13. The nurse is caring for the client diagnosed with chronic kidney disease (CKD) who is experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in this client?

1. There is increased excretion of phosphates and organic acids, which leads to an increase in arterial blood pH.

2. A shortened life span of red blood cells because of damage secondary to dialysis treatments in turn leads to metabolic acidosis.

3. The kidney cannot excrete increased levels of acid because it cannot excrete ammonia or cannot reabsorb sodium bicarbonate.

4. An increase in nausea and vomiting causes a loss of hydrochloric acid and the respiratory system cannot compensate adequately.

3. This is the correct scientific rationale for metabolic acidosis occurring in the client with CKD.

TEST-TAKING HINT: In the option "1," the test taker should note "increased excretion"; CKD does not have any type of increase in excretion, so the test taker could eliminate option "1." Option "4" does not even mention the renal system and a loss of hydrochloric acid results in metabolic alkalosis, not acidosis, so the test taker can eliminate this option.

14.The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first?

1. The client who has hemoglobin of 9.8 g/dL and hematocrit of 30%.

2. The client who does not have a palpable thrill or auscultated bruit.

3. The client who is complaining of being exhausted and is sleeping.

4. The client who did not take antihypertensive medication this morning.

2. This client's dialysis access is compromised and he or she should be assessed first.

TEST-TAKING HINT: The test taker must determine which client's situation is not normal or expected for the disease process, which in this question is CKD because all clients are in the dialysis unit.

15. The male client diagnosed with CKD has received the initial dose of erythropoietin, a biologic response modifier, one (1) week ago. Which complaint by the client indicates the need to notify the health-care provider?

1. The client complains of flu-like symptoms.

2. The client complains of being tired all the time.

3. The client reports an elevation in his blood pressure.

4. The client reports discomfort in his legs and back.

3. After the initial administration of erythropoietin, a client's antihypertensive medications may need to be adjusted. Therefore, this complaint requires notification of the HCP. Erythropoietin therapy is contraindicated in clients with uncontrolled hypertension.

TEST-TAKING HINT: The test taker should select the potentially life-threatening option or a complaint requiring the medication to be adjusted or discontinued. The nurse should notify the HCP if the medication is causing an adverse effect, not an expected side effect.

16. The nurse is developing a nursing care plan for the client diagnosed with CKD. Which nursing problem is a priority for the client?

1. Low self-esteem.

2. Knowledge deficit.

3. Activity intolerance.

4. Excess fluid volume.

4. Excess fluid volume is a priority because of the stress placed on the heart and vessels, which could lead to heart failure, pulmonary edema, and death.

TEST-TAKING HINT: The test taker must read the stem of the question and understand what the question is asking. This is a priority question. This means all the options are pertinent problems for CKD, but only one is a priority. Applying Maslow's hierarchy of needs is one way to determine priorities: physiological problems are priority over psychosocial problems, and life-threatening conditions take first priority.

17. The client with CKD is placed on a fluid restriction of 1,500 mL/day. On the 7 a.m. to 7 p.m. shift, the client drank an eight (8)-ounce cup of coffee, 4 ounces of juice, 12 ounces of tea, and 2 ounces of water with medications. What amount of fluid can the 7 p.m. to 7 a.m. nurse give to the client? _____________

720 mL. The nurse must add up how many milliliters of fluid the client drank on the 7 a.m. to 7 p.m. shift and then subtract that number from 1,500 mL to determine how much fluid the client can receive on the 7 p.m. to 7 a.m. shift. One (1) ounce is equal to 30 mL. The client drank 26 ounces (8 + 4 + 12 + 2) of fluid, or 780 mL (26 × 30) of fluid. There- fore, the client can have 720 mL (1,500 − 780) of fluid on the 7 p.m. to 7 a.m. shift.

TEST-TAKING HINT: The test taker must be knowledgeable of basic conversion factors. Use the drop-down calculator on the computer examination to ensure accuracy in computations.

18. The client diagnosed with CKD has a new arteriovenous fistula in the left forearm. Which intervention should the nurse implement?

