Question

ANSWER INCLUDING RATIONAL.

Maria is a 47 year old female with a long history of diabetes mellitus and hypertension. She was recently diagnosed with renal insufficiency 18 months ago. Her medication regimen include a diuretic and an oral anti-diabetic agent. She c/o anorexia and overall fatigue, nocturia and short of breath sometimes. Her current weight is 60 kg. She is being scheduled for sever diagnostic studies to evaluate for the renal disease. Diabetes mellitus is a known risk factor for renal failure.

Define ESRD:

It is the last stage in the progressive clinical syndrome called chronic kidney disease.

What is the best description of chronic kidney disease?

Symptoms are reversible with life- long medication

Condition has a rapid onset with frequent remissions

It is a fatal disorder unless renal replacement therapy is received   

There are frequent exacerbations since half of all nephrons are damaged

The following diagnostic tests were performed:

Hemoglobin

Serum creatinine and BUN

Serum calcium

Arterial blood gases

Serum potassium

Serum phosphorus

Urinary creatinine clearance

Which lab value is likely to be decreased in a client with chronic kidney disease?

Serum calcium    

Serum creatinine and BUN

Serum potassium

Serum phosphorus

Maria’s hemoglobin level is 7.8. What is the underlying pathology causing this abnormal lab value?

Hematuria results in blood loss

Fewer red blood cells are being formed    

Dehydration causes dilutional anemia

Renal waste products destroy red blood cells

Maria’s ABG results: pH 7.35, PO2 96, PCO2 30, HCO3 18. Recall her history – anorexia, weight, diabetes. What is the correct interpretation of these ABGs?

Respiratory acidosis compensated

Respiratory alkalosis compensated

Metabolic acidosis compensated   

Metabolic alkalosis compensated

Maria’s findings from the diagnostic test and lab test confirm the medical diagnosis of end stage renal disease. Other assessment findings include, +1 pitted edema, bilateral crackles in the lungs, and clear pale urine. Vital signs: T - 98.8, P - 86, R - 28, and BP - 178/92. Which additional assessment finding is consistent with ESRD?

Yellow gray pallor  

Clay-colored stool

Stridor

Fingernail clubbing

Maria’s vital sign was Vital signs: T - 98.8, P - 86, R - 28, and BP - 178/92. Which explanation best describes the pathology resulting in her hypertension?

Irritation of the pericardial lining of the heart due to uremic toxins increases blood pressure

An increase in the excretion of sodium and water from the kidneys causes hypertension

Activation of the renin-angiotensin cycle and excretion of aldosterone causes hypertension   

The increase of uremic waste products in the blood stream increases the blood pressure.

Maria’s condition worsens: urinary output low, lab values indicating worsening kidney function. Now she will be placed on dialysis. Maria has to weigh the benefits of hemodialysis versus peritoneal dialysis. Which factor is related to the use of hemodialysis?

High risk of abdominal infection

High risk of air embolus   

More easily performed at home

Treatments require more time

Maria is at high risk for the development of which problem while receiving hemodialysis?

Blood clot formation

Ascites

Hepatitis B and C

Hypertension

While assessing Maria’s AV graft site, the nurse palpates a buzzing sensation directly over the graft. Which documentation should the nurse enter into the nurse’s notes?

+4 bounding pulse palpated

Bruit intact and palpated

Thrill present and palpated  

Health care provider notified of graft occlusion

Prior to using the AV graft site for hemodialysis, Maria had a tunnel catheter to the right subclavian. Which intervention should the nurse include in her plan of care?

Instruct lab personnel to obtain blood specimens from the dual lumen catheter

Perform sterile dressing changes at the dual lumen catheter site   

Empty and record the drainage from the graft tubing regularly

Regularly rotate IV insertion sites above and below the graft site

Maria is scheduled for discharge. The nurse completes discharge teaching for the goal Client will manage her diet effectively while receiving hemodialysis 3 times a week (Monday, Wednesday and Friday). Which expected outcome should be included in the nurse’s teaching plan?

Client will adhere to a low protein diet

Client will select foods high in iron and calcium from a menu  

Client will identify the need to avoid fresh fruits and vegetables

Client will identify the need to increase her sodium and fluid intake

What is the maximum amount of weight that Maria should gain between each dialysis treatment?

1.5 kg    

2 kg

2.5 kg

3 kg

Maria was receiving dialysis for a year. She is scheduled for a right kidney transplant from her sister. Post-op, Maria is transferred to the ICU. She is drowsy but awakens easily. She is able to swallow sips of water. Her surgical incision site is clean, dry and intact. Which nursing assessment has the highest priority during the first 24 hour postoperative period?

Vital signs    

Bowel sounds

Range of motion

Pedal pulses

Maria was receiving dialysis for a year. She is scheduled for a right kidney transplant from her sister. Post-op, Maria is transferred to the ICU. She is drowsy but awakens easily. She is able to swallow sips of water. Her surgical incision site is clean, dry and intact. Where would you expect to find the surgical incision?

