Acute Kidney Injury and Chronic Kidney Disease (Ch. 34)

A client has undergone a kidney transplant and voices concerns about organ rejection to the nurse. The most appropriate response by the nurse would be: A. "You will be given medication to decrease the likelihood of your immune system attacking your new kidney." B. "Your new kidney will continue to work fine as long as you do not drink any alcohol." C. "There is no need to worry about rejection because the occurrence of rejection is low with kidney transplant." D. "Kidney transplantation is 100% successful, and there is no need for you to worry."

Answer: A. "You will be given medication to decrease the likelihood of your immune system attacking your new kidney." Rationale: The success of transplantation depends primarily on the degree of histocompatibility, adequate organ preservation, and immunologic management. Maintenance immunosuppressive therapy plays an essential role in controlling T- and B-cell activation. Kidney rejection is managed by the maintenance of immunosuppressive therapy medications. It is important to give factual information to the clients and not dismiss or overlook their concerns.

The nurse is educating a client with chronic kidney disease (CKD). What is the recommended daily fluid intake for this client? A. A daily fluid intake of 500 to 800 mL/day to maintain hydration B. A minimum of 2000 mL/day to flush out the kidneys D. No oral intake of fluids D. Intake equal to daily urine output to maintain hydration

Answer: A. A daily fluid intake of 500 to 800 mL/day to maintain hydration Rationale: Daily fluid intake of 500 to 800 mL/day will replace insensible water loss plus a quantity equal to the 24-hour urine output. Intake of 2000 mL will exceed the renal ability to excrete water and will lead to circulatory overload and edema.

A client is diagnosed with chronic kidney disease (CKD). The nurse will monitor for which manifestations of this disorder? Select all that apply. - Right ventricular dysfunction - Hypercalcemia - Anemia - Increased nitrogenous waste in blood - Osteodystrophy

Answer: Anemia, Increased nitrogenous waste in blood, Osteodystrophy Rationale: There are numerous manifestations of CKD. Blood urea nitrogen (BUN) rises as nitrogenous waste is not removed from the circulatory system. Anemia occurs as the renal production of erythropoietin declines. Abnormal resorption and remodeling of bone occurs. Blood levels of calcium fall as the kidneys lose the ability to excrete phosphate and to convert inactive vitamin D to its active form. Left ventricular dysfunction occurs as extracellular fluid, including blood, volume increases. Anemia fosters left ventricular hypertrophy.

A 35-year-old client is diagnosed with acute kidney injury (AKI) and is started on hemodialysis. The client is concerned with the diagnosis and wants to know what to expect in the progression of this disorder. Which statement best addresses the client's concern? A. "Once your condition improves you can be placed on peritoneal dialysis for the rest of your life." B. "Acute kidney injury is abrupt in onset and often reversible if recognized early and treated appropriately." C. "You will need to have a renal transplant to live a productive, healthy life." D. "The occurrence of acute kidney injury will always eventually result in chronic renal failure."

Answer: B. "Acute kidney injury is abrupt in onset and often reversible if recognized early and treated appropriately." Rationale: AKI is the result of a rapid decline in kidney function that increases blood levels of nitrogenous wastes. Once the underlying cause is treated, AKI is potentially reversible if the precipitating factors can be corrected or removed before permanent damage occurs.

Which dermatologic problem most often accompanies chronic kidney disease (CKD)? A. Hirsutism and psoriasis B. Dry skin and pruritus C. Petechiae and purpura D. Alopecia and fungal rashes

Answer: B. Dry skin and pruritus Rationale: Dry, itchy skin is a common consequence of CKD. Petechiae, purpura, hirsutism, psoriasis, alopecia, and fungal rashes are not noted to accompany or result from CKD.

A client with chronic kidney disease (CKD) is anemic. The nurse will attempt to alleviate the anemia in order to prevent which of the following? Select all that apply. - Decreased myocardial oxygen - Fatigue - Hypersomnia - Increased blood viscosity - Tachycardia

Answer: Decreased myocardial oxygen, Fatigue, Tachycardia Rationale: Uncorrected anemia provokes fatigue and insomnia, a decrease in blood viscosity, a decrease in myocardial oxygen supply, and tachycardia as the heart attempts to supply sufficient oxygen to the heart and brain.

The health care provider has prescribed an aminoglycoside (gentamicin) for a client. The nurse is aware that the client is at risk for: A. Chronic kidney disease B. Nephrotoxic acute tubular necrosis C. Ischemic acute tubular necrosis D. Postrenal failure

Answer: B. Nephrotoxic acute tubular necrosis Rationale: Pharmacologic agents that are directly toxic to the renal tubule include aminoglycosides (e.g., gentamicin), chemotherapeutic agents such as cystplastin and ifosfamide, and radiocontrast agents. Nephrotoxic agents cause tubular injury by inducing varying combinations of renal vasoconstriction, direct tubular damage, or intratubular obstruction. Postrenal failure results from obstruction of outflow of the kidneys. CKD and its treatment can interfere with the absorption, distribution, and elimination of drugs. Acute tubular necrosis (ATN) occurs most frequently in clients who have major trauma, severe hypovolemia, overwhelming sepsis, trauma, or burns.

Which symptom occurs in a client with chronic kidney disease (CKD) as a result of elevated serum phosphate levels and the development of phosphate crystals that occur with hyperparathyroidism? A. Uremia B. Pruritus C. Azotemia D. Asterixis

Answer: B. Pruritus Rationale: Pruritus is common in persons with CKD; it results from high phosphate levels and the development of phosphate crystals. Azotemia refers to elevated levels of nitrogenous wastes in the blood. Uremia is the accumulation of organic wastes in the blood. Asterixis, a sign of hepatic encephalopathy, is due to the inability of the liver to metabolize ammonia to urea.

A client with a diagnosis of end-stage renal disease received a kidney transplant 2 years ago that was deemed a success. During the most recent follow-up appointment, the nurse should prioritize the client for referral based on which statement? A. "I've noticed that my urine is a bit more concentrated than usual the last few days." B. "I've decided to try eating less fat and carbohydrates than I have been." C. "I'm feeling a bit under the weather these days and I'm a bit feverish." D. "The scarring on my flank where the surgery was done doesn't seem to be fading."

Answer: C. "I'm feeling a bit under the weather these days and I'm a bit feverish." Rationale: Clients who are taking immunosuppressants after a transplant are susceptible to infections, which require prompt treatment. Concentrated urine is not a sign of a problem and persistent scarring is inconsequential. Minor changes to diet should be assessed, but are not necessarily contraindicated.

A client has prerenal failure. The nurse knows that this type of failure is characterized by which relationship of blood urea nitrogen (BUN) to serum creatinine levels? A. An elevated BUN level and decreased creatinine level B. A BUN to creatinine level ratio of 10:1 C. A BUN to creatinine level ratio of 20:1 D. An elevated creatinine level and decreased BUN level

Answer: C. A BUN to creatinine level ratio of 20:1 Rationale: In prerenal failure, glomerular filtration rate (GFR) decreases, allowing more filtered urea to be reabsorbed into the circulatory system. Creatinine is filtered but remains in the forming urine. Therefore, the BUN to creatinine ratio rises to 20:1. A ratio of 10:1 is normal.

A client with significant burns on his lower body has developed sepsis on the third day following his accident. Which manifestation would the nurse anticipate for an ischemic acute tubular necrosis rather than prerenal failure? A. The client exhibits oliguria and frank hematuria B. The client exhibits pulmonary and peripheral edema. C. The client's GFR does not increase after restoration of renal blood flow D. The client undergoes emergency hemodialysis that does not result in decreased BUN and creatinine

Answer: C. The client's GFR does not increase after restoration of renal blood flow Rationale: In contrast to prerenal failure, the glomerular filtration rate (GFR) does not improve with the restoration of renal blood flow in acute renal failure caused by ischemic acute tubular necrosis. Edema, oliguria, and hematuria are not diagnostic of acute tubular necrosis (ATN), and hemodialysis does not normally fail to achieve a reduction in blood urea nitrogen (BUN) and creatinine.

The nurse caring for a group of clients should monitor which clients for the development of intrarenal failure? Select all that apply. - Client taking gentamicin for the treatment of a kidney infection - Client with acute glomerulonephritis - Client with septic shock from pneumonia - Client with lead poisoning - Client with a gastrointestinal hemorrhage

Answer: Client taking gentamicin for the treatment of a kidney infection, Client with acute glomerulonephritis, Client with septic shock from pneumonia, Client with lead poisoning Rationale: Causes of intrarenal kidney injury are acute tubular necrosis/acute renal injury; prolonged renal ischemia; exposure to nephrotoxic drugs such as gentamicin, heavy metals, and organic solvents; intratubular obstruction resulting from hemoglobinuria, myoglobinuria, myeloma light chains, uric acid casts, and acute renal disease (e.g., acute glomerulenephritis, pyelonephritis).

A student asks the nurse preceptor about a laboratory test called interleukin (IL)-18. Which statement by the nurse will assist the student in providing better care to clients with acute kidney injuries (AKI)? A. "This helps with the differentiation of kidney injury versus a rheumatic disease that is affecting the kidney." B. "This is one of the biomarkers which can help differentiate inflammation versus carcinoma in the kidney." C. "This is one of the new markers which helps confirm whether the kidney is trying to internally kill its own cells." D. "This is an inflammatory cytokine which is an early marker for ischemic AKI in the proximal tubule."

Answer: D. "This is an inflammatory cytokine which is an early marker for ischemic AKI in the proximal tubule." Rationale: Some new biomarkers for assessing AKI earlier than conventional parameters include IL-18. It is produced in the proximal tubule after AKI and is an inflammatory cytokine. This marker increases with ischemic AKI and is easily measured in the urine. IL-18 does not confirm carcinoma in the kidney or rheumatic disease. It also does not help confirm whether the kidney is trying to internally self-mutilate its own cells.

A 45-year-old female is being treated for ovarian cancer. Her treatment involves the chemotherapy agent cisplatin. The nurse should monitor the client for signs and symptoms of: A. chronic renal failure (CRF). B. glomerulonephritis. C. anemia. D. nephrotoxic acute tubular necrosis (ATN).

