Urden Critical Care Chapter 19: Kidney Disorders and Therapeutic Management

7. A patient with chronic kidney disease was admitted with severe electrolytes disturbances. The patient had been ill and missed several hemodialysis sessions. The patient is disoriented, dizzy, cold, clammy, and complains of severe abdominal cramping. The patient's electrocardiogram appears normal. Which electrolyte disturbance would the nurse suspect the patient may be experiencing? a. Hyponatremia b. Hypokalemia c. Hypercalcemia d. Hypochloremia

ANS: A Hyperkalemia, hypocalcemia, hyponatremia, hyperphosphatemia, and acid-base imbalances occur in kidney disease. Signs of hyponatremia include disorientation, muscle twitching, nausea, vomiting, abdominal cramps, headaches, dizziness, cold, clammy skin, tachycardia, and seizures. PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Assessment TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. The practitioner has ordered dialysis for a patient with acute heart failure who is unresponsive to diuretics. Which type of dialysis would the nurse anticipate being started on this patient? a. Intermittent ultrafiltration b. Continuous venovenous hemofiltration (CVVH) c. Continuous venovenous hemodialysis (CVVHD) d. Continuous venovenous hemodiafiltration (CVVHDF)

ANS: A Intermittent ultrafiltration using a peripheral venous catheter is more likely to be used to remove excess volume from patients with acute decompensated heart failure when the kidneys are unresponsive to diuretics. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

18. A patient is admitted with acute kidney injury (AKI). Which event from the patient's history was the most probable cause of the patient's AKI? a. Recent computed tomography of the brain with and without contrast b. Recent bout of acute heart failure after an acute myocardial infarction c. Twice-daily prescription of Lasix 40 mg by mouth d. Recent transurethral resection of the prostate

ANS: A Intravenous contrast media can be nephrotoxic, especially with the patient's preexisting cardiac disease. The other choices, although possible causes, are less likely than the intravenous contrast media. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. To remove fluid during hemodialysis, a positive hydrostatic pressure is applied to the blood and a negative hydrostatic pressure is applied to the dialysate bath. What is this process called? a. Ultrafiltration b. Hemodialysis c. Reverse osmosis d. Colloid extraction

ANS: A To remove fluid, a positive hydrostatic pressure is applied to the blood, and a negative hydrostatic pressure is applied to the dialysate bath. The two forces together, called transmembrane pressure, pull and squeeze the excess fluid from the blood. The difference between the two values (expressed in millimeters of mercury [mm Hg]) represents the transmembrane pressure and results in fluid extraction, known as ultrafiltration, from the vascular space. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE 1. Which situations place the critically ill patient at risk for prerenal acute kidney injury? (Select all that apply.) a. Prolonged hypotension b. Prolonged low cardiac output c. Kidney ischemia d. Renovascular thrombosis e. Obstruction of the bladder

ANS: A, B, D Patients with prolonged hypotension (sepsis, vasodilation), prolonged low cardiac output (heart failure, cardiogenic shock), prolonged volume depletion (dehydration, hemorrhage), and renovascular thrombosis (thromboemboli) place the patient at risk for prerenal acute kidney injury. Kidney ischemia places the patient at risk for intrarenal acute kidney injury and obstruction of the bladder places the patient at risk postrenal acute kidney injury. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nursing management plan for the patient with a urinary drainage catheter would include which interventions to prevent catheter-associated UTI (CAUTI)? (Select all that apply.) a. Insert urinary catheters using aseptic techniques. b. Change the urinary catheter daily. c. Review the need for the urinary catheter daily and remove promptly. d. Flush the urinary catheter q8 hours to maintain patency. e. Avoid unnecessary use of indwelling urinary catheters.

