Chapter 34- Acute Kidney Injury an Chronic Kidney Disease

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

Nephrotoxic acute tubular necrosis

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. A. Diabetes mellitus B. Substance use disorder C. Alcohol use disorder D. Hypertension E. Autoimmune diseases

A. Diabetes mellitus D. Hypertension

A nurse is assessing a client for early manifestations of chronic kidney disease (CKD). Which would the nurse expect the client to display? A. Hypertension B. Impotence C. Terry nails D. Asterixis

A. Hypertension

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

B. A daily fluid intake of 500 to 800 mL/day to maintain hydration

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. "Acute kidney injury is abrupt in onset and often reversible if recognized early and treated appropriately." B. "You will need to have a renal transplant to live a productive, healthy life." C. "The occurrence of acute kidney injury will always eventually result in chronic renal failure." D. "Once your condition improves you can be placed on peritoneal dialysis for the rest of your life."

A. "Acute kidney injury is abrupt in onset and often reversible if recognized early and treated appropriately."

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. A. Nephrotoxic substances B. Nonischemic reduced renal blood flow C. Obstruction of urinary outflow D. Ischemic injury E. Hormonal imbalance

A. Nephrotoxic substances B. Nonischemic reduced renal blood flow C. Obstruction of urinary outflow D. Ischemic injury

A client with a recent diagnosis of renal failure requiring hemodialysis is being educated in the dietary management of the disease. Which statement by the client shows an accurate understanding of this component of treatment? Select all that apply. A. "I'll increase the carbohydrates in my diet to provide sufficient energy." B. "I've made a list of high-phosphate foods so that I can try to avoid them." C. "I'm making a point of trying to eat lots of bananas and other food rich in potassium." D. "I don't think I've been drinking enough, so I want to include 8 to 10 glasses of water each day." E. "I'm going to try a high-protein, low-carbohydrate diet."

A. "I'll increase the carbohydrates in my diet to provide sufficient energy." B. "I've made a list of high-phosphate foods so that I can try to avoid them." Persons with chronic kidney disease (CKD) are usually encouraged to limit their dietary phosphorus as a means of preventing secondary hyperparathyroidism, renal osteodystrophy, and hypocalcemia. -Excessive protein, potassium, and fluids can be detrimental in individuals whose kidney disease requires hemodialysis. -Because protein intake is limited, carbohydrate consumption should increase to meet daily energy requirements.

With the increased risk of drug toxicity among chronically ill older adults, which statement by the nurse explains why the older adult's kidney is vulnerable to toxic injury? A. "The kidney is rich in blood supply and can concentrate toxins in high levels in the medullary portion of the kidney." B. "Every drug dosage should be determined by client weight but most clients refuse to get on the scale." C. "The health care provider does not always monitor for toxicity at each follow-up appointment." D. "Prescribed medications may not be monitored as closely as they should be since Medicare does not reimburse for routine laboratory testing."

A. "The kidney is rich in blood supply and can concentrate toxins in high levels in the medullary portion of the kidney."

Accumulation of nitrogenous wastes such as urea in the circulatory system is an early sigh of chronic kidney disease (CKD). The nurse knows that normal levels of urea in blood are approximately: A. 20 mg/dL (7.14 mmol/L) B. 60 mg/dL (21.42 mmol/L) C. 80 mg/dL (28.56 mmol/L) D. 100 mg/dL (35.70 mmol/L)

A. 20 mg/dL (7.14 mmol/L)

A client has been diagnosed with chronic kidney disease (CKD). Which drug category is usually administered to treat coexisting conditions that manifest early in CKD? A. Antihypertensive medications B. Antiarrhythmic medications C. Opioid analgesics D. Nonsteroidal anti-inflammatory drugs (NSAIDs)

A. Antihypertensive medications

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

A. Client taking gentamicin for the treatment of a kidney infection B. Client with septic shock from pneumonia C. Client with lead poisoning E. Client with acute glomerulonephritis

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

A. Dry skin and pruritus

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. A. Early transplantation is the preferred treatment when considering long-term effects. B. Less immune system suppression is needed in children than in adults. C. Corticosteroid therapy reduces the risk of growth retardation in children. D. Peritoneal dialysis is generally most appropriate for children younger than 6. E. Children older than 12 years will benefit from hemodialysis.

A. Early transplantation is the preferred treatment when considering long-term effects. D. Peritoneal dialysis is generally most appropriate for children younger than 6. E. Children older than 12 years will benefit from hemodialysis.

