Week 7 Concept: Elimination

Hemodialysis

100

A nurse is providing teaching to a client who has chronic kidney disease and is to start hemodialysis. Which of the following information should the nurse include in the teaching? a. Hemodialysis restores renal function. b. Hemodialysis replaces hormonal function of the renal system. c. Hemodialysis allows an unrestricted diet. d. Hemodialysis returns a balance to serum electrolytes.

Answer: D. Hemodialysis returns a balance to serum electrolytes by removing excess sodium, potassium, fluids, and waste products; and restores acid-base balance.

200

A nurse is caring for a client who is receiving hemodialysis and develops disequilibrium syndrome. Which of the following is an appropriate action by the nurse? a. Administer an opioid medication b. Monitor for hypertension c. Assess level of consciousness d. Increase the dialysis exchange rate

Answer: C. The nurse should assess the client’s level of consciousness. A change in urea levels can cause increased intracranial pressure and subsequently, the client’s level of consciousness is decreased.

300

A patient with diabetes mellitus and renal failure begins hemodialysis. Which diet is best on days between dialysis treatments? a. Low protein diet with unlimited amounts of water b. Low protein diet with prescribed amount of water c. No protein in the diet and use of a salt substitute d. No restrictions

Answer: B. The patient should follow a low-protein diet with a prescribed amount of water. The patient requires some protein to meet metabolic needs. Salt substitutes shouldn’t be used without a doctor’s order because it may contain potassium, which could make the patient hyperkalemic. Fluid and protein restrictions are needed.

400

A nurse is preparing to initiate hemodialysis for a client who has acute kidney injury and has been hospitalized. Which of the following are appropriate nursing actions? (Select all that apply) a. Review the client’s current medication history b. Assess the client’s arteriovenous fistula for a bruit c. Calculate the client’s total urine output during the shift d. Obtain the client’s weight e. Check the client’s serum electrolytes f. Use the client’s access site area for venipuncture

Answer: A., B., D., E. A. Reviewing the client’s current medication hx will determine what medications to hold until after dialysis. B. Assessing the client’s AV fistula for a bruit determines the patency of the fistula for dialysis. D. Obtaining the client’s weight before dialysis is needed to compare with the client’s weight after dialysis. E. Checking the client’s serum electrolytes determines the need for dialysis.

500

A nurse is planning postprocedure care for a client who received hemodialysis. Which of the following should the nurse include in the plan of care? (Select all that apply) a. Check BUN and serum creatinine b. Administer medications held prior to dialysis c. Observe for signs of hypovolemia d. Assess the access site for bleeding e. Evaluate blood pressure on side of AV access

Answer: A. The nurse should check the BUN and serum creatinine to determine the presence and degree of uremia or waste products that remain following dialysis. B. Medications that can be partially dialysed during the treatment should be withheld. After the treatment, the nurse should administer the medications. C. A client who is post-dialysis is at risk for hypovolemia due to a rapid decrease in fluid volume. D. The nurse should assess the access site for bleeding because heparin is administered during the procedure to prevent clotting of blood with the dialyzing surfaces.

Peritoneal Dialysis

100

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for the client? a. Impaired urinary elimination b. Self-care deficit c. Risk for infection d. Activity intolerance

Answer: C. Risk for infection Rationale: The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection.

200

A nurse is teaching a client about peritoneal dialysis. The nurse should tell the client the dwell time is: a. 10 minutes b. 20 minutes c. 30 minutes d. 60 minutes

Answer: B. 20 minutes Rationale: The average dwell time is about 20 minutes. The fluid infuses within 10 minutes, dwells for 20 minutes, and then drains in about 20 minutes. The diffusion on the small particles into the dialysis peaks in the first 10 minutes.

300

A male client has doubts about performing peritoneal dialysis at home. He informs the nurse about his existing upper respiratory infection. Which of the following suggestions can the nurse offer to the client while performing an at-home peritoneal dialysis? a) Perform deep-breathing exercises vigorously b) Avoid carrying heavy items c) Auscultate the lungs frequently d) Wear a mask when performing exchanges

Answer: D. Wear a mask when performing exchanges Rationale: The nurse should advise the client to wear a mask while performing exchanges. This prevents contamination of the dialysis catheter and tubing, and is usually advised to clients with upper respiratory infection. Auscultation of the lungs will not prevent contamination of the catheter or tubing. The client may also be advised to perform deep-breathing exercises to promote optimal lung expansion, but this will not prevent contamination. Clients with a fistula or graft in the arm should be advised against carrying heavy items.