ANS: A, C, E The key components of CAUTI prevention are to avoid unnecessary use of urinary catheters, insert urinary catheters using aseptic technique, adopt evidence-based standards for maintenance of urinary catheters, review the need for the urinary catheter daily, and remove the catheter promptly. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

8. A patient was admitted with an infection that had to be treated with gentamicin, an aminoglycoside antibiotic. After 3 days of administration, the patient developed oliguria, and an elevated blood urea nitrogen and creatinine levels. The nurse suspects the patient has developed what type of kidney injury? a. Prerenal b. Intrarenal c. Anuric d. Postrenal

ANS: B Any condition that produces an ischemic or toxic insult directly at parenchymal nephron tissue places the patient at risk for development of intrarenal. Ischemic damage may be caused by prolonged hypotension or low cardiac output. Toxic injury reaction may occur in response to substances that damage the kidney tubular endothelium, such as some antimicrobial medications and the contrast dye used in radiologic diagnostic studies. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. A patient was admitted with an infection that had to be treated with an aminoglycoside antibiotic. After few days, the patient developed oliguria and elevated blood urea nitrogen and creatinine levels. The patient's vital signs are stable. The nurse would anticipate the practitioner ordering which dialysis method for this patient? a. Peritoneal dialysis b. Hemodialysis c. Continuous renal replacement therapy d. Intermittent ultrafiltration

ANS: B As a treatment, hemodialysis separates and removes from the blood excess electrolytes, fluids, and toxins by means of a hemodialyzer. Hemodialysis would be the first choice for managing this patient with medication toxicity. PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Planning TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

13. The practitioner has ordered continuous renal replacement therapy (CRRT) for a patient with acute kidney injury. The patient needs both the removal of fluids and a moderate number of solutes. Which type of CRRT would the nurse anticipate being started on this patient? a. Slow continuous ultrafiltration (SCUF) b. Continuous venovenous hemofiltration (CVVH) c. Continuous venovenous hemodialysis (CVVHD) d. Continuous venovenous hemodiafiltration (CVVHDF)

ANS: B CVVH is indicated when the patient's clinical condition warrants removal of significant volumes of fluid and solutes. Fluid is removed by ultrafiltration in volumes of 5 to 20 mL/min or up to 7 to 30 L/24 hr. Removal of solutes such as urea, creatinine, and other small non-protein-bound toxins is accomplished by convection. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

2. A patient has developed acute kidney injury (AKI) secondary to cardiogenic shock. Which laboratory value would the nurse find helpful in evaluating patient's renal status? a. Serum sodium b. Serum creatinine c. Serum potassium d. Urine potassium

ANS: B In the acutely ill patient, small changes in the serum creatinine level and urine output may signal important declines in the glomerular filtration rate and kidney function. PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

11. What is the most common site for short-term vascular access for immediate hemodialysis? a. Subclavian artery b. Subclavian vein c. Femoral artery d. Radial vein

ANS: B Subclavian and femoral veins are catheterized when short-term access is required or when a graft or fistula vascular access is nonfunctional in a patient requiring immediate hemodialysis. Subclavian and femoral catheters are routinely inserted at the bedside. Most temporary catheters are venous lines only. Blood flows out toward the dialyzer and flows back to the patient through the same catheterized vein. A dual-lumen venous catheter is most commonly used. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

17. What is the recommended nutritional intake of protein to control azotemia in the patient with acute kidney injury? a. 0.5 to 1.0 g/kg/day b. 1.2 to 1.5 g/kg/day c. 1.7 to 2.5 g/kg/day d. 2.5 to 3.5 g/kg/day

ANS: B The recommended energy intake is between 20 and 30 kcal/kg/day, with 1.2 to 1.5 g/kg of protein per day to control azotemia (increased blood urea nitrogen level). PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

Chapter 19: Kidney Disorders and Therapeutic Management Urden: Priorities in Critical Care Nursing, 9th Edition MULTIPLE CHOICE 1. An elderly patient is in a motor vehicle accident and sustains a significant internal hemorrhage. The nurse knows the patient is at risk for developing what type of acute kidney injury (AKI)? a. Intrinsic b. Postrenal c. Prerenal d. Intrarenal

ANS: C Any condition that decreases blood flow, blood pressure, or kidney perfusion before arterial blood reaches the renal artery that supplies the kidney may be anatomically described as prerenal acute kidney injury (AKI). When arterial hypoperfusion caused by low cardiac output, hemorrhage, vasodilation, thrombosis, or other cause reduces the blood flow to the kidney, glomerular filtration decreases, and consequently urine output decreases. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodiafiltration (CVVHDF). The nurse understands the patient should be closely monitored for what circuit-related complications of the therapy? a. Hypervolemia, hypothermia, and hyperkalemia b. Access dislodgment, decreased outflow pressures, and bleeding c. Filter clotting, access failure, and air embolism d. Increased overflow pressure, dehydration, and calcium loss

