NCLEX Practice Exam: Renal Failure & Dialysis, Part 1

Continue to monitor vital signs The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. If the temperature is elevated excessively and remains elevated, sepsis would be suspected and a blood sample would be obtained as prescribed for culture and sensitivity purposes.

Diarrhea In renal failure, calcium absorption from the intestine declines, leading to increased smooth muscle contractions, causing diarrhea. CNS changes in renal failure rarely include headache. A serum calcium level of 5 mEq/L indicates hypercalcemia. As renal failure progresses, bleeding tendencies increase.

VS and weight Following dialysis, the client’s vital signs are monitored to determine whether the client is remaining hemodynamically stable. Weight is measured and compared with the client’s predialysis weight to determine effectiveness of fluid extraction. Laboratory studies are done as per protocol but are not necessarily done after the hemodialysis treatment has ended.

Increases osmotic pressure to produce ultrafiltration. Increasing the glucose concentration makes the solution increasingly more hypertonic. The more hypertonic the solution, the greater the osmotic pressure for ultrafiltration and thus the greater amount of fluid removed from the client during an exchange.

Explain that the pain will subside after the first few exchanges Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, the pain usually disappears after 1 to 2 weeks of treatment. The infusion amount should not be decreased, and the infusion should not be slowed or stopped.

Polyuria 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.

Lima beans Cantaloupe (1/4 small), spinach (1/2 cooked) and strawberries (1 ¼ cups) are high potassium foods and average 7 mEq per serving. Lima beans (1/3 c) averages 3 mEq per serving.

Check the catheter for kinks or obstruction. 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.

Assess the AV fistula for a bruit and thrill Assessment of the AV fistula for bruit and thrill is important because, if not present, it indicates a non-functioning fistula. No blood pressures or venipunctures should be taken in the arm with the AV fistula. When not being dialyzed, the AV fistula site may get wet. Immediately after a dialysis treatment, the access site is covered with adhesive bandages.

Notify the physician Disequilibrium syndrome may be due to the rapid decrease in BUN levels during dialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs of disequilibrium syndrome and appropriate treatments with anticonvulsant medications and barbituates may be necessary to prevent a life-threatening situation. The physician must be notified.

Pallor, diminished pulse, and pain in the left hand. Steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and a diminished pulse distal to the fistula. The client also complains of pain distal to the fistula, which is due to tissue ischemia. Warmth, redness, and pain more likely would characterize a problem with infection.

Osmosis and diffusion 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.

Accumulation of waste products Although clients with renal failure can develop stress ulcers, the nausea is usually related to the poisons of metabolic wastes that accumulate when the kidneys are unable to eliminate them. The client has electrolyte imbalances and oliguria, but these don’t directly cause nausea.

Maintain strict aseptic technique The major complication of peritoneal dialysis is peritonitis. Strict aseptic technique is required in caring for the client receiving this treatment. Although option 4 may assist in preventing infection, this option relates to an external site.

Palpation of a thrill over the fistula 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.

Administer oxygen 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.

A client with diabetes who has a heart catherization 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.

Tums (calcium carbonate) Phosphate binding agents that contain aluminum include Alu-caps, Basaljel, and Amphojel. These products are made from aluminum hydroxide. Tums are made from calcium carbonate and also bind phosphorus. Tums are prescribed to avoid the occurrence of dementia related to high intake of aluminum. Phosphate binding agents are needed by the client in renal failure because the kidneys cannot eliminate phosphorus.

Headache, deteriorating level of consciousness, and twitching. Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, and vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.

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