Acute Renal Failure Nursing Care Plan & Management


  • Is a sudden decline in renal function, usually marked by increased concentrations of blood urea nitrogen (BUN; azotemia) and creatinine; oliguria (less than 500 ml of urine in 24 hours); hyperkalemia; and sodium retention.
  • Acute renal failure are classified into following:
    • Prerenal failure – results from conditions that interrupt the renal blood supply; thereby reducing renal perfusion (hypovolemia, shock, hemorrhage, burns impaired cardiac output, diuretic therapy).
    • Postrenal failure – results from obstruction of urine flow.
    • Intrarenal failure – results from injury to the kidneys themselves (ischemia, toxins, immunologic processes, systemic and vascular disorders).


  • The disease progresses through three clinically distinct phase which is oliguric-anuric, diuretic, and recovery, distinguished primarily by changes in urine volume and BUN and creatinine levels.
  • Complication of ARF include dysrhythmias, increased susceptibility to infection, electrolyte abnormalities, GI bleeding due to stress ulcers, and multiple organ failure. Untreated ARF can also progress to chronic renal failure, end-stage renal disease, and death from uremia or related causes.
patho of acute renal failureAssessment:
  1. Oliguric-anuric phase: urine volume less than 400 ml per 24 hours; increased in serum creatinine, urea, uric acid, organic acids, potassium, and magnesium; lasts 3 to 5 days in infants and children, 10 to 14 days in adolescents and adults.
  2. Diuretic phase: begins when urine output exceeds 500 ml per 24 hours, end when BUN and creatinine levels stop rising; length is availabe.
  3. Recovery phase: asymptomatic; last several months to 1 year; some scar tissue may remain.
  4. In prerenal disease: decreased tissue turgor, dryness of mucous membranes, weight loss, flat neck veins, hypotension, tachycardia.
  5. In postrenal disease: difficulty in voiding, changes in urine flow.
  6. In Intrarenal disease: presentation varies; usually have edema, may have fever, skin rash.
  7. Nausea, vomiting, diarrhea, and lethargy may also occur.
Diagnostic Evaluation:
  1. Urinalysis shows proteinuria, hematuria, casts. Urine chemistry distinguishes various forms of ARF(prerenal, postrenal, intrarenal).
  2. Serum creatinine and BUN levels are elevated; arterial blood gas (ABG) levels, serum electrolytes may be abnormal.
  3. Renal ultrasonography estimates renal size and rules out treatable obstructive uropathy.
Primary Nursing Diagnosis
  • Fluid volume deficit related to excessive urinary output,vomiting,hemorrhage
Other Diagnoses that may occur in Nursing Care Plans For Acute Renal Failure
  • Ineffective tissue perfusion (renal)
  • Excess fluid volume
  • Risk for infection
Therapeutic and Pharmacologic Interventions:
  1. Surgical relief of obstruction may be necessary.
  2. Correction of underlying fluid excesses or deficits.
  3. Correction and control of biochemical imbalances.
  4. Restoration and maintenance of blood pressure through I.V. fluids and vasopressors.
  5. Maintenance of adequate nutrition: Low protein diet with supplemental amino acids and vitamins.
  6. Initiation of hemodialysis, peritoneal dialysis, or continuous renal replacement therapy for patients with progressive azotemia and other life-threatening complications.
Nursing Interventions:
  1. Monitor 24-hour urine volume to follow clinical course of the disease.
  2. Monitor BUN, creatinine, and electrolyte.
  3. Monitor ABG levels as necessary to evaluate acid-base balance.
  4. Weigh the patient to provide an index of fluid balance.
  5. Measure blood pressure at various times during the day with patients in supine, sitting, and standing positions.
  6. Adjust fluid intake to avoid volume overload and dehydration.
  7. Watch for cardiac dysrhythmias and heart failure from hyperkalemia, electrolyte imbalance, or fluid overload. Have resuscitation equipment available in case of cardiac arrest.
  8. Watch for urinary tract infection, and remove bladder catheter as soon as possible.
  9. Employ intensive pulmonary hygiene because incidence of pulmonary edema and infection is high.
  10. Provide meticulous wound care.
  11. Offer high-carbohydrate feedings because carbohydrates have a greater protein-sparing power and provide additional calories.
  12. Institute seizure precautions. Provide padded side rails and have airway and suction equipment at the bedside.
  13. Encourage and assist the patient to turn and move because drowsiness and lethargy may reduce activity.
  14. Explain that the patient may experience residual defects in kidney function for a long time after acute illness.
  15. Encourage the patient to report routine urinalysis and follow-up examinations.
  16. Recommend resuming activity gradually because muscle weakness will be present from excessive catabolism.
Documentation Guidelines
  • Physical findings:Urinary output and description of urine, fluid balance, vital signs, findings related to original disease process or insult,presence of pain or pruritus,mental status,GI status, and skin integrity
  • Condition of peritoneal or vascular access sites
  • Nutrition: Response to dietary or fluid restrictions, tolerance to food, maintenance of body weight
  • Complications:Cardiovascular,integumentary infection
Discharge and Home Healthcare Guidelines

All patients with ARF need an understanding of renal function,signs and symptoms of renal failure ,and how to monitor their own renal function. Patients who have recovered viable renal function still need to be monitored by a nephrologist for at least a year. Teach the patient that she or he may be more susceptible to infection than previously. Advise daily weight checks. Emphasize rest to prevent overexertion. Teach the patient or significant others about all medications, including dosage, potential side effects, and drug interactions. Explain that the patient should tell the healthcare professional about the medications if the patient needs treatment such as dental work or if a new medication is added. Explain that ongoing medical assessment is required to check renal function. Explain all dietary and fluid restrictions. Note if the restrictions are life-long or temporary.

Patients who have not recovered viable renal function need to understand that their condition may persist and even become chronic. If chronic renal failure is suspected, further outpatient treatment and monitoring are needed. Discuss with significant others the lifestyle changes that may be required with chronic renal failure.


Marilyn Sawyer Sommers, RN, PhD, FAAN , Susan A. Johnson, RN, PhD, Theresa A. Beery, PhD, RN , DISEASES AND DISORDERS A Nursing Therapeutics Manual, 2007 3rd ed


Welcome to your MSN Exam for Acute Renal Failure! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.


Exam Details

  • Number of Questions: 65 items
  • Mode: Practice Mode

Exam Instructions

  1. Practice Mode: This mode aims to facilitate effective learning and review.
  2. Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
  3. Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

Tips For Success

  • Read each question carefully. Take your time and don't rush.
  • Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
  • Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
  • Take breaks if you need them. It's not a race, and your understanding is what's most important.
  • Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!


Click 'Start Exam' when you're ready to begin. Best of luck!

💡 Hint

Think about the grand orchestra of our body and how each organ plays its part, especially the kidneys, which often deal in 'grams', not 'milligrams', when it comes to filtering out crucial substances.

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1. During a lively discussion at the University Hospital nursing station, Nurse Davis ponders on a physiology-related query. She asks, "On an average day, how much potassium chloride (KCL) do healthy kidneys manage to eliminate?"

💡 Hint

Consider a scenario where a storm hits suddenly and causes significant damage in a very short time. Now translate that to the context of renal health. What type of renal failure does this rapid, significant change most closely resemble?