ANS: C Circuit-related complications of continuous renal replacement therapy include air embolism, clotted hemofilter, poor ultrafiltration, blood leaks, broken filter, disconnection, access failure, and catheter dislodgement. PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Evaluation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

15. A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodialysis (CVVHD). The nurse understands that this type of continuous renal replacement therapy (CRRT) is indicated for the patient who needs what type of treatment? a. Fluid removal only b. Fluid removal and moderate solute removal c. Fluid removal and maximum solute removal d. Maximum fluid and solute removal

ANS: C Continuous venovenous hemodialysis (CVVHD) is indicated for patients who require fluid removal and maximum removal of solutes. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

4. A patient was admitted with liver failure and acute kidney injury (AKI). Which intravenous solution should the nurse question if it was ordered for this patient? a. D5W b. 0.9% NaCl c. Lactated Ringer solution d. 0.45% NaCl

ANS: C Lactated Ringer solution is contraindicated for patients with kidney or liver diseases or in lactic acidosis. PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

14. A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodialysis (CVVHD). The nurse understands the patient should be closely monitored for what patient-related complications of the therapy? a. Air embolism, access failure, and blood leaks b. Decreased inflow pressure, air bubbles, and power surge c. Infection, hypotension, and electrolyte imbalances d. Catheter dislodgement, decreased outflow pressure, and acid-base imbalances

ANS: C Patient-related complications of continuous renal replacement therapy (CRRT) include dehydration, hypotension, electrolyte imbalances, acid-base imbalances, blood loss, hemorrhage, hypotension, and infection. PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Evaluation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

5. To assess whether an arteriovenous fistula is functioning, what must the nurse do and why? a. Palpate the quality of the pulse distal to the site to determine whether a thrill is present; auscultate with a stethoscope to appreciate a bruit to assess the quality of the blood flow. b. Palpate the quality of the pulse proximal to the site to determine whether a thrill is present; auscultate with a stethoscope to appreciate a bruit to assess the quality of the blood flow. c. Palpate gently over the site of the fistula to determine whether a thrill is present; listen with a stethoscope over this site to appreciate a bruit to assess the quality of the blood flow. d. Palpate over the site of the fistula to determine whether a thrill is present; check whether the extremity is pink and warm.

ANS: C The nurse frequently assesses the quality of blood flow through the fistula. A patent fistula has a thrill when palpated gently with the fingers and a bruit when auscultated with a stethoscope. The extremity should be pink and warm to the touch. No blood pressure measurements, intravenous infusions, or laboratory phlebotomy is performed on the arm with the fistula. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Health Promotion and Maintenance

3. One therapeutic measure for treating hyperkalemia is the administration of dextrose and regular insulin. Which description regarding how this treatment works is accurate? a. Forces potassium out of the serum into the lymphatic space. b. Promotes higher excretion of potassium in the urine. c. Binds with potassium lowering available amounts. d. Forces potassium out of the serum into the cells.

ANS: D Acute hyperkalemia can be treated temporarily by intravenous administration of insulin and glucose. An infusion of 50 mL of 50% dextrose accompanied by 10 units of regular insulin forces potassium out of the serum and into the cells. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

10. A patient is admitted with sepsis and acute kidney injury (AKI). The patient is started on continuous renal replacement therapy (CRRT). The nurse knows that fluid is removed each hour is charted as what on the CRRT flow sheet? a. Convection b. Diffusion c. Replacement fluid d. Ultrafiltrate

ANS: D The fluid that is removed each hour is not called urine; it is known as ultrafiltrate. Typically, some of the ultrafiltrate is replaced through the continuous renal replacement therapy circuit by a sterile replacement fluid. Diffusion is the movement of solutes along a concentration gradient from a high concentration to a low concentration across a semipermeable membrane. Convection occurs when a pressure gradient is set up so that the water is pushed or pumped across the dialysis filter and carries the solutes from the bloodstream with it. PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential