PrepU Ch. 26: Acute Renal Failure and Chronic Kidney Disease
Chronic kidney disease impacts many systems in the body. What is the number one hematologic disorder caused by CKD? Anemia Polycythemia Leukocytosis Erythrocythemia
Anemia Explanation: The number one hematologic disorder that accompanies CKD is anemia. The other answers are incorrect.
A new client presents with elevated BUN, systemic edema, a BP of 145/93 mm Hg, recurrent infections, and a GFR of 51 mL/min/1.73 m2. What treatment should the nurse anticipate? Kidney transplant Dialysis Bone marrow transplant Intravenous antibiotics
Dialysis Explanation: These findings are suggestive of chronic kidney disease (CKD. , defined as kidney damage with a GFR less than 60 mL/min/1.73 m2 for 3 months or longer. Dialysis is a likely intervention. The disease is noninfectious, so antibiotics are not necessarily indicated. Dialysis would precede a transplant in nearly all circumstances. BMT is not a relevant intervention.
The nurse is instructing a patient with advanced kidney disease (AKD) about a dietary regimen. Which of the following restrictions should the nurse be sure to include in the treatment plan to decrease the progress of renal impairment in people with AKD? Carbohydrates Foods high in calcium Fats Dietary protein
Dietary protein Explanation: Restriction of dietary proteins may decrease the progress of renal impairment in people with advanced renal disease. Proteins are broken down to form nitrogenous wastes, and reducing the amount of protein in the diet lowers the blood urea nitrogen and reduces symptoms.
A patient sustained acute tubular injury approximately 2 hours ago. Which of the following phases of this disorder does the nurse recognize that the patient is in at this time? Recovery phase Convalescent phase Maintenance phase Initiating phase
Initiating phase Explanation: The onset, or initiating phase, which lasts hours or days, is the time from the onset of the precipitating event until tubular injury occurs.
A nurse, caring for a client with acute tubular necrosis (ATN) caused by myoglobinuria, knows this may be caused by which finding in their medical history? Select all that apply. Hyperkalemia Hyperthermia Prolonged seizures Alcohol abuse Muscle damage
Muscle damage Hyperthermia Alcohol abuse Prolonged seizures Explanation: Myoglobin, which stores oxygen in muscle fibers, is released when muscle is damaged. Large amounts of myoglobin, as in myoglobinuria, will cause tubular obstruction and damage to nephrons. Myoglobin is released from muscle by muscle trauma including extreme physical exercise, prolonged seizures, hyperthermia, potassium depletion, and alcohol abuse.
A geriatric nurse is caring for several clients. Which alterations in clients' health should the nurse attribute to age-related physiologic changes? A 78-year-old woman's GFR has been steadily declining over several years. An 81-year-old man's serum creatinine level has increased sharply since his last blood work. A 90-year-old woman's blood urea nitrogen (BUN) is rising. A dipstick of an 80-year-old man's urine reveals protein is present.
A 78-year-old woman's GFR has been steadily declining over several years. Explanation: A gradual decrease in GFR is considered a normal age-related change. Increased creatinine or BUN would warrant follow up, as would the presence of protein in a client's urine.
A client with a diagnosis of chronic kidney disease (CKD) may require the administration of which of the following drugs to treat coexisting conditions that carry a high mortality? Opioid analgesics Nonsteroidal anti-inflammatory drugs (NSAIDs) Antiarrhythmic medications Antihypertensive medications
Antihypertensive medications Explanation: Hypertension is a common result of CKD, and the mechanisms that produce hypertension in CKD include increased vascular volume, elevation of peripheral vascular resistance, decreased levels of renal vasodilator prostaglandins, and increased activity of the renin-angiotensin-aldosterone system. NSAIDs, opioids, and antiarrhythmics are not as frequently indicated for the treatment of CKD.
The nurse is caring for a patient who has had acute blood loss from ruptured esophageal varices. Which of the following does the nurse recognize is an early sign of prerenal failure? Baseline blood pressure of 150/90 mm Hg that is now 130/80 mm Hg Baseline heart rate of 100 bpm that has increased to 120 bpm Baseline urine output of 50 mL/hr that is now 10 mL/hr Foul smelling, cloudy urine
Baseline urine output of 50 mL/hr that is now 10 mL/hr Explanation: 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.