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2. Nurse Aiden is preparing to educate a group of student nurses about renal failure. He wants to highlight a type of renal failure that is characterized by a sudden and sharp deterioration in kidney function. Which type of renal failure is he referring to?

💡 Hint

This is the test that provides the most direct measure of kidney function. It is the most important renal function test in clinical practice because it can be used to diagnose and monitor kidney disease.

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3. Nurse Ava is conducting a seminar on renal function assessment for a group of trainee nurses. She poses a question to them, "Can you tell me, which renal function test is typically considered the most crucial one in clinical practice?"

💡 Hint

This is the mechanism by which the kidneys respond to changes in blood pressure or sodium levels. It is a feedback loop that helps to maintain the body's fluid and electrolyte balance.

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4. Nurse Mia is conducting a teaching session about the renal system for her junior colleagues. She's explaining the complex mechanism by which the kidneys regulate sodium (Na+) and potassium (K+) levels. Which option best captures the process Mia is describing?

💡 Hint

Picture dilute urine as a watered-down drink. The markers to confirm its presence would show low 'concentration' values, hinting that it's not as 'strong' as it should be. Now, consider which test results could symbolize this diluted state.

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5. At City Cross Hospital, Nurse Mitchell is evaluating a patient suspected of producing dilute urine. She considers, "Which tests and their corresponding results can confirm the presence of dilute urine?"

💡 Hint

Think of the condition as a tumultuous journey. In the phase we're looking for, the patient is right in the thick of things, stuck in a situation where the kidneys are struggling to maintain their basic functions.

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6. While caring for a patient with acute renal failure at Harmony Medical Center, Nurse Anderson reviews the various phases of the condition. She recalls, "During which phase of acute renal failure does oliguria occur, rendering the kidneys unable to effectively remove metabolic wastes, water, electrolytes, and acids?"

💡 Hint

Imagine your kidneys as diligent chemists, maintaining a balance of water and electrolytes. If the chemists become less adept, what might be some of the first changes you'd notice?

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7. Nurse Liam was conducting a health teaching session for patients at risk of kidney disease. He explained how some initial signs could be subtle and easily overlooked. One of the potential early indicators was a decrease in the ability to concentrate, alongside alterations in urine concentration and volume. He then posed a question to his audience, "Is it accurate to say that early signs of kidney disease often include a reduced ability in the concentration and dilution of urine?"

💡 Hint

Remember, urine isn't just water. It's a complex cocktail of waste materials, including electrolytes like those in sports drinks, but in this case, they're being removed rather than replenished. The balance of these electrolytes is important for our body's health.

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8. As part of her daily rounds, Nurse Ava is discussing with her patient, Mr. Johnson, about the significance of electrolytes in the body and how some of them are excreted via urine. She wants to educate him about the specific electrolytes typically found in urine. She asks him, "Mr. Johnson, do you remember which electrolytes we discussed are typically present in urine?"

💡 Hint

This is the activity that has the potential to cause the most harm to the patient. Physical activity can increase the risk of bleeding, which can be serious in the context of a renal biopsy.

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9. Nurse Olivia is attending to a patient who has recently undergone a renal biopsy. Among her post-procedure care actions, which one should she ideally refrain from doing?

💡 Hint

To keep our bodies in balance, the kidneys work tirelessly. In the process of filtering our blood, they excrete an impressive amount of substances including salt. Remember, this amount is also closely linked with your daily salt intake.

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10. Nurse Williams is educating her patient about kidney functions as part of a wellness check-up. She mentions the kidneys' role in managing salt levels in the body. On average, how much salt do healthy kidneys eliminate each day?

💡 Hint

This can make it difficult for the body to receive the oxygen and nutrients it needs, and it can also increase the risk of complications during surgery.

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11. Nurse Jackson is assisting a patient advancing speedily toward End-Stage Renal Disease (ESRD). The patient, anxious about his condition, inquires about the possibility of a kidney transplant. Considering the potential contraindications, Nurse Jackson knows that the patient's eligibility for a kidney transplant might be compromised by:

💡 Hint

In the vast world of pharmacology, some medicines, while beneficial for some conditions, may prove harmful for specific organs. These include a common class of drugs often used for pain relief, inflammation, and fever reduction.

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12. While caring for a patient with compromised kidney function at Serenity Medical Center, Nurse Thompson reflects on her pharmacology knowledge. She considers, "Which among these medications is known to be potentially harmful to the kidneys, exhibiting nephrotoxic properties?"

💡 Hint

This is the component that makes up the majority of urine's composition. It is essential for the body to function properly and helps to transport nutrients, remove waste products, and regulate body temperature.

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13. During a health education session, Nurse Emily is explaining to her patient about the composition of urine. She poses a question to her patient, "Can you tell me which component forms the majority of urine's composition?"

💡 Hint

This is the most important thing to do after a left nephrectomy, as it will help to ensure that the remaining kidney is functioning properly.

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14. Nurse Sara has been given the responsibility of caring for a patient who has just been transferred to her unit after undergoing a left nephrectomy. Sara knows she needs to prioritize certain aspects of care for her patient's well-being. She considers, "What would be my topmost priority in providing care for my patient following a left nephrectomy?"

💡 Hint

In the fascinating language of medicine, words often hint at their meanings. Consider a term that echoes the kidneys' crucial role in filtering waste products from the bloodstream, a role compromised when toxins build up.

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15. During her shift at Evergreen Hospital, Nurse Patterson encounters a patient with a suspected buildup of toxins in their blood. She ponders, "What is the medical term for the accumulation of toxins in one's bloodstream?"

💡 Hint

Reflect on the early stages of kidney failure. The kidneys are still functioning but with diminished efficiency, leading to an interesting paradox: an increase in a certain activity instead of the expected decrease.

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16. At Meadowland General Hospital, Nurse Philips admits a patient diagnosed with early stage chronic renal failure. As she carries out her assessment, she wonders, "Which of these symptoms is typically associated with a patient in the early stages of chronic renal failure?"

💡 Hint

This is the type of renal failure that is the least common type of renal failure.

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17. Nurse Mason is sharing an example with his students about a particular type of renal failure. He explains that this form of failure is brought about by an obstruction in the flow of urine, potentially due to an enlarged prostate or a tumor blocking the urethra, or even by calculi obstructing the ureter or kidney pelvis. Can the students identify the type of renal failure he is describing?

💡 Hint

Envision ESRD as a nearly empty gas tank, where the kidneys are running on minimal fuel. The GFR that defines this stage is quite low but slightly above a single digit.

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18. While caring for a patient with advanced renal disease at Riverside General Hospital, Nurse Bennett ponders over the severity of end-stage renal disease (ESRD). She questions, "What is the glomerular filtration rate (GFR) threshold in milliliters per minute that defines the occurrence of ESRD?"

💡 Hint

Picture the kidneys as a filtration plant working at its lowest efficiency in end-stage renal disease. The defining threshold of GFR is low, but not quite in single digits.

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19. During a seminar at Central City Hospital, Nurse Baker learns about the severity of end-stage renal disease. She recalls, "What is the threshold glomerular filtration rate (GFR) - in ml/min per 1.73m2 - that defines end-stage renal disease?"

💡 Hint

This is the phase of acute renal failure that is most likely to be associated with fluid and electrolyte imbalances. Nurses need to be vigilant about monitoring the patient's fluid status and serum electrolyte levels during this phase.

