Care of Patients with Acute Renal Failure and Chronic Kidney Disease
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Which statement regarding the pathophysiologic process of acute renal failure is true? A. Acute renal failure can result from conditions that cause inadequate kidney perfusion. B. Acute renal failure begins with a gradual process of decreased renal function. C. Acute renal failure results in damage to 90% to 95% of nephrons. D. Acute renal failure is irreversible.
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ANS: A There are many causes of acute renal failure. Conditions that cause inadequate perfusion of the kidney initiate autoregulatory responses that actually decrease urine output.
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A client is brought to the hospital with prerenal azotemia from hypovolemia. What intervention should be initiated if prerenal azotemia is to be reversed? A. Administration of aminoglycoside antibiotics B. Hydration with intravenous fluids C. Initiation peritoneal dialysis D. Restriction of PO fluid
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ANS: B Hypoperfusion of the kidney that results in prerenal azotemia can be reversed with increasing intravascular volume, increasing cardiac output, and increasing blood pressure. IV fluids are given to restore intravascular volume.
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A client with renal failure continues to put out adequate urine. What form of acute renal failure is the client experiencing? A. Prerenal B. Intrarenal C. Nonoliguric D. Postrenal
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ANS: C Some clients have a nonoliguric form of ARF, in which urine output remains near normal.
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. Which laboratory data would reflect early signs of renal tubular damage? A. Decreased hemoglobin level B. Increased serum sodium level C. Increased serum calcium level D. Decreased urine specific gravity
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ANS: D A decrease in urine specific gravity indicates a loss of urine-concentrating ability and is the earliest sign of renal tubular damage.
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Which laboratory data alteration would the nurse expect to see manifested in a client with renal failure? A. Hypokalemia and metabolic acidosis B. Hyperkalemia and metabolic alkalosis C. Hyperphosphatemia and hypocalcemia D. Hypophosphatemia and hypercalcemia
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ANS: C Normally, a reciprocal relationship exists between calcium and phosphate, which is mediated by vitamin D. In renal failure, hyperphosphatemia and hypocalcemia result from a deficiency of activated vitamin D and decreased tubular excretion of phosphate. A decrease in the GFR (glomerular filtration rate) increases the plasma phosphate level, leading to hyperphosphatemia. As phosphate levels increase, phosphate binds to calcium, resulting in a decrease in the serum calcium levels. In the presence of less activated vitamin D, less calcium can be absorbed through the intestinal mucosa.
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Which medication taken by a client diagnosed with acute renal failure may be a potential cause of the disorder? A. Acetaminophen B. Furosemide C. Ibuprofen D. Lanoxin
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ANS: C Acute renal failure can be caused by certain medications considered to have a nephrotoxic effect, such as NSAIDs, ACE inhibitors, and aminoglycoside antibiotics.
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Which intervention will prevent severe blood volume depletion that can lead to renal failure? A. Measuring urine specific gravity B. Encouraging clients' adequate intake of fluids C. Strict intake and output measurements D. Daily body weighing using the same scale
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ANS: B Encouraging clients to maintain adequate fluid intake helps avoid dehydration, which can lead to volume depletion and renal failure.
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Which of the following clients is most at risk of developing postrenal azotemia? A. 45-year-old female client diagnosed with renal calculi B. 73-year-old male client with congestive heart failure C. 55-year-old male client taking NSAIDs for arthritis pain D. 32-year-old female client recovering from glomerulonephritis
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ANS: A Causes of postrenal azotemia include disorders that obstruct the flow of urine, such as renal calculi.
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A client has been admitted to the hospital with oliguric acute renal failure. In the oliguric phase, what changes in laboratory data would the nurse anticipate in this client? A. Renal function indices return to baseline levels. B. Serum BUN, creatinine, and potassium levels and metabolic acidosis increase. C. A transient rise in BUN, creatinine, and potassium levels is followed by metabolic alkalosis. D. The BUN level starts to fall and continues to fall as creatine and potassium levels rise.
