Med-Surg Practice Test #4: Renal

Answer: C. "It's fine for the lab to draw my blood from my left arm."

Rationale: The fistula arm is protected so the access stays open and free of infection. Blood draws, IV lines and blood pressure readings are not done on the arm with the fistula, because needle sticks and tight cuffs can injure the vessel, cause clotting or introduce infection; the client should remind staff and may wear a medical alert band or sign that says which arm to avoid. Option A shows correct understanding: a palpable thrill (buzzing or vibration) and an audible bruit (whooshing sound) mean blood is flowing through the fistula, and the client reports right away if they are absent. Option B shows correct understanding because anything tight or constricting on that arm can slow flow and cause the fistula to clot. Option D shows correct understanding because sleeping on the arm compresses the fistula. Clients are also taught not to carry heavy bags on that arm and to report redness, warmth, drainage or fever.

Answer: A. The drained dialysate is cloudy, and the client has abdominal tenderness and a low-grade fever.

Rationale: Cloudy effluent is the classic early sign of peritonitis, the most serious common complication of peritoneal dialysis. Abdominal pain or tenderness and fever add to the concern. The nurse reports it right away and expects a sample of the effluent to be sent for cell count, Gram stain and culture, with antibiotics (often added to the dialysate) as the provider prescribes. Prevention centers on strict hand hygiene and aseptic technique during exchanges and daily care of the catheter exit site. Option B is expected; a sense of fullness during inflow is common and often eases as the client adjusts. Option C is the normal appearance of drained dialysate. Option D is a positioning problem: slow outflow is first managed by changing the client's position, checking the tubing for kinks and making sure the drainage bag is below the abdomen. Constipation can also slow outflow.

Answer: D. Dialysis disequilibrium syndrome

Rationale: Dialysis disequilibrium syndrome is most likely during the first few treatments, especially when the BUN is very high. Urea is removed from the blood faster than from the brain, so water moves into brain cells and causes cerebral swelling. Early signs include headache, nausea, vomiting, restlessness and confusion; severe cases can progress to seizures and coma. The nurse stops or slows the treatment per protocol, notifies the provider and monitors neurologic status. It is prevented by making early treatments shorter and gentler, as the nephrology team orders. Option A is wrong because an air embolism causes sudden shortness of breath, chest pain, low blood pressure and cyanosis. Option B is wrong because low potassium mainly causes muscle weakness and dysrhythmias, not this neurologic pattern. Option C is wrong because dialysis removes fluid; overload causes crackles, shortness of breath and edema, not headache and confusion during treatment.

Answer: B. Urine output that has dropped from about 100 mL/hr to 30 mL/hr over 8 hours, a temperature of 38.2°C (100.8°F), tenderness over the new kidney and a weight gain of 1.5 kg since yesterday

Rationale: Falling urine output, fever, tenderness over the graft and sudden weight gain (fluid retention) are signs of acute rejection or another problem with the new kidney, such as an obstruction, a urine leak or a blood flow problem. The provider must be notified right away so the cause can be found and treated quickly; rising creatinine and blood pressure are also watched closely. Because immunosuppressants can hide fever and other signs of infection, even small changes matter after a transplant. Option A is expected surgical pain that is well controlled. Option C is a common side effect of tacrolimus; it should be mentioned, and the provider follows the drug level, but it is not the most urgent finding. Option D is expected early after surgery and has resolved. The client must take immunosuppressants exactly as prescribed for the life of the graft.

Answer: B. The client reports bladder spasms and lower abdominal fullness, and catheter drainage over the last hour has been much less than the volume of irrigant infused.

Rationale: With continuous irrigation, the drainage should always be more than the irrigant infused. Drainage that is less than the infused volume, with spasms and a distended bladder, suggests the catheter is blocked, most often by a blood clot. The bladder keeps filling with irrigant, which causes pain and can stress the surgical site and increase bleeding. The nurse stops the irrigation, checks the tubing for kinks, and irrigates the catheter manually only if the provider's orders or facility protocol allow; if flow does not return, the nurse notifies the provider. Option A is expected: the goal is light pink to clear drainage, and the irrigation rate is adjusted as ordered to keep it that way. Bright red drainage with thick clots would need prompt reporting. Option C is common with a large catheter in place. Option D is expected: true urine output is the total drainage minus the irrigant infused, so this is the client's own urine.