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20. Nurse Collins is attending to a patient suffering from acute renal failure. Suddenly, the patient's urinary output spikes to 150 ml/hr, leading Nurse Collins to deduce that the patient has transitioned into the second phase of acute renal failure. During this phase, what signs and symptoms should she be vigilant about?

💡 Hint

Acute kidney rejection is a condition in which the body's immune system attacks the transplanted kidney.

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21. Nurse Thomas is educating a patient who has recently undergone a kidney transplant. He wants to ensure that the patient is aware of the signs and symptoms of acute kidney rejection. Which of the following symptoms should he advise the patient to watch out for?

💡 Hint

While each of these values should be monitored, potassium is a bit like a tightrope walker – it requires a delicate balance. Too much or too little in the blood can lead to serious, even life-threatening, heart rhythm issues.

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22. In the renal unit, Nurse Sarah is meticulously examining the lab results of a patient with acute renal failure. She realizes that one particular result needs immediate reporting to the physician. She discusses with a fellow nurse, "Among these results, which one do you think should be flagged to the doctor right away?"

💡 Hint

This phase involves prolonged exposure to the causative factors leading to a range of symptoms including fluid retention and electrolyte imbalances. This phase is synonymous with a state of upkeep or continuation over a certain period.

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23. In a busy morning shift, Nurse Wilson finds himself managing a patient exhibiting symptoms such as fluid volume excess, edema due to salt and water retention, hypertension, Azotemia, hyperkalemia, muscle weakness, nausea, diarrhea, and high serum creatinine and BUN levels. As he analyzes the case, he wonders which phase of Acute Renal Failure his patient could be in. Which phase is it?

💡 Hint

This electrolyte imbalance is characterized by low levels of sodium in the blood.

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24. Nurse William is caring for a female patient who was admitted with a diagnosis of acute renal failure. The patient is conscious, aware, and complaining of intense back pain, along with nausea, vomiting, and abdominal discomfort. Her vital statistics are blood pressure at 100/70 mm Hg, pulse rate at 110, respiration rate at 30, and an oral temperature of 100.4°F (38°C). Her electrolyte results show sodium levels at 120 mEq/L and potassium at 5.2 mEq/L, and she has only produced 50 ml of urine over the past 8 hours. What kind of electrolyte imbalance does the patient's condition suggest?

💡 Hint

Think of the kidneys as careful sieves, allowing some substances to pass while holding back others. These include key building blocks of our body, which are usually retained to keep the body functioning efficiently.

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25. While conducting a urinalysis at Heartland Regional Medical Center, Nurse Benson comes across a quandary concerning the standard components of urine. She muses, "Which of the following substances is typically not detected in urine?"

💡 Hint

While the kidneys' job isn't fighting off invaders, their failure can open the gates. What happens when the body's defenses are compromised?

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26. Nurse Jane was assisting a patient who had been recently diagnosed with acute renal failure. The patient, having done some research, wanted to understand the complications associated with his condition better. He asked Jane, "What is the most significant complication that I should be aware of as someone suffering from acute renal failure?"

💡 Hint

This is the complication that is most likely to lead to serious complications, such as stroke or heart attack. Nurses need to be vigilant about monitoring the patient's blood pressure during hemodialysis and to take steps to prevent or treat high blood pressure.

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27. As Nurse Miranda is discussing potential complications of hemodialysis with her team, she highlights the most common issue they need to anticipate. Which of these complications is typically the most frequent during hemodialysis?

💡 Hint

This is the stage of chronic renal failure in which the kidneys are no longer able to function adequately. It is a serious condition that requires specialized treatment, such as dialysis or kidney transplant.

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28. Nurse Isabel is caring for a patient with chronic renal failure. The patient's kidneys now possess too few nephrons to efficiently excrete metabolic waste and manage fluid and electrolyte balance. This advanced stage of chronic renal failure is referred to as what?

💡 Hint

This is the most common reason for using CRRT, as it is used to remove excess fluid from the blood.

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29. Nurse Lisa is caring for a patient in acute renal failure who has been identified as a suitable candidate for continuous renal replacement therapy (CRRT). Lisa is discussing with a medical student about the primary reason for recommending CRRT. She asks, "Could you tell me what's the most typical indication for implementing CRRT in patients?"

💡 Hint

This type of renal failure occurs before the kidneys are damaged, and it is caused by an impaired blood supply to the kidneys.

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30. Nurse Mark is caring for a patient, Mr. Brown, who is showing signs of renal dysfunction due to decreased blood flow to his kidneys from heart failure. Mark explains to Mr. Brown that there are different types of renal failure and the one he is most likely suffering from is due to an impaired supply of blood to the kidney, which can result from fluid volume deficit, hemorrhage, heart failure, or shock. Mark asks Mr. Brown, "Can you recall the type of renal failure we talked about that occurs due to an impaired blood supply to the kidneys?"

💡 Hint

Kidneys are remarkable for their balancing act with electrolytes, but when they falter, potassium is a key player to watch. Remember, too much of it could put your heart in a pinch - and the heart is one organ you definitely don't want to upset!

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31. Nurse James is providing education to his patient, Mr. Thompson, who has recently been diagnosed with kidney disease. James is explaining the potential complications of the disease, specifically serious electrolyte imbalances. He asks Mr. Thompson, "Can you recall which electrolyte disorder I mentioned as being particularly severe in connection with kidney disease?"

💡 Hint

This test measures how well your kidneys are filtering creatinine out of your blood.

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32. Working in the renal unit, Nurse David often has to explain complex kidney functions to his patients. He is currently discussing with a patient, Mrs. Lewis, the significance of assessing her kidney's filtration capabilities. David wants Mrs. Lewis to understand which test is most often monitored to evaluate glomerular filtration rate and overall kidney function. He asks her, "Mrs. Lewis, can you recall which diagnostic test we use to keep track of your kidneys' filtration performance and overall health?"

💡 Hint

Just as a stormy, cloudy sky can be a sign of impending rain, cloudiness in certain medical scenarios can signify trouble, specifically an infectious one. Reflect on how the body reacts when invaded by pathogens.

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33. In the tranquility of a home-care setting, Nurse Wilson assists a patient undergoing peritoneal dialysis. The patient remarks that the dialysate in the collection bag appears cloudy. Nurse Wilson considers, "What could be the potential explanation for the cloudiness observed in the dialysate collection bag?"

💡 Hint

A river flows freely until it reaches a dam or blockage, but what if the problem lies within the riverbed itself? The answer lies where the issue originates.

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34. Nurse Michael was providing education to a group of nursing students during their clinical rotation in the nephrology unit. One of his patients had recently suffered a sudden loss in kidney function due to a combination of severe hypertension, exposure to harmful substances, and muscle tissue breakdown from a heatstroke. He asked his students, "This patient's condition involves acute damage to renal tissue and nephrons, as well as acute tubular necrosis, leading to a drastic drop in tubular and glomerular function. What type of renal failure are we dealing with here?"

💡 Hint

The frequency of changing dialysate in CAPD paints a picture of the busy life of patients undergoing this treatment. It's a dance that happens more often than a daily coffee break but less frequently than a meal.

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35. At Springfield Clinic, Nurse Johnson is overseeing a patient who's been prescribed continuous ambulatory peritoneal dialysis (CAPD). She questions, "In the context of CAPD, after how many hours does the patient need to empty their peritoneal cavity and refresh the dialysate?"

💡 Hint

Think about how much you drink in a day. Your kidneys must process all that fluid, but they also recycle much of it back into your body. So, the actual amount they let go as urine might be less than you'd think.

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36. In a health class, Nurse Amelia is teaching about the kidney's role in water balance. She challenges her students with a question, "Could you tell me approximately how much water healthy kidneys typically excrete in a day?"

💡 Hint

This is the hormone that is responsible for the body's "water conservation" mechanism. When levels of this hormone are high, the kidneys absorb more water, which helps to prevent dehydration.

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37. During a tutoring session, Nurse Jack is helping a nursing student understand the body's fluid regulation mechanisms. He asks her a question, "Can you tell me which hormone plays a crucial role in controlling the absorption of water in our body?"

💡 Hint

NSAIDs do not interfere with the secretion of creatinine or the assay used to measure its serum concentration.

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38. In the midst of her bustling shift, Nurse Madison has to administer medication to a patient who is going to have their serum creatinine levels tested. She has to ensure that the medication she gives will not tamper with either the secretion of creatinine or the assay used to gauge its serum concentration. Which medication can she safely administer from the following options?

💡 Hint

The presence of these substances in urine is not a red flag.

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39. As Nurse John is discussing urinary composition with his fellow healthcare workers, he poses a true-or-false question to stimulate discussion, "Are we to believe that the presence of creatinine, phosphate, sulfates, and uric acid in urine is abnormal and indicative of renal failure?"

💡 Hint

This is a type of dialysis that is often used in the ICU setting. It is a continuous process that can be used to stabilize patients with acute kidney injury or to provide long-term dialysis for patients with chronic kidney failure.

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40. Nurse Jacob is explaining to a group of nursing students about a therapeutic process for renal failure. This process entails the continuous circulation of blood, either from artery to vein or vein to vein, wherein excess water and solutes are filtered out and directed into a collection device. As necessary, fluid can be supplemented with a balanced electrolyte solution during the treatment. What is the term for this procedure?

💡 Hint

Consider the nature of the diuretic phase, where the kidneys start to recover and produce a large amount of urine. Like a dried up riverbed after a heavy rainfall, what could this sudden flow possibly lead to?

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41. A week into treating a patient with acute renal failure, Nurse Alex notices that the patient has transitioned into the diuretic phase. As he continues to provide care, which condition should he be particularly watchful for during this phase?

💡 Hint

This is a type of kidney disease that can develop after a strep throat infection, as the body's immune system mistakenly attacks the kidneys.

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42. Nurse Matthew is reviewing the medical history of a new patient, noticing a past infection caused by group A beta-hemolytic streptococci. He's aware of the potential renal complications associated with this type of infection. He asks a colleague, "Can you remind me which renal disorder is often linked with a history of infection by group A beta-hemolytic streptococci?"

💡 Hint

A decrease in the BUN to creatinine ratio can be a sign of fluid volume excess, but it can also be a sign of malnutrition. However, it is more likely to be a sign of fluid volume excess in this case, as the patient is also suspected of having fluid volume imbalance.

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43. During a meeting with her team, Nurse Samantha discusses a case of a patient with suspected fluid volume imbalance and potential malnutrition. She asks her team, "Does an increase or decrease in the Blood Urea Nitrogen (BUN) to Creatinine ratio signal issues such as fluid volume excess or malnutrition?"

💡 Hint

This is the most common cause of ESRD, as it can damage the kidneys over time.

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44. Nurse Anna is educating a group of nursing students about the common causes of end-stage renal disease (ESRD). She poses a question to the group, "What chronic condition is considered the primary cause of ESRD among patients?"

💡 Hint

Understanding the patients' knowledge and perception of their medical conditions and treatments is crucial in nursing.

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45. Nurse Avery is attending to a female patient suffering from end-stage renal disease (ESRD). The patient expresses mixed feelings, stating she resents being dependent on the dialysis machine, yet feels relieved about starting dialysis as it will allow her to consume whatever she wishes. Drawing from this dialogue, which nursing diagnosis should Avery identify for her patient?

💡 Hint

Picture your body as a city, your kidneys the waste disposal plant. When the plant fails, waste builds up. What term describes this pollution of the body's environment?

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46. Nurse Samantha was deep in conversation with a colleague about one of her patients. The patient, a middle-aged man, had been exhibiting signs of lethargy, confusion, anorexia, and nausea.

As Samantha listed out the patient's symptoms, she highlighted that these conditions are often associated with the metabolic disruptions brought on by a certain medical state. She asked her colleague, "What's the medical term we use when these metabolic impairments, including Hyperkalemia, Acidosis, Hyperlipidemia, Hyperuricemia, and malnutrition, come into play?"

💡 Hint

When the kidneys fail, they are not able to remove excess potassium from the blood.

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47. During a lecture to nursing students, Nurse Annabelle is discussing the serious consequences of kidney failure. She mentions that one particular condition stands as the leading cause of death when kidneys fail. Which condition is she referring to?

💡 Hint

This is the type of renal failure that is most likely to be diagnosed in the later stages, as the symptoms are often mild or nonexistent in the early stages.

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48. Nurse Benjamin is explaining to a group of nursing students about a type of renal failure characterized by a gradual, stealthy process of kidney destruction, often remaining unnoticed for years while nephrons are damaged and the renal mass decreases. Is he discussing:

💡 Hint

This is a basic nursing task that can be safely delegated to a nursing assistant, as it does not require any specialized skills or knowledge.

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49. As a newly graduated Registered Nurse, you are tasked with the care of a patient suffering from acute renal failure and hypernatremia. The charge nurse instructs you to delegate some tasks to the nursing assistant on your team. You ponder, "Which of these patient care activities can I safely delegate to the nursing assistant?"

💡 Hint

Think about a water dam with a faulty gate. If the gate is not regulating the flow of water properly, what would be the logical step to prevent overflow?

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50. Nurse Victoria is working with a patient whose kidneys are struggling to regulate fluid and electrolyte balance and to eliminate metabolic waste products effectively. Given these conditions, what should the approach be towards the patient's fluid and sodium intake?

💡 Hint

Patients with chronic renal failure are at risk of fluid overload.

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51. Nurse Ethan is advising a patient suffering from chronic renal failure on the importance of keeping track of weight changes. He wants to make sure the patient knows when it's essential to report any weight changes to the doctor. Which of the following scenarios should he highlight as a crucial one for notifying the physician?

💡 Hint

This is a complication that is most likely to occur in patients who are new to dialysis. Symptoms can be sudden and severe, and it is important to seek medical attention immediately if they occur.

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52. Nurse Olivia, with her years of expertise, is vigilantly attending to a female patient who is experiencing her inaugural session of dialysis due to acute renal failure. Olivia knows that she must keep a close eye out for dialysis equilibrium syndrome, a complication that often occurs during the initial dialysis treatments. If this syndrome manifests, what signs and symptoms can Olivia expect to observe in her patient?

💡 Hint

The BUN test is one of the ways we monitor kidney health. This test measures the amount of urea nitrogen, a waste product of protein metabolism, in the blood. A "normal" range should indicate effective clearance of this waste by the kidneys.

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53. During her regular shift at the hospital, Nurse Stevens reviews lab results for her patients. She's analyzing the Blood Urea Nitrogen (BUN) values as part of her assessments. What is considered a typical range for BUN levels?

💡 Hint

This is the typical acidity level of urine because the kidneys produce urine that is slightly acidic in order to help to flush out acids from the body. If the urine were too alkaline, it would not be able to effectively flush out acids.

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54. Nurse Andrew is presenting a lecture on urinary system health to his patients. One topic of interest is the acidity of urine. He poses the following question to his audience, "What is the typical acidity level of urine?"

💡 Hint

As engaging as a detective story, healthcare often requires piecing together symptoms to gauge a situation's severity. Here, consider how post-dialysis symptoms may hint at a complication that necessitates more than just symptomatic treatment.

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55. After an intensive hemodialysis session at Sunshine Care Dialysis Center, Nurse Gray finds her patient writhing in discomfort. The patient laments a throbbing headache, waves of nausea, and an unshakeable restlessness. Prompted by these symptoms, she considers, "What would be the most suitable course of action to take under such circumstances?"

💡 Hint

Imagine the renal tubules as a busy highway, and nephrotoxins are like roadblocks. Now add in ischemia, akin to poor road maintenance due to lack of funding (or oxygen). The combination could lead to a serious accident or, in our case, a condition that spells disaster for the tubules.

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56. In a teaching session, Nurse Laura is explaining to her fellow nurses about certain renal conditions that can arise due to a combination of ischemia and exposure to nephrotoxins. She quizzes her colleagues, "Which renal condition is most likely to develop when a patient experiences both ischemia and exposure to a nephrotoxin simultaneously?"

💡 Hint

This is the primary goal of anti-hypertensive therapy in the context of chronic renal disease. It is important to remember that damage to either the kidneys or the heart can lead to further complications, such as kidney failure or heart attack.

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57. Nurse Hannah is teaching her patients about chronic kidney disease. She explains the purpose of anti-hypertensive therapy for those suffering from this condition. What is the primary goal of this treatment in the context of chronic renal disease?

💡 Hint

This is the type of diet that is best for people with renal failure. It provides enough calories, while restricting protein and ensuring that the majority of calories come from carbohydrates.

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58. Nurse Elizabeth is advising a patient with renal failure on dietary modifications. Keeping in mind the condition of the patient's kidneys, which kind of diet should she recommend?

💡 Hint

This is the most important nursing intervention in the oliguric phase of ARF, as it helps to prevent fluid overload and its complications.

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59. Nurse Julia is taking care of a male patient who is in the oliguric phase of acute renal failure (ARF). Among her nursing interventions, which one should she prioritize the most?

💡 Hint

These agents are named for their destructive nature, which is specifically targeted at the organ they damage, much like how a toxin would behave. They sound like they're "toxic" to a specific part of the anatomy.

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60. Nurse Parker is instructing her nursing students about various factors that can cause damage to kidney tissue. She asks her students if they can recall the name of these damaging agents. Which term is she referring to?

💡 Hint

Think about the transition of seasons, a process that doesn't happen overnight. Just as nature takes its time to shift from winter to spring or summer to fall, some health conditions need a certain time frame to move from transient to persistent.

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61. Nurse Benjamin is conducting a workshop on Chronic Kidney Disease (CKD) for a team of healthcare professionals. He asks the team, "According to the Kidney Disease Outcomes Quality Initiative (K/DOQI), CKD is defined as evidence of structural or functional kidney abnormalities, demonstrated by abnormal urinalysis, imaging studies, or histology, that persist for at least how many months, irrespective of whether the Glomerular Filtration Rate is decreased?"

💡 Hint

Think of the diuretic phase as a dam suddenly releasing its water. It's a period of increased urine output, which might sound good initially, but if not managed properly, the body could be left parched, much like the downstream areas after a dam release.

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62. In the hospital's renal unit, Nurse Robert has been caring for Marina, a patient with acute renal failure. After a week of treatment, Marina transitions into the diuretic phase. Robert knows this stage requires vigilant monitoring for certain conditions. He discusses with a junior nurse, "What potential condition should we carefully watch for during Marina's diuretic phase?"

💡 Hint

This is a condition that is often treated with hypertonic glucose, insulin infusions, and sodium bicarbonate. These treatments help to move potassium out of the bloodstream and into the cells, where it belongs.

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63. As Nurse Tristan attends to a male patient grappling with acute renal failure, he knows to anticipate specific treatments. In this case, he should expect the use of hypertonic glucose, insulin infusions, and sodium bicarbonate to alleviate which of the following conditions?

💡 Hint

The number might remind you of something you probably experience every day – the minutes on a clock. That's one loop around the hour hand. Consider the importance of this number in time and its significance in urine output.

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64. During her shift, Nurse Lily is closely monitoring the urine output of her patients. She needs to recognize if the urine output drops below a certain threshold, which is considered the minimum normal output per hour. What is this value?

💡 Hint

This is the result that is most likely to indicate hyperkalemia, a condition in which the level of potassium in the blood is too high. Hyperkalemia can be a life-threatening condition, especially in patients with acute renal failure.

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65. Nurse Liam is examining the latest lab results for a patient with acute renal failure. As he pores over the data, one particular result grabs his attention, prompting him to immediately report it to the physician. Which result is he most likely concerned about?

Nursing Care Plan

Nursing Diagnosis: Excess fluid volume

May be relate to

  • Compromised regulatory mechanism (renal failure)

Possibly evidenced by

  • Intake greater than output, oliguria; changes in urine specific gravity
  • Venous distension; blood pressure (BP)/central venous pressure (CVP) changes
  • Generalized tissue edema, weight gain
  • Changes in mental status, restlessness
  • Decreased Hb/hematocrit (Hct), altered electrolytes; pulmonary congestion on x-ray
Desired Outcomes
  • Display appropriate urinary output with specific gravity/laboratory studies near normal; stable weight, vital signs within patient’s normal range; and absence of edema.
Nursing Interventions
  • Accurately record intake and output (I&O) noting to include “hidden” fluids such as IV antibiotic additives, liquid medications, frozen treats, ice chips. Religiously measure gastrointestinal losses and estimate insensible losses (sweating), including wound drainage, nasogastric outputs, and diarrhea.
    • Rationale: Decrease in output (to less than 400 ml per 24 hours) may indicate acute failure, especially in high-risk patients. Accurate monitoring of I&O is necessary for determining renal function and fluid replacement needs and reducing risk of fluid overload. Do note that hypervolemia usually occurs in anuric phase of ARF and may mask the symptoms.
  • Monitor urine specific gravity.
    • Rationale: Measures the kidney’s ability to concentrate urine. In intrarenal failure, specific gravity is usually equal to or less than 1.010, indicating loss of ability to concentrate the urine.
  • Weigh daily at same time of day, on same scale, with same equipment and clothing.
    • Rationale: Daily body weight is best monitor of fluid status. A weight gain of more than 0.5 kg/day suggests fluid retention.
  • Assess skin, face, dependent areas for edema. Evaluate degree of edema (on scale of +1–+4).
    • Rationale: Edema occurs primarily in dependent tissues of the body, (hands, feet, lumbosacral area). Patient can gain up to 10 lb (4.5 kg) of fluid before pitting edema is detected. Periorbital edema may be a presenting sign of this fluid shift because these fragile tissues are easily distended by even minimal fluid accumulation.
  • Monitor heart rate (HR), BP, and JVD/CVP.
    • Rationale: Tachycardia and hypertension can occur because of: (1) failure of the kidneys to excrete urine, (2) excess fluid resuscitation during efforts to treat hypovolemia and/or hypotension or convert oliguric phase of renal failure, (3) changes in the renin-angiotensin system. Invasive monitoring may be needed for assessing intravascular volume, especially in patients with poor cardiac function.
  • Auscultate lung and heart sounds.
    • Rationale: Fluid overload may lead to pulmonary edema and HF evidenced by development of adventitious breath sounds, extra heart sounds.
  • Assess level of consciousness. Investigate changes in mentation, presence of restlessness.
    • Rationale: May reflect fluid shifts, accumulation of toxins, acidosis, electrolyte imbalances, or developing hypoxia.
  • Scatter desired beverages throughout the 24-hour period and give various offering (hot, cold, frozen).
    • Rationale: Helps avoid periods without fluids, minimizes boredom of limited choices, and reduces sense of deprivation and thirst.
  • Correct any reversible cause of ARF: replace blood loss, maximize cardiac output, discontinue nephrotoxic drug, relieve obstruction via surgery.
    • Rationale: Kidneys may be able to return to normal functioning, preventing or limiting residual effects.
  • Use appropriate safety measures (raising side rails and restraints.
    • Rationale: Patient with CNS involvement may be dizzy and/or confused.

Monitor diagnostic studies:  

  • Blood urea nitrogen (BUN), creatinine (cr)
    • Rationale: BUN assess management of renal dysfunction. Both values may increase but creatinine is a better indicator of renal function because it is not affected by hydration, diet, and tissue catabolism. Dialysis is usually indicated if ratio is higher than 10:1 or if therapy fails to indicate fluid overload or metabolic acidosis.
  • Urine sodium and Cr.
    • Rationale: In ATN, tubular functional integrity is lost and sodium resorption is impaired, resulting in increased sodium excretion. Urine creatinine is usually decreased as serum creatinine elevates.
  • Serum sodium.
    • Rationale: Hyponatremia may result from fluid overload (dilutional) or kidney’s inability to conserve sodium. Hypernatremia indicates total body water deficit.
  • Serum potassium.
    • Rationale: Lack of renal excretion and/or selective retention of potassium to excrete excess hydrogen ions leads to hyperkalemia, requiring prompt intervention.
  • Hb/Hct.
    • Rationale: Decreased values may indicate hemodilution (hypervolemia) however, during prolonged failure, anemia frequently develops as a result of RBC loss. Other possible causes (active or occult hemorrhage) should also be evaluated.
  • Serial chest x-rays.
    • Rationale: Increased cardiac size, prominent pulmonary vascular markings, pleural effusion, congestion indicate acute responses to fluid overload or chronic changes associated with renal and heart failure.
  • Administer and/or restrict fluids as indicated.
    • Rationale: Fluid management is usually calculated to replace output from all sources plus estimated insensible losses (metabolism, diaphoresis). Prerenal failure (azotemia) is treated with volume replacement and/or vasopressors. The oliguric patient with adequate circulating volume or fluid overload who is unresponsive to fluid restriction and diuretics requires dialysis. Note: During oliguric phase, “push/pull” therapy (push IV fluids and diurese with diuretics) may be tried to stimulate kidney function.

Administer medication as indicated: 

  • Diuretics:  furosemide (Lasix), bumetanide (Bumex), torsemide (Demadex), mannitol (Osmitrol).
    • Rationale: Given early in oliguric phase of ARF in an effort to convert to non-oliguric phase, flush the tubular lumen of debris, reduce hyperkalemia, and promote adequate urine volume.
  • Antihypertensives: clonidine (Catapres), methyldopa (Aldomet), prazosin (Minipress).
    • Rationale: May be given to treat hypertension by counteracting effects of decreased renal blood flow and/or circulating volume overload.
  • Calcium channel blockers.
    • Rationale: Given early in nephrotoxic ATN to reduce influx of calcium into kidney cells, thereby helping to maintain cell integrity and improve GFR.
  • Prostaglandins.
    • Rationale: Vasodilatory effect may improve circulating volume and reestablish renal blood flow to aid in clearing nephrotoxic agents from nephrons.
  • Insert indwelling catheter, as indicated.
    • Rationale: Catheterization excludes lower tract obstruction and provides means of accurate monitoring of urine output during acute phase; however, indwelling catheterization may be contraindicated because of increased risk of infection.
  • Prepare for dialysis as indicated: hemodialysis, peritoneal dialysis, or continuous renal replacement therapy (CRRT).
    • Rationale: Done to correct volume overload, electrolyte and acid-base imbalances, and to remove toxins. The type of dialysis chosen for ARF depends on the degree of hemodynamic compromise and patient’s ability to withstand the procedure.
  • During peritoneal dialysis, position the patient carefully: elevate the head of the bed.
    • Rationale: Doing so would reduce the pressure on the diaphragm and can aid in respiration.
  • Watch out for complications such as peritonitis, atelectasis, hypokalemia, pneumonia and/or shock.
    • Rationale: These complications are common for patients undergoing peritoneal dialysis.

Nursing Diagnosis: Risk for decreased cardiac output

Risk factors may include

  • Fluid overload (kidney dysfunction/failure, overzealous fluid replacement)
  • Fluid shifts, fluid deficit (excessive losses)
  • Electrolyte imbalance (potassium, calcium); severe acidosis
  • Uremic effects on cardiac muscle/oxygenation

Possibly evidenced by

  • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
  • Maintain cardiac output as evidenced by BP and HR/rhythm within patient’s normal limits; peripheral pulses strong and equal with adequate capillary refill time.
Nursing Interventions
  • Monitor BP and HR.
    • Rationale: Fluid volume excess, combined with hypertension (common in renal failure) and effects of uremia, increases cardiac workload and can lead to cardiac failure. In ARF, cardiac failure is usually reversible.
  • Observe ECG or telemetry for changes in rhythm.
    • Rationale: Changes in electromechanical function may become evident in response to progressing renal failure and accumulation of toxins and electrolyte imbalance. Peaked T wave, wide QRS, prolonged PR interval is usually associated with hyperkalemia. Flat T wave, peaked P wave, and appearance of the U waves usually indicate hypokalemia. Prolonged QT interval may reflect calcium deficit.
  • Auscultate heart sounds.
    • Rationale: Development of S3/S4 is indicative of failure. Pericardial friction rub may be only manifestation of uremic pericarditis, requiring prompt intervention and possibly acute dialysis.
  • Assess color of skin, mucous membranes, and nail beds. Note capillary refill time.
    • Rationale: Pallor may reflect vasoconstriction or anemia. Cyanosis is a late sign and is related to pulmonary congestion and/or cardiac failure.
  • Note occurrence of slow pulse, hypotension, flushing, nausea and vomiting, and depressed level of consciousness.
    • Rationale: Use of drugs (like antacids) containing magnesium can result in hypermagnesemia, potentiating the neuromuscular dysfunction and risk of a respiratory or cardiac arrest. Use aluminum-hydroxide-based antacid.
  • Monitor for GI bleeding by guaiac testing all stools for blood.
    • Rationale: Gastrointestinal bleeding is a known complication of renal failure; however, its pathogenesis remains uncertain. Some have attributed gastrointestinal bleeding to the effects of uremia on the gastrointestinal mucosa; others have suggested that uremia may affect platelet adhesiveness, which may explain the prolonged gastrointestinal bleeding seen in patients with renal failure. In addition, the role of heparinization and the widespread use of antiplatelet agents in patients on dialysis have been implicated in the etiology of gastrointestinal bleeding.
  • Investigate reports of muscle cramps, numbness of fingers, with muscle twitching, hyperreflexia.
    • Rationale: Neuromuscular indicators of hypocalcemia, which can also affect cardiac contractility and function.
  • Maintain bed rest or encourage adequate rest and provide assistance with care and desired activities.
    • Rationale: Reduces oxygen consumption and cardiac workload.

Monitor laboratory studies: 

  • Potassium.
    • Rationale:During oliguric phase, hyperkalemia is present but often shifts to hypokalemia in diuretic or recovery phase. Any potassium value associated with ECG changes requires intervention. Note: A serum level of 6.5 mEq or higher constitutes a medical emergency.
  • Calcium.
    • Rationale: In addition to its own cardiac effects, calcium deficit enhances the toxic effects of potassium.
  • Magnesium.
    • Rationale: Dialysis or calcium administration may be necessary to combat the CNS-depressive effects of an elevated serum magnesium level.
  • Administer and/or restrict fluids as indicated.
    • Rationale: Cardiac output depends on circulating volume (affected by both fluid excess and deficit) and myocardial muscle function.
  • Provide supplemental oxygen if indicated.
    • Rationale: Maximizes available oxygen for myocardial uptake to reduce cardiac workload and cellular hypoxia.

Administer medications as indicated:

  • Inotropic agents: digoxin (Lanoxin)
    • Rationale: May be used to improve cardiac output by increasing myocardial contractility and stroke volume. Dosage depends on renal function and potassium balance to obtain therapeutic effect without toxicity.
  • Calcium gluconate
    • Rationale: Serum calcium is often low but usually does not require specific treatment in ARF. Calcium gluconate may be given to treat hypocalcemia and to offset the effects of hyperkalemia by modifying cardiac irritability.
  • Aluminum hydroxide gels (Amphojel, Basaljel)
    • Rationale: Increased phosphate levels may occur as a result of failure of glomerular filtration and require use of phosphate-binding antacids to limit phosphate absorption from the GI tract.
  • Glucose and/or insulin solution
    • Rationale: Temporary measure to lower serum potassium by driving potassium into cells when cardiac rhythm is endangered.
  • Sodium bicarbonate or sodium citrate
    • Rationale: May be used to correct acidosis or hyperkalemia (by increasing serum pH) if patient is severely acidotic and not suffering from fluid overload.
  • Sodium polystyrene sulfonate (Kayexalate) with or without sorbitol.
    • Rationale: Exchange resin trades sodium for potassium in the GI tract to lower serum potassium level. Sorbitol may be included to cause osmotic diarrhea to help excrete potassium.
  • Prepare for/assist with dialysis as necessary.
    • Rationale: May be indicated for persistent dysrhythmias, progressive HF unresponsive to other therapies.

Nursing Diagnosis: Nutrition: imbalanced, risk for less than body requirements

Risk factors may include

  • Protein catabolism; dietary restrictions to reduce nitrogenous waste products
  • Increased metabolic needs
  • Anorexia, nausea/vomiting; ulcerations of oral mucosa

Possibly evidenced by

  • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
  • Maintain/regain weight as indicated by individual situation, free of edema.
Nursing Interventions
  • Assess and document dietary intake.
    • Rationale: Aids in identifying deficiencies and dietary needs. General physical condition, uremic symptoms (nausea, anorexia), and multiple dietary restrictions affect food intake.
  • Provide frequent, small feedings.
    • Rationale: Minimizes anorexia and nausea associated with uremic state and/or diminished peristalsis.
  • Give patient/SO a list of permitted foods or fluids and encourage involvement in menu choices.
    • Rationale: Provides patient with a measure of control within dietary restrictions. Food from home may enhance appetite.
  • Offer frequent mouth care or rinse with diluted acetic acid solution. Give gums, hard candy, breath mints between meals.
    • Rationale: Mucous membranes may become dry and cracked. Mouth care soothes, lubricates, and helps freshen mouth taste, which is often unpleasant because of uremia and restricted oral intake. Rinsing with acetic acid helps neutralize ammonia formed by conversion of urea.
  • Weigh daily.
    • Rationale: The fasting or catabolic patient normally loses 0.2–0.5 kg/day. Changes in excess of 0.5 kg may reflect shifts in fluid balance.
  • Monitor laboratory studies: BUN, albumin, transferrin, sodium, and potassium.
    • Rationale: Indicators of nutritional needs, restrictions, and necessity for and effectiveness of therapy.
  • Consult with dietitian support team.
    • Rationale: Determines individual calorie and nutrient needs within the restrictions, and identifies most effective route and product (oral supplements, enteral or parenteral nutrition).
  • Provide high-calorie, low to moderate protein diet. Include complex carbohydrates and fat sources to meet caloric needs and essential amino acids. Avoid concentrated sugar sources. Give anorectic patients small, frequent meals.
    • Rationale: The amount of needed exogenous protein is less than normal unless patient is on dialysis. Carbohydrates meet energy needs and limit tissue catabolism, preventing keto acid formation from protein and fat oxidation. Carbohydrate intolerance mimicking DM may occur in severe renal failure. Essential amino acids improve nitrogen balance and nutritional status, stimulate repair of tubular epithelial cells, and enhance patient’s ability to fight systemic complications.
  • Maintain proper electrolyte balance by strictly monitoring levels.
    • Rationale: Medications and decrease in GFR can cause electrolyte imbalances and may further cause renal injury.
  • Restrict potassium, sodium, and phosphorus intake as indicated.
    • Rationale: Restriction of these electrolytes may be needed to prevent further renal damage, especially if dialysis is not part of treatment, and/or during recovery phase of ARF.

Administer medications as indicated:

  • Iron preparations
    • Rationale: Iron deficiency may occur if protein is restricted, patient is anemic, or GI function is impaired.
  • Calcium carbonate
    • Rationale: Restores normal serum levels to improve cardiac and neuromuscular function, blood clotting, and bone metabolism. Note: Low serum calcium is often corrected as phosphate absorption is decreased in the GI system. Calcium may be substituted as a phosphate binder.
  • Vitamin D
    • Rationale: Necessary to facilitate absorption of calcium from the GI tract.
  • B complex and C vitamins, folic acid
    • Rationale: Vital as coenzyme in cell growth and actions. Intake is decreased because of protein restrictions.
  • Antiemetics: prochlorperazine (Compazine), trimethobenzamide (Tigan).
    • Rationale: Given to relieve N/V and may enhance oral intake.

Nursing Diagnosis: Risk for Infection

Risk factors may include

  • Depression of immunologic defenses (secondary to uremia)
  • Invasive procedures/devices (e.g., urinary catheterization)
  • Changes in dietary intake/malnutrition

Possibly evidenced by

  • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
  • Experience no signs/symptoms of infection.
Nursing Interventions
  • Promote good hand washing by patient and staff.
    • Rationale: Reduces risk of cross contamination.
  • Avoid invasive procedures, instrumentation, and manipulation of indwelling catheters whenever possible. Use aseptic technique when caring and manipulating IV and invasive lines. Change site dressings per protocol. Note edema, purulent drainage.
    • Rationale: Limits introduction of bacteria into body. Early detection of developing infection may prevent sepsis.
  • Provide routine catheter care and promote meticulous perineal care. Keep urinary drainage system closed and remove indwelling catheter as soon as possible.
    • Rationale: Reduces bacterial colonization and risk of ascending UTI.
  • Encourage deep breathing, coughing, frequent position changes.
    • Rationale: Prevents atelectasis and mobilizes secretions to reduce risk of pulmonary infections.
  • Assess skin integrity.
    • Rationale: Excoriations from scratching may become secondarily infected.
  • Monitor vital signs.
    • Rationale: Fever (higher than 100.4°F) with increased pulse and respirations is typical of increased metabolic rate resulting from inflammatory process, although sepsis can occur without a febrile response.
  • Monitor laboratory studies: WBC count with differential.
    • Rationale: Although elevated WBCs may indicate generalized infection, leukocytosis is commonly seen in ARF and may reflect injury within the kidney. A shifting of the differential to the left is indicative of infection.
  • Obtain specimen(s) for culture and sensitivity and administer appropriate antibiotics as indicated.
    • Rationale: Verification of infection and identification of specific organism aids in choice of the most effective treatment. Note: A number of anti-infective agents require adjustments of dose and/or time while renal clearance is impaired.

Nursing Diagnosis: Risk for Deficient Fluid Volume

Risk factors may include

  • Excessive loss of fluid (diuretic phase of ARF, with rising urinary volume and delayed return of tubular reabsorption capabilities)

Possibly evidenced by

  • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
  • Display I&O near balance; good skin turgor, moist mucous membranes, palpable peripheral pulses, stable weight and vital signs, electrolytes within normal range.
Nursing Interventions
  • Measure I&O accurately. Weigh daily. Calculate insensible fluid losses.
    • Rationale: Assessment can help estimate fluid replacement needs. Fluid intake should approximate losses through urine, nasogastric or wound drainage, and insensible water losses (diaphoresis, metabolism).
  • Provide allowed fluids throughout 24-hr period.
    • Rationale: Diuretic phase of ARF may revert to oliguric phase if fluid intake is not maintained or nocturnal dehydration occurs.
  • Monitor BP (noting postural changes) and HR.
    • Rationale: Orthostatic hypotension and tachycardia suggest hypovolemia.
  • Note signs and symptoms of dehydration: dry mucous membranes, thirst, dulled sensorium, peripheral vasoconstriction.
    • Rationale: In diuretic or postobstructive phase of renal failure, urine output can exceed 3 L/day. Extracellular fluid volume depletion activates the thirst center, and sodium depletion causes persistent thirst, unrelieved by drinking water. Continued fluid losses including inadequate replacement may lead to hypovolemic state.
  • Control environmental temperature; limit bed linens as indicated.
    • Rationale:May reduce diaphoresis, which contributes to overall fluid losses.
  • Monitor laboratory studies
    • Rationale: In nonoliguric ARF or in diuretic phase of ARF, large urine losses may result in sodium wasting while elevated urinary sodium acts osmotically to increase fluid losses. Restriction of sodium may be indicated to break the cycle.

Nursing Diagnosis: Deficient Knowledge

May be related to

  • Lack of exposure/recall
  • Information misinterpretation
  • Unfamiliarity with information resources

Possibly evidenced by

  • Questions/request for information, statement of misconception
  • Inaccurate follow-through of instructions/development of preventable
  • Complications
Desired Outcomes
  • Verbalize understanding of condition/disease process, prognosis, and potential complications.
  • Identify relationship of signs/symptoms to the disease process and correlate symptoms with causative factors.
  • Verbalize understanding of therapeutic needs.
  • Initiate necessary lifestyle changes and participate in treatment regimen.
Nursing Interventions
  • Review disease process, prognosis, and precipitating factors if known.
    • Rationale: Provides knowledge base from which patient can make informed choices.
  • Explain level of renal function after acute episode is over.
    • Rationale: Patient may experience residual defects in kidney function, which may or may not be permanent.
  • Discuss renal dialysis or transplantation if these are likely options for the future.
    • Rationale: Although these options would have been previously presented by the physician, patient may now be at a point when options need to be considered and may desire additional input.
  • Review dietary plan and restrictions. Include fact sheet listing food restrictions.
    • Rationale: Adequate nutrition is necessary to promote tissue healing; adherence to restrictions may prevent complications.
  • Encourage patient to observe characteristics of urine and amount, frequency of output.
    • Rationale:Changes may reflect alterations in renal function and need for dialysis.
  • Establish regular schedule for weighing.
    • Rationale: Useful tool for monitoring fluid and dietary needs.
  • Provide emotional support to the patient and family.
    • Rationale: To reassure them of the all the procedures that patient may undergo.
  • Review fluid restriction. Remind patient to spread fluids over entire day and to include all fluids (ice) in daily fluid counts.
    • Rationale: Depending on the cause and stage of ARF, patient may need to either restrict or increase intake of fluids.
  • Discuss activity restriction and gradual resumption of desired activity. Encourage use of energy-saving, relaxation, and diversional techniques.
    • Rationale: Patient with severe ARF may need to restrict activity and/or may feel weak for an extended period during lengthy recovery phase, requiring measures to conserve energy and reduce boredom.
  • Discuss reality of continued presence of fatigue.
    • Rationale: Decreased metabolic energy production, presence of anemia, and states of discomfort commonly result in fatigue.
  • Determine ADLs and personal responsibilities. Identify available resources and support systems.
    • Rationale: Helps patient manage lifestyle changes and meet personal needs.
  • Recommend scheduling activities with adequate rest periods.
    • Rationale: Prevents excessive fatigue and conserves energy for healing, tissue regeneration.
  • Review use of medication. Encourage patient to discuss all medications and herbal supplements with physician.
    • Rationale: Medications that are concentrated in and/or excreted by the kidneys can cause toxic cumulative reactions and/or permanent damage to kidneys. Some supplements may interact with prescribed medications and may electrolytes.
  • Stress necessity of follow-up care, laboratory studies.
    • Rationale: Renal function may be slow to return following acute failure (up to 12 mo), and deficits may persist, requiring changes in therapy to avoid recurrence.
  • Identify symptoms requiring medical intervention: decreased urinary output, sudden weight gain, presence of edema, lethargy, bleeding, signs of infection, altered mentation.
    • Rationale: Prompt evaluation and intervention may prevent serious complications or progression to chronic renal failure.

Other Possible Nursing Care Plans
  • Fluid Volume, deficient (specify)—dependent on cause, duration, and stage of recovery.
  • Fatigue—decreased metabolic energy production/dietary restriction, anemia, increased energy requirements, e.g., fever/inflammation, tissue regeneration.
  • Infection, risk for—depression of immunologic defenses (secondary to uremia), changes in dietary intake/malnutrition, increased environmental exposure.
  • Therapeutic Regimen: ineffective management—complexity of therapeutic regimen, economic difficulties, perceived benefit.