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 of the following types of drugs? Sulfonylureas Diuretics Calcium channel blockers Beta adrenergic blockers
Diuretics Explanation: Diuretics, which directly affect renal excretion of sodium, can alter the fractional excretion of sodium. The other drug types listed do not affect this parameter of renal function.
Which of the following integumentary problems most often accompanies chronic kidney disease? Alopecia Dry skin and pruritus Petechiae and purpura Hirsutism and psoriasis
Dry skin and pruritus Explanation: Dry, itchy skin is a common consequence of CKD. Petechiae, purpura, hirsutism, and psoriasis are not noted to accompany or result from CKD.
A patient in renal failure has marked decrease in renal blood flow caused by hypovolemia, caused by gastrointestinal bleeding. The nurse is aware that this form of renal failure can be reversed if the bleeding is under control. Which of the following forms of acute renal injury does this patient have? Chronic renal failure Intrarenal failure Prerenal failure Postrenal failure
Prerenal failure Explanation: Prerenal failure, the most common form of acute renal failure, is characterized by a marked decrease in renal blood flow. It is reversible if the cause of the decreased renal blood flow can be identified and corrected before kidney damage occurs.
The nurse assesses a client for prerenal failure. Which conditions increase the risk for developing this type of kidney failure? Select all that apply. Prolonged renal ischemia Severe burns Septic shock Glomerulonephritis Severe dehydration
Severe burns Septic shock Severe dehydration Explanation: 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.
A nurse is assessing a client for early manifestations of chronic kidney disease (CKD). Which would the nurse expect the client to display? Impotence Terry nails Asterixis Hypertension
Hypertension Explanation: Hypertension is commonly an early manifestation of CKD. The mechanisms that cause the hypertension are multifactorial; they include increased vascular volume, increased peripheral vascular resistance, decreased levels of renal vasodilator prostaglandins, and increase activity of the renin-angiotensin-aldosterone system. Impotence occurs in as many as 56% of males on dialysis. Terry nails are dark band just behind the leading edge of a fingernail followed by a white band that occur in the late stages. Asterixis, a sign of hepatic encephalopathy, is due to the inability of the liver to metabolize ammonia to urea.
A patient with stage 5 chronic kidney disease (CKD) is presenting with fever and chest pain, especially when taking a deep breath. The nurse detects a pericardial friction rub on auscultation. Which of the following conditions does the nurse suspect is common with this stage of kidney disease? Pulmonary embolism Pulmonary edema Myocardial infarction Pericarditis
Pericarditis Explanation: Pericarditis occurs in many people with stage 5 CKD due to the uremia and prolonged diaylsis. The manifestations of uremic pericarditis resemble those of viral pericarditis with all its potential complications, including cardiac tamponade. The presenting signs include mild to severe chest pain with respiratory accentuation and a pericardial friction rub. Fever is variable in the absence of infection and is more common in dialysis than uremic pericarditis.
The primary care provider for a newly admitted hospital patient has added the glomerular filtration rate (GFR) to the blood work scheduled for this morning. The patient's GFR will be extrapolated from serum levels of: myoglobin. urea. protein. creatinine.
creatinine. Explanation: In clinical practice, GFR is usually estimated using the serum creatinine concentration. The presence of myoglobin or large amounts of protein in the urine is suggestive of renal failure. Serum blood urea nitrogen levels are clinically useful; however, GFR is not calculated from these values.
Accumulation of nitrogenous wastes such a 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 which of the following? 60 mg/dL 20 mg/dL 100 mg/dL 80 mg/dL
20 mg/dL Explanation: Normal levels of blood urea nitrogen are approximately 20 mg/dL or less. The level increases as CKD worsens and can go as high as 800 mg/dL.
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 need to increase water intake The kidneys are functioning normally Concentrated urine A loss of over half the client's normal kidney function
A loss of over half the client's normal kidney function Explanation: 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. The GFR is not diagnostic for concentrated urine or the need to drink more water.
Bruising of the skin is a manifestation of bleeding disorders in patients with CKD. True False
True Explanation: Bleeding disorders manifested by persons with CKD include epistaxis, menorrhagia, gastrointestinal bleeding, and bruising of skin and subcutaneous tissues.
