HESI CASE STUDIES

Judy Harrison is a 38-year-old African American female with a long history of diabetes mellitus type 2 and hypertension. She has experienced renal insufficiency for the last two years. Her current medications include an angiotensin converting enzyme inhibitor (ACEI), a diuretic, and an oral hypoglycemic agent. She reports to the nurse at the clinic that she has lost her appetite and is very fatigued. She adds that she has to get up to go to the bathroom several times during the night and has trouble catching her breath at times. Her current weight is 114 lbs (51.7 kg). She is scheduled for diagnostic studies to evaluate for the onset of end-stage renal disease (ESRD). - correct answer Background for Chronic Kidney Disease HESI Case Study Which explanation by the nurse is an accurate description of CKD? -There are frequent exacerbations since half of all nephrons are damaged -It is a fatal disorder unless renal replacement therapy is received. -The condition has a rapid onset with frequent remissions -symptoms are reversible with lifelong medication - correct answer It is a fatal disorder unless renal replacement therapy is received. CKD is fatal unless some form of renal replacement therapy dialysis or organ transplant is done whereas acute renal failure has a good prognosis for the return of kidney function if appropriate supportive care is provided during the acute. -symptoms are reversible with lifelong medication = chronic kidney disease is progressive irreversible kidney injury acute renal failure may be reversible with adequate supportive care during the acute episode -The condition has a rapid onset with frequent remissions = acute renal failure has a rapid onset but chronic kidney disease has a gradual onset occurring over months or years neither form of renal failure has frequent periods of remission -There are frequent exacerbations since half of all nephrons are damaged = half of all nephrons are often damaged in acute renal failure in CKD about 90% of nephrons are typically involved What additional information in Judy's history may be related to the onset of ESRD? A) Hypertension B) Polycystic Kidney Disease C) Hysterectomy at age 35 D) Female gender E) African-American ethnicity F) Hypertension - correct answer E + F African American ethnicity = African American clients are more likely to develop ESKD and have hypertensive ESKD Hypertension Polycystic Kidney Disease = Polycystic kidney disease gene mutation will develop kidney cysts by age 30 half of these people develop CKD by age 50 -hysterectomy at age 35 = this is not a risk factor for CKD -Female gender = CKD does not seem to be more common in either gender -HTN = hypertension is one of the primary causes of CKD the vast majority of clients with CKD have hypertension which may be either the cause or the result of CKD Which lab value is likely to be decreased in a client with chronic kidney disease? -Serum K+ -Serum BUN and Creatinine -Serum Ca+ -Serum Phosphorous - correct answer Serum calcium = Serum calcium is decreased in CKD in response to an increase in serum phosphorus -serum potassium levels are increased in CKD as the kidney loses the ability to remove potassium from the body clients with CKD should be assessed carefully for symptoms of hyperkalemia - serum creatinine and BUN are tests which evaluate the removal of nitrogenous wastes by the kidney. Both are increased in CKD although BUN levels are directly impacted by protein intake hydration status and other factors - serum phosphorus is increased as less phosphorus is excreted by the kidney Judy's hemoglobin level is 7.8. Which underlying pathology does the nurse recognize as the cause of this abnormal lab value? -Fewer red blood cells are being formed -hematuria results in blood loss -renal waste products destroy red blood cells -dehydration causes dilutional anemia - correct answer Fewer red blood cells are being formed = hemoglobin is decreased as the kidneys become less able to produce erythropoietin necessary for the formation of red blood cells -hematuria results in blood loss = CKD does not result in hematuria -renal waste products destroy red blood cells = this does not occur in CKD -dehydration causes dilutional anemia = if dehydration occurred it would be likely to result in a high hemoglobin level rather than a low level What is the correct interpretation of these ABGs? Metabolic acidosis (compensated) respiratory alkalosis (compensated) metabolic alkalosis (compensated) respiratory acidosis (compensated) - correct answer Metabolic acidosis (compensated) = an excessive bicarbonate is excreted, the HCO3 level decreases causing metabolic acidosis (decreased pH). compensation occurs when an increased rate and depth of respirations reduce the CO2 levels returning the pH to low normal - alkalosis would be indicated by an increased pH rather than decreased pH -respiratory acidosis (compensated) = this is a compensated acidosis but if it were respiratory in nature the CO2, would be elevated rather than decreased Which additional assessment finding is consistent with ESRD? A) Clay colored stool b) tall tented T waves on c) electrocardiogram d) decrease attention span e) stridor f) yellow Gray pallor - correct answer B, D, F Tall tented T waves on electrocardiogram = potassium excretion occurs mainly through the kidney. any increase in potassium load during the later stages of CKD can lead to hyperkalemia (high serum potassium levels) Decreased