1. Teach the client to carry heavy objects with the right arm.

2. Perform all laboratory blood tests on the left arm.

3. Instruct the client to lie on the left arm during the night.

4. Discuss the importance of not performing any hand exercises.

1. Carrying heavy objects in the left arm could cause the fistula to clot by putting undue stress on the site, so the client should carry objects with the right arm.

TEST-TAKING HINT: The test taker must notice the adjectives, such as "left" and "right." Options "2" and "3" have the nurse doing something to the arm with the fistula.

19.The male client diagnosed with CKD secondary to diabetes has been receiving dialysis for 12 years. The client is notified he will not be placed on the kidney transplant list. The client tells the nurse he will not be back for any more dialysis treatments. Which response by the nurse is most therapeutic?

1. "You cannot just quit your dialysis. This is not an option."

2. "You're angry at not being on the list, and you want to quit dialysis?"

3. "I will call your nephrologist right now so you can talk to the HCP."

4. "Make your funeral arrangements because you are going to die.

2. Reflecting the client's feelings and restating them are therapeutic responses the nurse should use when addressing the client's issues.

TEST-TAKING HINT: When asked to select a therapeutic response, the test taker should select an option with some type of "feeling" in the response, such as "angry" in option "2."

20. The nurse is discussing kidney transplants with clients at a dialysis center. Which population is less likely to participate in organ donation?

1. Caucasian.

2. African American.

3. Asian.

4. Hispanic

2. Many in the African American culture believe the body must be kept intact after death, and organ donation is rare among African Americans. This is also why a client of African American descent will be on a transplant waiting list longer than people of other races. This is because of tissue-typing compatibility. Remember, this does not apply to all African Americans; every client is an individual.

TEST-TAKING HINT: The nurse must be aware of cultural differences in health care.

21. The client receiving dialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first?

1. Place the client in the Trendelenburg position.

2. Turn off the dialysis machine immediately.

3. Bolus the client with 500 mL of normal saline.

4. Notify the health-care provider as soon as possible.

1. The nurse should place the client's chair with the head lower than the body, which will shunt blood to the brain; this is the Trendelenburg position.

TEST-TAKING HINT: The Trendelenburg position is often used as a distracter in questions, and the nurse needs to know it is only used in cases where blood needs to be shunted to the brain.

22. The nurse caring for a client diagnosed with CKD writes a client problem of "noncompliance with dietary restrictions." Which intervention should be included in the plan of care?

1. Teach the client the proper diet to eat while undergoing dialysis.

2. Refer the client and significant other to the dietitian.

3. Explain the importance of eating the proper foods.

4. Determine the reason for the client not adhering to the diet.

4. Noncompliance is a choice the client has a right to make, but the nurse should determine the reason for the noncompliance and then take appropriate actions based on the client's rationale. For example, if the client has financial difficulties, the nurse may suggest how the client can afford the proper foods along with medications, or the nurse may be able to refer the client to a social worker.

TEST-TAKING HINT: The test taker must always clarify and understand exactly what the question is asking the nurse to do. Answer options "1," "2," and "3" have the nurse do- ing the talking; only option "4" is allowing the client to explain the lack of compliance.

23. The client diagnosed with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse?

1. Inability to auscultate a bruit over the fistula.

2. The client's abdomen is soft is nontender, and has bowel sounds.

3. The dialysate being removed from the client's abdomen is clear.

4. The dialysate instilled was 1,500 mL and removed was 1,500 ml

4. Because the client is in ESRD, the fluid must be removed from the body, so the output should be more than the amount instilled. These assessment data require intervention by the nurse.

TEST-TAKING HINT: The words "warrant immediate intervention" should clue the test taker into selecting an option with abnormal or unexpected data for the client.

24. The client receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the client?

1. Notify the HCP if oral temperature is 102°F or greater.

2. Apply ice to the access site if it starts bleeding at home.

3. Keep fingernails short and try not to scratch the skin.

4. Encourage the significant other to make decisions for the client.

3. Uremic frost, which results when the skin attempts to take over the function of the kidneys, causes itching, which can lead to scratching, possibly resulting in a break in the skin.