Which of the following individuals likely faces the greatest risk for the development of chronic kidney disease? A client whose diagnosis of thyroid cancer necessitated a thyroidectomy A first-time mother who recently lost 1.5 L of blood during a postpartum hemorrhage A client with a recent diagnosis of type 2 diabetes who does not monitor his blood sugars or control his diet A client who experienced a hemorrhagic stroke and now has sensory and motor deficits
A client with a recent diagnosis of type 2 diabetes who does not monitor his blood sugars or control his diet Explanation: Chronic kidney disease (CKD) is a pathophysiologic process that results in the loss of nephrons and a decline in renal function that has persisted for more than 3 months. CKD can result from diabetes, hypertension, glomerulonephritis, lupus (SLE), and polycystic kidney disease. The prevalence and incidence of CKD continue to grow, reflecting the growing elderly population and the increasing number of people with diabetes and hypertension. Hemorrhage may result in acute renal failure, but it is not associated with chronic kidney disease. Stroke and loss of the thyroid gland are not noted to underlie cases of chronic kidney disease.
A client who has developed renal failure with associated high serum phosphate levels. To avoid the development of osteodystrophy, the healthcare provider will try to avoid phosphate-binding agents that contain which compound? Calcium acetate Aluminum salts Sevelamer hydrochloride Calcium carbonate
Aluminum salts Explanation: Aluminum-containing antacids can contribute to the development of osteodystrophy, whereas calcium-containing phosphate binders can lead to hypercalcemia, thus worsening soft tissue calcification, especially in persons receiving vitamin D therapy. Sevelamer hydrochloride is a newer phosphate-binding agent that does not contain calcium or aluminum.
A client with a long-standing diagnosis of chronic kidney disease has been experiencing increasing fatigue, lethargy, and activity intolerance in recent weeks. His care team has established that his GFR remains at a low, but stable, level. Which of the following assessments is most likely to inform a differential diagnosis? Blood work for white cells and differential Assessment of pancreatic exocrine and endocrine function Blood work for hemoglobin, red blood cells, and hematocrit Cystoscopy and ureteroscopy
Blood work for hemoglobin, red blood cells, and hematocrit Explanation: 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. Pancreatic function is not typically affected by CKD, and endoscopic examination is less likely to reveal a cause of fatigue. An infectious etiology is possible and would be informed by white cell assessment, but this is less likely than anemia given the client's complaints.
The health care provider is reviewing lab results of a client. Select the test that is the best measurement of overall kidney function? Urine albumin levels Blood urea nitrogen (BUN) Glomerular filtration rate (GFR) Serum creatinine levels
Glomerular filtration rate (GFR) Explanation: GFR is the best overall measure of kidney function. GFR is usually estimated using the serum creatinine concentration. Creatinine, a by-product of muscle metabolism, is produced at a fairly constant rate, is freely filtered in the glomerulus, and is not reabsorbed in the renal tubules. Essentially all of the creatinine filtered by the kidneys is lost in the urine; therefore, serum creatinine is an indirect measure of GFR. Proteinuria serves as a key adjunctive tool for measuring nephron injury and repair. Urine normally contains small amounts of protein. Blood tests for BUN and creatinine provide information regarding the ability to remove nitrogenous wastes from the blood.
A drug abuser was found unconscious after shooting up heroin 2 days prior. Because of the pressure placed on the hip and arm, the client has developed rhabdomyolysis. The nurse knows this can: Cause compartment syndrome in the lower extremities Be cured by administering an anticoagulant immediately Obstruct the renal tubules with myoglobin and damage tubular cells Cause the kidney to develop renal stones due to stasis
Obstruct the renal tubules with myoglobin and damage tubular cells Explanation: 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. Myoglobinuria most commonly results from muscle trauma but may result from exertion, hyperthermia, sepsis, prolonged seizures, and alcoholism or drug abuse. Rhabdomyolysis is not cured with anticoagulation administration nor does it cause kidney stones. Compartment syndrome occurs when there is insufficient blood supply to muscles and nerves due to increased pressure within one of the body's compartments.
While assessing a peritoneal dialysis client in his or her 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: Too much sugar in the dialysis solution Bowel perforation Peritonitis Bladder erosion
Peritonitis Explanation: 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.