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ANS: B The oliguric phase of acute renal failure is characterized by the accumulation of nitrogenous wastes, resulting in increasing levels of serum BUN, creatinine, and potassium and a bicarbonate deficit (metabolic acidosis).
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A 45-year-old man is brought to the emergency department with a right renal calculi causing obstruction. What findings would the nurse expect to see visualized on an x-ray study of the right kidney? A. Normal-sized kidneys bilaterally B. An enlarged right kidney resulting from hydronephrosis C. A shrunken, atrophied right kidney secondary to urinary obstruction D. Dilation of the left kidney in response to obstruction on the right side
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ANS: B An obstruction caused by renal calculi often causes hydronephrosis. On x-ray film, the affected kidney appears enlarged as compared with the unaffected kidney.
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A client has been diagnosed with prerenal azotemia. What clinical manifestations can the nurse expect this client to exhibit? A. Tachycardia, decreased urinary output, and hypotension B. Bradycardia, decreased urinary output, and hypotension C. Bradycardia, scanty urine output, and rising serum electrolyte levels D. Tachycardia, large quantities of dilute urine, and normal serum electrolyte levels
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ANS: A The signs and symptoms of prerenal azotemia are tachycardia, decreased urinary output, hypotension, decreased CVP, and lethargy.
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A client admitted with acute renal failure progresses from the oliguric to the diuretic phase of the disorder. What primary problems might the nurse expect this client to exhibit? A. Hypervolemia with dilute urine B. Hypovolemia and electrolyte loss C. Hypervolemia and electrolyte excess D. Hypovolemia with concentrated urine
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ANS: B When the client moves from the oliguric to the diuretic phase, hypovolemia and electrolyte losses are the primary problems. In the oliguric phase, fluid and electrolytes are retained.
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A client with acute renal failure develops hyperkalemia. What drug should the nurse be prepared to administer? A. Kayexalate B. Furosemide C. Dopamine D. Mannitol
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ANS: A Kayexalate (sodium polystyrene) is a cation exchange resin that exchanges sodium for potassium. This drug can be given orally or as a retention enema.
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A client with acute renal failure has been prescribed a fluid restriction. The client asks how much fluid will be permitted each day. What is the nurse's best response? A. \"Each health care provider decides this individually, based on the amount of permanent damage to your kidneys.\" B. \"You will be permitted to drink an amount equal to the urine you excrete, plus 500 mL.\" C. \"The amount of fluid you can drink is dependent on how much protein you eat each day.\" D. \"You will be permitted to drink approximately 2 L of fluid each day.\"
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ANS: B Fluid intake is generally calculated to equal the amount of urine excreted plus 500 mL.
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A nurse is caring for a client with acute renal failure who has had a femoral vein cannulation for hemodialysis access. For what complication of this procedure should the nurse remain alert? A. Ascites B. Hematoma C. Skin necrosis D. Renal artery occlusion
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ANS: B 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.
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A client with acute renal failure has begun treatment with continuous arteriovenous hemofiltration (CAVH). For what complication of this treatment should the nurse monitor this client? A. Bleeding B. Thrombosis C. Hypertension D. Fluid overload
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ANS: A The greatest risk for clients undergoing CAVH is bleeding resulting from the anticoagulants used to prevent membrane clotting.
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A client with suspected diminished renal functioning has come to the outpatient clinic for an appointment. What laboratory test would be most accurate in assessing this client's renal reserve? A. 24-hour urine for creatinine clearance B. Serum blood urea nitrogen level C. Urine specific gravity D. Serum sodium level
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ANS: A A 24-hour creatinine clearance test is necessary to detect changes in renal reserve. Creatinine clearance is a measure of the glomerular filtration rate. The ability of the glomeruli to act as a filter is decreased in renal disease.
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What statement regarding renal insufficiency (stage II) is true? A. Renal function is reduced, but there is no accumulation of metabolic wastes. B. The healthier kidney compensates for the diseased kidney. C. There is decreased responsiveness to diuretics. D. The kidneys are unable to maintain homeostasis
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ANS: C Stage II renal insufficiency is characterized by a decreased responsiveness to diuretics, the beginning accumulation of metabolic wastes, and decreasing GFR.
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Which of the following manifestations would alert the nurse to a potentially dangerous complication in the client with chronic renal failure? A. Nausea and vomiting B. Soft, less audible heart sounds C. Paresthesias of the hands and feet D. Anemia accompanied by folic acid deficiencies
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ANS: B Soft, less audible heart sounds can signal the accumulation of fluid within the pericardial sac. Fluid accumulation results from the accumulation of uremic toxins causing inflammation of the pericardium and subsequent fluid buildup. Excessive amounts of fluid within the pericardial sac can result in cardiac tamponade, a medical-surgical emergency.
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The renal failure client's respiration rate is rapid and increased in depth. What does this indicate about the client's renal failure? A. The client's blood oxygen level is low. B. The client's blood carbon dioxide is low. C. The client's renal failure is worsening. D. The client's blood pH is too high.
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ANS: C As renal failure advances, acid retention increases and pH decreases. The respiratory system compensates by increasing the rate and depth of respirations to excrete carbon dioxide from the lungs.
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A client with chronic renal failure has developed uremic pericarditis. In assessing the cardiovascular system of this client, what sounds would the nurse expect to hear? A. A harsh, blowing murmur at the left sternal border B. An irregular heartbeat, accompanied by a precordial lift C. A pericardial friction rub, present in systole and diastole D. Soft, distant heart sounds accompanied by an S3
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ANS: C The classic sign of acute pericarditis is the scratchy sound associated with a pericardial friction rub. This sound can be heard in both systole and diastole. Soft, distant heart sounds can be present if the pericarditis is accompanied by an effusion
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A client with mildly diminished renal reserve asks how to prevent further damage to the kidneys. What is the nurse's best response? A. \"Unfortunately, further kidney damage is inevitable with time.\" B. \"You will need to follow a high-protein diet to preserve kidney function.\" C. \"Ask if any newly prescribed medications, foods, or diagnostic tests pose a risk to your kidney function.\" D. \"The diuretics you are taking will prevent further damage by initiating enough urine to remove wastes.\"
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ANS: C Clients with even mild kidney impairment should try to avoid nephrotoxic substances that could potentially harm the kidneys.
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A nurse is caring for a client with chronic renal failure who has developed severe metabolic acidosis. What assessment finding would be expected in this client? A. Hyperventilation B. Bradycardia C. Hypotension D. Seizures
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ANS: A With severe metabolic acidosis, the client will develop hyperventilation, or Kussmaul respiration. DIF: Cogniti
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A nurse is providing dietary teaching to a client who is on hemodialysis. What instruction should 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. \"You will need less protein, because dialysis makes more amino acids available for use.\" D. \"Dialysis removes wastes from the body, so it does not matter how much protein you eat.\"
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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 dialysis.
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Which assessment parameter should the nurse monitor in a client with chronic renal failure to determine fluid and sodium retention status? A. Weight and blood pressure B. Intake and output C. Muscle strength D. Capillary refill
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ANS: A Weight and blood pressure are helpful in estimating fluid and sodium retention. Weight and blood pressure rise with excess fluid and sodium.
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A client with chronic renal failure is on a sodium- and potassium-restricted diet. The client asks if a salt substitute can be used. What is the nurse's best response? A. \"Salt substitutes contain some sodium and should be used in moderation.\" B. \"Salt substitutes contain potassium and therefore should not be used.\" C. \"Salt substitutes may be used once dialysis is begun.\" D. \"You may use a salt substitute any time you like.\"
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ANS: B The client is taught to avoid salt substitutes because most contain potassium. In chronic renal failure, hyperkalemia is a danger because it can lead to cardiac dysrhythmias.