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. A. Fatigue B. Tachycardia C. Increased blood viscosity D. Decreased myocardial oxygen E. Hypersomnia

A. Fatigue B. Tachycardia D. Decreased myocardial oxygen 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.

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. A. Increase in iron intake via food and supplementation B. Dietary consult to focus on low phosphate foods and high fiber options C. Type and crossmatch for an immediate blood transfusion D. Educational handout on foods to help increase the blood platelet count E. Injection of an erythropoietin-stimulating agent

A. Increase in iron intake via food and supplementation E. Injection of an erythropoietin-stimulating agent Normal Hemoglobin = 11-16g/dL Clients with renal problems do need to watch their phosphate levels there is no indication in the laboratory values that this client has a low platelet count.

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

A. Increased nitrogenous waste in blood C. Anemia E. Osteodystrophy 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.

Vitamin D metabolism is deranged in clients with chronic kidney disease (CKD). The nurse recognizes that which statement regarding vitamin D is correct? A. Kidneys convert inactive vitamin D to its active form, calcitriol. B. Calcitriol stimulates release of parathyroid hormone (PTH). C. Suppression of parathyroid hormone release is characteristic of CKD. D. Calcitriol blocks gastrointestinal absorption of calcium.

A. Kidneys convert inactive vitamin D to its active form, calcitriol.

The client with substance use disorder was found unconscious after overdosing on heroin 2 days prior. Because of prolonged pressure on the muscles the client has developed myoglobinuria, causing which complication? A. Obstruction of the renal tubules with myoglobin and damaged tubular cells B. Hypokalemia and metabolic acidosis C. Development of renal stones due to stasis D. Compartment syndrome in the lower extremities

A. Obstruction of the renal tubules with myoglobin and damaged tubular cells Myoglobin normally is not found in the serum or urine. It has a low molecular weight; if it escapes into the circulation, it is rapidly filtered in the glomerulus. A life-threatening condition known as rhabdomyolysis occurs when increasing myoglobinuria levels cause myoglobin to precipitate in the renal tubules, leading to obstruction and damage to surrounding tubular cells.

While assessing a peritoneal dialysis client in the home, the nurse notes that the fluid draining from the abdomen is cloudy, is white in color, and contains a strong odor. The nurse suspects this client has developed a serious complication known as: A. Peritonitis B. Bowel perforation C. Too much sugar in the dialysis solution D. Bladder erosion

A. Peritonitis Potential problems with peritoneal dialysis include infection, catheter malfunction, dehydration, hyperglycemia, and hernia. Bowel perforation can occur, but the fluid would be stool colored. -The client may develop hyperglycemia; however, this will not cause the fluid to be cloudy. -If bladder erosion had occurred, the fluid would look like urine and not be cloudy and white.

A client in renal failure has marked decrease in renal blood flow caused by hypovolemia, the result of gastrointestinal bleeding. The nurse is aware that this form of renal failure can be reversed if the bleeding is under control. Which form of acute renal injury does this client have? A. Prerenal failure B. Intrarenal failure C. Postrenal failure D. Chronic renal failure

A. Prerenal failure Prerenal failure, the most common form of acute renal failure, is characterized by a marked decrease in renal blood flow. It is reversible

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. Pruritus B. Asterixis C. Azotemia D. Uremia

A. Pruritus 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.

The nurse recognizes that acute renal injury is characterized by which of the following? A. Rapid decline in renal function B. Irreversible damage to nephrons C. Decreased blood urea nitrogen (BUN) D. Low incidence of mortality

A. Rapid decline in renal function BUN increases there is high incidence of mortality reversible damage

Hypertension frequently accompanies chronic kidney disease (CKD). The nurse knows that which mechanisms can contribute to this hypertension? Select all that apply. A. Renin-angiotensin-aldosterone (RAAS) activation B. Increased vasodilator prostaglandins C. Sodium retention D. Increased vasoconstriction E. Increased blood volume

A. Renin-angiotensin-aldosterone (RAAS) activation C. Sodium retention D. Increased vasoconstriction E. Increased blood volume Activation of the RAAS, resulting in vasoconstriction and sodium and water retention, contribute to hypertension in CKD. Prostaglandins that maintain renal artery perfusion are decreased. Renal failure compounds the retention of sodium and fluid, adding to the increase in blood volume.

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

A. Severe burns B. Septic shock E. Severe dehydration 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.

An 86-year-old female client has been admitted to the hospital for the treatment of dehydration and hyponatremia after she curtailed her fluid intake to minimize urinary incontinence. The client's admitting laboratory results are suggestive of prerenal failure. The nurse should be assessing this client for which early sign of prerenal injury? A. Sharp decrease in urine output B. Excessive voiding of clear urine C. Acute hypertensive crisis D. Intermittent periods of confusion

A. Sharp decrease in urine output Dehydration and its consequent hypovolemia can result in acute renal failure that is prerenal in etiology. The kidney normally responds to a decrease in GFR with a decrease in urine output. Thus, an early sign of prerenal injury is a sharp decrease in urine output.