400

After teaching a group of students about how to perform peritoneal dialysis, which statement would indicate to the instructor that the students need additional teaching? a) "The effluent should be allowed to drain by gravity." b) "It is important to use strict aseptic technique." c) "The infusion clamp should be open during infusion." d) "It is appropriate to warm the dialysate in a microwave."

Answer: D. "It is appropriate to warm the dialysate in a microwave." Rationale: The dialysate should be warmed in a commercial warmer and never in a microwave oven. Strict aseptic technique is essential. The infusion clamp is opened during the infusion and clamped after the infusion. When the dwell time is done, the drain clamp is opened and the fluid is allowed to drain by gravity into the drainage bag.

500

The client with chronic renal failure has an indwelling abdominal catheter for peritoneal dialysis. The client spills water on the catheter dressing while bathing. The nurse should immediately: a. Change the dressing. b. Reinforce the dressing. c. Flush the peritoneal dialysis catheter. d. Scrub the catheter with providone-iodine.

Answer: A. Change the dressing Rationale: Clients with peritoneal dialysis catheters are at high risk for infection. A wet dressing is a conduit for bacteria to reach the catheter insertion site. The nurse ensures that the dressing is kept dry at all times. Reinforcing the dressing is not a safe practice to prevent infection in this circumstance. Flushing the catheter is not indicated. Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnection of peritoneal dialysis.

Glomerulonephritis

100

A patient with a diagnosis of glomerulonephritis with fluid retention might have which of the following laboratory values? A. Proteinuria B. Low specific gravity C. Low serum creatinine D. High hemoglobin

A. Rationale: Patients with glomerulonephritis will have a urinalysis that reveals proteinuria and elevated specific gravity. Blood tests indicate elevated plasma BUN and serum creatinine; hemoglobin and hematocrit may be low related to fluid retention.

200

A client with glomerulonephritis is at risk of developing acute renal failure. The nurse monitors the client for which sign of this complication? a) bradycardia b) hypertension c) decreased cardiac output d) decreased central venous pressure

B - Acute renal failure caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of acute renal failure is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. Acute renal failure from prerenal causes is characterized by decreased blood pressure or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for renal failure.

300

Which of the following conditions most commonly causes acute glomerulonephritis? A) A congenital condition leading to renal dysfunction. B) Prior infection with group A Streptococcus within the past 10-14 days. C) Viral infection of the glomeruli. D) Nephrotic syndrome.

B Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.

400

A client has been admitted to the hospital with a diagnosis of acute glomerulonephritis. During history-taking the nurse first asks the client about a recent history of: a) bleeding ulcer b) deep vein thrombosis c) myocardial infarction d) streptococcal infection

D- The predominant cause of acute glomerulonephritis is infection with beta hemolytic Streptococcus 3 weeks before the onset of symptoms. In addition to bacteria, other infectious agents that could trigger the disorder include viruses, fungi, and parasites. Bleeding ulcer, deep vein thrombosis, and myocardial infarction are not precipitating causes.

500

A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Select all that apply A) Urine specific gravity of 1.040. B) Urine output of 350 ml in 24 hours. C) Brown ("tea-colored") urine. D) Generalized edema.

A, B, and C Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark "tea colored" urine caused by large amounts of red blood cells. There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis.

Renal Failure

100

A nurse is explaining the concept of fluid restriction to a client with chronic renal failure who has started hemodialysis. The nurse tells the client that the fluid restriction is planned by adding the amount of the daily urine output (if any) and: a) 1800 to 2000 ml b) 1200 to 1500 ml c) 500 to 700 ml d) 200 to 300 ml

C - The usual allowable daily fluid intake of the hemodialysis client is the total of the daily urine output plus 500 to 700 mL. Options 1 and 2 identify high volumes of fluid intake, and option 4 identifies an insufficient volume.

200

A nurse is analyzing the laboratory results of a client with chronic renal failure who is receiving epoetin alfa (Epogen). The nurse interprets that the medication is having the expected effect if the results indicate an increase in which of the following levels? a) red blood cells b) potassium c) creatinine d) phosphorus

A - Epoetin alfa is erythropoietin that has been manufactured through the use of recombinant DNA technology. It is used to treat anemia in the client with chronic renal failure. The other levels rise as a result of the pathology of renal failure and have nothing to do with the effects of this medication.