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A nurse observes tall, peaked T waves on the ECG of a client with ESRD. What would be the nurse's best action? A. Prepare an ampule of sodium bicarbonate to counteract metabolic acidosis. B. Nothing; this is a normal finding for individuals with ESRD. C. Check the serum potassium level. D. Repeat the ECG
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ANS: C Tall, peaked T waves are a manifestation of hyperkalemia; thus, the nurse should check the potassium level.
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A client with chronic renal failure says that he will be going to the dentist for a planned tooth extraction. What would be the nurse's best response? A. \"You may take any medication for pain that the dentist prescribes.\" B. \"You should receive prophylactic antibiotics before any dental procedure.\" C. \"You should rinse your mouth with an antiseptic solution once the tooth is removed.\" D. \"Have your dentist check all of your teeth, because kidney problems can cause tooth decay.\"
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ANS: B To prevent sepsis from oral cavity bacteria, the client should be given prophylactic antibiotics before any dental procedure.
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A nurse is administering digoxin to a client with renal disease who has a history of congestive heart failure. For what must the nurse monitor this client? A. Signs of concurrent damage to the liver caused by the metabolism of digoxin B. Signs of muscle tetany caused by the binding of digoxin with calcium C. Signs of digoxin toxicity, because digoxin is excreted by the kidneys D. Skin eruptions and erythema caused by digoxin
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ANS: C Digoxin is excreted by the kidneys. In the presence of renal failure, drug levels are more likely to accumulate, leading to digoxin toxicity.
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A client hospitalized for worsening renal failure suddenly becomes restless and agitated. The assessment reveals tachycardia and crackles bilaterally at the bases of the lungs. What conclusion can the nurse draw from this information? A. The client requires an antianxiety agent. B. The client is developing pulmonary edema. C. The client has not taken the prescribed medications. D. The client is upset about the decline in kidney function.
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ANS: B Restlessness, anxiety, tachycardia, dyspnea, and crackles at the bases of the lungs are early manifestations of pulmonary edema.
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A client has hypertension chronic renal insufficiency. Which of the following are the most effective drugs for controlling hypertension and preserving renal function? A. Angiotension-converting enzyme inhibitors B. Beta-adrenergic blockers C. Calcium channel blockers D. Alpha-adrenergic blockers
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ANS: A Research indicates that ACE inhibitors appear to be the most effective drugs to slow the progression of renal failure.
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Which measure would be appropriate for the nurse to take in caring for a client with chronic renal failure receiving dialysis via a right arm fistula? A. Take the client's blood pressure in both arms. B. Take the client's blood pressure in the left arm only. C. Place the right arm in a sling to protect it from injury. D. Have the client perform active ROM arm exercises to aid blood flow to the fistula.
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ANS: B The blood pressure should be taken in the left arm only to prevent occlusion of the dialysis fistula.
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What assessment would help the nurse determine the patency of a client's AV fistula for dialysis? A. The presence of a strong pulsation at the site of the venous-arterial anastomosis B. Equivalent blood pressure measurements in each arm C. The presence of a thrill, but no bruit D. The presence of a thrill and bruit
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ANS: D The presence of a thrill and bruit are signs that the fistula is patent, without thrombosis.
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To reduce the occurrence of AV fistula thrombus, which action by the nurse would be most appropriate? A. Instruct the client to restrict use of the arm with the fistula for 1 hour after dialysis. B. Run IV fluids as ordered directly into the fistula after dialysis to prevent clotting. C. Rotate needle insertion sites with each dialysis treatment. D. Apply pressure to the puncture site.
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ANS: C Rotation of needle insertion sites with each treatment reduces the risk of thrombus formation at the puncture site.
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In assessing a client after dialysis, a nurse finds a slight elevation in body temperature as compared with predialysis measures. What is the nurse's best action? A. Document the finding as the only action. B. Prepare to culture the fistula site. C. Encourage the client to drink at least 1 L of fluid. D. Notify the physician, because this signals impending sepsis.
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ANS: A The client's temperature may be elevated because the dialysis machine warms the blood slightly. An excessive temperature elevation from baseline can signal sepsis and, in this case, the nurse should inform the physician and obtain blood cultures.
