Diabetes, Renal Failure and Dialysis

Dialysis

100

Dialysis allows for the exchange of particles across a semipermeable membrane by which of the following actions? 1. Osmosis and diffusion 2. Passage of fluid toward a solution with a lower solute concentration 3. Allowing the passage of blood cells and protein molecules through it. 4. Passage of solute particles toward a solution with a higher concentration.

What is A. Osmosis allows for the removal of fluid from the blood by allowing it to pass through the semipermeable membrane to an area of high concentrate (dialysate), and diffusion allows for passage of particles (electrolytes, urea, and creatinine) from an area of higher concentration to an area of lower concentration. Fluid passes to an area with a higher solute concentration. The pores of a semipermeable membrane are small, thus preventing the flow of blood cells and protein molecules through it.

200

5. A nurse is assessing the patency of an arteriovenous fistula in the left arm of a client who is receiving hemodialysis for the treatment of chronic renal failure. Which finding indicates that the fistula is patent? a. Absence of bruit on auscultation of the fistula. b. Palpation of a thrill over the fistula c. Presence of a radial pulse in the left wrist d. Capillary refill time less than 3 seconds in the nail beds of the fingers on the left hand

What is B. The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and bruit indicate patency of the fistula. Although the presence of a radial pulse in the left wrist and capillary refill time less than 3 seconds in the nail beds of the fingers on the left hand are normal findings, they do not assess fistula patency.

300

A patient receiving hemodialysis treatment arrives at the hospital with a blood pressure of 200/100, a heart rate of 110, and a respiratory rate of 36. Oxygen saturation on room air is 89%. He complains of shortness of breath, and +2 pedal edema is noted. His last hemodialysis treatment was yesterday. Which of the following interventions should be done first? a. Administer oxygen b. Elevate the foot of the bed c. Restrict the client’s fluids d. Prepare the client for hemodialysis.

What is A. Airway and oxygenation are always the first priority. Because the client is complaining of shortness of breath and his oxygen saturation is only 89%, the nurse needs to try to increase his levels by administering oxygen. The client is in pulmonary edema from fluid overload and will need to be dialyzed and have his fluids restricted, but the first interventions should be aimed at the immediate treatment of hypoxia. The foot of the bed may be elevated to reduce edema, but this isn’t the priority.

400

A patient is diagnosed with chronic renal failure and told she must start hemodialysis. Patient teaching would include which of the following instructions? a. Follow a high potassium diet b. Strictly follow the hemodialysis schedule c. There will be a few changes in your lifestyle. d. Use alcohol on the skin and clean it due to integumentary changes.

What is B. strictly follow the hemodialysis schedule To prevent life-threatening complications, the patient must follow the dialysis schedule. Alcohol would further dry the patient's skin more than it already is. The patient should follow a low-potassium diet because potassium levels increase in chronic renal failure. The patient should know hemodialysis is time-consuming and will definitely cause a change in current lifestyle.

500

2. A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the dwell clamp is opened to allow the dialysate to drain. The nurse notes that the drainage has stopped and only 500 ml has drained; the amount the dialysate instilled was 1,500 ml. Which of the following interventions would be done first? a. Change the client’s position. b. Call the physician. c. Check the catheter for kinks or obstruction. d. Clamp the catheter and instill more dialysate at the next exchange time.

C. The first intervention should be to check for kinks and obstructions because that could be preventing drainage. After checking for kinks, have the client change position to promote drainage. Don’t give the next scheduled exchange until the dialysate is drained because abdominal distention will occur, unless the output is within parameters set by the physician. If unable to get more output despite checking for kinks and changing the client’s position, the nurse should then call the physician to determine the proper intervention.

Renal Failure

100

A client is admitted to the hospital and has a diagnosis of early stage chronic renal failure. Which of the following would the nurse expect to note on assessment of the client? 1. Polyuria 2. Polydipsia 3. Oliguria 4. Anuria

What is: 1. Polyuria occurs early in chronic renal failure and if untreated can cause severe dehydration. Polyuria progresses to anuria, and the client loses all normal functions of the kidney. Oliguria and anuria are not early signs, and polydipsia is unrelated to chronic renal failure.

