The client with chronic renal failure has a glomerular filtration rate (GFR) of 40 mL/min/1.73 m², as measured by a 24-hour creatinine clearance. What is the nurse's interpretation of this finding?

Choice A reason: Hemodialysis rapidly removes fluid and solutes, which can cause significant hemodynamic shifts, including hypotension, in unstable patients. It involves high blood flow rates and ultrafiltration, stressing the cardiovascular system. For a hemodynamically unstable patient with acute renal failure, hemodialysis is less suitable due to its potential to exacerbate hypotension and circulatory collapse.

Choice B reason: Peritoneal dialysis uses the peritoneal membrane for slow fluid and solute exchange, which is gentler on hemodynamics. However, it is less efficient for rapid correction of hypervolemia and hyperkalemia in acute renal failure. It also carries risks of peritonitis and is impractical in critically ill patients with abdominal trauma or instability.

Choice C reason: Continuous venovenous hemodialysis (CVVHD) is ideal for hemodynamically unstable patients. It provides slow, continuous fluid and solute removal, minimizing cardiovascular stress. CVVHD effectively manages hypervolemia and hyperkalemia in acute renal failure by maintaining steady-state clearance, reducing the risk of hypotension compared to intermittent hemodialysis, making it the best choice.

Choice D reason: Plasmapheresis removes plasma components, not fluid or electrolytes like potassium, and is used for conditions like autoimmune disorders, not acute renal failure. It does not address hypervolemia or hyperkalemia and can cause hemodynamic instability due to rapid plasma exchange, making it inappropriate for this patient’s needs.

When assessing a client with suspected ventilatory failure, potential indicators include decreased PaO2, increased heart rate, and increased PaCO2.

A. Decreased PaO2 is a key indicator of ventilatory failure. The client’s PaO2 levels of 60 mmHg at 1030 and 55 mmHg at 1200, compared to the reference range of 75-100 mmHg, show impaired oxygen exchange, reflecting inadequate ventilation. This aligns with the client’s low oxygen saturation (88% and 85%) and symptoms like dyspnea and accessory muscle use, indicating respiratory distress.

B. Increased heart rate is another indicator. The client’s heart rate rose from 110/min at 1030 to 115/min at 1200, above normal ranges, suggesting a compensatory response to hypoxia and respiratory distress. This tachycardia, coupled with symptoms like fatigue and difficulty speaking, supports ventilatory failure as the body attempts to meet oxygen demands, aligning with Maslow’s physiological needs for oxygenation.

C. High oxygen saturation is not an indicator of ventilatory failure. The client’s oxygen saturation is low (88% at 1030, 85% at 1200), which is consistent with ventilatory failure, not high saturation. High oxygen saturation would suggest adequate oxygenation, contradicting the client’s clinical presentation of wheezing, decreased breath sounds, and low PaO2.

D. Increased PaCO2 is a hallmark of ventilatory failure. The client’s PaCO2 levels of 54 mmHg at 1030 and 58 mmHg at 1200, above the reference range of 35-45 mmHg, indicate CO2 retention due to inadequate ventilation. This, along with the client’s respiratory acidosis (pH 7.32 and 7.30) and symptoms like increased respiratory rate and fatigue, confirms ventilatory failure.