Answer: D. nephrotoxic acute tubular necrosis (ATN). Rationale: The development of nephrotoxic acute tubular necrosis is due to the concentration effect of the kidney. The prolonged exposure to the chemotherapy agent causes the ATN. The disease state would progress faster than the CRF, and the glomerulus would not be affected. Anemia is not related to this type of chemotherapy.

A child has received a kidney transplant at the age of 3. Knowing he will be on immunosuppressive agents like corticosteroids, the nurse should educate the parents about which long-term side effects? Select all that apply. - Development of cataracts - Growth retardation - Frequent hematuria - Hypertension - Excess weight loss

Answer: Development of cataracts, Growth retardation, Hypertension Rationale: Early transplantation in young children is regarded as the best way to promote physical growth, improve cognitive function, and foster psychosocial development. Immunosuppressive therapy in children is similar to that used in adults. All immunosuppressive agents have side effects, including increased risk for infection. Corticosteroids carry the risk for hypertension, orthopedic complications (especially aseptic necrosis), cataracts, and growth retardation. Steroids usually are associated with weight gain. Frequent hematuria is caused by something other than steroids and should be reported.

When educating a group of nursing students about the primary causes of chronic kidney disease (CKD) in Western societies, the nurse asks, "What do you think are the main causes of CKD in adults?" Which student answer(s) is deemed correct? Select all that apply. - Autoimmune diseases - Substance use disorder - Alcohol use disorder - Diabetes mellitus - Hypertension

Answer: Diabetes mellitus, Hypertension Rationale: Hypertension and diabetic kidney disease are the two main causes of CKD in Western societies. It is not autoimmune disease, substance use disorder, or alcohol use disorder.

A client with chronic kidney disease reports having extreme fatigue, chest pressure when walking and trouble breathing when lying supine in bed. The client's current hemoglobin level is 8.3 g/dL (83 g/L). Which intervention(s) will likely be prescribed for this client during this visit? Select all that apply. - Increase in iron intake via food and supplementation - Type and crossmatch for an immediate blood transfusion - Injection of an erythropoietin-stimulating agent - Educational handout on foods to help increase the blood platelet count - Dietary consult to focus on low phosphate foods and high fiber options

Answer: Increase in iron intake via food and supplementation, Injection of an erythropoietin-stimulating agent Rationale: Iron and erythropoietin-stimulating agents (ESA) are used to treat anemia and decrease red blood cell (RBC) transfusions and their associated risks. Clients with renal problems do need to watch their phosphate levels; however, it will not help to increase RBC counts. The newest guidelines recommend that restrictive RBC transfusion threshold, in which the transfusion is not indicated until the hemoglobin level is 7 g/dL (70 g/L). It is recommended for hospitalized adult clients who are hemodynamically stable. Lean meats such as fish, chicken and turkey are rich in protein, zinc and vitamin B12; all help increase the blood platelet count, but there is no indication in the laboratory values that this client has a low platelet count.

A client is diagnosed with acute renal injury. The nurse will evaluate the client for which possible causes of this disorder? Select all that apply. - Nephrotoxic substances - Nonischemic reduced renal blood flow - Hormonal imbalance - Ischemic injury - Obstruction of urinary outflow

Answer: Nephrotoxic substances, Nonischemic reduced renal blood flow, Ischemic injury, Obstruction of urinary outflow Rationale: Acute renal injury can result from ischemia, reduced renal blood without ischemia, nephrotoxic substances (including some drugs), and obstruction of urinary outflow. Hormonal imbalance does not usually cause renal injury.

A child is diagnosed with chronic kidney disease (CKD). The nurse knows that which statements regarding supportive renal therapy in children are true? Select all that apply. - Peritoneal dialysis is generally most appropriate for children younger than 6. - Early transplantation is the preferred treatment when considering long-term effects. - Less immune system suppression is needed in children than in adults. - Corticosteroid therapy reduces the risk of growth retardation in children. - Children older than 12 years will benefit from hemodialysis.

Answer: Peritoneal dialysis is generally most appropriate for children younger than 6., Early transplantation is the preferred treatment when considering long-term effects., Children older than 12 years will benefit from hemodialysis. Rationale: Children between birth and 5 years of age often are managed with peritoneal dialysis. For those older than 12 years of age hemodialysis is usually preferred. Early transplantation in young children is the best choice to promote physical growth, improve cognitive function, and foster psychosocial development. Immunosuppressive therapy in children is similar to that required in adults. Corticosteroids such as prednisone have risk for growth retardation.

The nurse assesses a client for prerenal failure. Which conditions increase the risk for developing this type of kidney failure? Select all that apply. - Septic shock - Severe burns - Severe dehydration - Prolonged renal ischemia - Glomerulonephritis

Answer: Septic shock, Severe burns, Severe dehydration Rationale: Prerenal failure occurs with conditions such as burns, septic shock, and dehydration, which decrease renal perfusion. Glomerulonephritis and prolonged renal ischemia will result in intrarenal kidney injury.