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RENAL - 4th semester

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1. What are intrarenal causes of acute kidney injury (AKI) (select all that apply)? a. Anaphylaxis b. Renal stones c. Bladder cancer d. Nephrotoxic drugs e. Acute glomerulonephritis f. Tubular obstruction by myoglobin

1. d, e, f. Intrarenal causes of acute kidney injury (AKI) include conditions that cause direct damage to the kidney tissue, including nephrotoxic drugs, acute glomerulonephritis, and tubular obstruction by myoglobin, or prolonged ischemia. Anaphylaxis and other prerenal problems are frequently the initial cause of AKI. Renal stones and bladder cancer are among the postrenal causes of AKI.

10. In caring for the patient with AKI, what should the nurse be aware of? a. The most common cause of death in AKI is irreversible metabolic acidosis. b. During the oliguric phase of AKI, daily fluid intake is limited to 1000 mL plus the prior day's measured fluid loss. c. Dietary sodium and potassium during the oliguric phase of AKI are managed according to the patient's urinary output. d. One of the most important nursing measures in managing fluid balance in the patient with AKI is taking accurate daily weights.

10. d. Measuring daily weights with the same scale at the same time each day allows for the evaluation and detection of excessive body fluid gains or losses. Infection is the leading cause of death in AKI, so meticulous aseptic technique is critical. The fluid limitation in the oliguric phase is 600 mL plus the prior day's measured fluid loss. Dietary sodium and potassium intake are managed according to the plasma levels.

11. A 68-year-old man with a history of heart failure resulting from hypertension has AKI as a result of the effects of nephrotoxic diuretics. Currently his serum potassium is 6.2 mEq/L (6.2 mmol/L) with cardiac changes, his BUN is 108 mg/dL (38.6 mmol/L), his serum creatinine is 4.1 mg/dL (362 mmol/L), and his serum HCO − is 14 mEq/L 3 (14 mmol/L). He is somnolent and disoriented. Which treatment should the nurse expect to be used for him? a. Loop diuretics b. Renal replacement therapy c. Insulin and sodium bicarbonate d. Sodium polystyrene sulfonate (Kayexalate)

11. b. This patient has at least three of the six common indications for renal replacement therapy (RRT), including (1) high potassium level, (2) metabolic acidosis, and (3) changed mental status. The other indications are (4) volume overload, resulting in compromised cardiac status (this patient has a history of hypertension), (5) BUN greater than 120 mg/dL, and (6) pericarditis, pericardial effusion, or cardiac tamponade. Although the other treatments may be used, they will not be as effective as RRT for this older patient. Loop diuretics and increased fluid are used if the patient is dehydrated. Insulin and sodium bicarbonate can be used to temporarily drive the potassium into the cells. Sodium polystyrene sulfonate (Kayexalate) is used to actually decrease the amount of potassium in the body.

12. Prevention of AKI is important because of the high mortality rate. Which patients are at increased risk for AKI (select all that apply)? a. An 86-year-old woman scheduled for a cardiac catheterization b. A 48-year-old man with multiple injuries from a motor vehicle accident c. A 32-year-old woman following a C-section delivery for abruptio placentae d. A 64-year-old woman with chronic heart failure admitted with bloody stools e. A 58-year-old man with prostate cancer undergoing preoperative workup for prostatectomy

12. a, b, c, d, e. High-risk patients include those exposed to nephrotoxic agents and advanced age (a), massive trauma (b), prolonged hypovolemia or hypotension (possibly b and c), obstetric complications (c), cardiac failure (d), preexisting chronic kidney disease, extensive burns, or sepsis. Patients with prostate cancer may have obstruction of the outflow tract, which increases risk of postrenal AKI (e).

13. Priority Decision: A patient on a medical unit has a potassium level of 6.8 mEq/L. What is the priority action that the nurse should take? a. Place the patient on a cardiac monitor. b. Check the patient's blood pressure (BP). c. Instruct the patient to avoid high-potassium foods. d. Call the lab and request a redraw of the lab to verify results.

13. a. Dysrhythmias may occur with an elevated potassium level and are potentially lethal. Monitor the rhythm while contacting the physician or calling the rapid response team. Vital signs should be checked. Depending on the patient's history and cause of increased potassium, instruct the patient about dietary sources of potassium; however, this would not help at this point. The nurse may want to recheck the value but until then the heart rhythm needs to be monitored.

14. A patient with AKI has a serum potassium level of 6.7 mEq/L (6.7 mmol/L) and the following arterial blood gas results: pH 7.28, PaCO 30 mm Hg, PaO 86 mm Hg, HCO − 18 mEq/L (18 mmol/L). The nurse recognizes that treatment of the acid-base problem with sodium bicarbonate would cause a decrease in which value? a. pH b. Potassium level c. Bicarbonate level d. Carbon dioxide level

14. b. During acidosis, potassium moves out of the cell in exchange for H+ ions, increasing the serum potassium level. Correction of the acidosis with sodium bicarbonate will help to shift the potassium back into the cells. A decrease in pH and the bicarbonate and PaCO2 levels would indicate worsening acidosis.

15. In replying to a patient's questions about the seriousness of her chronic kidney disease (CKD), the nurse knows that the stage of CKD is based on what? a. Total daily urine output b. Glomerular filtration rate c. Degree of altered mental status d. Serum creatinine and urea levels

15. b. Stages of chronic kidney disease are based on the GFR. No specific markers of urinary output, mental status, or azotemia classify the degree of chronic kidney disease (CKD).

16. The patient with CKD is receiving dialysis, and the nurse observes excoriations on the patient's skin. What pathophysiologic changes in CKD can contribute to this finding (select all that apply)? a. Dry skin b. Sensory neuropathy c. Vascular calcifications d. Calcium-phosphate skin deposits e. Uremic crystallization from high BUN

16. a, b, d. Pruritus is common in patients receiving dialysis. It causes scratching from dry skin, sensory neuropathy, and calcium-phosphate deposition in the skin. Vascular calcifications contribute to cardiovascular disease, not to itching skin. Uremic frost rarely occurs without BUN levels greater than 200 mg/dL, which should not occur in a patient on dialysis; urea crystallizes on the skin and also causes pruritis.

17. What causes the gastrointestinal (GI) manifestation of stomatitis in the patient with CKD? a. High serum sodium levels b. Irritation of the GI tract from creatinine c. Increased ammonia from bacterial breakdown of urea d. Iron salts, calcium-containing phosphate binders, and limited fluid intake

17. c. Uremic fetor, or the urine odor of the breath, is caused by high urea content in the blood. Increased ammonia from bacterial breakdown of urea leads to stomatitis and mucosal ulcerations. Irritation of the gastrointestinal (GI) tract from urea in CKD contributes to anorexia, nausea, and vomiting. Ingestion of iron salts and calcium-containing phosphate binders, limited fluid intake, and limited activity cause constipation.

18. The patient with CKD is brought to the emergency department with Kussmaul respirations. What does the nurse know about CKD that could cause this patient's Kussmaul respirations? a. Uremic pleuritis is occurring. b. There is decreased pulmonary macrophage activity. c. They are caused by respiratory compensation for metabolic acidosis. d. Pulmonary edema from heart failure and fluid overload is occurring.

18. c. Kussmaul respirations occur with severe metabolic acidosis when the respiratory system is attempting to compensate by removing carbon dioxide with exhalations. Uremic pleuritis would cause a pleural friction rub. Decreased pulmonary macrophage activity increases the risk of pulmonary infection. Dyspnea would occur with pulmonary edema.

19. Which serum laboratory value indicates to the nurse that the patient's CKD is getting worse? a. Decreased BUN b. Decreased sodium c. Decreased creatinine d. Decreased calculated glomerular filtration rate (GFR)

19. d. As GFR decreases, BUN and serum creatinine levels increase. Although elevated BUN and creatinine indicate that waste products are accumulating, the calculated GFR is considered a more accurate indicator of kidney function than BUN or serum creatinine.

2. An 83-year-old female patient was found lying on the bathroom floor. She said she fell 2 days ago and has not been able to take her heart medicine or eat or drink anything since then. What conditions could be causing prerenal AKI in this patient (select all that apply)? a. Anaphylaxis b. Renal calculi c. Hypovolemia d. Nephrotoxic drugs e. Decreased cardiac output

2. c, e. Because the patient has had nothing to eat or drink for 2 days, she is probably dehydrated and hypovolemic. Decreased cardiac output (CO) is most likely because she is older and takes heart medicine, which is probably for heart failure or hypertension. Both hypovolemia and decreased CO cause prerenal AKI. Anaphylaxis is also a cause of prerenal AKI but is not likely in this situation. Nephrotoxic drugs would contribute to intrarenal causes of AKI and renal calculi would be a postrenal cause of AKI.

20. What is the most serious electrolyte disorder associated with kidney disease? a. Hypocalcemia b. Hyperkalemia c. Hyponatremia d. Hypermagnesemia

20. b. Hyperkalemia can lead to life-threatening dysrhythmias. Hypocalcemia leads to an accelerated rate of bone remodeling and potentially to tetany. Hyponatremia may lead to confusion. Elevated sodium levels lead to edema, hypertension, and heart failure. Hypermagnesemia may decrease reflexes, mental status, and blood pressure.

21. For a patient with CKD the nurse identifies a nursing diagnosis of risk for injury: fracture related to alterations in calcium and phosphorus metabolism. What is the pathologic process directly related to the increased risk for fractures? a. Loss of aluminum through the impaired kidneys b. Deposition of calcium phosphate in soft tissues of the body c. Impaired vitamin D activation resulting in decreased GI absorption of calcium d. Increased release of parathyroid hormone in response to decreased calcium levels

21. c. The calcium-phosphorus imbalances that occur in CKD result in hypocalcemia, from a deficiency of active vitamin D and increased phosphorus levels. This leads to an increased rate of bone remodeling with a weakened bone matrix. Aluminum accumulation is also believed to contribute to the osteomalacia. Osteitis fibrosa involves replacement of calcium in the bone with fibrous tissue and is primarily a result of elevated levels of parathyroid hormone resulting from hypocalcemia.

22. Priority Decision: What is the most appropriate snack for the nurse to offer a patient with stage 4 CKD? a. Raisins b. Ice cream c. Dill pickles d. Hard candy

22. d. A patient with CKD may have unlimited intake of sugars and starches (unless the patient is diabetic) and hard candy is an appropriate snack and may help to relieve the metallic and urine taste that is common in the mouth. Raisins are a high-potassium food. Ice cream contains protein and phosphate and counts as fluid. Pickled foods have high sodium content.

23. Which complication of chronic kidney disease is treated with erythropoietin (EPO)? a. Anemia b. Hypertension c. Hyperkalemia d. Mineral and bone disorder

23. a. Erythropoietin is used to treat anemia, as it stimulates the bone marrow to produce red blood cells.

24. The patient with CKD asks why she is receiving nifedipine (Procardia) and furosemide (Lasix). The nurse understands that these drugs are being used to treat the patient's a. anemia. b. hypertension. c. hyperkalemia. d. mineral and bone disorder.

24. b. Nifedipine (Procardia) is a calcium channel blocker and furosemide (Lasix) is a loop diuretic. Both are used to treat hypertension.

25. Which drugs will be used to treat the patient with CKD for mineral and bone disorder (select all that apply)? a. Cinacalcet (Sensipar) b. Sevelamer (Renagel) c. IV glucose and insulin d. Calcium acetate (PhosLo) e. IV 10% calcium gluconate

25. a, b, d. Cinacalcet (Sensipar), a calcimimetic agent to control secondary hyperparathyroidism; sevelamer (Renagel), a noncalcium phosphate binder; and calcium acetate (PhosLo), a calcium-based phosphate binder are used to treat mineral and bone disorder in CKD. IV glucose and insulin and IV 10% calcium gluconate along with sodium polystyrene sulfonate (Kayexalate) are used to treat the hyperkalemia of CKD.

26. What accurately describes the care of the patient with CKD? a. A nutrient that is commonly supplemented for the patient on dialysis because it is dialyzable is iron. b. The syndrome that includes all of the signs and symptoms seen in the various body systems in CKD is azotemia. c. The use of morphine is contraindicated in the patient with CKD because accumulation of its metabolites may cause seizures. d. The use of calcium-based phosphate binders in the patient with CKD is contraindicated when serum calcium levels are increased.

26. d. In the patient with CKD, when serum calcium levels are increased, calcium-based phosphate binders are not used. The nutrient supplemented for patients on dialysis is folic acid. The various body system manifestations occur with uremia, which includes azotemia. Meperidine is contraindicated in patients with CKD related to possible seizures.

27. During the nursing assessment of the patient with renal insufficiency, the nurse asks the patient specifically about a history of a. angina. b. asthma. c. hypertension. d. rheumatoid arthritis.