A client receiving continuous ambulatory peritoneal dialysis (CAPD) treatments has excessive weight gain in the past 24 hours and tells the nurse excessive amounts of fluids were consumed while out with family. What change in the client's dialysis order will the nurse anticipate once relaying these findings to the health care provider? A. Switching the client from 2.5% to a 4.25% dextrose dialysate B. Reducing the volume of dialysate from 3 L to 1 L C. Increasing the dialysate dwell time from 6 hours to 8 hours D. Preparing the client for a hemodialysis treatment

A. Switching the client from 2.5% to a 4.25% dextrose dialysate Given the client is in a state of fluid volume excess, the goal will be to remove additional fluid with the dialysis treatment.

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. "The scarring on my flank where the surgery was done doesn't seem to be fading." B. "I'm feeling a bit under the weather these days and I'm a bit feverish." C. "I've noticed that my urine is a bit more concentrated than usual the last few days." D. "I've decided to try eating less fat and carbohydrates than I have been."

B. "I'm feeling a bit under the weather these days and I'm a bit feverish."

A geriatric nurse is caring for several clients. Which alterations in health should the nurse attribute to age-related physiologic changes? A. An 81-year-old man's serum creatinine level has increased sharply since his last blood work. B. A 78-year-old woman's GFR has been steadily declining over several years. C. A 90-year-old woman's blood urea nitrogen (BUN) is rising. D. A dipstick of an 80-year-old man's urine reveals protein is present.

B. A 78-year-old woman's GFR has been steadily declining over several years.

The nurse is instructing a client with advanced kidney disease (AKD) about a dietary regimen. Which restriction should the nurse be sure to include in the treatment plan to decrease the progress of renal impairment in people with AKD? A. Fats B. Dietary protein C. Carbohydrates D. Foods high in calcium

B. Dietary protein

A client is beginning to recover from acute tubular necrosis. During which phase of acute kidney injury will the nurse assess an increase in urine output? A. Onset phase B. Diuretic phase C. Oliguric phase D. Recovery phase

B. Diuretic phase The onset phase lasts hours/days and is the time from the onset of the precipitating event until tubular injury occurs. -The oliguric phase is characterized by a marked decrease in glomerular filtration rate, causing sudden retention of endogenous metabolites, such as urea, potassium, sulfate, and creatinine. -The diuretic phase occurs when the kidneys try to heal and one will see an increase/excessive output (diuresis) of dilute urine. -The recovery phase is the period during which tubular edema resolves and renal function improves. There is normalization of fluid and electrolyte balance.

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. A. Frequent hematuria B. Hypertension C. Growth retardation D. Development of cataracts E. Excess weight loss

B. Hypertension C. Growth retardation D. Development of cataracts

A client is to receive a radiocontrast media as part of a diagnostic scan. Which intervention is intended to reduce the nephrotoxic effects of the radiocontrast media? A. Having the client take nothing by mouth B. Increasing the normal saline intravenous infusion rate prior to the exam C. Administering one unit of packed red blood cells D. Administering ibuprofen 600 mg prior to the procedure

B. Increasing the normal saline intravenous infusion rate prior to the exam

Reduced glomerular filtration rate (GFR), with a serum creatinine level that remains in the normal range, is associated with which factor of normal age-related change? A. Calcium intake B. Muscle mass C. Drug tolerance D. Renal perfusion

B. Muscle mass

The GFR is considered to be the best measure of renal function. What is used to estimate the GFR? A. BUN B. Serum creatinine C. Albumin level D. Serum protein

B. Serum creatinine

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 new markers which helps confirm whether the kidney is trying to internally kill its own cells." C. "This is an inflammatory cytokine which is an early marker for ischemic AKI in the proximal tubule." D. "This is one of the biomarkers which can help differentiate inflammation versus carcinoma in the kidney."

C. "This is an inflammatory cytokine which is an early marker for ischemic AKI in the proximal tubule."

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 creatinine level and decreased BUN level B. An elevated BUN level and decreased creatinine level C. A BUN to creatinine level ratio of 20:1 D. A BUN to creatinine level ratio of 10:1

C. A BUN to creatinine level ratio of 20:1 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.

Chronic kidney disease impacts many systems in the body. What is the most common hematologic disorder caused by CKD? A. Polycythemia B. Erythrocythemia C. Anemia D. Leukocytosis

C. Anemia

The nurse is caring for a client who has had acute blood loss from ruptured esophageal varices. What does the nurse recognize is an early sign of prerenal failure? A. Baseline blood pressure of 150/90 mm Hg that is now 130/80 mm Hg B. Baseline heart rate of 100 bpm that has increased to 120 bpm C. Baseline urine output of 50 mL/hr that is now 10 mL/hr D. Foul smelling, cloudy urine

C. Baseline urine output of 50 mL/hr that is now 10 mL/hr The kidney normally responds to a decrease in the glomerular filtration rate with a decrease in urine output. Thus, an early sign of prerenal failure is a sharp decrease in urine output.

