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The nurse is caring for a patient who has had progressive chronic kidney disease (CKD) for several years and is starting hemodialysis. Which of the following information about diet should the nurse include in patient teaching?
- A. Increased calories are needed because glucose is lost during hemodialysis.
- B. Unlimited fluids are allowed since retained fluid is removed during dialysis.
- C. More protein will be allowed because of the removal of urea and creatinine by dialysis.
- D. Dietary sodium and potassium are unrestricted because these levels are normalized by dialysis.
Correct Answer: C
Rationale: Once the patient is started on dialysis and nitrogenous wastes are removed, there is less protein lost, therefore more protein in the diet is encouraged. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.
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The nurse is caring for a patient who is receiving hemodialysis and has symptoms of nausea, vomiting, and sudden onset of confusion. Which of the following actions is priority?
- A. Infuse a hypotonic solution.
- B. Increase the rate of the dialysis.
- C. Administer an antiemetic medication.
- D. Stop the dialysis solution.
Correct Answer: D
Rationale: The patient's symptoms suggest disequilibrium syndrome, which is a rare complication of modern HD and develops as a result of very rapid changes in the composition of the extracellular fluid. Urea, sodium, and other solutes are removed more rapidly from the blood than from the cerebrospinal fluid and the brain. This creates a high osmotic gradient in the brain resulting in the shift of fluid into the brain, causing cerebral edema. Manifestations include nausea, vomiting, confusion, restlessness, headaches, twitching and jerking, and seizures. Treatment consists of slowing or stopping dialysis and infusing hypertonic saline solution, albumin, or mannitol to draw fluid from the brain cells back into the systemic circulation.
The nurse is caring for a patient with a left arm arteriovenous fistula. Which of the following actions should the nurse include in the plan of care to maintain the patency of the fistula?
- A. Check the fistula site for a bruit and thrill.
- B. Assess the rate and quality of the left radial pulse.
- C. Compare blood pressures in the left and right arms.
- D. Irrigate the fistula site with saline every 8-12 hours.
Correct Answer: A
Rationale: The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula.
The nurse is caring for a patient with end-stage renal disease (ESRD). Which of the following findings indicate that the nurse should consult with the health care provider before giving the prescribed erythropoiesis-stimulating agent (ESA)?
- A. Creatinine 99 mcmol/L.
- B. Oxygen saturation 89%
- C. Hemoglobin level 130 g/L.
- D. Blood pressure 98/56 mm Hg
Correct Answer: C
Rationale: High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when ESA is administered to a target hemoglobin of 110 g/L with a range of 100-120 g/L. Hemoglobin levels higher than 120 g/L indicate a need for a decrease in erythropoiesis-stimulating agent dose. The other information will also be reported to the health care provider but will not affect whether the medication is administered.
The nurse is caring for a patient with severe heart failure who develops elevated blood urea nitrogen (BUN) and creatinine levels. The nurse will plan care to meet which of the following goals of treatment?
- A. Replace fluid volume
- B. Prevent hypertension.
- C. Maintain cardiac output.
- D. Dilute nephrotoxic substances.
Correct Answer: C
Rationale: The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct.
The nurse is assessing a patient who had a kidney transplant 8 years ago and is receiving the immunosuppressants tacrolimus, cyclosporin, and prednisone. Which of the following findings is of most concern to the nurse?
- A. The blood glucose is 7.9 mmol/L.
- B. The patient's blood pressure is 150/92.
- C. There is a nontender lump in the axilla
- D. The patient has a round, moonlike face.
Correct Answer: C
Rationale: A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result of persistent immunosuppressive therapy. The elevated glucose, moon face, and hypertension are possible adverse effects of the prednisone and should be addressed, but they are not as great a concern as the possibility of a malignancy.