NCLEX - RENAL Day2 (Part 1)

A nurse is preparing an educational presentation on herbal supplements for the local community center. The nurse anticipates discussion of saw palmetto with what type of clients?

• Clients diagnosed with dyslipidemia
• Clients experiencing major depression
• Clients with benign prostatic hyperplasia
• Perimenopausal clients experiencing hot flashes
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Answer explanation

Saw palmetto is an herbal preparation often used by clients to treat symptoms of benign prostatic hyperplasia. Although studies are not conclusive on its mechanism or effectiveness, it is still publicly promoted and used. Saw palmetto should be taken cautiously with anticoagulants and antiplatelets because it may increase the risk for bleeding (Option 3). (Option 1) Garlic is indicated to promote cardiovascular health and may reduce triglyceride levels and increase HDL cholesterol. (Option 2) St. John's wort has been used for centuries to treat depression. It may cause hypertension and serotonin syndrome when used with other antidepressants. (Option 4) Black cohosh is an herbal supplement often used by perimenopausal clients experiencing hot flashes.

The nurse is preparing to administer furosemide to a client who is experiencing heart palpitations. Which of the following actions would be a priority for the nurse to take?

• Calculate total urinary output
• Hold the furosemide
• Notify the health care provider
• Obtain a 12-lead ECG
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Answer explanation

Furosemide is a potassium-depleting loop diuretic, and this client's potassium level is low. The normal reference range is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). Hypokalemia can lead to heart palpitations and/or dysrhythmias. The nurse should initially hold the client's scheduled dose of furosemide (Option 2). If furosemide is administered, the client's potassium level could further decrease, leading to worsening cardiac symptoms. (Option 1) A brief, focused assessment, including calculating intake and output, may be important before notifying the health care provider (HCP). However, the first action is to hold the scheduled dose of furosemide based on the laboratory results. A low potassium level is justification for not administering the furosemide regardless of intake and output. (Option 3) The priority action is to hold the dose of furosemide; after assessing the client, the nurse should notify the HCP of the potassium level and reported heart palpitations. (Option 4) A 12-lead ECG may be ordered when notifying the HCP; however, the priority action is to first hold the dose of furosemide.

A nurse is reviewing the laboratory values for a 3-year-old client with nephrotic syndrome. The nurse interprets the results to most clearly reflect which physiologic process related to nephrotic syndrome?

• Glomerular injury
• Hepatic impairment
• Inherited hypercholesterolemia
• Malnutrition
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Answer explanation

Nephrotic syndrome is a collection of symptoms resulting from various causes of glomerular injury. Below are the 4 classic manifestations of nephrotic syndrome: . Massive proteinuria - caused by increased glomerular permeability . Hypoalbuminemia - resulting from excess protein loss in the urine . Edema - specifically periorbital and peripheral edema and ascites; caused by low serum protein and albumin as fluid is pulled into interstitial spaces and body cavities . Hyperlipidemia - related to increased compensatory protein and lipid production by the liver Additional symptoms include decreased urine output, fatigue, pallor, and weight gain. The most common cause of nephrotic syndrome in children is minimal change nephrotic syndrome, which is generally considered idiopathic. Less common secondary causes may be related to systemic disease or infection, such as glomerulonephritis, drug toxicity, or acquired immunodeficiency syndrome. (Option 2) Ascites and edema are often associated with liver disease. However, these symptoms result from fluid shifts related to hypoalbuminemia in nephrotic syndrome. (Option 3) Lipid levels (normal total cholesterol <200 mg/dL [5.2 mmol/L]) can increase with nephrotic syndrome as the liver produces increased lipids and proteins to compensate for protein loss. (Option 4) Although low serum albumin (normal 3.5-5.0 g/dL [35-50 g/L]) could result from malnutrition, hypoalbuminemia in nephrotic syndrome is related to massive proteinuria (negative to trace protein on urinalysis is usually considered normal).

The nurse has taught the parents of a 6-year-old client with nephrotic syndrome. Which of the following statements by the parents would require follow-up?