27. c. The most common causes of CKD in the United States are diabetes mellitus and hypertension. The nurse should obtain information on long-term health problems that are related to kidney disease. The other disorders are not closely associated with renal disease.

28. The patient with chronic kidney disease is considering whether to use peritoneal dialysis (PD) or hemodialysis (HD). What are advantages of PD when compared to HD (select all that apply)? a. Less protein loss b. Rapid fluid removal c. Less cardiovascular stress d. Decreased hyperlipidemia e. Requires fewer dietary restrictions

28. c, e. Peritoneal dialysis is less stressful for the cardiovascular system and requires fewer dietary restrictions. Peritoneal dialysis actually contributes to more protein loss and increased hyperlipidemia. The fluid and creatinine removal are slower with peritoneal dialysis than hemodialysis.

29. What does the dialysate for PD routinely contain? a. Calcium in a lower concentration than in the blood b. Sodium in a higher concentration than in the blood c. Dextrose in a higher concentration than in the blood d. Electrolytes in an equal concentration to that of the blood

29. c. Dextrose or icodextrin or amino acid is added to dialysate fluid to create an osmotic gradient across the membrane to remove excess fluid from the blood. The dialysate fluid has no potassium so that potassium will diffuse into the dialysate from the blood. Dialysate also usually contains higher calcium to promote its movement into the blood. Dialysate sodium is usually less than or equal to that of blood to prevent sodium and fluid retention.

3. Acute tubular necrosis (ATN) is the most common cause of intrarenal AKI. Which patient is most likely to develop ATN? a. Patient with diabetes mellitus b. Patient with hypertensive crisis c. Patient who tried to overdose on acetaminophen d. Patient with major surgery who required a blood transfusion

3. d. Acute tubular necrosis (ATN) is primarily the result of ischemia, nephrotoxins, or sepsis. Major surgery is most likely to cause severe kidney ischemia in the patient requiring a blood transfusion. A blood transfusion hemolytic reaction produces nephrotoxic injury if it occurs. Diabetes mellitus, hypertension, and acetaminophen overdose will not contribute to ATN.

31. In which type of dialysis does the patient dialyze during sleep and leave the fluid in the abdomen during the day? a. Long nocturnal hemodialysis b. Automated peritoneal dialysis (APD) c. Continuous venovenous hemofiltration (CVVH) d. Continuous ambulatory peritoneal dialysis (CAPD)

31. b. Automated peritoneal dialysis (APD) is the type of dialysis in which the patient dialyzes during sleep and leaves the fluid in the abdomen during the day. Long nocturnal hemodialysis occurs while the patient is sleeping and is done up to six times per week. Continuous venovenous hemofiltration (CVVH) is a type of continuous renal replacement therapy used to treat AKI. Continuous ambulatory peritoneal dialysis (CAPD) is dialysis that is done with exchanges of 1.5 to 3 L of dialysate at least four times daily.

32. To prevent the most common serious complication of PD, what is important for the nurse to do? a. Infuse the dialysate slowly. b. Use strict aseptic technique in the dialysis procedures. c. Have the patient empty the bowel before the inflow phase. d. Reposition the patient frequently and promote deep breathing.

32. b. Peritonitis is a common complication of peritoneal dialysis (PD) and may require catheter removal and termination of dialysis. Infection occurs from contamination of the dialysate or tubing or from progression of exit-site or tunnel infections and strict sterile technique must be used by health professionals as well as the patient to prevent contamination. Too-rapid infusion may cause shoulder pain and pain may be caused if the catheter tip touches the bowel. Difficulty breathing, atelectasis, and pneumonia may occur from pressure of the fluid on the diaphragm, which may be prevented by elevating the head of the bed and promoting repositioning and deep breathing.

33. A patient on hemodialysis develops a thrombus of a subcutaneous arteriovenous (AV) graft, requiring its removal. While waiting for a replacement graft or fistula, the patient is most likely to have what done for treatment? a. Peritoneal dialysis b. Peripheral vascular access using radial artery c. Silastic catheter tunneled subcutaneously to the jugular vein d. Peripherally inserted central catheter (PICC) line inserted into subclavian vein

33. c. A more permanent, soft, flexible Silastic double-lumen catheter is used for long-term access when other forms of vascular access have failed. These catheters are tunneled subcutaneously and have Dacron cuffs that prevent infection from tracking along the catheter.

34. A man with end-stage kidney disease is scheduled for hemodialysis following healing of an arteriovenous fistula (AVF). What should the nurse explain to him that will occur during dialysis? a. He will be able to visit, read, sleep, or watch TV while reclining in a chair. b. He will be placed on a cardiac monitor to detect any adverse effects that might occur. c. The dialyzer will remove and hold part of his blood for 20 to 30 minutes to remove the waste products. d. A large catheter with two lumens will be inserted into the fistula to send blood to and return it from the dialyzer.

34. a. While patients are undergoing hemodialysis, they can perform quiet activities that do not require the limb that has the vascular access. Blood pressure is monitored frequently and the dialyzer monitors dialysis function but cardiac monitoring is not usually indicated. The hemodialysis machine continuously circulates both the blood and the dialysate past the semipermeable membrane in the machine. Graft and fistula access involve the insertion of two needles into the site: one to remove blood from and the other to return blood to the dialyzer.

35. What is the primary way that a nurse will evaluate the patency of an AVF? a. Palpate for pulses distal to the graft site. b. Auscultate for the presence of a bruit at the site. c. Evaluate the color and temperature of the extremity. d. Assess for the presence of numbness and tingling distal to the site.

35. b. A patent arteriovenous fistula (AVF) creates turbulent blood flow that can be assessed by listening for a bruit or palpated for a thrill as the blood passes through the graft. Assessment of neurovascular status in the extremity distal to the graft site is important to determine that the graft does not impair circulation to the extremity but the neurovascular status does not indicate whether the graft is open.

36. A patient with AKI is a candidate for continuous renal replacement therapy (CRRT). What is the most common indication for use of CRRT? a. Azotemia b. Pericarditis c. Fluid overload d. Hyperkalemia

36. c. Continuous renal replacement therapy (CRRT) is indicated for the patient with AKI as an alternative or adjunct to hemodialysis to slowly remove solutes and fluid in the hemodynamically unstable patient. It is especially useful for treatment of fluid overload, but hemodialysis is indicated for treatment of hyperkalemia, pericarditis, or other serious effects of uremia.

37. A patient rapidly progressing toward end-stage kidney disease asks about the possibility of a kidney transplant. In responding to the patient, the nurse knows that what is a contraindication to kidney transplantation? a. Hepatitis C infection b. Coronary artery disease c. Refractory hypertension d. Extensive vascular disease

37. d. Extensive vascular disease is a contraindication for renal transplantation, primarily because adequate blood supply is essential for the health of the new kidney. Other contraindications include disseminated malignancies, refractory or untreated cardiac disease, chronic respiratory failure, chronic infection, or unresolved psychosocial disorders. Coronary artery disease (CAD) may be treated with bypass surgery before transplantation and transplantation can relieve hypertension. Hepatitis B or C infection is not a contraindication.

38. Priority Decision: During the immediate postoperative care of a recipient of a kidney transplant, what should the nurse expect to do? a. Regulate fluid intake hourly based on urine output. b. Monitor urine-tinged drainage on abdominal dressing. c. Medicate the patient frequently for incisional flank pain. d. Remove the urinary catheter to evaluate the ureteral implant.

38. a. Fluid and electrolyte balance is critical in the transplant recipient patient, especially because diuresis often begins soon after surgery. Fluid replacement is adjusted hourly based on kidney function and urine output. Urine-tinged drainage on the abdominal dressing may indicate leakage from the ureter implanted into the bladder and the health care provider should be notified. The donor patient may have a flank or laparoscopic incision(s) where the kidney was removed. The recipient has an abdominal incision where the kidney was placed in the iliac fossa. The urinary catheter is usually used for 2 to 3 days to monitor urine output and kidney function.

39. A patient received a kidney transplant last month. Because of the effects of immunosuppressive drugs and CKD, what complication of transplantation should the nurse be assessing the patient for to decrease the risk of mortality? a. Infection b. Rejection c. Malignancy d. Cardiovascular disease

39. a. Infection is a significant cause of morbidity and mortality after transplantation because the surgery, the immunosuppressive drugs, and the effects of CKD all suppress the body's normal defense mechanisms, thus increasing the risk of infection. The nurse must assess the patient as well as use aseptic technique to prevent infections. Rejection may occur but for other reasons. Malignancy occurrence increases later due to immunosuppressive therapy. Cardiovascular disease is the leading cause of death after renal transplantation but this would not be expected to cause death within the first month after transplantation.

4. Priority Decision: A dehydrated patient is in the Injury stage of the RIFLE staging of AKI. What would the nurse first anticipate in the treatment of this patient? a. Assess daily weight b. IV administration of fluid and furosemide (Lasix) c. IV administration of insulin and sodium bicarbonate d. Urinalysis to check for sediment, osmolality, sodium, and specific gravity

4. b. Injury is the stage of RIFLE classification when urine output is less than 0.5 mL/kg/hr for 12 hours, the serum creatinine is increased times two or the glomerular filtration rate (GFR) is decreased by 50%. This stage may be reversible by treating the cause or, in this patient, the dehydration by administering IV fluid and a low dose of a loop diuretic, furosemide (Lasix). Assessing the daily weight will be done to monitor fluid changes but it is not the first treatment the nurse should anticipate. IV administration of insulin and sodium bicarbonate would be used for hyperkalemia. Checking the urinalysis will help to determine if the AKI has a prerenal, intrarenal, or postrenal cause by what is seen in the urine but with this patient's dehydration, it is thought to be prerenal to begin treatment.

5. What indicates to the nurse that a patient with oliguria has prerenal oliguria? a. Urine testing reveals a low specific gravity. b. Causative factor is malignant hypertension. c. Urine testing reveals a high sodium concentration. d. Reversal of oliguria occurs with fluid replacement.

5. d. In prerenal oliguria, the oliguria is caused by a decrease in circulating blood volume and there is no damage yet to the renal tissue. It can be reversed by correcting the precipitating factor, such as fluid replacement for hypovolemia. Prerenal oliguria is characterized by urine with a high specific gravity and a low sodium concentration, whereas oliguria of intrarenal failure is characterized by urine with a low specific gravity and a high sodium concentration. Malignant hypertension causes damage to renal tissue and intrarenal oliguria.

6. In a patient with AKI, which laboratory urinalysis result indicates tubular damage? a. Hematuria b. Specific gravity fixed at 1.010 c. Urine sodium of 12 mEq/L (12 mmol/L) d. Osmolality of 1000 mOsm/kg (1000 mmol/kg)

6. b. A urine specific gravity that is consistently 1.010 and a urine osmolality of about 300 mOsm/kg is the same specific gravity and osmolality as plasma. This indicates that tubules are damaged and unable to concentrate urine. Hematuria is more common with postrenal damage. Tubular damage is associated with a high sodium concentration (greater than 40 mEq/L).

7. Metabolic acidosis occurs in the oliguric phase of AKI as a result of impairment of a. ammonia synthesis. b. excretion of sodium. c. excretion of bicarbonate. d. conservation of potassium.

7. a. Metabolic acidosis occurs in AKI because the kidneys cannot synthesize ammonia or excrete acid products of metabolism, resulting in an increased acid load. Sodium is lost in urine because the kidneys cannot conserve sodium. Impaired excretion of potassium results in hyperkalemia. Bicarbonate is normally generated and reabsorbed by the functioning kidney to maintain acid- base balance.

8. What indicates to the nurse that a patient with AKI is in the recovery phase? a. A return to normal weight b. A urine output of 3700 mL/day c. Decreasing sodium and potassium levels d. Decreasing blood urea nitrogen (BUN) and creatinine levels

8. d. The blood urea nitrogen (BUN) and creatinine levels remain high during the oliguric and diuretic phases of AKI. The recovery phase begins when the glomerular filtration returns to a rate at which BUN and creatinine stabilize and then decrease. Urinary output of 3 to 5 L/ day, decreasing sodium and potassium levels, and fluid weight loss are characteristic of the diuretic phase of AKI.

9. While caring for the patient in the oliguric phase of AKI, the nurse monitors the patient for associated collaborative problems. When should the nurse notify the health care provider? a. Urine output is 300 mL/day. b. Edema occurs in the feet, legs, and sacral area. c. Cardiac monitor reveals a depressed T wave and elevated ST segment. d. The patient experiences increasing muscle weakness and abdominal cramping.