An 86-year-old female patient is admitted to the hospital for the treatment of dehydration and hyponatremia after she curtailed her fluid intake to prevent urinary incontinence. The patient's most recent laboratory results are suggestive of acute renal failure. The nurse recognizes that this patient has which type of failure? Prerenal Postrenal Intrinsic Intrarenal
Prerenal Explanation: Prerenal failure occurs when vascular volume and renal perfusion are decreased, for example by dehydration. Postrenal failure is the result of obstruction of urine outflow. Intrarenal (intrinsic) failure occurs when nephrons are destroyed.
The nurse is reviewing the diagnosis of four male clients. Select the diagnosis that places the clients at risk for developing postrenal kidney failure. Prostatic hyperplasia Acute pyelonephritis Severe hypovolemia Intratubular obstruction
Prostatic hyperplasia Explanation: The most common cause of postrenal kidney failure is prostatic hyperplasia. Postrenal failure results from conditions that obstruct urine outflow. The obstruction can occur in the ureter, bladder, or urethra. Intratubular obstruction and acute pyelonephritis are intrarenal causes of kidney failure, and severe hypovolemia is a prerenal cause.
The nurse recognizes that acute renal injury is characterized by which of the following? Irreversible damage to nephrons Low incidence of mortality Decreased blood urea nitrogen (BUN) Rapid decline in renal function
Rapid decline in renal function Explanation: Acute renal injury is a rapid decline in kidney function. BUN rises as nitrogenous wastes are not removed from the circulation. If the cause can be ameliorated, the injury is usually reversible. Most at risk are seriously ill clients; the mortality rate is between 40% and 90% in these clients.
The GFR is considered to be the best measure of renal function. What is used to estimate the GFR? Serum creatinine Albumin level Serum protein BUN
Serum creatinine Explanation: In clinical practice, GFR is usually estimated using the serum creatinine concentration. The other answers are not used to estimate the GFR.
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 of the following early signs of prerenal injury? Acute hypertensive crisis Sharp decrease in urine output Excessive voiding of clear urine Intermittent periods of confusion
Sharp decrease in urine output Explanation: 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. Post-renal failure is obstructive in etiology, and intrinsic (or intrarenal) renal failure is reflective of deficits in the function of the kidneys themselves.
A 56-year-old woman has been diagnosed with CKD. She first went to the doctor due to complications of hypertension. How are hypertension and CKD related? The mechanisms that produce hypertension in CKD are due to decreases in vascular volume, elevation of peripheral vascular resistance, increased levels of renal vasodilator prostaglandins, and decreased activity of the renin--angiotensin system. The mechanisms that produce hypertension in CKD are directly related to sporadic increases in the activity of the renin--angiotensin system. The mechanisms that produce hypertension in CKD include an increased vascular volume and increased activity of the renin--angiotensin system. The mechanisms relate to increases in hydrostatic pressure on the renal vasculature causes inflammation and irreversible damage.
The mechanisms that produce hypertension in CKD include an increased vascular volume and increased activity of the renin--angiotensin system. Explanation: Hypertension commonly is an early manifestation of CKD. The mechanisms that produce hypertension in CKD are multifactorial; they include an increased vascular volume, elevation of peripheral vascular resistance, decreased levels of renal vasodilator prostaglandins, and increased activity of the renin--angiotensin system.
A patient with chronic kidney disease (CKD) will be managed with peritoneal dialysis. The nurse will give the patient which of the following descriptions of this type of dialysis? The dialyzer is usually a hollow cylinder composed of bundles of capillary tubes. Vascular access is achieved through an internal arteriovenous fistula or an external arteriovenous shunt. Treatment involves the introduction into the peritoneum of a sterile dialyzing solution, which is drained after a specified time. Treatments typically occur three times each week for three to four hours.
Treatment involves the introduction into the peritoneum of a sterile dialyzing solution, which is drained after a specified time. Explanation: In peritoneal dialysis, a sterile dialyzing solution is instilled into the peritoneum through a catheter over approximately 10 minutes. The solution remains ("dwells") in the peritoneal cavity for a determined time interval, then drains into a sterile bag. Shunts, fistulas, and artificial dialyzers are associated with hemodialysis, which is usually performed three times weekly. The frequency of peritoneal dialysis varies, but is normally performed more often than hemodialysis and can be done at home.