• I will encourage my child to play with other children
• I will monitor my child's urine for protein every day
• I will provide a healthy diet without added salt for my child
• I will report swelling or rapid weight gain to the health care provider
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Answer explanation

Nephrotic syndrome is characterized by increased permeability of the glomerulus to proteins (eg, albumin, immunoglobulins) and most commonly affects children age 2-7. This results in hypoalbuminemia, lowering the plasma oncotic pressure; therefore, it allows fluids to exit the vascular space more easily and remain in the tissues. Clinical manifestations include generalized edema, weight gain, loss of appetite (from ascites), and decreased urine output. The loss of immunoglobulins causes increased susceptibility to infection. Parents should minimize the risk for infection by limiting the client's physical contact with others during periods of relapse (Option 1). (Options 2 and 4) During remission, parents should monitor the client for indicators of disease relapse (eg, check urine protein, weigh the client, monitor for edema). (Option 3) Clients with nephrotic syndrome should consume a diet low in sodium. This is particularly important when the client is experiencing edema or other symptoms of relapse.

Which of the following observations by the charge nurse would require immediate follow-up?

• A nurse is using gentle pressure to flush a kidney pelvis catheter with 5 mL of fluid
• A nursing assistant hangs a urinary drainage bag on the wheelchair handle when transporting a client
• An indwelling urinary catheter is taped to the client's upper, inner thigh
• Total 24-hour oral fluid intake for a client with a urinary diversion device is 2800 mL
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Answer explanation

An indwelling urinary catheter is a device used to drain urine from the bladder. The catheter is inserted through the urethra into the bladder where a balloon is inflated to keep the catheter in place while urine drains into a collection bag. To maintain gravity flow, the drainage bag should be hung below the level of the bladder. Impaired urine flow can lead to urinary retention and distension of the bladder. The nurse should immediately follow-up if the drainage bag is hung above the level of the bladder (eg, wheelchair handle) because this will impede urine flow (Option 2). (Option 1) Catheters placed in the kidney pelvis are irrigated using gentle pressure and small amounts of sterile saline solution (≤5 mL at one time) to avoid damaging renal tissues. (Option 3) Securing an indwelling urinary catheter by taping it to a client's leg is acceptable to maintain gravity flow and prevent kinks and occlusions. Also, hook-and-loop fastener securement devices may be available at certain facilities. (Option 4) Fluid intake of 3000 mL/day should be encouraged in clients after surgery involving the urinary system. Increased fluid intake ensures the maintenance of a high urinary output, reducing the risk for infection and calculi. Dilute urine is less irritating to the skin surrounding the stoma site.

The nurse assesses a client with benign prostatic hyperplasia. Which client statement requires further assessment?

• I have a burning sensation when I urinate
• I have been having some dribbling after I finish urinating
• I missed 3 days of finasteride while on a trip last week
• I was awakened 3 times last night by the need to urinate
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Answer explanation

Benign prostatic hyperplasia (BPH) is an abnormal prostate enlargement that most commonly affects male clients age >50. The prostate gradually enlarges and compresses the urethra, causing voiding problems. Symptoms include urinary urgency, frequency, and hesitancy, dribbling urine after voiding, nighttime frequency (nocturia), and urinary retention. Treatment includes lifestyle changes and medications that shrink or slow growth of the prostate, and symptom management interventions (eg, voiding schedule, avoidance of caffeine and antihistamines). Surgical prostate resection may be required. Clients with BPH have increased risk for urinary tract infection (UTI) because of incomplete bladder emptying and urine retention. Symptoms of UTI are often similar to those of BPH; however, burning sensation with urination and cloudy/foul-smelling urine are specific UTI symptoms that require further assessment and treatment (Option 1). (Options 2 and 4) Dribbling after urination and nocturia are expected findings with BPH. (Option 3) Finasteride (Proscar) is a medication that inhibits further growth of the prostate. Appreciable differences in prostate size are noticed only after several months of therapy. Missing three doses would not cause immediate or long-term adverse effects.

The nurse gathers history from a 58-year-old client with acute urinary retention. What questions help assess for benign prostatic hyperplasia?

• Do you feel the need to urinate again immediately after urinating?
• Do you have to strain to begin your stream of urine?
• How often do you engage in sexual intercourse?
• How often do you wake at night with the urge to urinate?
• Is your stream of urine weak or intermittent?

Answer explanation

With increasing age (typically age >50), male clients experience hormone changes that can lead to prostate enlargement, known as benign prostatic hyperplasia (BPH). BPH is often not diagnosed until it begins to compress the surrounding bladder and urethra, causing voiding difficulties and abnormalities. Clients with BPH exhibit the following signs and symptoms: · Urinary retention . Sensation of incomplete emptying and/or increased urgency to void (Option 1) · Straining or difficulty initiating voiding (hesitancy) (Option 2) · Weak and/or intermittent stream of urine during voiding (Option 5) · Frequent voiding patterns throughout the day (eg, urinating more than once in 2 hours) and night (nocturia) (Option 4) (Option 3) Frequency of sexual intercourse is unrelated to urinary retention and BPH in the male client.