9. d. Hyperkalemia is a potentially life-threatening complication of AKI in the oliguric phase. Muscle weakness and abdominal cramping are signs of the neuromuscular impairment that occurs with hyperkalemia. In addition, hyperkalemia can cause the cardiac conduction abnormalities of peaked T wave, prolonged PR interval, prolonged QRS interval, and depressed ST segment. Urine output of 300 mL/day is expected during the oliguric phase, as is the development of peripheral edema.

A trauma patient arrives at the critical care unit (CCU) after an assault. Upon assessment, the nurse identifies Grey-Turner sign. This is indicative of potential trauma sustained to which part of the body? A Kidney B Liver C Bladder D Spleen

The patient in renal failure has experienced a severe hypotensive event, and the ratio of blood urea nitrogen (BUN) to creatinine is 15:1. The nurse is aware that this is an example of what type of kidney injury? A Prerenal B Intrarenal C Postrenal D Chronic

What is the most appropriate treatment for contrast-induced acute kidney injury (AKI)? A Administration of the smallest dose of low contrast media possible, vigorous fluid volume expansion, and avoidance of repeat contrast media injections within 48 hours B Stopping all nephrotoxic drugs, hydration with an intravenous infusion of fenoldopam, and oral administration of oral N-acetylcysteine C Administration of oral N-acetylcysteine, intravenous sodium bicarbonate, and an intravenous infusion of fenoldopam D Aggressive hydration with intravenous normal saline during and after the procedure coupled with administration of intravenous sodium bicarbonate

A 52-year-old man with stage 2 chronic kidney disease is scheduled for an outpatient diagnostic procedure using contrast media. Which action should the nurse take? A Assess skin turgor to determine hydration status. B Insert a urinary catheter for the expected diuresis. C Evaluate the patient's lower extremities for edema. D Check the patient's urine for the presence of ketones.

A Preexisting kidney disease is the most important risk factor for the development of contrast-associated nephropathy and nephrotoxic injury. If contrast media must be administered to a high-risk patient, the patient needs to have optimal hydration. The nurse should assess the hydration status of the patient before the procedure is perfumed. Indwelling catheter use should be avoided whenever possible to decrease the risk of infection.

Which signs and symptoms in a patient's recent history may provide clues to the rapid onset of a kidney problem? A Decrease in appetite and metallic taste B Increase in appetite C Stabbing headache or lightheadedness D Sudden weight loss

A ?

The nurse notes that the patient has a potassium level of 3.1 mEq/L. Which condition(s) could be related? A Serum sodium level of 125 mEq/L B Lasix 40 mg by mouth twice daily C Nasogastric (NG) tube to low constant suction D Insulin drip titrated to blood glucose of 90 mg/dL E Epinephrine drip titrated to systolic blood pressure greater than 90 mm Hg

A B C D

A patient is having an abdominal computed tomography (CT) scan with intravenous (IV) contrast in the morning. Which instructions should be included in the teaching for this procedure? Select all that apply. A The patient should report any allergies to shellfish. B The patient should drink several glasses of water after the procedure. C The patient should drink 3 glasses of water before the procedure. D PT should be NPO and have IV fluids discontinued before the test. E PT will have an IV started if not already in place.

A B C E

Which of the following patient statements needs to be explored further regarding kidney function? A "These are the only shoes I could wear today." B "I had to use three pillows to sleep last night." C "I have this funny metallic taste in my mouth all the time." D "I have been drinking eight glasses of water each day." E "I have been taking ibuprofen twice a day for the past month."

A B C E

Which nursing actions are important in the management of a patient with an arteriovenous (AV) fistula? Select all that apply. A Auscultate the bruit. B Palpate the thrill. C Draw all laboratory work from the fistula. D Avoid constrictive clothing on the limb containing the access. E Take blood pressure (BP) measurements in the fistula arm.

A B D

A patient is admitted with jugular venous distention, bounding pulses, tachycardia, and peripheral edema. What effect will the release of atrial natriuretic peptide (ANP) have in this situation? A Diuresis B Vasoconstriction C Decreased cardiac preload D Increased cardiac afterload E Blocking the release of aldosterone

A C E

A patient in the oliguric phase after an acute kidney injury has had a 250 mL urine output and an emesis of 100 mL in the past 24 hours. What is the patient's fluid restriction for the next 24 hours?

ANS: 950 mL The general rule for calculating fluid restrictions is to add all fluid losses for the previous 24 hours, plus 600 mL for insensible losses: (250 + 100 + 600 = 950 mL).

19. Which of the following diuretics maybe combined to work on different parts of the nephron? a. Loop and thiazide diuretics b. LoOp and osmotic diuretics c. Osmotic and carbonic anhydrase inhibitor diuretics d. Thiazide and osmotic diuretics

ANS: A A thiazide diuretic such as chlorothiazide (Diuril) or metolazone (Zaroxolyn) may be administered and followed by a loop diuretic to take advantage of the fact that these medications work on different parts of the nephron. Sometimes a thiazide diuretic is added to a loop diuretic to compensate for the development of loop diuretic resistance.

12. A patient needing vascular access for hemodialysis asks the nurse what the differences are between an arteriovenous (AV) fistula and a graft. The nurse explains that one advantage of the fistula is that it a. is much less likely to clot. b. increases patient mobility. c. can accommodate larger needles. d. can be used sooner after surgery.

ANS: A AV fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impact on needle size or patient mobility.

17. The nurse is caring for a patient who had kidney transplantation several years ago. Which assessment finding may indicate that the patient is experiencing adverse effects to the prescribed corticosteroid? a. Joint pain b. Tachycardia c. Postural hypotension d. Increase in creatinine level

ANS: A Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over a prolonged period. Increased creatinine level, orthostatic dizziness, and tachycardia are not caused by corticosteroid use.

2. Loss of albumin from the vascular space may result in a. peripheral edema. b. extra heart sounds. c. hypertension. d. hyponatremia.

ANS: A Decreased albumin levels in the vascular space result in a plasma-to-interstitium fluid shift, creating peripheral edema. A decreased albumin level can occur as a result of protein-calorie malnutrition, which occurs in many critically ill patients in whom available stores of albumin are depleted. A decrease in the plasma oncotic pressure results, and fluid shifts from the vascular space to the interstitial space.

23. In a patient with acute kidney injury (AKI) who requires hemodialysis, a temporary vascular access is obtained by placing a catheter in the left femoral vein. Which intervention will be included in the plan of care? a. Place the patient on bed rest. b. Start continuous pulse oximetry. c. Discontinue the retention catheter. d. Restrict the patients oral protein intake.

ANS: A The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to remain in place because accurate measurement of output will be needed. There is no indication that the patient needs continuous pulse oximetry.

13. When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula? a. Check the fistula site for a bruit and thrill. b. Assess the rate and quality of the left radial pulse. c. Compare blood pressures in the left and right arms. d. Irrigate the fistula site with saline every 8 to 12 hours.

ANS: A The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula.

24. A patient in acute renal failure presents with a potassium level of 6.9 mg/dL. He has had no urine output in the past 4 hours despite urinary catheter insertion and Lasix 40 mg intravenous push. Vital signs are as follows: HR, 76 beats/min; respiratory rate, 18 breaths/min; and BP, 145/96 mm Hg. He is given 100 mL of 50% dextrose in water and 20 U of regular insulin intravenous push. A repeat potassium level 2 hours later shows a potassium level of 4.5 mg/dL. What order would now be expected? a. Sodium Kayexalate 15 g PO b. Nothing; this represents a normal potassium level c. Lasix 40 mg IVP d. 0.9% normal saline at 125 mL/hr

ANS: A This patient appears to be in acute anuric renal failure. The potassium was not eliminated from the body; it was simply shifted intracellularly. Soon the potassium will return to the bloodstream, and the Kayexalate will help permanently remove it from the body. Lasix is not expected to work in the presence of anuria. The patients vital signs do not support hypovolemia. In the presence of anuria, a large fluid infusion can precipitate congestive heart failure.

7. 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. This process is known as 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.

7. 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. This process is known as a. ultrafiltration. c. reverse osmosis. b. hemodialysis. d. colloid extraction.

20. A patient with hypertension and stage 2 chronic kidney disease (CKD) is receiving captopril (Capoten). Before administration of the medication, the nurse will check the patients a. glucose. b. potassium. c. creatinine. d. phosphate.

ANS: B Angiotensin-converting enzyme (ACE) inhibitors are frequently used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention. Therefore, careful monitoring of potassium levels is needed in patients who are at risk for hyperkalemia. The other laboratory values also would be monitored in patients with CKD but would not affect whether the captopril was given or not.

9. A patient has been hospitalized for a subtotal gastrectomy. After the procedure, an infection developed that eventually had to be treated with gentamicin, an aminoglycoside antibiotic. After 3 days of administration, oliguria occurred, and subsequent laboratory values indicated elevated BUN and creatinine levels. The patient is transferred to the critical care unit with acute kidney injury (previously known as acute tubular necrosis). Which dialysis method would be most appropriate for the patients condition? a. Peritoneal dialysis b. Hemodialysis c. Continuous renal replacement therapy d. Continuous venovenous hemodialysis (CVVH)

ANS: B As a treatment, hemodialysis literally separates and removes from the blood the excess electrolytes, fluids, and toxins by use of a hemodialyzer. Although hemodialysis is efficient in removing solutes, it does not remove all metabolites. Furthermore, electrolytes, toxins, and fluids increase between treatments, necessitating hemodialysis on a regular basis.

13. The patient is a gravida 6, para 1. She is admitted after a cesarean section after an amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less than 80 mm Hg. Her temperature is 38C, and her condition has caused her to develop prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter, which was placed into her right femoral access, and started on vasopressors with a fair response (BP, 80/50 mm Hg; HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis, the patient was begun on CVVH. Which of the statements best describes CVVH? a.Complete renal replacement therapy requiring large volumes of ultrafiltrate and filter replacement b.Complete renal replacement therapy that allows removal of solutes and modification of the volume and composition of extracellular fluid to occur evenly over time c.Involves the introduction of sterile dialyzing fluid through an implanted catheter into the abdominal cavity, which relies on osmosis, diffusion, and active transport to help remove waste from the body d.Complete renal replacement therapy that allows an exchange of fluid, solutes, and solvents across a semipermeable membrane at 100 to 300 mL/hr

ANS: B Continuous venovenous hemodialysis is indicated when the patients 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 nonprotein-bound toxins is accomplished by convection. The replacement fluid rate of flow through the continuous renal replacement therapy circuit can be altered to achieve desired fluid and solute removal without causing hemodynamic instability.

11. A patient is admitted to the critical care unit in congestive heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. Which of the following diagnostic tests would give the best information about the internal kidney structures, such as the parenchyma, calyces, pelvis, ureters, and bladder? a. Kidneyureterbladder (KUB) b. Intravenous pyelography (IVP) c. Renal ultrasonography (ECHO) d. Renal angiography

ANS: B Intravenous pyelography allows visualization of the internal kidney parenchyma, calyces, pelvis, ureters, and bladder. Kidneyureterbladder flat-plate radiography of the abdomen determines the position, size, and structure of the kidneys, urinary tract, and pelvis. It is useful for evaluating the presence of calculi and masses and is usually followed by additional tests. In ultrasonography, high-frequency sound waves are transmitted to the kidneys and urinary tract, and the image is viewed on an oscilloscope. This noninvasive procedure identifies fluid accumulation or obstruction, cysts, stones or calculi, and masses. It is useful for evaluating the kidneys before biopsy. Angiography is injection of contrast into arterial blood perfusing the kidneys. It allows for visualization of renal blood flow and may also visualize stenosis, cysts, clots, trauma, and infarctions.

26. Which of the following medications is considered a loop diuretic? a. Acetazolamide (Diamox) b. Furosemide (Lasix) c. Mannitol d. Metolazone (Zaroxolyn)

ANS: B Loop diuretics include furosemide (Lasix), bumetanide (Bumex), and torsemide (Torsemide). Furosemide is the most frequently used diuretic in critical care patients. It may be administered orally, as an intravenous (IV) bolus, or as a continuous IV infusion. Diamox is a carbonic anhydrase inhibitor diuretic. Mannitol is an osmotic diuretic, and Zaroxolyn is a thiazide diuretic.

19. A patient with chronic kidney disease (CKD) brings all home medications to the clinic to be reviewed by the nurse. Which medication being used by the patient indicates that patient teaching is required? a. Multivitamin with iron b. Milk of magnesia 30 mL c. Calcium phosphate (PhosLo) d. Acetaminophen (Tylenol) 650 mg

ANS: B Magnesium is excreted by the kidneys, and patients with CKD should not use over-the-counter products containing magnesium. The other medications are appropriate for a patient

17. A patient has been on complete bed rest for 3 days. The health care provider has ordered for the patient to sit at the bedside for meals. The patient complains of feeling dizzy and faint while sitting at the bedside. The nurse anticipates that the patient is experiencing a. orthostatic hypertension. b. orthostatic hypotension. c. hypervolemia. d. electrolyte imbalance.

