Maria is a 47 year old female with a long history of diabetesmellitus and hypertension. She was recently diagnosed with renalinsufficiency 18 months ago. Her medication regimen include adiuretic and an oral anti-diabetic agent. She c/o anorexia andoverall fatigue, nocturia and short of breath sometimes. Hercurrent weight is 60 kg. She is being scheduled for severdiagnostic studies to evaluate for the renal disease. Diabetesmellitus is a known risk factor for renal failure.

Define ESRD:

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

What is the best description of chronic kidneydisease?

Symptoms are reversible with life- long medication

Condition has a rapid onset with frequent remissions

It is a fatal disorder unless renal replacement therapy isreceived   

There are frequent exacerbations since half of all nephrons aredamaged

The following diagnostic tests were performed:


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 clientwith chronic kidney disease?

Serum calcium    

Serum creatinine and BUN

Serum potassium

Serum phosphorus

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

Hematuria results in blood loss

Fewer red blood cells are beingformed    

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 thecorrect 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 testconfirm the medical diagnosis of end stage renal disease. Otherassessment findings include, +1 pitted edema, bilateral crackles inthe lungs, and clear pale urine. Vital signs: T – 98.8, P – 86, R -28, and BP – 178/92. Which additional assessment finding isconsistent with ESRD?

Yellow gray pallor  

Clay-colored stool


Fingernail clubbing

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

Irritation of the pericardial lining of the heart due to uremictoxins increases blood pressure

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

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

The increase of uremic waste products in the blood streamincreases the blood pressure.

Maria’s condition worsens: urinary output low, labvalues indicating worsening kidney function. Now she will be placedon dialysis. Maria has to weigh the benefits of hemodialysis versusperitoneal dialysis. Which factor is related to the use ofhemodialysis?

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 whichproblem while receiving hemodialysis?

Blood clot formation


Hepatitis B and C


While assessing Maria’s AV graft site, the nursepalpates a buzzing sensation directly over the graft. Whichdocumentation should the nurse enter into the nurse’snotes?

+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, Mariahad a tunnel catheter to the right subclavian. Which interventionshould the nurse include in her plan of care?

Instruct lab personnel to obtain blood specimens from the duallumen catheter

Perform sterile dressing changes at the dual lumen cathetersite   

Empty and record the drainage from the graft tubingregularly

Regularly rotate IV insertion sites above and below the graftsite

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

Client will adhere to a low protein diet

Client will select foods high in iron and calcium from amenu  

Client will identify the need to avoid fresh fruits andvegetables

Client will identify the need to increase her sodium and fluidintake

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

1.5 kg    

2 kg

2.5 kg

3 kg

Maria was receiving dialysis for a year. She isscheduled 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 isclean, dry and intact. Which nursing assessment has the highestpriority during the first 24 hour postoperativeperiod?

Vital signs    

Bowel sounds

Range of motion

Pedal pulses

Maria was receiving dialysis for a year. She isscheduled 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 isclean, dry and intact. Where would you expect to find the surgicalincision?

Right upper quad

Left lower quad

Right lower quad above and slightly medial to the iliaccrest   

Left lower quad above and slightly medial to the iliac crest

Which intervention should be included in the plan ofcare during the immediate postoperative period forMaria?

Monitor her urinary output hourly using anurometer  

Assess her surgical incision every shift

Monitor her nasogastric tube every 4 hours

Encourage her to use the incentive spirometer every 4 hourswhile awake

Which nursing diagnosis has the greatest priority whencaring for a client receiving immunosuppressiveagents?




Risk of infection

Which interventions are important to include in Maria’splan of care while she is receiving multipleimmunosuppressnts?

Restrict Maria’s activity to bedrest with use of the bedsidecommode

Instruct visitors that fresh flowers should not be taken intothe room   

Change the IV site daily

Reinforce, but do not routinely change any dressings

A week after surgery, Maria is discharged home. Two dayslater, she calls the nurse to report that she is experiencing morepain than she thinks she should be having. What is the best initialresponse by the nurse?

Going home often causes anxiety, which can increase yourpain

You may have developed a tolerance to your pain medication

Describe the location and type of pain you arehaving    

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

One week after surgery, Maria is discharged home. Threedays later, she calls the nurse to report that she is experiencingmore pain than she thinks she should be having. What is the bestinitial response by the nurse?

Going home often causes anxiety, which can increase yourpain

You may have developed a tolerance to your pain medication

Describe the location and type of pain you arehaving   

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

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

Take her prescribed diuretic and analgesic and record when shevoids

Increase her fluid intake and report any increase in herweight

Monitor her temperature and report over 101 F

Advise her to come to the clinic right away for furtherevaluation   


1. BESTDESCRIPTION OF CHRONIC KIDNEY DISEASE: Chronic kidneydisease has a rapid onset with frequent remissions. It is notreversible as the body’s ability to maintain fluid and electrolytebalance fails.


  • Serum calcium level decreased in renal disease due to retentionof phosphorus, As the calcium and phosphorus have the reciprocalrelation so with the increase in serum phosphorus level there iscorresponding decrease in the calcium level which further leads tobone disease.

3. Maria’s HB is 7.8, the decrease in the haemoglobin level isdue to the decrease in the production of erythropoietin whichstimulates the bone marrow to produce more RBC’s.

4. Interpretation of ABG: From the ABG value it is interpretedthat the Maria has METABOLIC ACIDOSIS because the kidney cannotexcrete increased loads of acid results in metabolic acidosis.Decreased acid excretion is also results from the inability of thekidney tubules to excrete ammonia and to reabsorb sodium.

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

6. Causesof hypertension in Chronic Renal disease:Activation of renin angiotensin cycle and excretion of aldosteronecauses hypertension.

7. Factorsrelated to use ofhemodialysis:  Peritoneal dialysiscan be more easily performed at home so it is more beneficial.

8. Maria is at a risk of developing nephrogenic ascites due toimbalance between the fluid and electrolyte balance in the bodybecause of renal disease.

9. THRILL PRESENT AND PALPATED : nurse document these notes inher documentation as buzzing sensation is positive sign ofsuccessfull dialysis.

10. Sterile dressing should be changed on alternate days andsite is cleaned with 2% chlorhexidine and allow to air dry for60-90 seconds.

11. Client have to identify the need to increase her sodium andfluid intake as dialysis leads to hypotension so sodium in dietmaintains serum sodium level in body.

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

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

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

15. Immediate post operative care include assess the urineoutput every hourly by using urometer to check the properfunctioning of kidneys and to assess the site of incision for anysign of infection.

16. When the patient is on immunosuppresive agents then thefirst priority diagnosis is risk of infection as theimmunosuppresive agents suppress the immunity of the patient tofight against disease, so proper interventions must be taken toprevent the risk of infection.

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

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

18. The best initial response by the nurse sholud be: ask thepatient to describe the location and type of pain she is having, soas to assess the level of pain and to provide accuratetreatment.

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

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

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