300

A nurse is caring for a client newly diagnosed with chronic renal failure who has recently begun hemodialysis. The nurse determines that the client has not tolerated the procedure optimally if the client experiences which symptoms that represent disequilibrium syndrome? a) restlessness, irritability, and generalized weakness b) headache, deteriorating level of consciousness, and seizures c) hypertension, tachycardia, and fever d) hypotension, bradycardia, and hypothermia

B - Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. It results from the rapid removal of solutes from the body during hemodialysis. The blood-brain barrier interferes with equally efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. It most often occurs in clients who are new to dialysis, and is prevented by dialyzing for shorter times or at reduced blood flow rates.

400

A nurse has formulated a nursing diagnosis of Risk for Infection for a hemodialysis client with an arteriovenous (AV) fistula in the right arm. The nurse determines that the client has best met the outcome criteria for this nursing diagnosis if which of the following observations is made? a) the client states her or she should do careful handwashing once a day b) the client states her or she should avoid blood pressure measurement in the right arm c) the client's temperature does not exceed 100.6F d) the client's white blood cell (WBC) count is 7500/mm3

D - General indicators that the client is not experiencing infection include a normal temperature and a normal WBC count. Option C is incorrect because the temperature is elevated above normal. The client should also use proper handwashing technique as a general preventive measure; however, handwashing once per day is insufficient, and is therefore incorrect. It is true that the client should avoid blood pressure measurement in the affected arm; however, this would relate more closely to the nursing diagnosis Risk for injury.

500

A nurse is developing a teaching plan for a client with chronic renal failure who has been started on hemodialysis. The nurse would plan to include which of the following pieces of information in discussions with the client? a) it's unnecessary to stay within the fluid restriction on the day before hemodialysis b) it's all right to eat unlimited protein on the day before hemodialysis c) daily medications should be taken after hemodialysis, not before d) daily medications should be double-dosed if going for hemodialysis that day

C - Many medications are dialyzable, which means they are removed from the bloodstream during dialysis. Because of this, many medications are withheld on the day of dialysis until after the procedure. It is not typical for medications to be "double-dosed" because there is no way to be certain how much of each medication is cleared by dialysis. Clients receiving hemodialysis are not routinely taught that it is acceptable to disregard dietary and fluid restrictions.

Medications

100

The nurse is providing dietary instructions to a client who has been prescribed cyclosporine (Sandimmune). Which food item should the nurse instruct the client to exclude from the diet? A. Red meats B. Orange juice C. Grapefruit juice D. Green leafy vegetables

Rationale: C. A compound present in grapefruit juice inhibits metabolism of cyclosporine. As a result, consumption of grapefruit juice can raise cyclosporine levels by 50-100% thereby increasing risk of toxicity.

200

Phenazopyridine (Pyridium) is prescribed for a client for symptomatic relief of pain resulting from a lower urinary tract infection. The nurse should provide the client with which information regarding this medication? A. Take the medication at bedtime B. Take the medication before meals C. Discontinue the medication if a headache occurs D. A reddish orange discoloration of the urine may occur

Rationale: D. The nurse should instruct the client that a reddish-orange discoloration of urine may occur. The nurse should also instruct the client that this discoloration can stain fabric. The medication should be taken after meals to reduce possible GI upset. A headache is an occasional side effect and doesn't warrant discontinuation of the medication.

300

A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication? A. Diuretics B. Antibiotics C. Antitussives D. Decongestants

Rationale: D. In the client with benign prostatic hyperplasia, episodes of urinary retention can be triggered by certain medications such as decongestants, anticholinergics, and antidepressants. The client should be questioned about the use of these medications if the client has urinary retention. Retention can be precipitated by other factors such as alcohol consumption, infection, bed rest, and becoming chilled.

400

Bethanechol chloride (Urecholine) is prescribed for a client with urinary retention. Which disorder would be a contraindication to the administration of this medication? A. Gastric atony B. Urinary strictures C. Neurogenic atony D. Gastroesophageal reflux

Rationale: B. Urecholine can be hazardous to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increasing pressure within the urinary tract. Elevation of pressure could rupture the bladder in clients with these conditions.

500

The nurse is reviewing the lab results for a client receiving tacrolimus (Prograf). Which result would indicate to the nurse that the client is experiencing an adverse effect of the medication? A. Blood glucose of 200 mg/dL B. Potassium level of 3.8 mEq/L C. Platelet count of 300,000 cells/mm3 D. WBC count of 6,000 cells/mm3

Rationale: A. A blood glucose level of 200 mg/dL is significantly elevated above the normal range of 70-110mg/dL and suggests an adverse effect.