A client with a history of chronic kidney disease (CKD) is experiencing increasing fatigue, lethargy, and activity intolerance. The care team has established that the client's glomerular filtration rate (GFR) remains at a low, but stable, level. Which laboratory assessments will most likely be prescribed to help determine the cause of these new symptoms? A. Cystoscopy and ureteroscopy B. Blood work for white cells and differential C. Blood work for hemoglobin, red blood cells, and hematocrit D. Assessment of pancreatic exocrine and endocrine function

C. Blood work for hemoglobin, red blood cells, and hematocrit Anemia is a frequent and debilitating consequence of CKD. The anemia may be due to chronic blood loss, hemolysis, bone marrow suppression due to retained uremic factors, and decrease in red cell production due to impaired production of erythropoietin and iron deficiency.

Several urine tests can be useful in establishing a diagnosis of acute renal failure (ARF). The nurse must consider that fractional excretion of sodium can be particularly affected by administration of which type of drug? A. Sulfonylureas B. Calcium channel blockers C. Diuretics D. Beta-adrenergic blockers (beta-blockers)

C. Diuretics

A client has a marked decrease in the glomerular filtration rate (GFR); lab values with high blood urea nitrogen (BUN), potassium, and creatinine levels; urine output less than 10 mL/hr; 3+ pitting edema in the lower extremities; and BP 170/95. Which phase of acute tubular necrosis (ATN) does the nurse identify the client is in based on assessment data? A. Onset phase B. Initiating phase C. Maintenance phase D. Recovery phase

C. Maintenance phase The maintenance phase of acute tubular necrosis is characterized by a marked decrease in the GFR, causing sudden retention of endogenous metabolites—such as urea, potassium, sulfate, and creatinine—that normally are cleared by the kidneys. Urine output usually is lowest at this point.

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 undergoes emergency hemodialysis that does not result in decreased BUN and creatinine C. The client's GFR does not increase after restoration of renal blood flow D. The client exhibits pulmonary and peripheral edema.

C. The client's GFR does not increase after restoration of renal blood flow 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.

The primary care provider for a newly admitted hospital client has added the glomerular filtration rate (GFR) to the blood work scheduled for this morning. The client's GFR results return as 50 mL/minute/1.73 m2. The nurse explains to the client that this result represents: A. a need to increase water intake. B. that the kidneys are functioning normally. C. a loss of over half the client's normal kidney function. D. concentrated urine.

C. a loss of over half the client's normal kidney function. In clinical practice, GFR is usually estimated using the serum creatinine concentration. A GFR below 60 mL/minute/1.73 m2 represents a loss of one half or more of the level of normal adult kidney function.

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. anemia. C. nephrotoxic acute tubular necrosis (ATN). D. glomerulonephritis.

C. nephrotoxic acute tubular necrosis (ATN). 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.

Which individual likely faces the greatest risk for the development of chronic kidney disease? A. A first-time mother who recently lost 1.5 L of blood during a postpartum hemorrhage B. A client whose diagnosis of thyroid cancer necessitated a thyroidectomy C. A client who experienced a hemorrhagic stroke and now has sensory and motor deficits D. A client with a recent diagnosis of type 2 diabetes who does not monitor blood sugars or control diet

D. A client with a recent diagnosis of type 2 diabetes who does not monitor blood sugars or control diet

A client with chronic kidney disease (CKD) will be managed with peritoneal dialysis. Which description of this type of dialysis is most accurate? A. Vascular access is achieved through an internal arteriovenous fistula or an external arteriovenous shunt. B. Treatments typically occur three times each week for 3 to 4 hours. C. The dialyzer is usually a hollow cylinder composed of bundles of capillary tubes. D. Treatment involves the introduction into the peritoneum of a sterile dialyzing solution, which is drained after a specified time.

D. Treatment involves the introduction into the peritoneum of a sterile dialyzing solution, which is drained after a specified time.

The parents of a child who has been diagnosed with chronic kidney disease (CKD) ask the nurse about manifestations of the disease. Which information is the most appropriate information to provide these parents? Select all that apply. Developmental delay Delayed cognitive development Secondary hyperparathyroidism Growth impairment Accelerated sexual maturation Early-onset puberty

Developmental delay Delayed cognitive development Secondary hyperparathyroidism Growth impairment