attention span = problems ranging from lethargy to seizures or coma which may indicate uremic encephalopathy Yellow-gray pallor = the client with ESRD often exhibits a yellow Gray pallor as the result of anemia and uremia. in addition the client with ESRD may exhibit other skin manifestations such as bruising and uremic frost (a very late manifestation) - Stridor is a crowing respiratory noise due to bronchoconstriction it is not an expected finding in ESRD - Clay-colored stools = not a manifestation seen in ESRD Which explanation best describes the pathology resulting in her hypertension? -An increase in the excretion of sodium and water from the kidneys causes hypertension -activation of the renin angiotensin cycle and excretion of aldosterone causes hypertension -the increase of uremic waste products in the bloodstream increase the blood pressure -irritation of the pericardial lining of the heart due to uremic toxins increases the blood pressure - correct answer Activation of the renin-angiotensin cycle and excretion of aldosterone causes hypertension = the renin angiotensin cycle causes vasoconstriction of the periphery which increases the blood pressure. in addition the excretion of aldosterone causes the retention of sodium and water further increasing the fluid volume which increases the blood pressure - An increase in the excretion of sodium and water from the kidneys causes hypertension = hypertension would be caused by an increase in the retention of sodium and water rather than an increase in the excretion - the increase of uremic waste products in the bloodstream increase the blood pressure = this is the probable cause for gastrointestinal manifestations such as anorexia, nausea and vomiting -irritation of the pericardial lining of the heart due to uremic toxins increases the blood pressure = explains the cause of pericarditis Which assessment finding indicates to the nurse that the desired outcome of the calcium acetate (PhosLo) has been achieved? Serum hemoglobin of 12 g/dL serum glucose of 90 mg/dL serum phosphorus of 4.0 mg/dL Serum hematocrit of 32% - correct answer Serum phosphorous of 4.0 mg/dL = calcium acetate (PhosLo) acts as a phosphate binder reducing the high serum phosphorus levels commonly found in the client with CKD -hemoglobin and hematocrit are not affected by the use of PhosLo - serum glucose of 90 mg/dL = this normal glucose level is managed with the clients glipizide (Glucotrol) Which assessment should the nurse perform to determine if the desired outcome of the captopril (Capoten) has been achieved? Blood pressure Intake and output apical pulse finger stick glucose - correct answer Blood pressure = captopril (Capoten) is an ACE inhibitor used as an antihypertensive agent -Intake and output = this would be an approximate assessment measure for a diuretic such as furosemide (lasix) but not for captopril - Apical pulse = this does not provide data as to the desired outcome of the captopril -finger stick glucose = this would be an appropriate assessment measure for a hypoglycemic agent such as glipizide (Glucotrol) but not for captopril Which assessment data indicates to the nurse that the desired outcome of the epoetin alfa (Epogen) has been achieved? Conjunctival sac returns to a reddish-pink color Normo-active bowel sounds no evidence of edema consumed 100% of diet - correct answer Conjunctival sac returns to a reddish-pink color = this assessment finding reflects an improvement in the client's anemia. epogen stimulates the production of RBCs resulting in an increase in hematocrit it is used to treat the anemia common in clients with CKD -Normo-active bowel sounds = this is not an indicator for the desired outcome of epogen - no evidence of edema = this assessment finding is an indicator use to assess the effectiveness of a diuretic such as a furosemide (Lasix) but not epogen - consumed 100% of diet = this is not the best indicator that the desired outcome of a Epoetin has been achieved although an improvement in dietary intake may be a secondary benefit of a reduction in fatigue Based on these diagnoses, which nursing intervention should be included in Judy's plan of care? -Encourage oral fluid intake -avoid any substances and intramuscular injections -encourage patient to ask questions and discuss fears about diagnosis -offer high protein snacks frequently - correct answer Encourage pt to ask questions and discuss fears about diagnosis = an open atmosphere that allows for discussion can decrease anxiety. facilitate discussions with family members about the prognosis and the impact on lifestyle -Encourage oral fluid intake = fluid restrictions will be instituted -avoid any substances and intramuscular injections = although the client with CKD is likely to bruise easily due to a reduction in platelets avoidance of injections is not necessary -offer high protein snacks frequently = protein is restricted to reduce the accumulation of waste products associated with protein metabolism which causes the manifestations of uremia Which intervention is most important for the nurse to implement? -Hold the dose of Key Ciel and contact the HCP to report the serum potassium level -calculate the millimeters of medication needed in record the amount on the fluid intake record - administer the dose of Key Ciel and document the serum potassium level in the medical record -ask the pharmacist to supply a tablet rather than an elixir since the patient is on fluid restriction - correct answer Hold the dose of Kay Ciel and contact the HCP to report the serum potassium level = the serum potassium level is elevated and administering additional potassium in any form is potentially dangerous to the client -calculate the millimeters of medication needed in record the amount on the fluid intake record = if the potassium level was within normal limits and the medication was given this would be an appropriate intervention however since the potassium level is high this is not the correct intervention - administer the dose of Key Ciel and document the serum potassium level in the medical record = this is not an appropriate intervention considering the client's elevated serum potassium level -ask the pharmacist to supply a tablet rather than an elixir since the patient is on fluid restriction = the HCP must be contacted regarding this change since the administration of this prescription would be unsafe for the client in any form there is another intervention that should be implemented What intervention should the nurse implement? -administer the prescribed tablet -request a faxed copy of the prescription -obtain the name of the office nurse - ask to speak directly to the HCP - correct answer Ask to speak directly with the HCP = the medication prescription is unsafe and requires direct communication with the prescribing HCP -administer the prescribed tablet = this is an unsafe intervention since the client's serum potassium is elevated -request a faxed copy of the prescription = requesting a written copy of a prescription is always desirable but in this case will only confirm an unsafe prescription -obtain the name of the office nurse = this is an appropriate action but it is not the most important action at this time Which statement should serve as the basis for the nurse's reply? - state nurse practice acts indicate that the professional nurse should only administer legally prescribed medications - the nurses job description in most hospital policy manuals clearly states that adhering to the HCP's prescriptions is required - only the prescribing HCP is legally liable for the administration of a prescribed but unsafe medication - the professional nurse can be held accountable for the administration of any unsafe medication - correct answer The professional nurse can be held accountable for the administration of any unsafe medication. - state nurse practice acts indicate that the professional nurse should only administer legally prescribed medications = the nurse practice act in each state does establish the legal regulation of the practice of nursing however the issue in question is not the legality of the prescription but rather the safety - the nurses job description in most hospital policy manuals clearly states that adhering to the HCP's prescriptions is required = the nurse must use sound professional judgment to determine if a prescribed medication or treatment is safe and should collaborate with the prescribing HCP. in addition the nurse must be careful to act within the limits of the state nurse practice act and may not administer a Med or medical treatment without a prescription - only the prescribing HCP is legally liable for the administration of a prescribed but unsafe medication = this is an inaccurate statement liability extends beyond the HCP Which risk factors relate to the use of hemodialysis? A) Noncompliant because treatments require more time B) bowel or bladder perforation C) orthostatic hypotension D) ascites E) hemorrhage - correct answer C + E orthostatic hypotension = hypotension can occur in up to 50% of HD treatments - hemorrhage = the heparin required during HD increases the risk for extensive bleeding. all invasive procedures must be avoided for four to six hours after dialysis. continually monitor the client for hemorrhage during and for at least one hour after dialysis - Noncompliant because treatments require more time = peritoneal dialysis typically requires a longer period of time for the exchange of fluid than does hemodialysis - bowel or bladder perforation = this is a serious complication associated with peritoneal dialysis. observe four and document any change in the color of the outflow. brown colored effluent occurs with a bowel perforation. if the outflow is the same color as urine and has the same glucose level a bladder perforation is probable - ascites = ascites is not a potential complication of hemodialysis Judy is at increased risk for the development of which problem if she chooses peritoneal dialysis as a course of treatment? - hepatitis B&C - hypertension - abdominal infection - osteoarthritis - correct answer Abdominal infection = peritoneal dialysis places the client at high risk for peritonitis since the catheter and fluid entered the peritoneal cavity. the client must be heparinized during hemodialysis therefore bleeding is a more likely potential complication than thrombosis - hepatitis B&C = clients on hemodialysis are at a greater risk for contracting hepatitis B&C then clients on peritoneal dialysis because of the equipment used in hemodialysis. hepatitis B vaccine is encouraged for clients with CKD - hypertension = the client is at risk for developing hypotension during treatment due to the fluid being removed. nausea vomiting diaphoresis, tachycardia and dizziness are common signs of hypotension - osteoarthritis = osteoarthritis is not a potential complication of hemodialysis What is the best description of an AV graft?