The nurse is receiving the morning report on four clients on a medical-surgical unit. Based on the information provided, which clients are at greatest risk for developing end-stage renal disease (ESRD)? (Select all that apply)

Choice A reason: White crystals (uremic frost) and yellowish skin in CKD indicate severe uremia due to toxin accumulation from impaired kidney function. Applying medicated lotion addresses skin symptoms but does not treat the underlying uremia, which can lead to life-threatening complications like metabolic acidosis, hyperkalemia, or encephalopathy. This action is secondary to addressing systemic toxicity through dialysis.

Choice B reason: Elevated BUN, creatinine, and uremic frost signify advanced CKD with uremia, requiring urgent dialysis to remove toxins and excess fluids. Notifying the provider ensures timely intervention to prevent complications such as seizures, coma, or cardiac arrhythmias due to electrolyte imbalances and toxin buildup, making this the priority action for patient safety.

Choice C reason: A cardiac monitor detects arrhythmias, which may occur in CKD due to hyperkalemia or fluid overload. However, monitoring alone does not address the root cause of uremia. Without dialysis to correct metabolic imbalances, arrhythmias may persist or worsen, making this action less urgent than initiating dialysis to stabilize the patient’s condition.

Choice D reason: Assessing a fistula for bruit and thrill ensures vascular access patency for dialysis. While important, it is not the priority when uremic symptoms are present, as dialysis orders must be secured first to address the acute uremic state and prevent life-threatening complications like encephalopathy or cardiac arrest due to toxin accumulation.

Choice A reason: Antihypertensives are routinely used in ESRD to manage hypertension caused by fluid overload and renin-angiotensin system dysregulation. Controlling blood pressure prevents cardiovascular complications like heart failure or stroke, which are common in ESRD due to chronic volume and pressure overload, making this medication appropriate.

Choice B reason: ADH is not used in ESRD, as it promotes water reabsorption, worsening fluid overload in anuric patients. ESRD patients rely on dialysis for fluid balance, and ADH could exacerbate hypertension or pulmonary edema. Its use is more relevant in conditions like diabetes insipidus, not renal failure.

Choice C reason: Erythrocyte-stimulating agents, like erythropoietin, are standard in ESRD to treat anemia caused by reduced erythropoietin production by failing kidneys. These agents stimulate red blood cell production, improving oxygen delivery and reducing fatigue, making them essential for managing ESRD-related anemia and improving quality of life.

Choice D reason: Phosphate binders are used in ESRD to manage hyperphosphatemia by binding dietary phosphate in the gut, preventing its absorption. This reduces the risk of vascular calcification and secondary hyperparathyroidism, common complications in ESRD due to impaired phosphate excretion, making these medications a standard part of therapy.