TEST-TAKING HINT: The test taker must read the question carefully. A temperature of 102°F is usually not acceptable in any client. Fostering dependence in any chronic illness is not encouraged by the nurse and so the test taker could eliminate option "4."

The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?

A. Palpation of a thrill over the fistula

B. Presence of a radial pulse in the left wrist

C. Visualization of enlarged blood vessels at the fistula site

D. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand

Ans: Palpation of a thrill over the fistula

Rationale: 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. Enlarged visible blood vessels at the fistula site are a normal observation but are not indicative of fistula patency. Although the presence of a radial pulse in the left wrist and capillary refill less than 3 seconds in the nail beds of the fingers on the left hand indicate adequate circulation to the hand, they do not assess fistula patency.

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply.

A. Check the level of the drainage bag.

B. Reposition the client to his or her side.

C. Contact the health care provider (HCP).

D. Place the client in good body alignment.

E. Check the peritoneal dialysis system for kinks.

F. Increase the flow rate of the peritoneal dialysis solution.

ANS: A,B,D,E

Rationale: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing and peritoneal dialysis system are also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the HCP. Increasing the flow rate should not be done and also is not associated with the amount of outflow solution.

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication?

A. Warmth, redness, and pain in the left hand

B. Ecchymosis and audible bruit over the fistula

C. Edema and reddish discoloration of the left arm

D. Pallor, diminished pulse, and pain in the left hand

D. Pallor, diminished pulse, and pain in the left hand

Rationale: Perfusion is the priority concept
Steal syndrome results from vascular insufficiency after the 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, caused by tissue ischemia. Warmth and redness probably would characterize a problem with infection. Ecchymosis and a bruit are normal findings for a fistula.

The nurse is reviewing a client's record and notes that the health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding?

A. Elevated creatinine level

B. Decreased hemoglobin level

C. Decreased red blood cell count

D. Increased number of white blood cells in the urine

Ans: Elevated creatinine level

Rationale:
The creatinine level is the most specific laboratory test to determine renal function. The creatinine level increases when at least 50% of renal function is lost. A decreased hemoglobin level and red blood cell count are associated with anemia or blood loss and not specifically with decreased renal function. Increased white blood cells in the urine are noted with urinary tract infection.

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 38.5°C (101.2°F). Which nursing action is most appropriate?

1. Encourage fluid intake.

2. Notify the health care provider.

3. Continue to monitor vital signs.

4. Monitor the site of the shunt for infection.

Ans: 2

Rationale:
A temperature of 101.2°F (38.5°C) is significantly elevated and may indicate infection. The nurse should notify the health care provider (HCP). Dialysis clients cannot have fluid intake encouraged. Vital signs and the shunt site should be monitored, but the HCP should be notified first.

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

1. Monitor the client.

2. Elevate the head of the bed.

3. Assess the fistula site and dressing.

4. Notify the health care provider (HCP).

Ans: 4

Rationale:
Disequilibrium syndrome may be caused by rapid removal of solutes from the body during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs and symptoms of disequilibrium syndrome and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The HCP must be notified. Monitoring the client, elevating the head of the bed, and assessing the fistula site are correct actions, but the priority action is to notify the HCP.

A client with an arteriovenous fistula in the left arm who is undergoing hemodialysis is at risk for infection. Which should the nurse formulate as the best outcome goal for this client problem?

1. The client washes hands at least once per day.

2. The client's temperature remains lower than 101°F (38.3°C).

3. The client avoids blood pressure (BP) measurement in the left arm.

4. The client's white blood cell (WBC) count remains within normal limits.

Ans: 4

Rationale:
General indicators that the client is not experiencing infection include a temperature and WBC count within normal limits. The client also should use proper hand-washing technique as a general preventive measure. Hand washing once per day is insufficient. It is true that the client should avoid BP measurement in the affected arm; however, this would relate more closely to the problem of risk for injury.