication for pain that the dentist prescribes.

ANS: C

To prevent sepsis from oral cavity bacteria, the client should be given prophylactic antibiotics before any dental procedure. Rinsing the mouth with antiseptic solution would not be sufficient to prevent infection. Kidney disease may have contributed to the dental decay through loss of calcium from the teeth, but this cannot be confirmed. Clients with kidney disease should not take antibiotics known to be nephrotoxic. Dosage adjustments based on the clients kidney function may be needed.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1557

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Teaching/Learning

35. A client hospitalized for worsening kidney injury suddenly becomes restless and agitated. Assessment reveals tachycardia and crackles bilaterally at the bases of the lungs. Which is the nurses first intervention?

a.

Begin ultrafiltration.

b.

Administer an antianxiety agent.

c.

Place the client on mechanical ventilation.

d.

Place the client in high Fowlers position.

ANS: D

Restlessness, anxiety, tachycardia, dyspnea, and crackles at the bases of the lungs are early manifestations of pulmonary edema, which is a complication of kidney failure. Initial treatment of pulmonary edema consists of placing the client in high Fowlers position and administering oxygen. Mechanical ventilation and ultrafiltration may be indicated if symptoms become worse. An antianxiety agent would not be helpful. Morphine, however, has both vasoactive and sedating effects.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

36. The nurse is caring for a client with chronic kidney disease who has developed uremia. Which assessment finding does the nurse correlate with this problem?

a.

Decreased breath sounds

b.

Foul-smelling urine

c.

Heart rate of 50 beats/min

d.

Respiratory rate of 40 breaths/min

ANS: D

A client with uremia will also have metabolic acidosis. With severe metabolic acidosis, the client will develop hyperventilation, or Kussmaul respirations, as the body attempts to compensate for the falling pH. The other manifestations would not be associated with acidosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

37. A client has end-stage kidney disease (ESKD). The nurse observes tall, peaked T waves on the clients cardiac monitor. Which action by the nurse is best?

a.

Check the serum potassium level.

b.

Document the finding in the clients chart.

c.

Prepare to give sodium bicarbonate.

d.

Call the health care provider to request an electrocardiogram (ECG).

ANS: A

Tall, peaked T waves are a manifestation of hyperkalemia. Thus, the nurse should check the potassium level. Afterward, the nurse should report findings to the provider. The client may need an ECG, but treatment may be based on monitor tracings and potassium levels. Sodium bicarbonate is not warranted. Documentation is important but is not the priority.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

38. Which assessment parameter does the nurse monitor in a client with chronic kidney disease to determine fluid and sodium retention status?

a.

Capillary refill

b.

Intake and output

c.

Muscle strength

d.

Weight and blood pressure

ANS: D

Weight and blood pressure are helpful in estimating fluid and sodium retention. Weight and blood pressure rise with excess fluid and sodium. Weight is the most accurate noninvasive assessment for fluid status and therefore sodium status. Capillary refill also gives information on perfusion and oxygenation so is not specific for fluid status. Intake and output are part of the assessment for fluid status but do not account for insensitive water losses. Muscle strength is unrelated.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

39. The nurse is caring for a client who is receiving peritoneal dialysis (PD). Which nursing intervention has the greatest priority when a dialysis exchange is performed?

a.

Adding potassium and antibiotic to the dialysate bags

b.

Positioning the client on either side

c.

Using sterile technique when hooking up dialysate bags

d.

Warming the dialysate fluid in a microwave oven

ANS: C

Peritonitis is the major complication of PD. The most common cause of peritonitis is connection site contamination. To prevent peritonitis, use meticulous sterile technique when caring for the PD catheter and when hooking up or clamping off dialysate bags. This safety precaution is the priority. Never warm dialysate fluid in the microwave. Positioning the client may help with the flow of fluid. Clients may need additives to their dialysate fluid, but potassium and antibiotics are not added together because interactions between them can reduce the effectiveness of the antibiotic.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment)

MSC: Integrated Process: Nursing Process (Implementation)

40. The nurse is providing a client with a peritoneal dialysis exchange. The nurse notes the presence of cloudy peritoneal effluent. Which action by the nurse is most appropriate?

a.

Document the finding in the clients chart.

b.

Collect a sample to send to the laboratory.

c.

Reposition the client on the left side.

d.

Increase the free water content in the next bag.

ANS: B

Cloudy or opaque effluent is an early sign of peritonitis. The nurse should collect and send a sample for culture. Then the nurse should document the finding. The other two options are not appropriate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

41. A client is 12 hours postkidney transplantation. The nurse notes that the client has put out 2000 mL of urine in 10 hours. Which assessment does the nurse carry out first?

a.

Skin turgor

b.

Blood pressure

c.

Serum blood urea nitrogen (BUN) level

d.

Weight of the client

ANS: B

After transplantation, the client may have diuresis. Excessive diuresis might cause hypotension. Hypotension needs to be prevented because it can reduce blood flow and oxygen to the new kidney, threatening graft survival. The other assessments can give information about fluid balance, but hypotension is the main concern here, so the nurse needs to check the clients blood pressure, then notify the provider.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

42. A client who underwent kidney transplantation 7 days ago has developed the following signs: urine output, 50 mL/12 hr; temperature, 102.2 F (39 C); lethargy; serum creatinine, 2.1 mg/dL; blood urea nitrogen (BUN), 54 mg/dL; and potassium, 5.6 mEq/L. Which initial intervention does the nurse anticipate for this client?

a.

Immediate hemodialysis

b.

Increased dose of immune suppressive drugs

c.

Initiation of IV antibiotics after cultures are obtained

d.

Placement of a catheter for peritoneal dialysis

ANS: B

Oliguria, lethargy, elevated temperature, and increases in serum electrolyte levels, BUN, and creatinine, 1 week to 2 years post-transplantation are hallmarks of acute rejection, which can be reversible with increased immune suppressive therapy. The client does not need hemodialysis, peritoneal dialysis, or antibiotics at this point.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

43. The nurse is assessing a client with acute kidney injury and hears the following sound when auscultating the lungs. For what complication does the nurse plan care? (Click the media button to hear the audio clip.)

a.

ac tamponade

b.

Pericarditis

c.

Pulmonary edema

d.

Myocardial Infarction

ANS: B

The sound heard is a pericardial friction rub. This is heard in pericarditis because the pericardial sac becomes inflamed from uremic toxins. Other manifestations include low-grade fever, tachycardia, and chest pain. A tamponade would manifest as muffled heart tones. Pulmonary edema would manifest with crackles in the lungs. A myocardial infarction may or may not have abnormal chest sounds associated with it.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

MULTIPLE RESPONSE

1. A client asks the nurse, What are the advantages of peritoneal dialysis over hemodialysis? Which response by the nurse is accurate? (Select all that apply.)

a.

It will give you greater freedom in your scheduling.

b.

You have less chance of getting an infection.

c.

You need to do it only three times a week.

d.

You do not need a machine to do it.

e.

You will have fewer dietary restrictions.

ANS: A, D, E

Although peritoneal dialysis is slower than hemodialysis, it does not require a specially trained registered nurse and can be done at home, allowing for greater flexibility in scheduling. Peritoneal dialysis is ambulatory, and a machine is not needed. Nursing implications for hemodialysis include vascular access care and diet restrictions, whereas peritoneal dialysis allows for a more flexible diet (abdominal catheter care is still necessary).

DIF: Cognitive Level: Comprehension/Understanding REF: Table 71-9, p. 1558

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Teaching/Learning

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