Answer: C. A temperature of 39.0°C (102.2°F), shaking chills, a heart rate of 118/min and a blood pressure of 96/60 mm Hg

Rationale: A stone that blocks the ureter while infection is present can lead to rapid sepsis, because infected urine is trapped behind the blockage. Fever, chills, a fast heart rate and falling blood pressure in a client with an obstructing stone are an emergency. The nurse reports right away and expects blood and urine cultures, IV fluids, IV antibiotics and urgent drainage of the kidney with a ureteral stent or a nephrostomy tube, as the urology team decides. Option A is the classic renal colic of a ureteral stone; it needs prompt pain relief, but it is expected. Option B is expected because the stone irritates the lining of the urinary tract. Option D is common with renal colic and is treated with an antiemetic. The nurse also strains all urine so a passed stone can be analyzed.

Answer: A. A UTI may first appear as new confusion, a fall or poor appetite, without burning or urgency.

Rationale: Older adults often do not have the classic burning, urgency and frequency, and they may not develop a fever. A UTI may show up as new or worsening confusion, falls, weakness, a loss of appetite or new incontinence. The nurse reports these changes, but also remembers that confusion has many other causes, such as dehydration, medications, low oxygen and other infections, so a full assessment is needed. Option B is wrong because older adults often have a blunted fever response. Option C is wrong because flank pain and costovertebral angle tenderness point to an upper tract infection (pyelonephritis), not a simple bladder infection. Option D is wrong because cloudy or smelly urine can come from dehydration or diet, and bacteria in the urine without symptoms (asymptomatic bacteriuria) is common in older adults and generally is not treated with antibiotics; overtreatment raises the risk of C. difficile and resistant organisms.

Answer: D. Acute post-streptococcal glomerulonephritis

Rationale: Acute post-streptococcal glomerulonephritis usually appears 1 to 3 weeks after a group A streptococcal throat or skin infection. Immune complexes inflame the glomeruli, causing blood in the urine (tea- or cola-colored), swelling around the eyes, decreased urine output and high blood pressure from sodium and water retention. Nursing care includes monitoring blood pressure, daily weights, intake and output, and following the sodium and fluid limits the provider prescribes; antihypertensives and diuretics may be ordered. Option A is wrong because nephrotic syndrome is defined by heavy protein loss in the urine, low albumin, high lipids and widespread edema; frank cola-colored urine and high blood pressure are more typical of glomerulonephritis. Option B is wrong because pyelonephritis causes fever, chills, flank pain and urinary symptoms. Option C is wrong because kidney stones cause severe colicky flank pain, not swelling and high blood pressure after a sore throat.

Answer: A. The AP lays the drainage bag on the client's abdomen while turning the client.

Rationale: The drainage bag must stay below the level of the bladder at all times, including when the client is turned, walked or moved. Raising the bag above the bladder lets urine flow back into the bladder and increases the risk of a catheter-associated urinary tract infection (CAUTI). The nurse corrects the AP and reinforces keeping the bag low but off the floor. Option B is correct because securing the catheter prevents pulling and irritation of the urethra. Option C is correct because routine cleaning with soap and water, moving from the meatus outward along the catheter, is part of standard catheter care. Option D is correct because kinks block drainage and the bed frame keeps the bag below the bladder; the bag should not hang on a side rail that will be raised. The best way to prevent CAUTI is to remove the catheter as soon as it is no longer needed.

Answer: C. Signs of dehydration and low serum sodium and potassium

Rationale: In the diuretic phase of acute kidney injury, the kidneys begin to make urine again but cannot yet concentrate it well. Large volumes of dilute urine can cause dehydration and losses of sodium and potassium. The nurse monitors intake and output, daily weights, blood pressure (watching for orthostatic changes), skin turgor and mucous membranes, and serum electrolytes, and gives IV fluids and electrolyte replacement as prescribed. BUN and creatinine fall gradually as kidney function recovers. Option A is a concern in the oliguric phase, when the kidneys retain fluid. Option B is also typical of the oliguric phase, when potassium builds up; in the diuretic phase potassium is more likely to drop. Option D is not a typical finding of this phase.