200

Which of the following clients is at greatest risk for developing acute renal failure? 1. A dialysis client who gets influenza 2. A teenager who has an appendectomy 3. A pregnant woman who has a fractured femur 4. A client with diabetes who has a heart catherization

What is: 4. Clients with diabetes are prone to renal insufficiency and renal failure. The contrast used for heart catherization must be eliminated by the kidneys, which further stresses them and may produce acute renal failure. A teenager who has an appendectomy and a pregnant woman with a fractured femur isn’t at increased risk for renal failure. A dialysis client already has end-stage renal disease and wouldn’t develop acute renal failure

300

Name four consequences of chronic renal failure

What is Fluid overload, retention of urea, creatinine, and potassium, hormonal problems, deficiency in erythropoietin, phosphorus retention, and insufficiency of hormonal vitamin D

400

If a patient is in the diuretic phase of acute kidney injury, the nurse must monitor for which serum electrolyte imbalances? a. Hyperkalemia and hyponatremia b. Hyperkalemia and hypernatremia c. Hypokalemia and hyponatremia d. Hypokalemia and hypernatremia

What is C, Hypokalemia and hyponatremia In the diuretic phase of AKI, the kidneys have recovered the ability to excrete wastes but not the ability to concentrate urine. Hypovolemia and hypotension can result from massive fluid losses. Because of the large losses of fluid and electrolytes, the patient must be monitored for hyponatremia, hypokalemia, and dehydration.

500

RIFLE defines three stages of Acute Kidney Injury based on changes in: a. blood pressure and urine osmolality. b. fractional excretion of urinary sodium. c. estimation of GFR with the MDRD equation. d. serum creatinine or urine output from baseline.

What is D. The first three stages are characterized by the serum creatinine level and urine output. The RIFLE classification is used to describe the stages of AKI. RIFLE standardizes the diagnosis of AKI. Risk (R) is the first stage of AKI, followed by injury (I), which is the second stage, and then increasing in severity to the final or third stage of failure (F). The two outcome variables are loss (L) and end-stage kidney disease (E).

Pharmacology

100

The client with chronic renal failure tells the nurse he takes magnesium hydroxide (milk of magnesia) at home for constipation. The nurse suggests that the client switch to psyllium hydrophilic mucilloid (Metamucil) because: 1. MOM can cause magnesium toxicity 2. MOM is too harsh on the bowel 3. Metamucil is more palatable 4. MOM is high in sodium

What is 1. Magnesium is normally excreted by the kidneys. When the kidneys fail, magnesium can accumulate and cause severe neurologic problems. MOM is harsher than Metamucil, but magnesium toxicity is a more serious problem. A client may find both MOM and Metamucil unpalatable. MOM is not high in sodium.

200

Which of the following actions by the nurse is most important when caring for a client with renal disease? 1. Identify medications that have the potential for nephrotoxity 2. Check the specific gravity of the urine daily 3. Eliminate potassium rich foods from the diet 4. Encourage the client to void every 4 hours

What is 1. Nephrotoxic drugs should, if possible, be avoided in patients with renal disease because the consequences of nephrotoxicity are likely to be more serious when the renal reserve is already reduced.

300

The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication: 1. Just before dialysis 2. During dialysis 3. On return from dialysis 4. The day after dialysis

What is 3. Antihypertensive medications such as enalapril are given to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. No rationale exists for waiting a full day to resume the medication. This would lead to ineffective control of the blood pressure.

400

Name three therapies for elevated potassium levels (hyperkalemia) and how they work

What is Regular Insulin IV: • Potassium moves into cells when insulin is given. • IV glucose is given concurrently to prevent hypoglycemia. • When effects of insulin diminish, potassium shifts back out of cells. Sodium Bicarbonate: • Therapy can correct acidosis and cause a shift of potassium into cells. Calcium Gluconate IV • Generally used in advanced cardiac toxicity (with evidence of hyperkalemic ECG changes). • Calcium raises the threshold for excitation, resulting in dysrhythmias. Hemodialysis: • Most effective therapy to remove potassium. • Works within a short time. Sodium Polystyrene Sulfonate (Kayexalate) • Cation-exchange resin is administered by mouth or retention enema. • When resin is in the bowel, potassium is exchanged for sodium. • Therapy removes 1 mEq of potassium per gram of drug. • It is mixed in water with sorbitol to produce osmotic diarrhea, allowing for evacuation of potassium-rich stool from body. Dietary Restriction • Potassium intake is limited to 40 mEq/day. • Primarily used to prevent recurrent elevation; not used for acute elevation.

500

The nurse is reviewing a list of components contained in the peritoneal dialysis solution with the client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse bases the response knowing that the glucose:

What is makes the solution hypertonic. The more hypertonic the solution, the greater the osmotic pressure for ultrafiltration, and the greater amount of fluid removed from the client during an exchange.

Diabetes

100

How does diabetes lead to kidney disease?

What is high blood pressure and high glucose levels in blood that may overwork the kidneys

200

What type of diabetes medication has an increased risk of renal failure?

What is Metformin

300

True or False When diabetes is controlled, the patient will never be diagnosed for chronic kidney disease

What is false Diabetes is one of the main causes of CKD. Even if Diabetes is controlled, patients can still be at risk for CKD. However, CKD does not always mean that the diabetic patients will have renal failure.

400

The male client diagnosed with CKD secondary to diabetes has been receiving dialysis for 12 years. The client is notified he will not be placed on the kidney transplant list. The client tells the nurse he will not be back for any more dialysis treatments. Which response by the nurse is most therapeutic? A. “You cannot just quit your dialysis. This is not an option.” B. “Your angry at not being on the list, and you want to quit dialysis?” C. “I will call your nephrologist right now so you can talk to the HCP.” D. “Make your funeral arrangements because you are going to die.”

What is B Reflecting the client’s feelings and restating them are therapeutic responses the nurse should use when addressing the client’s issues.

500

A diabetic patient is admitted for evaluation of renal function because of recent fatigue, weakness, and elevated BUN and serum creatinine levels. While obtaining a nursing history, the nurse identifies an early symptom of renal insufficiency when the patient states, a. "I get up several times every night to urinate." b. "I wake up in the night feeling short of breath." c. "My memory is not as good as it used to be." d. "My mouth and throat are always dry and sore."

What is A Polyuria occurs early in chronic kidney disease (CKD) as a result of the inability of the kidneys to concentrate urine. The other symptoms would be expected later in the progression of CKD.

Labs

100

What is the GFR?

What is Glomerular Filtration Rate, which tests the level of functioning in the kidneys, and can determine the stage of renal failure.

200

What is normal creatinine level? What does a high creatinine level indicate?

What is 0.5-1.5mg/dL, and high levels of creatinine indicate a diminishing filtering ability.

300

In the client experiencing acute renal failure the nurse should evaluate which laboratory diagnostic tests to assess renal function? Select all that apply. a. Blood urea nitrogen b. Creatinine c. Electrolytes d. Complete blood count

What is A and B. Blood urea nitrogen and creatinine evaluate renal function. Electrolytes will provide information on hyponatremia and hyperkalemia. Complete blood count will indicate the degree of anemia in a renal client. 

400

A patient with acute renal failure (ARF) has an arterial blood pH of 7.30. The nurse will assess the patient for: a. tachycardia. b. rapid respirations. c. poor skin turgor. d. vasodilation.

What is B Rationale: Patients with metabolic acidosis caused by ARF may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Tachycardia and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in ARF.

500

The client with acute renal failure has a serum potassium level of 5.8 mEq/L. The nurse would plan which of the following as a priority action? 1. Allow an extra 500 ml of fluid intake to dilute the electrolyte concentration. 2. Encourage increased vegetables in the diet 3. Place the client on a cardiac monitor 4. Check the sodium level

What is 3. The client with hyperkalemia is at risk for developing cardiac dysrhythmias and cardiac arrest. Because of this the client should be placed on a cardiac monitor. Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly. Vegetables are a natural source of potassium in the diet, and their use would not be increased. The nurse may also assess the sodium level because sodium is another electrolyte commonly measured with the potassium level. However, this is not a priority action at this time.