ANS: B Orthostatic hypotension produces subjective feelings of weakness, dizziness, or faintness. Orthostatic hypotension occurs with hypovolemia or prolonged bed rest or as a side effect of medications that affect blood volume or blood pressure.

4. Percussion of kidneys is usually done to a. assess the size and shape of the kidneys. b. detect pain in the renal area. c. elicit a fluid wave. d. evaluate fluid status.

ANS: B Percussion is performed to detect pain in the area of a kidney or to determine excess accumulation of air, fluid, or solids around the kidneys. Percussion of the kidneys also provides information about kidney location, size, and possible problems.

3. Which of the following IV solutions is recommended for treatment of prerenal failure? a. Dextrose in water b. Normal saline c. Albumin d. Lactated Ringer solution

ANS: B Prerenal failure is caused by decreased perfusion and flow to the kidney. It is often associated with trauma, hemorrhage, hypotension, and major fluid losses. If contrast dye is used, aggressive fluid resuscitation with normal saline (NaCl) is recommended.

2. Which of the following laboratory values is the most help in evaluating a patient for acute renal failure? a. Serum sodium b. Serum creatinine c. Serum potassium d. Urine potassium

ANS: B Serum creatinine is the most reliable predictor of kidney function. 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.

9. Which of the following urine values reflects a decreased ability of the kidneys to concentrate urine? a. pH of 5.0 b. Specific gravity of 1.000 c. No casts d. Urine sodium of 140 mEq/24 hr

ANS: B Specific gravity measures the density or weight of urine compared with that of distilled water. The normal urinary specific gravity is 1.005 to 1.025. For comparison, the specific gravity of distilled water is 1.000. Because urine is composed of many solutes and substances suspended in water, the specific gravity should always be higher than that of water.

14. A patient is admitted to the critical care unit in congestive heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The patient urinalysis has a specific gravity of 1.040. What could be the potential cause for this value? a. Volume overload b. Volume deficit c. AcIdosis d. Urine ketones

ANS: B Specific gravity ranges from 1.003 to 1.030. Possible causes for increased values include volume deficit, glycosuria, proteinuria, and prerenal acute kidney injury (AKI). Possible causes for decreased values include volume overload and interrenal AKI.

11. The most common site for short-term vascular access for immediate hemodialysis is the 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.

1. After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take? a. Elevate the patients arm above the level of the heart. b. Report the patients symptoms to the health care provider. c. Remind the patient about the need to take a daily low-dose aspirin tablet. d. Educate the patient about the normal vascular response after AVG insertion.

ANS: B The patients complaints suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevation of the arm above the heart will decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.

23. An alert and oriented patient presents with a pulmonary artery wedge pressure of 4 mm Hg and a cardiac index of 0.8. The BUN is 44 mg/dL, creatinine is 3.2 mg/dL, and BP is 88/36 mm Hg. Urine output is 15 mL/hr. Lungs are clear to auscultation with no peripheral edema noted. Which of the following treatments would the physician most likely order? a. Lasix 40 mg intravenous push b. 0.9% normal saline at 125 mL/hr c. Dopamine 15 mg/kg/min d. Transfuse 1 U of packed red blood cells

ANS: B The patients hemodynamic parameters are most consistent with hypovolemia. The renal failure would then most probably be prerenal from inadequate blood flow. The treatment of choice for hypovolemia is fluid resuscitation. Important criteria when calculating fluid volume replacement include baseline metabolism, environmental temperature, and humidity. The rate of replacement depends on cardiopulmonary reserve, adequacy of kidney function, urine output, fluid balance, ongoing loss, and type of fluid replaced.

15. The patient is a gravida 6, para 1. She is admitted after a cesarean section after an amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less than 80 mm Hg. Her temperature is 38°C, and her condition has caused her to develop prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter, which was placed into her right femoral access, and started on vasopressors with a fair response (BP, 80/50 mm Hg; HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis, the patient was begun on CVVH. Which of the statements best describes CVVH? a. Complete renal replacement therapy requiring large volumes of ultrafiltrate and filter replacement b. Complete renal replacement therapy that allows removal of solutes and modification of the volume and composition of extracellular fluid to occur evenly over time c. Involves the introduction of sterile dialyzing fluid through an implanted catheter into the abdominal cavity, which relies on osmosis, diffusion, and active transport to help remove waste from the body d. Complete renal replacement therapy that allows an exchange of fluid, solutes, and solvents across a semipermeable membrane at 100 to 300 mL/hr

ANS: B Continuous venovenous hemodialysis 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. The replacement fluid rate of flow through the continuous renal replacement therapy circuit can be altered to achieve desired fluid and solute removal without causing hemodynamic instability.

18. Which data obtained when assessing a patient who had a kidney transplant 8 years ago and who is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone) will be of most concern to the nurse? a. The blood glucose is 144 mg/dL. b. The patients blood pressure is 150/92. c. There is a nontender lump in the axilla. d. The patient has a round, moonlike face.

ANS: C A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result of chronic immunosuppressive therapy. The elevated glucose, moon face, and hypertension are possible side effects of the prednisone and should be addressed, but they are not as great a concern as the possibility of a malignancy.

14. The patient is a gravida 6, para 1. She is admitted after a cesarean section after an amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less than 80 mm Hg. Her temperature is 38C, and her condition has caused her to develop prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter, which was placed into her right femoral access, and started on vasopressors with a fair response (BP, 80/50 mm Hg; HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis, the patient was begun on CVVH. Identify three complications of CVVH therapy. a. Fat emboli, increased ultrafiltration, and hypertension b. Hyperthermia, overhydration, and power surge c. Air embolism, decreased inflow pressure, and electrolyte imbalance d. Blood loss, decreased outflow resistance, and acidbase imbalance

ANS: C Air embolism, decreased inflow pressure, electrolyte imbalances, blood leaks, access failure, and clotted hemofilter are just a few complications that can occur with continuous venovenous hemodialysis.

1. An elderly patient is in a motor vehicle accident and sustains a significant internal hemorrhage. Which category of renal failure is the patient at the greatest risk of developing? a. Intrinsic b. Postrenal c. Prerenal d. Acute tubular necrosis

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. Any condition that produces an ischemic or toxic insult directly at parenchymal nephron tissue places the patient at risk for development of intrarenal AKI. Any obstruction that hinders the flow of urine from beyond the kidney through the remainder of the urinary tract may lead to postrenal AKI. When the internal filtering structures are pathologically affected, the condition was previously known as acute tubular necrosis.

A patient undergoes a nephrectomy after having massive trauma to the kidney. Which assessment finding obtained postoperatively is most important to communicate to the surgeon? a. Blood pressure is 102/58. b. Incisional pain level is 8/10. c. Urine output is 20 mL/hr for 2 hours. d. Crackles are heard at both lung bases.

ANS: C Because the urine output should be at least 0.5 mL/kg/hr, a 40 mL output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life threatening as decreased renal perfusion. In addition, the nurse can medicate the patient for pain.

22. Which of the following information obtained by the nurse who is caring for a patient with end-stage renal disease (ESRD) indicates the nurse should consult with the health care provider before giving the prescribed epoetin alfa (Procrit)? a. Creatinine 1.2 mg/dL b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg

ANS: C High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when EPO is administered to a target hemoglobin of >12 g/dL. Hemoglobin levels higher than 12 g/dL indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider, but will not affect whether the medication is administered.

25. A patient with chronic renal failure receives hemodialysis treatments 3 days a week. Every 2 weeks, the patient requires a transfusion of 1 or 2 U of packed red blood cells. What is the probable reason for this patients frequent transfusion needs? a. Too much blood phlebotomized for tests b. Increased destruction of red blood cells because of the increased toxin levels c. Lack of production of erythropoietin to stimulate red blood cell formation d. Fluid retention causing hemodilution

ANS: C In chronic renal failure, the kidneys do not produce sufficient amounts of erythropoietin in response to normal stimuli such as anemia or hypotension. The other choices are not reasons for frequent blood transfusions in this patient.

10. A patient is admitted to the critical care unit in congestive heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The nurse suspects the main cause of ascites is a. Hypervolemia. b. dehydration. c. volume overload. d. liver damage.

ANS: C Individuals with kidney failure may have ascites caused by volume overload, which forces fluid into the abdomen because of increased capillary hydrostatic pressures. However, ascites may or may not represent fluid volume excess. Severe ascites in persons with compromised liver function may result from decreased plasma proteins. The ascites occurs because the increased vascular pressure associated with liver dysfunction forces fluid and plasma proteins from the vascular space into the interstitial space and abdominal cavity. Although the individual may exhibit marked edema, the intravascular space is volume depleted, and the patient is hypovolemic.

5. Which of the following IV solutions is contraindicated for patients with kidney or liver disease or in lactic acidosis? 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.

14. When a patient who has had progressive chronic kidney disease (CKD) for several years is started on hemodialysis, which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis. b. Unlimited fluids are allowed since retained fluid is removed during dialysis. c. More protein will be allowed because of the removal of urea and creatinine by dialysis. d. Dietary sodium and potassium are unrestricted because these levels are normalized by dialysis.

ANS: C Once the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.

12. A patient is admitted to the critical care unit in congestive heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The patient weight upon admission was 176 lb. The patients weight the next day is 184 lb. What is the approximate amount of fluid retained with this weight gain? a. 800 mL b. 2200 mL c. 3600 mL d. 8000 mL

ANS: C One liter of fluid equals 1 kg, which is 2.2 pounds; 8 pounds equals 3.6 kg, which is 3.6 liters; 3.6 liters is equal to 3600 mL.

30. The RN observes an LPN/LVN carrying out all of the following actions while caring for a patient with stage 2 chronic kidney disease. Which action requires the RN to intervene? a. The LPN/LVN administers erythropoietin subcutaneously. b. The LPN/LVN assists the patient to ambulate in the hallway. c. The LPN/LVN gives the iron supplement and phosphate binder with lunch. d. The LPN/LVN carries a tray containing low-protein foods into the patients room.

ANS: C Oral phosphate binders should not be given at the same time as iron because they prevent the iron from being absorbed. The phosphate binder should be given with a meal and the iron given at a different time. The other actions by the LPN/LVN are appropriate for a patient with renal insufficiency.

10. A patients renal calculus is analyzed as being very high in uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid eating a. milk and dairy products. b. legumes and dried fruits. c. organ meats and sardines. d. spinach, chocolate, and tea.

ANS: C Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.

8. Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess the a. blood urea nitrogen (BUN) and creatinine. b. blood glucose level. c. patients bowel sounds. d. level of consciousness (LOC).

ANS: C Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not affect the nurses decision to give the medication.

4. A patient who has acute glomerulonephritis is hospitalized with acute kidney injury (AKI) and hyperkalemia. Which information will the nurse obtain to evaluate the effectiveness of the prescribed calcium gluconate IV? a. Urine output b. Calcium level c. Cardiac rhythm d. Neurologic status

ANS: C The calcium gluconate helps prevent dysrhythmias that might be caused by the hyperkalemia. The nurse will monitor the other data as well, but these will not be helpful in determining the effectiveness of the calcium gluconate.

5. A patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which of these orders for the patient will the nurse question? a. NPO for 6 hours before IVP procedure b. Normal saline 500 mL IV before procedure c. Ibuprofen (Advil) 400 mg PO PRN for pain d. Dulcolax suppository 4 hours before IVP procedure

ANS: C The contrast dye used in IVPs is potentially nephrotoxic, and concurrent use of other nephrotoxic medications such as the NSAIDs should be avoided. The suppository and NPO status are necessary to ensure adequate visualization during the IVP. IV fluids are used to ensure adequate hydration, which helps reduce the risk for contrast-induced renal failure.

6. To assess whether or not an arteriovenous fistula is functioning, what must be done 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 critical care 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.

26. Which information about a patient who was admitted 10 days previously with acute kidney injury (AKI) caused by dehydration will be most important for the nurse to report to the health care provider? a. The blood urea nitrogen (BUN) level is 67 mg/dL. b. The creatinine level is 3.0 mg/dL. c. Urine output over an 8-hour period is 2500 mL. d. The glomerular filtration rate is <30 mL/min/1.73m2.

ANS: C The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy.

17. A patient has sepsis and is placed on broad-spectrum antibiotics. Her temperature is 37.8C. Her BUN level is elevated. She continues on vasopressor therapy. What other steps should be taken to protect the patient from inadequate organ perfusion? a. Increase net ultrafiltrate of fluid. b. Discontinue vasopressor support. c. Assess the patient for blood loss and hypotension. d. Notify the physician of access pressures.

ANS: C The patient should be assessed for blood loss or response to blood products and medications. The nurse should use ordered vasopressor support and decrease the net ultrafiltrate to zero.

1. After the insertion of an arteriovenous graft (AVG) in the right forearm, a 54-year-old patient complains of pain and coldness of the right fingers. Which action should the nurse take? a. Teach the patient about normal AVG function. b. Remind the patient to take a daily low-dose aspirin tablet. c. Report the patient's symptoms to the health care provider. d. Elevate the patient's arm on pillows to above the heart level.

ANS: C The patient's complaints suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevation of the arm above the heart will further decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.

8. As serum osmolality rises, intravascular fluid equilibrium will be maintained by the release of a. ketones. c. antidiuretic hormone. b. glucagon. d. potassium.

ANS: C When the serum osmolality level increases, antidiuretic hormone is released from the posterior pituitary gland and stimulates increased water resorption in the kidney tubules. This expands the vascular space, returns the serum osmolality level back to normal, and results in more concentrated urine and an elevated urine osmolality level.

11. To prevent the recurrence of renal calculi, the nurse teaches the patient to a. use a filter to strain all urine. b. avoid dietary sources of calcium. c. drink diuretic fluids such as coffee. d. have 2000 to 3000 mL of fluid a day.

ANS: D A fluid intake of 2000 to 3000 mL daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.

16. The patient complains of a metallic taste and loss of appetite. The nurse is concerned that the patient has developed a. glycosuria. b. proteinuria. c. myoglobin. d. uremia.

ANS: D A history of recent onset of nausea and vomiting or appetite loss caused by taste changes (uremia often causes a metallic taste) may provide clues to the rapid onset of kidney problems. Glycosuria is the presence of glucose in the urine. Proteinuria is the presence of protein in the urine. Myoglobin is the presence of red blood cells in the urine.

4. One therapeutic measure for treating hyperkalemia is the administration of dextrose and regular insulin. How do these agents lower potassium? a. They force potassium out of the cells and into the serum, lowering it on a cellular level. b. They promote higher excretion of potassium in the urine. c. They bind with resin in the bowel and are eliminated in the feces. d. They force potassium out of the serum and into the cells, thus causing potassium to lower.

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.

1. Which of the following assessment findings would indicate fluid volume excess? a.Venous filling of the hand veins greater than 5 seconds b.Distended neck veins in the supine position c.Presence of orthostatic hypotension d.Third heart sound

ANS: D Auscultation of the heart requires not only assessing rate and rhythm but also listening for extra sounds. Fluid overload is often accompanied by a third or fourth heart sound, which is best heard with the bell of the stethoscope.

15. The patient is a gravida 6, para 1. She is admitted after a cesarean section after an amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less than 80 mm Hg. Her temperature is 38C, and her condition has caused her to develop prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter, which was placed into her right femoral access, and started on vasopressors with a fair response (BP, 80/50 mm Hg; HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis, the patient was begun on CVVH. Why would this therapy be chosen for this patient? a.Hyperdynamic patients can better tolerate abrupt fluid and solute changes. b.It is the treatment of choice for patients with diminished renal perfusion who are unresponsive to diuretics. c.It is indicated for patients who require large-volume removal for severe uremia or critical acidbase imbalances. d.It is indicated for hemodynamically unstable patients, who are often intolerant of the abrupt fluid and solute changes that can occur with hemodialysis.

ANS: D Continuous venovenous hemodialysis is indicated for patients who require large-volume removal for severe uremia or critical acidbase imbalances or for those who are resistant to diuretics.

5. Differentiating ascites from distortion caused by solid bowel contents in the distended abdomen is accomplished by a. assessing for bowel sounds in four quadrants. b. palpation of the liver margin. c. measuring abdominal girth. d. the presence of a fluid wave.

ANS: D Differentiating ascites from distortion by solid bowel contents is accomplished by producing what is called a fluid wave. The fluid wave is elicited by exerting pressure to the abdominal midline while one hand is placed on the right or left flank. Tapping the opposite flank produces a wave in the accumulated fluid that can be felt under the hands.

11. Which information will be most useful to the nurse in evaluating improvement in kidney function for a patient who is hospitalized with acute kidney injury (AKI)? a. Blood urea nitrogen (BUN) level b. Urine output c. Creatinine level d. Calculated glomerular filtration rate (GFR)

ANS: D GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.

15. Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient slows the inflow rate when experiencing pain. b. The patient leaves the catheter exit site without a dressing. c. The patient plans 30 to 60 minutes for a dialysate exchange. d. The patient cleans the catheter while taking a bath every day.

ANS: D Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis.

2. A patient with acute kidney injury (AKI) has an arterial blood pH of 7.30. The nurse will assess the patient for a. vasodilation. b. poor skin turgor. c. bounding pulses. d. rapid respirations.

ANS: D Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.

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.

27. After noting lengthening QRS intervals in a patient with acute kidney injury (AKI), which action should the nurse take first? a. Document the QRS interval. b. Notify the patients health care provider. c. Look at the patients current blood urea nitrogen (BUN) and creatinine levels. d. Check the chart for the most recent blood potassium level.

ANS: D The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patients health care provider. The BUN and creatinine will be elevated in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval also is appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening bradycardia.

19. Which electrolytes are cations? a. Sodium, potassium, and chloride c. Bicarbonate, chloride, and calcium b. Sodium, chloride, and bicarbonate d. Sodium, potassium, and magnesium

ANS: D A balance exists between cations (positively charged ions), anions (negatively charged ions), and other substances in the fluid compartments. Cations are sodium, potassium, magnesium, and calcium. Anions are chloride and bicarbonate.

1. In the critical care unit, weight is monitored __________. a. As needed b. Once per shift c. Daily d. Weekly

Answer: C Rationale: In the critical care unit, weight is monitored daily. Significant fluctuations in body weight over a 1- to 2-day period indicate fluid gains and losses. Rapid weight gains or losses of more than 2 pounds per day usually indicate fluid rather than nutritional factors. One liter of fluid equals 1 kg, or approximately 2.2 pounds.

4. The nurse knows that the normal range for a BUN is __________. a. 1-12 b. 4-16 c. 7-20 d. 9-24

Answer: C Rationale: The normal value for BUN is about 7 to 20 mg/dL, which is increased when kidney function deteriorates. With kidney dysfunction the BUN is elevated because of a decrease in the glomerular filtration rate (GFR) and resulting decrease in urea excretion. Elevations in the BUN can be correlated with the clinical manifestations of uremia. As the BUN rises, symptoms of uremia become more pronounced. However, a drop in the GFR with an increase in the BUN also may be caused by hypovolemia and dehydration, nephrotoxic drugs, or a sudden hypotensive episode. In these cases the rise in BUN is caused by a decreased GFR in the presence of normal kidney function.

A patient has a serum creatinine of 0.9 mg/dL at 7:00 this morning. The nurse on the second shift, 12 hours later, notes that the serum creatinine is now 1.8 mg/dL and that the patient's urine output for the previous 12 hours has been 35 mL/h. The patient weighs 93 kg. Acute kidney injury (AKI) is suspected. Using the RIFLE acronym, this patient's data represents what stage of acute kidney function? A RISK B INJURY C FAILURE D LOSS

A urinalysis reveals that a patient has protein and red blood cells in the urine. The nurse understands that this can happen as a result of which pathophysiologic process? A The outer epithelium layer of the glomerulus has been damaged. B The middle basement membrane layer of the glomerulus has been damaged. C The inner endothelial lining of the glomerulus has been damaged. D The middle endothelial membrane layer of the glomerulus is working.

Which statement by a patient with chronic kidney disease (CKD) indicates an understanding of the purpose of sevelamer (Renagel) with meals? A "I need this drug to prevent indigestion." B "I need this drug to keep my body from absorbing too much phosphorus from food." C "I need to take this drug to improve my thyroid function." D "I need to take this drug with meals to avoid constipation."

The home care nurse visits a 34- year-old woman receiving peritoneal dialysis. Which statement, if made by the patient, indicates a need for immediate follow-up by the nurse? A "Drain time is faster if I rub my abdomen." B "The fluid draining from the catheter is cloudy." C "The drainage is bloody when I have my period." D "I wash around the catheter with soap and water."

B the primary clinical manifestation of peritonitis is a cloudy peritoneal effluent.

Which physiologic mechanisms are the result of the hormonal processes of the kidneys? A Removal of waste B Maintenance of fluid and electrolyte balance C Blood pressure control D Red blood cell production E Maintenance of acid-base balance

C D

What is the fluid resuscitation choice for the patient with a traumatic brain injury (TBI)? A 4% albumin B 0.9% normal saline C 0.45% NaCl D Mannitol

What is the most reliable and accurate estimate of glomerular filtration and kidney function? A Creatinine B Creatinine clearance C Blood urea nitrogen D Cystatin C

Which meal is the best choice for a patient with chronic kidney disease (CKD) to eat for lunch? A Tomato soup, grilled low-fat cheese sandwich, and diet soda B Tuna salad on lettuce with low-salt crackers and iced tea C Cheeseburger with french fries, a side salad, and a milkshake D Ham and cheese sandwich on whole-grain bread with pickle, potato chips, and milk

Which finding is consistent with a hypovolemic state? A CVP of 3 mm Hg B PAOP of 8 mm Hg C CI of 2.0 L/min/m2 D MAP of 80 mm Hg

Which layer of the kidney contains the pyramids? A Cortex B Loops of Henle C Medulla D Vasa recta

At what MAP does the ability of the kidneys to auto regulate blood flow begin to fail? A < 88 mmHg B < 90 mmHg C >160 mmHg D > 150 mmHg

Which is a measurement of right ventricular preload? A CI B CVP C MAP D PAOP

B ?

What is the most common cause of acute kidney injury (AKI) in the critically ill patient? A Heart failure B Shock C Respiratory failure D Sepsis

Acidification of the urine is accomplished by the transport of bicarbonate and hydrogen in which part of the kidney? A Collecting duct B Distal tubule C Proximal convoluted tubule D Loop of Henle

16. What is a continuous venovenous hemodialysis filter permeable to? a. Electrolytes b. Red blood cells c. Protein d. Lipids

ANS: A A continuous venovenous hemodialysis filter is permeable to solutes such as urea, creatinine, uric acid, sodium, potassium, ionized calcium, and drugs not bound by proteins.

9. The nurse has instructed a patient who is receiving hemodialysis about appropriate dietary choices. Which menu choice by the patient indicates that the teaching has been successful? a. Scrambled eggs, English muffin, and apple juice b. Oatmeal with cream, half a banana, and herbal tea c. Split-pea soup, whole-wheat toast, and nonfat milk d. Cheese sandwich, tomato soup, and cranberry juice

ANS: A Scrambled eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate.

13. When calculating the anion gap, the predominant cation is a. sodium. b. potassium. c. chloride. d. bicarbonate.

ANS: A The anion gap is a calculation of the difference between the measurable extracellular plasma cations (sodium and potassium) and the measurable anions (chloride and bicarbonate). In plasma, sodium is the predominant cation, and chloride is the predominant anion.

12. A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft? a. A fistula is much less likely to clot. b. A fistula increases patient mobility. c. A fistula can accommodate larger needles. d. A fistula can be used sooner after surgery.

ANS: A Arteriovenous (AV) fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impact on needle size or patient mobility.

2. Loss of albumin from the vascular space may result in a. peripheral edema. c. hypertension. b. extra heart sounds. d. hyponatremia.

24. A patient with renal failure reports all of the following during the medical history. Which is most likely to have precipitated the patient's renal failure? a. Recent computed tomography of the brain with and without contrast b. A recent bout of congestive heart failure after an acute myocardial infarction c. Twice-daily prescription of Lasix 40 mg by mouth d. A recent bout of benign prostatic hypertrophy and transurethral resection of the prostate

ANS: A Intravenous contrast media can be nephrotoxic, especially with the patient's pre-existing cardiac disease. The other choices, although possible causes, are less likely than the intravenous contrast media.

6. The most important assessment parameters for evaluating the patient's fluid status is to measure a. daily weights. c. intake and output. b. urine and serum osmolality. d. hemoglobin and hematocrit levels.

ANS: A One of the most important assessments of kidney and fluid status is the patient's weight. In the critical care unit, weight is monitored for each patient every day and is an important vital signs measurement.

15. The substance most responsible for maintaining the colloid osmotic pressure is a. intravascular plasma proteins. c. extracellular sodium. b. intracellular potassium. d. interstitial potassium.

ANS: A Osmotic pressure is created by solutes and other substances (e.g., albumin, globulin, fibrinogen) suspended in fluid. Colloid osmotic pressure is created primarily by the presence of plasma proteins in the intravascular space. Plasma proteins exert a pull on water molecules and therefore produce osmotic pressure, which retains fluid within the intravascular compartment.

22. Complications of kidney function in older adults will occur with the presence of a. proteinuria. c. BUN. b. vasopressin. d. creatine.

ANS: A Proteinuria is associated with complication in both the kidney and cardiovascular systems. Vasopressin, blood urea nitrogen, and creatine are found in normal kidney function.

8. Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the a. bowel sounds. b. blood glucose. c. blood urea nitrogen (BUN). d. level of consciousness (LOC).

ANS: A Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not affect the nurse's decision to give the medication.

2. Where does the concentration and dilution of urine occur? a. In the juxtamedullary nephrons c. In the peritubular capillaries b. In the cortical nephrons d. In the internal nephron

ANS: A The juxtamedullary nephrons have long loops of Henle that have an important role in the concentration and dilution of urine. The peritubular capillaries, known as the vasa recta, surround the juxtamedullary nephrons, maintaining a concentration gradient to concentrate the urine. Most nephrons are cortical nephrons. Both types of cortical nephrons

8. A patient who is not on any medications is admitted to your unit with severe hypokalemia. Laboratory values taken upon admission to the ED are serum K+, 2.2 mEq/L; BUN, 15 mg/dL; and creatinine, 1.2 mg/dL. Urine output is averaging 45 mL/hr. The ED nurse reports that the patient received a total of 80 mEq of potassium over 4 hours via a right subclavian central venous line. After admission to your unit, the physician orders a repeat potassium level. The result is K+, 2.4 mEq/L. What other information would be beneficial at this time? a. Magnesium level c. Calcium level b. Repeat creatinine level d. Hemoglobin level

ANS: A The levels of other intracellular electrolytes, such as calcium and potassium, are affected by the level of magnesium The most important functions of magnesium are ensuring the transport of sodium and potassium across the cell membrane and as a co-factor in many intracellular enzyme reactions. Depletion of magnesium liberates potassium to the extracellular fluid, which causes an increase in the excretion of potassium by the kidney and hypokalemia. If the patient has a low magnesium level, it could explain the lack of response to the potassium infusions. The other levels have little effect on serum potassium level or its response to infusions.

16. The primary waste product(s) that are measured to determine kidney function is/are a. urea and creatinine. c. BUN and creatine. b. creatinine. d. BUN, sodium, and potassium.

ANS: A Urea and creatinine are the primary waste products that are measured in determining kidney function. Urea is measured as blood urea nitrogen and is the end product of protein metabolism and results from the breakdown of ammonia in the liver. Like urea, creatinine accumulates when the glomerulus is unable to filter it from the blo

2. A patient is admitted to the critical care unit in congestive heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The nurse would expect to see elevated values in the following laboratory results: (Select all that apply). a. BUN. b. creatinine. c. glucose. d. hemoglobin and hematocrit. e. protein.

ANS: A, B, D With kidney dysfunction, the blood urea nitrogen (BUN) is elevated because of a decrease in the glomerular filtration rate and resulting decrease in urea excretion. Elevations in the BUN can be correlated with the clinical manifestations of uremia; as the BUN rises, symptoms of uremia become more pronounced. Creatinine levels are fairly constant and are affected by fewer factors than BUN. As a result, the serum creatinine level is a more sensitive and specific indicator of kidney function than BUN. Creatinine excess occurs most often in persons with kidney failure resulting from impaired excretion. Decreased hematocrit value can indicate fluid volume excess because of the dilutional effect of the extra fluid load. Decreases also can result from anemias, blood loss, liver damage, or hemolytic reactions. In individuals with acute kidney failure, anemia may occur early in the disease.

1. Which of the following conditions is associated between kidney failure and respiratory failure? (Select all that apply.) a. ARDS b. Lower GFR c. Increased urine output d. Decreased urine output e. Decreased blood flow to the kidneys

ANS: A, B, D, E Mechanical ventilation for respiratory failure can alter kidney function. Positive-pressure ventilation reduces blood flow to the kidney, lowers the glomerular filtration rate, and decreases urine output. Kidney failure increasesinflammation, causes the lung vasculature to become more permeable, and contributes to the development of acute respiratory distress syndrome.

1. Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis (select all that apply)? a. Avoid commercial salt substitutes. b. Drink 1500 to 2000 mL of fluids daily. c. Take phosphate-binders with each meal. d. Choose high-protein foods for most meals. e. Have several servings of dairy products daily.

ANS: A, C, D Patients who are receiving peritoneal dialysis should have a high-protein diet. Phosphate binders are taken with meals to help control serum phosphate and calcium levels. Commercial salt substitutes are high in potassium and should be avoided. Fluid intake is limited in patients requiring dialysis. Dairy products are high in phosphate and usually are limited.

1. Which of the following may be present in the patient with significant fluid volume overload? (Select all that apply.) a. S3 or S4 may develop. b. Distention of the hand veins will disappear if the hand is elevated. c. When testing the quality of skin turgor, the skin will not return to the normal position for several seconds. d. Tachycardia with hypotension may be present. e. Dependent edema may be present.

ANS: A, E A gallop and dependent edema are indicative of fluid excess; the other signs are indicative of fluid volume deficit.

7. Which patient information will the nurse plan to obtain in order to determine the effectiveness of the prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance

ANS: B Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate.

11. The function of aldosterone is primarily a. excretion of potassium through the renal tubules. b. control of sodium and water. c. regulation of bicarbonate. d. reabsorption of sodium and potassium.

ANS: B Aldosterone acts on the distal tubule to facilitate sodium and water resorption, resulting in an expanded circulating blood volume and increased blood pressure. When the arterial blood pressure increases, the juxtaglomerular apparatus reduces the release of renin, and the renin-angiotensin-aldosterone system is less active.

8. Which electrolytes pose the most potential hazard if not within normal limits for a person with renal failure? a. Phosphorous and calcium c. Magnesium and sodium b. Potassium and calcium d. Phosphorous and magnesium

ANS: B Although most electrolytes, such as potassium, become increasingly elevated in patients with acute renal failure, calcium levels are reduced. In each case, these conditions produce life-threatening cardiac dysrhythmias.

31. A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2 L inflows. Which information should the nurse report immediately to the health care provider? a. The patient has an outflow volume of 1800 mL. b. The patient's peritoneal effluent appears cloudy. c. The patient has abdominal pain during the inflow phase. d. The patient's abdomen appears bloated after the inflow.

ANS: B Cloudy appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient.

29. A patient has arrived for a scheduled hemodialysis session. Which nursing action is most appropriate for the registered nurse (RN) to delegate to a dialysis technician? a. Teach the patient about fluid restrictions. b. Check blood pressure before starting dialysis. c. Assess for causes of an increase in predialysis weight. d. Determine the ultrafiltration rate for the hemodialysis.

ANS: B Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of the appropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN.

16. Which information in a patient's history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation? a. The patient has type 1 diabetes. b. The patient has metastatic lung cancer. c. The patient has a history of chronic hepatitis C infection. d. The patient is infected with the human immunodeficiency virus.

ANS: B Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant.

11. A patient is admitted to the critical care unit in congestive heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. Which of the following diagnostic tests would give the best information about the internal kidney structures, such as the parenchyma, calyces, pelvis, ureters, and bladder? a. Kidney-ureter-bladder (KUB) c. Renal ultrasonography (ECHO) b. Intravenous pyelography (IVP) d. Renal angiography

ANS: B Intravenous pyelography allows visualization of the internal kidney parenchyma, calyces, pelvis, ureters, and bladder. Kidney-ureter-bladder flat-plate radiography of the abdomen determines the position, size, and structure of the kidneys, urinary tract, and pelvis. It is useful for evaluating the presence of calculi and masses and is usually followed by additional tests. In ultrasonography, high-frequency sound waves are transmitted to the kidneys and urinary tract, and the image is viewed on an oscilloscope. This noninvasive procedure identifies fluid accumulation or obstruction, cysts, stones or calculi, and masses. It is useful for evaluating the kidneys before biopsy. Angiography is injection of contrast into arterial blood perfusing the kidneys. It allows for visualization of renal blood flow and may also visualize stenosis, cysts, clots, trauma, and infarctions.

19. The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required? a. Multivitamin with iron b. Magnesium hydroxide c. Acetaminophen (Tylenol) d. Calcium phosphate (PhosLo)

ANS: B Magnesium is excreted by the kidneys, and patients with CKD should not use over-the-counter products containing magnesium. The other medications are appropriate for a patient with CKD.

20. For micturition to occur, stimulation from what receptor(s) will cause the parasympathetic messages to contract the detrusor muscle of the bladder? a. Bladder wall and ureters c. Ureters and urethra b. Bladder wall and urethra d. Urethra

ANS: B Nervous system control in the urinary tract is reflected in the process of micturition, or the release of urine. Bladder fullness stimulates stretch receptors in the bladder wall and a portion of the urethra. Signals are carried through nerves in the sacral area and return as parasympathetic messages to contract the detrusor muscle of the bladder.

2. When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of a. persistent skin tenting b. rapid, deep respirations. c. bounding peripheral pulses. d. hot, flushed face and neck.

ANS: B Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.

4. Percussion of kidneys is usually done to a. assess the size and shape of the kidneys. c. elicit a fluid wave. b. detect pain in the renal area. d. evaluate fluid status.

3. Which of the following IV solutions is recommended for treatment of prerenal failure? a. Dextrose in water c. Albumin b. Normal saline d. Lactated Ringer solution

2. Which of the following laboratory values is the most help in evaluating a patient for acute renal failure? a. Serum sodium c. Serum potassium b. Serum creatinine d. Urine potassium

9. Which of the following urine values reflects a decreased ability of the kidneys to concentrate urine? a. pH of 5.0 c. No casts b. Specific gravity of 1.000 d. Urine sodium of 140 mEq/24 hr

37. Which assessment finding for a patient who has had a cystectomy with an ileal conduit the previous day is most important for the nurse to communicate to the physician? a. Cloudy appearing urine b. Hypotonic bowel sounds c. Heart rate 102 beats/minute d. Continuous drainage from stoma

ANS: C Tachycardia may indicate infection, hemorrhage, or hypovolemia, which are all serious complications of this surgery. The urine from an ileal conduit normally contains mucus and is cloudy. Hypotonic bowel sounds are expected after bowel surgery. Continuous drainage of urine from the stoma is normal.

13. The most common site for short-term vascular access for immediate hemodialysis is the a. subclavian artery. c. femoral artery. b. subclavian vein. d. radial vein.

36. A 74-year-old who is progressing to stage 5 chronic kidney disease asks the nurse, "Do you think I should go on dialysis? Which initial response by the nurse is best? a. "It depends on which type of dialysis you are considering." b. "Tell me more about what you are thinking regarding dialysis." c. "You are the only one who can make the decision about dialysis." d. "Many people your age use dialysis and have a good quality of life."

ANS: B The nurse should initially clarify the patient's concerns and questions about dialysis. The patient is the one responsible for the decision and many people using dialysis do have good quality of life, but these responses block further assessment of the patient's concerns. Referring to which type of dialysis the patient might use only indirectly responds to the patient's question.

23. Which intervention will be included in the plan of care for a male patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein? a. Start continuous pulse oximetry. b. Restrict physical activity to bed rest. c. Restrict the patient's oral protein intake. d. Discontinue the urethral retention catheter.

ANS: B The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to remain in place because accurate measurement of output will be needed. There is no indication that the patient needs continuous pulse oximetry.

20. To control azotemia, the recommended nutritional intake of protein is a. .5 to 1.0 g/kg/day. c. 1.7 to 2.5 g/kg/day. b. 1.2 to 1.5 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 grams/kg of protein per day to control azotemia (increased blood urea nitrogen level).

6. The following substances, among others, are found in a urine sample: urea, creatinine, sodium, chlorine, potassium, glucose, and bicarbonate ions. Which of the following could account for this abnormal finding? a. Blood pressure of 76/30 mm Hg c. Blood glucose of 36 mg/dL b. Blood glucose of 456 mg/dL d. Blood potassium level of 4.1 mEq/L

ANS: B This glucose reading is above the threshold concentration. Glucose is normally completely reabsorbed from the tubules. Above the threshold level, the tubules are unable to reabsorb all of the glucose, and some spills into the urine. All of the other findings in this urine sample are normal findings.

3. Which of the following auscultatory parameters may exist in the presence of hypovolemia? a. Hypertension b. Third or fourth heart sound c. Orthostatic hypotension d. Vascular bruit

ANS: C A drop in systolic blood pressure of 20 mm Hg or more, a drop in diastolic blood pressure of 10 mm Hg or more, or a rise in pulse rate of more than 15 beats/min from lying to sitting or from sitting to standing indicates orthostatic hypotension. The drop in blood pressure occurs because a sufficient preload is not immediately available when the patient changes position. The heart rate increases in an attempt to maintain cardiac output and circulation.

3. Which of the following auscultatory parameters may exist in the presence of hypovolemia? a. Hypertension c. Orthostatic hypotension b. Third or fourth heart sound d. Vascular bruit

16. The patient is a gravida 6, para 1. She is admitted after a cesarean section after an amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less than 80 mm Hg. Her temperature is 38°C, and her condition has caused her to develop prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter, which was placed into her right femoral access, and started on vasopressors with a fair response (BP, 80/50 mm Hg; HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis, the patient was begun on CVVH. Identify three complications of CVVH therapy. a. Fat emboli, increased ultrafiltration, and hypertension b. Hyperthermia, overhydration, and power surge c. Air embolism, decreased inflow pressure, and electrolyte imbalance d. Blood loss, decreased outflow resistance, and acid-base imbalance

14. Which type of intravenous fluid will not create a shift of fluids within the vascular space? a. Hypertonic c. Isotonic b. Hypotonic d. Osmotic pressure

ANS: C An isotonic solution has roughly the same concentration of particles as the blood plasma; cells within an isotonic solution maintain consistency and do not lose or gain fluid to their surroundings. A hypertonic solution contains a greater concentration of particles than that inside the cell and causes fluid to be drawn out of the cells. Used inappropriately, too much fluid may be withdrawn, causing a withering of the cell (crenation). A hypotonic solution contains a lesser concentration of particles than that inside the cell and causes fluid to be drawn into the cells. If used incorrectly, a hypotonic solution can cause too much fluid to enter the cell, causing the cells to swell and burst (hemolysis). Osmotic pressure is created by solutes and other substances (e.g., albumin, globulin, fibrinogen) suspended in fluid.

22. A 55-year-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication? a. Creatinine 1.6 mg/dL b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg

ANS: C High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when erythropoietin (EPO) is administered to a target hemoglobin of >12 g/dL. Hemoglobin levels higher than 12 g/dL indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider but will not affect whether the medication is administered.

17. Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation? a. Postural hypotension b. Recurrent tachycardia c. Knee and hip joint pain d. Increased serum creatinine

ANS: C Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over a prolonged period. Increased creatinine level, orthostatic dizziness, and tachycardia are not caused by corticosteroid use.

7. To prevent acid-base disturbances, the ratio between carbonic acid and bicarbonate should be a. 10 mEq of carbonic acid to 20 mEq of bicarbonate. b. 20 mEq of carbonic acid to 10 mEq of bicarbonate. c. 1 mEq of carbonic acid to 20 mEq of bicarbonate. d. 20 mEq of carbonic acid to 1 mEq of bicarbonate.

ANS: C Bicarbonate levels in the body are in balance with carbonic acid (H2CO3) levels. The ratio between the two must remain proportional at 1 mEq of carbonic acid to 20 mEq of bicarbonate; otherwise, acid-base disturbances will result.

9. The functional unit of the kidney is known as the a. Bowman capsule. c. nephron. b. glomerulus. d. distal tubule.

ANS: C Each kidney is made up of about 1 million nephrons, the functional units of the kidneys. Each nephron is made up of several distinct structures, which are the glomerulus, Bowman capsule, proximal tubule, loop of Henle, distal tubule, and collecting duct.

10. Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check laboratory results for a. potassium level. b. total cholesterol. c. serum phosphate. d. serum creatinine.

ANS: C If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. The calcium carbonate should not be given until the phosphate level is lowered. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered.

10. Ammonia, hydrogen, and ammonium are secreted in the a. loop of Henle. c. glomerulus. b. collecting duct. d. proximal tubule.

ANS: C In addition to its major role in resorbing water and solutes from the filtrate, the proximal tubule secretes organic anions and cations into the tubular lumen. Ammonia is produced from the metabolism of glutamine in the mitochondria of the proximal tubule cells, where ammonia (NH3) combines with hydrogen (H+) to form ammonium (NH4+), which is secreted into the proximal tubule lumen.

10. A patient is admitted to the critical care unit in congestive heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The nurse suspects the main cause of ascites is a. hypervolemia. c. volume overload. b. dehydration. d. liver damage.

5. Which of the following IV solutions is contraindicated for patients with kidney or liver disease or in lactic acidosis? a. D5W c. Lactated Ringer solution b. 0.9% NaCl d. 0.45% NaCl

ANS: C Lactated Ringer solution is contraindicated for patients with kidney or liver diseases or in lactic acidosis.

22. What is the dose for low-dose dopamine? a. 1 to 2 mcg/kg/min c. 2 to 3 mcg/kg/min b. 1 to 2 mg/kg/min d. 2 to 3 mg/kg/min

ANS: C Low-dose dopamine (2-3 mcg/kg/min), previously known as renal-dose dopamine, is frequently infused to stimulate blood flow to the kidney. Dopamine is effective in increasing urine output in the short term, but tolerance of the dopamine renal receptor to the medication is theorized to develop in the critically ill patients who are most at risk for acute kidney injury.

14. A 64-year-old male patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis. b. Unlimited fluids are allowed because retained fluid is removed during dialysis. c. More protein is allowed because urea and creatinine are removed by dialysis. d. Dietary potassium is not restricted because the level is normalized by dialysis.

17. Maintaining a normal range of serum potassium is important for a. fluid regulation. c. nervous impulse conduction. b. acid-base buffering. d. triggering ADH release.

ANS: C Potassium functions in the body to aid in nervous impulse conduction and muscle contraction.

4. A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV? a. Urine volume b. Calcium level c. Cardiac rhythm d. Neurologic status

1. The initial filtering of the blood occurs in which structure? a. The distal tubule c. The glomerulus b. The proximal tubule d. The collecting tubule

ANS: C The first structure of each nephron is the glomerulus, a high-pressure capillary bed that serves as the filtering point for the blood. Positive filtration pressure in the glomerulus is achieved as a result of the high arterial pressure as the blood enters the afferent arteriole and the resistance created by the smaller efferent arteriole as the blood exits the glomerulus. As a result of the positive-pressure gradient, fluid and solutes are filtered through the glomerular capillary walls.

27. A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first? a. Notify the patient's health care provider. b. Document the QRS interval measurement. c. Check the medical record for most recent potassium level. d. Check the chart for the patient's current creatinine level.

ANS: C The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient's health care provider. The BUN and creatinine will be elevated in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval is also appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening dysrhythmias.

19. A patient has sepsis and is placed on broad-spectrum antibiotics. Her temperature is 37.8°C. Her BUN level is elevated. She continues on vasopressor therapy. What other steps should be taken to protect the patient from inadequate organ perfusion? a. Increase net ultrafiltrate of fluid. b. Discontinue vasopressor support. c. Assess the patient for blood loss and hypotension. d. Notify the physician of access pressures.

ANS: C The patient should be assessed for blood loss or response to blood products and medications. The nurse should use ordered vasopressor support and decrease the net ultrafiltrate to zero.

21. Laboratory results come back on a newly admitted patient. They are as follows: serum BUN, 64 mg/dL; serum creatinine, 2.4 mg/dL; urine osmolality, 210 mOsm/kg; specific gravity, 1.002; and urine sodium, 96 mEq/L. The urine output has been 120 mL since admission 2 hours ago. These values are most consistent with which of the following diagnoses? a. Prerenal failure b. Postrenal failure c. Oliguric renal failure d. Acute kidney injury (AKI)

ANS: D Urinary sodium less than 10 mEq/L (low) suggests a prerenal condition. Urinary sodium greater than 40 mEq/L (in the presence of an elevated serum creatinine and the absence of a high salt load) suggests intrarenal damage has occurred. The urine output does not seem to suggest oliguria. The other options do not fit the data as presented.

21. A new order for IV gentamicin (Garamycin) 60 mg BID is received for a patient with diabetes who has pneumonia. When evaluating for adverse effects of the medication, the nurse will plan to monitor the patients a. urine osmolality. b. serum potassium. c. blood glucose level. d. blood urea nitrogen (BUN) and creatinine.

ANS: D When a patient at risk for chronic kidney disease (CKD) receives a nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels. The other laboratory values would not be useful in determining the effect of the gentamicin.

3. Which of the following, if found in the urine, suggests damage to the glomerular membrane? a. Creatinine c. Sodium b. Bicarbonate ions d. Albumin

ANS: D Large molecules such as albumin and red blood cells are prevented from entering the filtrate. The presence of large molecules in the urine is a signal that the glomerular membrane is damaged or affected by disease.

35. A patient complains of leg cramps during hemodialysis. The nurse should first a. massage the patient's legs. b. reposition the patient supine. c. give acetaminophen (Tylenol). d. infuse a bolus of normal saline.

ANS: D Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.

12. Which of the following conditions would result in an increased release of renin? a. Increased release of angiotensin I b. Increased release of angiotensin II c. Increased amount of sodium in the distal convoluted tubule d. Reduced pressure in the glomerulus

ANS: D Renin is released in response to reduced pressure in the glomerulus, sympathetic stimulation of the kidneys, and a decrease in the amount of sodium in the distal convoluted tubule. Renin is converted to angiotensin I, which is converted to the powerful vasoconstrictor angiotensin II. Angiotensin II stimulates the adrenal glands to secrete aldosterone, which acts on the distal tubules to resorb sodium from the tubular lumen into the circulation. When sodium is retained, so is water. Angiotensin II also constricts the renal vasculature, reducing kidney blood flow and available glomerular filtrate, sending a signal to the posterior pituitary to release antidiuretic hormone. The two systems intertwine to maintain fluid and electrolyte balance.

37. After receiving change-of-shift report, which patient should the nurse assess first? a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L d. Patient who has just returned from having hemodialysis and has a heart rate of 124/min

ANS: D The patient who is tachycardic after hemodialysis may be bleeding or excessively hypovolemic and should be assessed immediately for these complications. The other patients also need assessments or interventions but are not at risk for life-threatening complications.

23. Laboratory results come back on a newly admitted patient. They are as follows: serum BUN, 64 mg/dL; serum creatinine, 2.4 mg/dL; urine osmolality, 210 mOsm/kg; specific gravity, 1.002; and urine sodium, 96 mEq/L. The urine output has been 120 mL since admission 2 hours ago. These values are most consistent with which of the following diagnoses? a. Prerenal failure c. Oliguric renal failure b. Postrenal failure d. Acute tubular necrosis

4. If the patient's blood pressure drops, which of the following will help maintain adequate glomerular pressure? a. Constriction of the afferent arteriole c. Dilation of the collecting tubule b. Dilation of the efferent arteriole d. Constriction of the efferent arteriole

ANS: D When the mean arterial blood pressure is decreased, the afferent arteriole dilates and the efferent arteriole constricts to maintain a higher pressure in the glomerular capillary bed and maintain the glomerular filtration rate at 125 mL/min. The ability of the kidneys to autoregulate blood flow begins to fail when the mean arterial blood pressure is less than 80 mm Hg or greater than 180 mm Hg.

The kidneys are highly vascular and receive approximately how much of the cardiac output? 10% 20% 50% 75%

21. When renin eventually stimulates angiotensin II, the adrenal glands then secrete a. aldosterone. c. ADH. b. potassium. d. vasopressin.

ANS: A A reduction in vascular volume stimulates the release of renin. Renin converts to angiotensin I, which converts to the powerful vasoconstrictor angiotensin II. In turn, angiotensin II stimulates the adrenal glands to secrete aldosterone, which acts on the distal tubules to resorb sodium from the tubular lumen into the circulation.

A dialysis patient is experiencing chronic anemia secondary to renal failure. Which of the following statements is TRUE? A Erythropoietin is released in response to anemia or prolonged hypoxia. B Erythropoietin suppresses red blood cell production in the bone marrow. C Erythropoietin is active for approximately 72 hours after release. D An absence of erythropoietin is managed only through transfusion therapy.

A patient with a traumatic brain injury is being assessed by the nurse for fluid volume status. Peripheral edema in this patient is more likely to be a result of which problem? A Hypoalbuminemia B Hypovolemia C Hypervolemia D Intracranial pressure hypertension

6. The most important assessment parameters for evaluating the patients fluid status is to measure a. daily weights. b. urine and serum osmolality. c. intake and output. d. hemoglobin and hematocrit levels.

ANS: A One of the most important assessments of kidney and fluid status is the patients weight. In the critical care unit, weight is monitored for each patient every day and is an important vital signs measurement.