Right upper quad

Left lower quad

Right lower quad above and slightly medial to the iliac crest   

Left lower quad above and slightly medial to the iliac crest

Which intervention should be included in the plan of care during the immediate postoperative period for Maria?

Monitor her urinary output hourly using an urometer  

Assess her surgical incision every shift

Monitor her nasogastric tube every 4 hours

Encourage her to use the incentive spirometer every 4 hours while awake

Which nursing diagnosis has the greatest priority when caring for a client receiving immunosuppressive agents?

Pain

Fatigue

Diarrhea

Risk of infection

Which interventions are important to include in Maria’s plan of care while she is receiving multiple immunosuppressnts?

Restrict Maria’s activity to bedrest with use of the bedside commode

Instruct visitors that fresh flowers should not be taken into the room   

Change the IV site daily

Reinforce, but do not routinely change any dressings

A week after surgery, Maria is discharged home. Two days later, she calls the nurse to report that she is experiencing more pain than she thinks she should be having. What is the best initial response by the nurse?

Going home often causes anxiety, which can increase your pain

You may have developed a tolerance to your pain medication

Describe the location and type of pain you are having    

The health care provider will need to call you back later if you need more pain medication

One week after surgery, Maria is discharged home. Three days later, she calls the nurse to report that she is experiencing more pain than she thinks she should be having. What is the best initial response by the nurse?

Going home often causes anxiety, which can increase your pain

You may have developed a tolerance to your pain medication

Describe the location and type of pain you are having   

The health care provider will need to call you back later if you need more pain medication

Maria states she feels very sore over her kidney area and she cannot remember voiding in the last 24 hours.

Take her prescribed diuretic and analgesic and record when she voids

Increase her fluid intake and report any increase in her weight

Monitor her temperature and report over 101 F

Advise her to come to the clinic right away for further evaluation   

Answer 1

1. BEST DESCRIPTION OF CHRONIC KIDNEY DISEASE: Chronic kidney disease has a rapid onset with frequent remissions. It is not reversible as the body's ability to maintain fluid and electrolyte balance fails.

2. WHICH LAB VALUE DECREASED IN PATIENT WITH CHRONIC KIDNEY DISEASE?

• Serum calcium level decreased in renal disease due to retention of phosphorus, As the calcium and phosphorus have the reciprocal relation so with the increase in serum phosphorus level there is corresponding decrease in the calcium level which further leads to bone disease.

3. Maria's HB is 7.8, the decrease in the haemoglobin level is due to the decrease in the production of erythropoietin which stimulates the bone marrow to produce more RBC's.

4. Interpretation of ABG: From the ABG value it is interpreted that the Maria has METABOLIC ACIDOSIS because the kidney cannot excrete increased loads of acid results in metabolic acidosis. Decreased acid excretion is also results from the inability of the kidney tubules to excrete ammonia and to reabsorb sodium.

5. Fingernail clubbing is present in patient with chronic kidney disease as clubbing may aslo occur due to increase amount of phosphorus in the body, as in renal disease the excretion of phosphorus is decreased and is accumulated inside the body leads to toxicity hance causes fingernail clubbing.

6. Causes of hypertension in Chronic Renal disease: Activation of renin angiotensin cycle and excretion of aldosterone causes hypertension.

7. Factors related to use of hemodialysis:  Peritoneal dialysis can be more easily performed at home so it is more beneficial.

8. Maria is at a risk of developing nephrogenic ascites due to imbalance between the fluid and electrolyte balance in the body because of renal disease.

9. THRILL PRESENT AND PALPATED : nurse document these notes in her documentation as buzzing sensation is positive sign of successfull dialysis.

10. Sterile dressing should be changed on alternate days and site is cleaned with 2% chlorhexidine and allow to air dry for 60-90 seconds.

11. Client have to identify the need to increase her sodium and fluid intake as dialysis leads to hypotension so sodium in diet maintains serum sodium level in body.

12. Average 1.5 kg of weight gain occur between dialysis treatment which is actual the body weight not the fluid weight.

13. First priority after post operative care is to assess the changes in the vital signs for ythe first 24 hrs. As any change in vital signs leads to major complications.

14. Theincisional site is at right lower quadrant above and slightly medial to iliac crest.

15. Immediate post operative care include assess the urine output every hourly by using urometer to check the proper functioning of kidneys and to assess the site of incision for any sign of infection.

16. When the patient is on immunosuppresive agents then the first priority diagnosis is risk of infection as the immunosuppresive agents suppress the immunity of the patient to fight against disease, so proper interventions must be taken to prevent the risk of infection.

17. While Maria is on multiple immunosuppresive agents then the interventions include:

• Instruct the visitors that the fresh flowers should not be taken into room, as they contain the allergic agents.

18. The best initial response by the nurse sholud be: ask the patient to describe the location and type of pain she is having, so as to assess the level of pain and to provide accurate treatment.

19. Nurse should ask the location and type of pain so as to provide the accurate care plan.

20. Ask the client to take her prescribed diuretics and analgesics and record when she voids.