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The physician has prescribed lisinopril for a client with chronic renal failure and hypertension. Which intervention is appropriate for the administration of this drug? A. Administer the drug at 9 AM every morning. B. Administer the drug before hemodialysis. C. Administer the drug during hemodialysis. D. Administer the drug after hemodialysis.
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ANS: D Vasoactive drugs can cause hypotension during hemodialysis and should be held until after hemodialysis.
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During hemodialysis, a client with chronic renal failure develops headache, nausea and vomiting and restlessness. Which initial action by the nurse would be most appropriate? A. Notify the physician immediately. B. Discontinue the hemodialysis immediately. C. Order a blood urea nitrogen level STAT. D. Administer an intravenous bolus of dextrose solution.
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ANS: A Headache, nausea, vomiting, and restlessness may be signs of dialysis disequilibrium syndrome. Rapid decreases in fluid and the BUN level can cause cerebral edema and increased ICP. Early recognition and treatment of this syndrome are essential in preventing a life-threatening situation.
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Which response by the 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 milk the dialysis tubing with every exchange.\" C. \"I will keep the drainage bag at the level of my abdomen.\" D. \"I will stand to decrease the pressure inside the abdomen during the outflow.\"
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ANS: A Constipation is the primary cause of inflow and outflow problems. To prevent constipation, clients are placed on a bowel regimen before the placement of a peritoneal catheter
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A nurse is caring for a client who is undergoing peritoneal dialysis. The nurse notes the color of the effluent to appear cloudy. What is the nurse's best action? A. Irrigate the peritoneal catheter. B. Notify the health care provider. C. Document the finding as the only action. D. Change the dialysate.
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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.
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In assessing a client on CAPD who has had repeated episodes of peritonitis, the home care nurse notes a decline in the amount of outflow. What physiologic explanation can account for this decline? A. The antibiotics prescribed for peritonitis can lead to scarring of the peritoneal membrane and decreased outflow. B. The peritoneal catheter has caused a chronic inflammatory process and, therefore, must be changed. C. Residue from the dialysate fluid has collected along the lumen of the catheter, impeding the flow of effluent. D. Repeated episodes of peritonitis have caused a decline in the ultrafiltration capability.
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ANS: D Repeated episodes of peritonitis can damage the peritoneal membrane, resulting in diminished ultrafiltration capability, which may necessitate transfer to hemodialysis.
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A client with a recently placed peritoneal dialysis catheter has decreased dialysate flow. Which of the following interventions will improve flow? A. Milk the tubing. B. Verify tube placement by x-ray. C. Raise and then lower the drainage bag. D. Disconnect and flush the tubing.
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ANS: A Fibrin clot formation can occur after PD catheter placement. Milking the tubing may dislodge the fibrin clot and improve dialysate flow.
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A client who underwent kidney transplantation 7 days ago has developed oliguria, an increased temperature, lethargy, and elevations in the serum creatinine, BUN, and potassium levels. Which intervention should the nurse anticipate for this client? A. Conservative management of symptoms, until dialysis is required as a result of chronic rejection B. Increase in the doses of immunosuppressive drugs to combat acute rejection C. Immediate removal of the transplanted kidney because of hyperacute rejection D. Institution of peritoneal dialysis to aid the transplanted kidney
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ANS: B Oliguria, lethargy, elevated temperature, and increases in serum electrolyte levels 1 week to 2 years post-transplantation are hallmarks of acute rejection, which can be reversible with increased immunosuppressive therapy.
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A nurse is assessing a renal transplant recipient for maintenance of prescribed drug therapy. Which statement by the client indicates a need for more teaching? A. \"I will need to continue to take insulin for my diabetes.\" B. \"I will have to take the immunosuppressants 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.
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ANS: D A crucial role of the nurse in the long-term follow-up of the renal transplant client is in the maintenance of prescribed drug therapy. Such clients will need to take immunosuppressants for the rest of their lives to prevent rejection of the kidney.