The nurse is caring for a 78-year-old client with a urinary tract infection (UTI). Which assessment finding would be most concerning and require immediate follow-up by the nurse?

• Confusion
• Presbyopia
• Temperature 100.2°F (37.8°C)
• White blood cell count 12,000/mm³
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Answer explanation

Confusion is a common clinical manifestation of urinary tract infections in the elderly but still should be cause for concern and requires follow-up to rule out other possible causes. Confusion is not a normal finding in the elderly adult client. Some causes of confusion in the elderly include dehydration, lack of blood flow to the brain (stroke), decreased ability to metabolize medications, and concurrent infections. (Option 2) Presbyopia is the decrease in ability to see objects close up. This is common in clients over age 40. (Option 3) The elderly tend to have a lower body temperature, so 100.2 F (37.8 C) is considered febrile. This elevation is probably a result of the UTI and the nurse should follow up after further assessing the confusion. (Option 4) An elevated WBC count would be expected in the presence of a current infection.

The nurse is caring for a client with acute poststreptococcal glomerulonephritis. Which of the following findings would the nurse expect to observe? Select all that apply.

• orthostatic hypotension
• increased urine output
• elevated BUN level
• rust-colored urine
• weight gain

Answer explanation

Acute poststreptococcal glomerulonephritis (APSGN) can occur 1 to 2 weeks after infection with some strains of group A beta-hemolytic Streptococcus. APSGN is characterized by inflammation and injury to the glomeruli, which impairs kidney function, leading to: • Oliguria (low urine output [eg, <1 ml/kg/hr in children and <0.5 mL/kg/hr in adults]) • Periorbital and peripheral edema due to sodium and water retention from a decreased glomerular filtration rate • Elevated serum creatinine and BUN levels due to impaired filtration (Option 3) • Hematuria and proteinuria from increased glomerular permeability, which allows leakage of blood and protein into the urine (producing dark, rust-colored urine) (Option 4) • Hypertension and weight gain due to fluid volume overload (Option 5) • Nonspecific symptoms (eg, anorexia, general malaise, weakness) (Option 1) Clients with APSGN experience hypertension (not orthostatic hypotension) associated with increased fluid volume. (Option 2) Decreased, not increased, urine output is characteristic of APSGN due to impaired filtration by the kidneys.

The nurse is evaluating the effectiveness of the medication regimen for a client with chronic kidney disease who is receiving sodium polystyrene sulfonate. It would indicate that the medication regimen has been effective if the client's most recent laboratory test results indicate

• an increase in the serum calcium level
• an increase in the serum creatinine level
• a decrease in the serum potassium level
• a decrease in the serum phosphate level
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Answer explanation

Clients with chronic kidney disease (CKD) are at risk for both hyperkalemia (potassium >5.0 mEq/L [5.0 mmol/L]) and hyperphosphatemia (phosphate >4.5 mg/dL [1.45 mmol/L]) due to the decreased glomerular filtration rate. If left untreated, hyperkalemia may cause life-threatening cardiac dysrhythmias. Because of this, sodium polystyrene sulfonate may be prescribed. Sodium polystyrene sulfonate works in the gastrointestinal tract to exchange sodium for potassium, thereby eliminating excess potassium through the stool and reducing the serum potassium level (Option 3). Depending on the severity of the CKD, dialysis may also be required. (Option 1) Decreased kidney function may result in hypocalcemia (calcium <9.0 mg/dL [2.25 mmol/L]), not hypercalcemia, due to lower activation of vitamin D and impaired absorption of calcium. Calcium supplements, not sodium polystyrene sulfate, may be used to increase serum calcium levels. (Option 2) Sodium polystyrene sulfonate does not affect serum creatinine levels. Creatinine levels may decrease initially after dialysis. (Option 4) Clients with CKD typically experience hyperphosphatemia, not hypophosphatemia (phosphate <3 mg/dL [0.97 mmol/L]). Phosphate binders (eg, calcium carbonate, sevelamer), not sodium polystyrene sulfonate, may be administered to eliminate phosphate through the stool.