Adult 2 Test 4

a patient is very ill and is admitted to the ICU with rapidly progressing glomerulonephritis. the nurse monitors for manifestations of which prognosis?
a. gradual improvement after IV fluids
b. end stage kidney disease
c. stroke r/t malignant HTN
d. full recovery if aggressively treated

b. end stage kidney disease

a patient and family are trying to plan a schedule that coordinates with the patient's hemodialysis regimen. the patient asks "how often will i have to go and how long does it take?" what is the nurse's best response?
a. it varies. you will have to call your HCP for specific instructions
b. if you follow diet and fluid therapies, you spend less time in dialysis, about 12 hr per week
c. most patients require about 12 hr per week; this is usually divided into 3 4hr treatments
d. many patients prefer to have treatments that occur every night while sleeping

c. most patients require about 12 hr per week; this is usually divided into 3 4hr treatments

the nurse is reviewing the patient's HX, assessment findings, and lab results for a patient with suspected kidney problems. which manifestation is the main feature of nephrotic syndrome?
a. abrupt onset flank symmetry
b. proteinuria \> 3.5 g in 24 hr
c. Na \> 148
d. total cholesterol of 190

b. proteinuria \> 3.5 g in 24 hr

a patient has been receiving erythropoietin. which statement by the patient indicates that the therapy is producing the desired effect?
a. i have been passing more urine than i was before
b. i can do my housework with less fatigue
c. i can swallow and eat much better than before
d. i have less pain and discomfort now

b. i can do my housework with less fatigue

the nurse is caring for a patient with a nephrostomy. the nurse notifies the HCP about which finding?
a. urine drainage is red-tinged 4h after surgery
b. amount of drainage decreased and the patient has back pain
c. there is a small steady drainage for the first 4h post surgery
d. the nephrostomy site looks dry and intact

b. amount of drainage decreased and the patient has back pain

which of the following lab test results does NOT indicate hepatic cell destruction?
a. elevated AST
b. elevated ALT
c. increased INR
d. elevated LDH
e. increased albumin

e. increased albumin

the fluid shift that occurs in peritonitis may result in which of the following events?
a. intracellular fluid moving into the peritoneal cavity
b. significant increase in circulatory volume
c. decreased circulatory volume and hypovolemic shock
d. increased bowel motility caused by increased fluid volume

c. decreased circulatory volume and hypovolemic shock

how is neomycin sulfate used to treat patients with cirrhosis?
a. it restores normal function to the liver cells
b. it prevents future infections of the liver
c. it treats the current infection the patient has
d. it decreases the rate of ammonia production

d. it decreases the rate of ammonia production

a patient will undergo an abdominal paracentesis. which factor provides an additional safety measure?
a. the procedure is performed using ultrasound
b. general anesthesia is administered
c. a trocar is inserted into the peritoneal cavity
d. the procedure is performed at the bedside

a. the procedure is performed using ultrasound

the nurse is assessing a patient with liver trauma and finds that the patient is confused, with a BP of 86/50, HR 128, and cool, clammy skin. what does the nurse suspect?
a. liver hemorrhage
b. septic shock
c. GI bleeding
d. liver cancer

a. liver hemorrhage

A client had an exploratory laparotomy to treat the cause of peritonitis, and has a large incision that is closed with staples and two abdominal drains. Which finding(s) would the nurse report immediately to the surgeon? Select all that apply.
A. Serosanguineous drainage
B. Increased abdominal distention
C. Fever and chills
D. Pain level 2 on a scale of 0 to 10
E. Passing flatus

B. Increased abdominal distention
C. Fever and chills

The nurse is caring for an older adult client who experiences an exacerbation of ulcerative colitis with severe diarrhea and rectal bleeding that have lasted a week. For which complication(s) will the nurse assess? Select all that apply.
A. Increased BUN
B. Hypokalemia
C. Leukocytosis
D. Anemia
E. Hyponatremia

A. Increased BUN
B. Hypokalemia
C. Leukocytosis
D. Anemia
E. Hyponatremia

The nurse is teaching a client about nutrition and diverticulosis. Which food will the nurse teach the client to avoid?
A. Cucumber
B. Beans
C. Carrot
D. Radish

A. Cucumber

The nurse is caring for a client who is diagnosed with cirrhosis? Which serum laboratory values will the nurse expect to be abnormal? Select all that apply.
A. Prothrombin time
B. Serum bilirubin
C. Albumin
D. Aspartate aminotransferase (AST)
E. Lactate dehydrogenase (LDH)
F. Acid phosphatase

A. Prothrombin time
B. Serum bilirubin
C. Albumin
D. Aspartate aminotransferase (AST)
E. Lactate dehydrogenase (LDH)

The nurse is caring for a client in end-stage liver failure. Which interventions should implemented when observing for hepatic encephalopathy? Select all that apply.
A. Assess the client's neurologic status as prescribed.
B. Monitor the client's hemoglobin and hematocrit levels.
C. Monitor the client's serum ammonia level.
D. Monitor the client's electrolyte values daily.
E. Prepare to insert an esophageal balloon tamponade tube.
F. Make sure the client's fingernails are short.

A. Assess the client's neurologic status as prescribed.
C. Monitor the client's serum ammonia level.

The nurse is caring for a client diagnosed with hepatitis A. Which transmission-based precautions are required when providing care for this client? Select all that apply.
A. Place client in a private room.
B. Wear a mask when handling patient bedpan.
C. Wear gloves when touching the client.
D. Wear a gown when providing personal care to this patient.
E. Wear eye goggles when providing care.

D. Wear a gown when providing personal care to this patient.

A young adult client admitted with a diagnosis of cholecystitis from cholelithiasis has severe abdominal pain, nausea, and vomiting. Based on these assessment findings, which client problem is the highest priority for nursing intervention at this time?
A. Anxiety
B. Risk for dehydration
C. Acute pain
D. Malnutrition

C. Acute pain

A client is admitted to the hospital yesterday with a diagnosis of acute pancreatitis. What assessment findings will the nurse expect for this client? Select all that apply.
A. Severe boring abdominal pain
B. Jaundice
C. Nausea and/or vomiting
D. Decreased serum amylase level
E. Leukocytosis
F. Dyspnea

A. Severe boring abdominal pain
B. Jaundice
C. Nausea and/or vomiting
E. Leukocytosis
F. Dyspnea

When obtaining a health history and physical assessment from a 68 year-old male client who has a history of an enlarged prostate, which finding does the nurse consider significant? Select all that apply.
A. Distended bladder
B. Absence of a bruit
C. Frequency of urination
D. Dribbling urine after voiding
E. Chemical exposure in the workplace

A. Distended bladder
C. Frequency of urination
D. Dribbling urine after voiding

A client is on a 24-hour urine collection. At midpoint during the collection, the client tells the nurse that some of the urine was discarded. What action will the nurse take? Select all that apply.
A. No action is required.
B. Reinforce client education
C. Notify the laboratory staff
D. Restart the urine collection
E. Document the discarded urine
F. Notify the healthcare provider

B. Reinforce client education
C. Notify the laboratory staff
E. Document the discarded urine
F. Notify the healthcare provider

The nurse is admitting a client undergoing a CT scan with contrast. Which finding does the nurse report as a possible immediate hypersensitivity reaction? Select all that apply.
A. Nausea
B. Pruritis
C. Urticaria
D. Laryngeal stridor
E. Flushing of the skin

B. Pruritis
C. Urticaria
D. Laryngeal stridor
E. Flushing of the skin

Which assessment finding would require the nurse to take immediate action in a client who is one hour post kidney biopsy? Select all that apply.
A. Pink-tinged urine
B. Nausea and vomiting
C. Increased bowel sounds
D. Reports of flank pain
E. The patient is ambulating to the bathroom

A. Pink-tinged urine

Which assessment data would the nurse anticipate in a client with acute pyelonephritis? Select all that apply.
A. Urinary frequency
B. Dysuria
C. Oliguria
D. Heart rate 120
E. Uremia
F. Costovertebral angle tenderness

A. Urinary frequency
B. Dysuria
D. Heart rate 120
F. Costovertebral angle tenderness

The nurse is reviewing the client's laboratory data prior to a nephrostomy tube insertion. Which data requires the nurse to take action?
A. White blood cells in the urine
B. INR of 2.1
C. Hematocrit 44%
D. Creatinine 0.8 mg/dL

B. INR of 2.1

The nurse is caring for a male client 8 hours after a nephrectomy. Which assessment data requires immediate nursing intervention?
A. Abdominal distension
B. Urine output 38 ml in the last hour
C. Blood pressure 108/64 mmHg
D. Hemoglobin 14 g/dL

A. Abdominal distension

A 62-year-old client was admitted 2 days ago with traumatic injuries and hypovolemic shock. Which lab result is most important for the nurse to report to the health care provider immediately?
A. Serum sodium 132 mEq/L (mmol/L)
B. Serum potassium 6.9 mEq/L (mmol/L)
C. Blood urea nitrogen 24 mg/dL (mmol/L)
Hematocrit 32% (0.32 volume fraction); hemoglobin 9.2 g/dL (92 g/L)

B. Serum potassium 6.9 mEq/L (mmol/L)

The nurse is caring for a 74 year old client scheduled for a cardiac catheterization with contrast dye. What nursing action is appropriate? Select all that apply.
A. Assess creatinine clearance using a 24 hour urine collection test.
B. Assess for co-existing conditions of diabetes, heart failure, and kidney disease.
C. Collaborate with the provider about whether IV fluids should be infused before the test
D. Notify the provider regarding changes in serum creatinine from 0.2 to 0.4 mg/dL in 24 hours.
E. Alert the provider to a glomerular filtration rate (GFR) < 60 mL/min/1.73 m2

B. Assess for co-existing conditions of diabetes, heart failure, and kidney disease.
C. Collaborate with the provider about whether IV fluids should be infused before the test
E. Alert the provider to a glomerular filtration rate (GFR) < 60 mL/min/1.73 m2

The nurse is preparing a client with stage 3 CKD for discharge. Which client statement indicates the need for further teaching?
A. "I will be sure to attend my follow up appointment with my nephrologist."
B. "I will increase my protein intake so my body can heal."
C. "I will weigh myself daily and call the doctor if my weight increases by 2 pounds or more.
D. "I will take my blood pressure each day and keep a daily log."

B. "I will increase my protein intake so my body can heal."

The nurse is caring for a 38 year old male with hypertension and Stage 1 CKD. The client reports lifestyle changes and feeling "better" and has stopped taking a prescribed diuretic. What is the appropriate nursing response?
A. "The diuretic will reduce your blood pressure which may slow or prevent progression of your chronic kidney disease."
B. "Your primary health care provider prescribed the diuretic because it will reverse the damage caused by kidney disease."
C. "Taking medications is a personal decision, and you have the right to decline this prescription."
D. "Since you have implemented lifestyle changes the diuretic is likely not needed."

A. "The diuretic will reduce your blood pressure which may slow or prevent progression of your chronic kidney disease."

A client who performs home continuous ambulatory peritoneal dialysis reports that the drainage (effluent) has become cloudy in the past 24 hours. What is the priority nursing action?
A. Remove the peritoneal catheter.
B. Notify the nephrology health care provider.
C. Obtain a sample of effluent for culture and sensitivity.
D. Teach the client that effluent should be clear or slightly yellow.

C. Obtain a sample of effluent for culture and sensitivity.

renal threshold (TB)

the point at which the kidney is overwhelmed with glucose and can no longer reabsorb (aka transport maximum)

afferent arterioles (TB)

smallest renal arteries
feed nephrons directly to form urine

uremia (TB)

buildup of nitrogenous waste products in the blood from inadequate elimination r/t kidney failure

s/s uremia (TB)

key features: anorexia, n/v, muscle cramps, pruritus, fatigue, lethargy
metallic taste in mouth, uremic frost on skin, edema, hiccups, dyspnea, paresthesias

nephrostomy (TB)

surgical creation of opening directly into the kidney
diverts urine externally and prevents further kidney damage

complications of nephrostomy (TB)

decreased/absent drainage, cloudy/foul smelling drainage, leakage of blood/urine from site, back pain

functions of the renal system

maintain f/e balance, rid the body of *water* soluble waste products, maintain normal blood volume and osmolarity, produce EPO, activate *vitamin d* to facilitate *calcium* absorption, a/b balance

nephron

functioning unit of the kidney
1 million per kidney (2 million total)- all nephrons work independently of each other

nephron functions

filtration of water soluble substances from the blood, reabsorption of filtered items, secretion of waste products

glomerulus

site of fluid filtration from blood to the nephron
more permeable than other capillaries (BUT prevents transport of blood cells and proteins)

glomerular filtration rate (GFR)

determined by filtration pressure within the glomeruli- *each glomeruli can regulate its own GFR*
1-3 L of GFR gets turned into urine (the rest is reabsorbed)

normal GFR

125 ml/min
want MINIMUM \>90

things affecting GFR

high/low BP, NaCl, glucose, *blood volume*

what renal hormonal regulation regulates BP?

RAAS system

renal hormonal regulation: prostaglandins

regulate GFR, renal vascular resistance, renin production

renal hormonal regulation: bradykinin

dilates renal vasculature to maintain renin BF- released after angiotensin II

renal hormonal regulation: erythropoietin (EPO)

triggers RBC formation in marrow

renal hormonal regulation: vitamin d

converted to active form in the kidney, helps to reabsorb calcium

effects of aging on the renal system

loss of cortical tissue (becomes smaller), membranes thicken (reducing filtration ability), BF decreases 10% per decade, tubular changes cause loss of ability to concentrate urine (nocturnal polyuria)

normal creatinine

0.6-1.2

creatinine reflection of renal system

reflects GFR (more kidney function specific!)
*no other pathologic condition other than renal disease increases this*

BUN normal

10-20

BUN reflection on renal system

INDIRECT measure (highlights overall hydration)
can also reflect: diet, GI bleeding, tissue breakdown, protein

renal cell carcinoma (RCC) risk factors

cigarette smoking, obesity, HTN, exposure to heavy metals

RCC s/s

OFTEN ASYMPTOMATIC UNTIL LATE IN DISEASE COURSE
CVA tenderness, hematuria (LATE), palpable abd mass, bone pain/ SOB/ angina from metastatic disease (LATE), anemia, erythrocytosis, low H&H, hypercalcemia, high ESR, high creatinine and BUN

RCC staging

1- in capsule
2- into perirenal fat
3- in renal vein, local lymphatics
4- metastasis (commonly lung, heart, liver, other kidney, bone)

RCC TX

surgical removal common (*nephrectomy*... watch for blood loss)- *compensation by other kidney may take days or weeks*
chemo has LIMITED effectiveness
microwave ablation or cryoablation used only when surgery is not an option

obstruction

interference with urine flow- can occur at any point within the system, causing urinary stasis and predisposes to UTI
can lead to post-renal acute renal failure and acute tubular necrosis depending on where the obstruction is

obstruction pathogenesis

changes secondary to obstruction depend on location and size of obstruction; hydrostatic pressure increases proximal to the obstruction, dilation follows with reduction in GFR, eventually portions of the kidney become ischemic

obstruction s/s

DEPENDS ON LOCATION OF OBSTRUCTION
*hydroureter*: obstruction in or below ureter
*hydronephrosis*: enlarged kidney due to dilation
thickening bladder wall, bladder neck obstruction

obstruction TX

DEPENDS ON LOCATION AND SIZE
surgical intervention, stent placement, nephrostomy

infections of the intrarenal system risk factors

increasing age, vesicoureteral reflux of urine, congenital abnormalities, female, pregnancy, neurogenic bladder, urinary obstruction, obesity, DM, sickle cell trait

normal renal host defenses of infection

acidic pH and urea in urine, prostatic secretions in men (urethral secretions in women), micturition (unidirectional flow), epithelial cells

acute pyelonephritis etiology

pregnancy, obstruction, urinary reflux, young women, infants, elderly, E. coli (in 80% of cases)
UNILATERAL

acute pyelonephritis pathogenesis

usually an "ascending" infection, can arrive via bloodstream, bacteria binds to epithelial cells, inflammatory response/ damage to parenchymal tissue, r/t NSAID use due to papillary necrosis and reflux of urine

acute pyelonephritis s/s

SUDDEN ONSET: *fever/chills, CVA tenderness, burning, urgency, frequency*, dysuria, flank/ back/ loin pain, abd discomfort, n/v, fatigue, nocturia

acute pyelonephritis TX

abx therapy, hospitalized for more severe cases (IV abx, fluids)

chronic pyelonephritis etiology

urinary obstruction, urinary reflux, neurogenic bladder
characterization: small atrophied kidneys with diffuse scarring

chronic pyelonephritis pathogenesis

chronic or recurrent infections, chronic interstitial inflammation, reduction in the number of functional nephrons, potential for chronic kidney disease-eventually affects renal function!

chronic pyelonephritis s/s

may be minimal!
flank pain *less intense* than acute
USUALLY incidental diagnosis: HTN, UTI, elevated creatinine, hyponatremia, nocturia, hyperkalemia, acidosis

chronic pyelonephritis TX

correct underlying problem, prolonged abx, support existing renal function

renal tuberculosis
(very briefly touched on in TB and panopto)

urinary tract is most common site for TB outside the lungs
invades kidneys through the bloodstream
inflammatory response forms scar tissue replacing normal kidney tissue

primary glomerulopathies

ONLY KIDNEYS ARE INVOLVED
acute/chronic glomerulonephritis, nephrotic syndrome

secondary glomerulopathies

injury due to drug exposure, infection, systemic or vascular pathology
SLE, goodpasture's syndrome, amyloidosis, diabetic glomerulopathy, hep b/c, cirrhosis, SCD, multiple myeloma

acute glomerulonephritis patho

infection occurs- s/s don't appear for \>10 days
seen frequently in: men after acute strep infection, HX infections, breathing problems, BP management, urination pattern changes

acute glomerulonephritis s/s

*cola colored urine, proteinuria, hematuria*, oliguria, edema, HTN, increased BUN and creatinine

acute glomerulonephritis TX

abx, prevent complications, supportive care, temp dialysis, plasmapheresis

chronic glomerulonephritis s/s

circulatory overload (edema, weight gain, JVD, crackles), uremic assessment (slurred speech, tremors, asterixis, skin changes), decreased GFR, high BUN and creat, hypocalcemia, hyperphosphatemia, hyperkalemia
*ALWAYS LEADS TO ESRD!!!*

chronic glomerulonephritis TX

focuses on slowing disease progression
diet changes, sufficient fluid intake, drug therapy to manage s/s, preparing early for ESRD

nephrotic syndrome patho

increased permeability of the glomeruli allows bigger molecules to pass through
*massive loss of protein* into the urine (MAIN FEATURE: 3.5 g/24 hr)

nephrotic syndrome s/s

*hypoalbuminemia*, hyperlipidemia, edema, hypercoagulability, renal insufficiency

nephrotic syndrome TX

treat underlying process (confirmed by renal biopsy), immunosuppressive therapy, ACEI, antilipids, mild diuretics, Na restriction, diet changes

diabetic nephropathy

leading cause of ESRD!
microvascular damage, *first s/s is albuminemia*

diabetic nephropathy TX

PREVENTION- manage DM over lifespan... routinely monitor urine in DM!!!

polycystic kidney disease (PKD) (TB)

autosomal dominant genetic disorder- fluid filled cysts develop in nephrons...cause progressive kidney enlargement

PKD s/s (TB)

abd/flank pain, HTN, nocturia, frequent UTI, increased abd girth, constipation, hematuria, Na wasting, progression to kidney failure with anuria

renovascular disease (TB)

any process that affects the renal arteries...may severely narrow the lumen and greatly reduce blood flow to kidney tissues
ex- renal vein thrombosis, renal artery stenosis

renovascular disease s/s (TB)

significant difficult to control HTN, poorly controlled DM or sustained hyperglycemia, elevated creatinine, decreased GFR

how to prevent kidney and GU trauma

wear a seatbelt, practice safe walking habits, use caution when riding bicycles and motorcycles, wear appropriate protective clothing when participating in contact sports (avoid all contact sports and high risk activities if only one kidney)

hyperacute transplant rejection

onset within 48h of surgery
increased T, BP; pain at transplant site
TX: immediate removal of transplant

acute transport rejection

onset 1wk to any time after surgery (occurring over days to weeks)
oliguria/anuria, T \> 37.8 (100 F), HTN, enlarged tender kidney, lethargy, elevated creat/BUN/K, fluid retention
TX: increase dose of immunosuppressants

chronic transplant rejection

onset gradual over months to years
gradual increase in BUN/creat, fluid retention, changes in electrolyte levels, fatigue
TX: conservative management until dialysis required

acute renal failure/acute tubular necrosis/AKI

abrupt deterioration of renal function...potentially reversible! key features: an/oliguria, HIGH creat

acute renal failure risk factors

*DM, HTN*, HF, liver failure, atherosclerosis, advanced age

pre-renal acute renal failure etiology

*diminished perfusion to kidneys*
decrease in blood volume via dehydration, burns, hypotension, shock, HF, sepsis, pericardial tamponade

pre-renal acute renal failure pathogenesis

decreased perfusion triggers decreased GFR, autoregulatory mechanisms protect the renal parenchyma to a point, correction of underlying problem will prevent tissue damage if done quickly
*if uncorrected: hypoperfusion will lead to ischemia of renal parenchyma and acute tubular necrosis (ATN)*

intra-renal acute renal failure etiology

*actual damage to kidney tissue*
acute glomerulonephrosis, drug induced/nephrotoxins (contrast media, ACEI, bactrim DS, renal artery stenosis/thrombosis), ATN (renal cellular hypoxia)

post-renal acute renal failure etiology

obstruction of normal urine outflow from kidney...*cannot excrete urine*
BPH, kinked/obstructed catheters, tumors, strictures, calculi

post-renal acute renal failure s/s

if only one kidney is affected- other will increase production to compensate
persistent obstruction- increased pressure from urine backup can cause irreversible ATN
EASIEST TO TX- RENAL FXN NORMALIZES QUICKLY AFTER TX

s/s stages of acute renal failure: *oliguric*

first stage
volume overload, hyperkalemia, metabolic acidosis, azotemia, uremia, uremic syndrome
TX: temp dialysis