21. Which of the following diuretics maybe combined to work on different parts of the nephron? a. Loop and thiazide diuretics b. Loop and osmotic diuretics c. Osmotic and carbonic anhydrase inhibitor diuretics d. Thiazide and osmotic diuretics

13. When calculating the anion gap, the predominant cation is a. sodium. c. chloride. b. potassium. d. bicarbonate.

25. A 72-year-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first? a. Insert urethral catheter. b. Obtain renal ultrasound. c. Draw a complete blood count. d. Infuse normal saline at 50 mL/hour.

ANS: A The patient's elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of a retention catheter is the first action to prevent ongoing postrenal failure for this patient. The other actions also are appropriate, but should be implemented after the retention catheter.

13. When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula? a. Auscultate for a bruit at the fistula site. b. Assess the quality of the left radial pulse. c. Compare blood pressures in the left and right arms. d. Irrigate the fistula site with saline every 8 to 12 hours.

26. A patient in acute renal failure presents with a potassium level of 6.9 mg/dL. He has had no urine output in the past 4 hours despite urinary catheter insertion and Lasix 40 mg intravenous push. Vital signs are as follows: HR, 76 beats/min; respiratory rate, 18 breaths/min; and BP, 145/96 mm Hg. He is given 100 mL of 50% dextrose in water and 20 U of regular insulin intravenous push. A repeat potassium level 2 hours later shows a potassium level of 4.5 mg/dL. What order would now be expected? a. Sodium Kayexalate 15 g PO b. Nothing; this represents a normal potassium level c. Lasix 40 mg IVP d. 0.9% normal saline at 125 mL/hr

ANS: A This patient appears to be in acute anuric renal failure. The potassium was not eliminated from the body; it was simply shifted intracellularly. Soon the potassium will return to the bloodstream, and the Kayexalate will help permanently remove it from the body. Lasix is not expected to work in the presence of anuria. The patient's vital signs do not support hypovolemia. In the presence of anuria, a large fluid infusion can precipitate congestive heart failure.

3. A patient is admitted to the critical care unit in congestive heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The nurse would expect to see elevated values in the following laboratory results: (Select all that apply). a. BUN. b. creatinine. c. glucose. d. hemoglobin and hematocrit. e. protein.

1. Causes of the presence of myoglobin could include (Select all that apply.) a. bleeding. b. traumatic damage to the skeletal muscle. c. asthmatic attack. d. rhabdomyolysis. e. cocaine abuse.

ANS: A, B, D, E Although a few red blood cells (RBCs) in the urine are normal, discernibly bloody urine usually indicates bleeding within the urinary tract or kidney trauma. The presence of myoglobin can make the urine appear red. Microscopic examination of the urine fails to reveal RBCs, with myoglobin being present instead. Myoglobin in the urine may result from skeletal muscle damage (e.g., traumatic crush injury) or rhabdomyolysis. Rhabdomyolysis may develop in patients admitted to a critical care unit for many reasons, including traumatic injury, cocaine abuse, status epilepticus, heat prostration, or collapse during intense physical exercise (e.g., running a marathon race on a hot day).

2. To prevent catheter-associated UTI (CAUTI), the nurse should (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.

2. Which of the following may be present in the patient with significant fluid volume overload? (Select all that apply.) a. S3 or S4 may develop. b. Distention of the hand veins will disappear if the hand is elevated. c. When testing the quality of skin turgor, the skin will not return to the normal position for several seconds. d. Tachycardia with hypotension may be present. e. Dependent edema may be present.

ANS: A, E A gallop and dependent edema are indicative of fluid excess; the other signs are indicative of fluid volume deficit.

12. A patient has acute kidney injury (previously known as acute tubular necrosis). The following blood work was noted: complete blood count shows a white blood cell count of 11,000 mm3, a hemoglobin of 8 g/dL, and a hematocrit of 30%. His chemistry panel shows serum potassium, 4.5 mg/dL; serum sodium, 135 mg/dL; serum calcium, 8.5 mg/dL; BUN, 20 mg/dL; and creatinine, 1.5 mg/dL. What laboratory value(s) need(s) to be treated most immediately and why? a. Administration of 5% dextrose in water and insulin because the patient is hyperkalemic and needs this level reduced b. Administration of Epogen to treat anemia c. Administration of a broad-spectrum antibiotic to treat the elevated blood cell count d. Administration of a calcium supplement for low calcium

ANS: B A patient showing signs of anemia per his hematocrit and hemoglobin must be treated. Epogen is used because it helps stimulate erythrocyte production by the bone marrow.

8. Which electrolytes pose the most potential hazard if not within normal limits for a person with renal failure? a. Phosphorous and calcium b. Potassium and calcium c. Magnesium and sodium d. Phosphorous and magnesium

28. When caring for a dehydrated patient with acute kidney injury who is oliguric, anemic, and hyperkalemic, which of the following prescribed actions should the nurse take first? a. Insert a urinary retention catheter. b. Place the patient on a cardiac monitor. c. Administer epoetin alfa (Epogen, Procrit). d. Give sodium polystyrene sulfonate (Kayexalate).

ANS: B Since hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to monitor the cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. The catheter allows monitoring of the urine output, but does not correct the cause of the renal failure.

18. To control azotemia, the recommended nutritional intake of protein is a. .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 grams/kg of protein per day to control azotemia (increased blood urea nitrogen level).

14. A patient has acute tubular necrosis. The following blood work was noted: complete blood count shows a white blood cell count of 11,000 mm3, a hemoglobin of 8 g/dL, and a hematocrit of 30%. His chemistry panel shows serum potassium, 4.5 mg/dL; serum sodium, 135 mg/dL; serum calcium, 8.5 mg/dL; BUN, 20 mg/dL; and creatinine, 1.5 mg/dL. What laboratory value(s) need(s) to be treated most immediately and why? a. Administration of 5% dextrose in water and insulin because the patient is hyperkalemic and needs this level reduced b. Administration of Epogen to treat anemia c. Administration of a broad-spectrum antibiotic to treat the elevated blood cell count d. Administration of a calcium supplement for low calcium

ANS: B A patient showing signs of anemia per his hematocrit and hemoglobin must be treated. Epogen is used because it helps stimulate erythrocyte production by the bone marrow.

20. Before administration of captopril (Capoten) to a patient with stage 2 chronic kidney disease (CKD), the nurse will check the patient's a. glucose. b. potassium. c. creatinine. d. phosphate.

ANS: B Angiotensin-converting enzyme (ACE) inhibitors are frequently used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention. Therefore careful monitoring of potassium levels is needed in patients who are at risk for hyperkalemia. The other laboratory values would also be monitored in patients with CKD but would not affect whether the captopril was given or not.

28. A 42-year-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first? a. Insert a urinary retention catheter. b. Place the patient on a cardiac monitor. c. Administer epoetin alfa (Epogen, Procrit). d. Give sodium polystyrene sulfonate (Kayexalate).

ANS: B Because hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to monitor the cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. The catheter allows monitoring of the urine output but does not correct the cause of the renal failure.

7. Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance

18. Chloride plays a major role in maintaining a. cellular immunity. c. bone strength. b. serum osmolality. d. adenosine triphosphate (ATP).

ANS: B Chloride plays a major role in maintaining serum osmolality, water balance, and acid-base balance. The primary function of phosphorus is the formation of adenosine triphosphate, which provides intracellular energy for active transport mechanisms across the cell membrane. Additional functions of phosphorus include cell membrane structure, acid-base balance, oxygen delivery to the tissues, cellular immunity, and bone strength.

34. The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider? a. Heart rate b. Urine output c. Creatinine clearance d. Blood urea nitrogen (BUN) level

ANS: B Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. The other data will be monitored but are not the most important determinants of fluid infusion rate.

17. A patient has been on complete bed rest for 3 days. The health care provider has ordered for the patient to sit at the bedside for meals. The patient complains of feeling dizzy and faint while sitting at the bedside. The nurse anticipates that the patient is experiencing a. orthostatic hypertension. c. hypervolemia. b. orthostatic hypotension. d. electrolyte imbalance.

20. What is the dose for low-dose dopamine? a. 1 to 2 mcg/kg/min b. 1 to 2 mg/kg/min c. 2 to 3 mcg/kg/min d. 2 to 3 mg/kg/min

ANS: C Low-dose dopamine (23 mcg/kg/min), previously known as renal-dose dopamine, is frequently infused to stimulate blood flow to the kidney. Dopamine is effective in increasing urine output in the short term, but tolerance of the dopamine renal receptor to the medication is theorized to develop in the critically ill patients who are most at risk for acute kidney injury.

5. A 48-year-old patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which order for the patient will the nurse question? a. NPO for 6 hours before procedure b. Ibuprofen (Advil) 400 mg PO PRN for pain c. Dulcolax suppository 4 hours before procedure d. Normal saline 500 mL IV infused before procedure

ANS: B The contrast dye used in IVPs is potentially nephrotoxic, and concurrent use of other nephrotoxic medications such as the nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided. The suppository and NPO status are necessary to ensure adequate visualization during the IVP. IV fluids are used to ensure adequate hydration, which helps reduce the risk for contrast-induced renal failure.

32. The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The patient's central venous pressure (CVP) is decreased. c. The patient has a level 7 (0 to 10 point scale) incisional pain. d. The blood urea nitrogen (BUN) and creatinine levels are elevated.

ANS: B The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant.

26. A 62-year-old female patient has been hospitalized for 8 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? a. The creatinine level is 3.0 mg/dL. b. Urine output over an 8-hour period is 2500 mL. c. The blood urea nitrogen (BUN) level is 67 mg/dL. 2 d. The glomerular filtration rate is <30 mL/min/1.73m .

ANS: B The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy.

24. A 25-year-old male patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider? a. Serum creatinine level 2.1 mg/dL b. Serum potassium level 6.5 mEq/L c. White blood cell count 11,500/μL d. Blood urea nitrogen (BUN) 56 mg/dL

ANS: B The hyperkalemia associated with crushing injuries may cause cardiac arrest and should be treated immediately. The nurse also will report the other laboratory values, but abnormalities in these are not immediately life threatening.

13. The mobilization of calcium from bone stores is accomplished through the influence of which hormone? a. Antidiuretic hormone (ADH) c. Thyroid-stimulating hormone (TSH) b. Parathyroid hormone (PTH) d. Erythropoietin

ANS: B The mobilization of calcium from bone stores is accomplished through the influence of parathyroid hormone. The kidneys secrete erythropoietin, the hormone that controls erythrocyte (red blood cell) production in the bone marrow.

33. During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Check patient's blood pressure (BP). c. Review the hematocrit (Hct) level. d. Give prescribed PRN antiemetic drugs.

ANS: B The patient's complaints of nausea and dizziness suggest hypotension, so the initial action should be to check the BP. The other actions may also be appropriate based on the blood pressure obtained.

25. An alert and oriented patient presents with a pulmonary artery wedge pressure of 4 mm Hg and a cardiac index of 0.8. The BUN is 44 mg/dL, creatinine is 3.2 mg/dL, and BP is 88/36 mm Hg. Urine output is 15 mL/hr. Lungs are clear to auscultation with no peripheral edema noted. Which of the following treatments would the physician most likely order? a. Lasix 40 mg intravenous push c. Dopamine 15 μg/kg/min b. 0.9% normal saline at 125 mL/hr d. Transfuse 1 U of packed red blood cells

ANS: B The patient's hemodynamic parameters are most consistent with hypovolemia. The renal failure would then most probably be prerenal from inadequate blood flow. The treatment of choice for hypovolemia is fluid resuscitation. Important criteria when calculating fluid volume replacement include baseline metabolism, environmental temperature, and humidity. The rate of replacement depends on cardiopulmonary reserve, adequacy of kidney function, urine output, fluid balance, ongoing loss, and type of fluid replaced.

3. The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary collaborative treatment goal in the plan will be a. augmenting fluid volume. b. maintaining cardiac output. c. diluting nephrotoxic substances. d. preventing systemic hypertension.

ANS: B The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct.

7. Which of the following parameters is indicative of volume overload? a. Central venous pressure of 4 mm Hg b. Pulmonary artery occlusion pressure (PAOP) of 18 mm Hg c. Cardiac index of 2.5 L/min/m2 d. Mean arterial pressure of 40 mm Hg

ANS: B The pulmonary artery occlusion pressure (PAOP) represents the left atrial pressure required to fill the left ventricle. When the left ventricle is full at the end of diastole, this represents the volume of blood available for ejection. It is also known as left ventricular preload and is measured by the PAOP. The normal PAOP is 5 to 12 mm Hg. In fluid volume excess, PAOP rises. In fluid volume deficit, PAOP is low.

The nurse is caring for a 68-year-old man who had coronary artery bypass surgery 3 weeks ago. If the patient is now is in the oliguric phase of acute kidney disease, which action would be appropriate to include in the plan of care? A Provide foods high in potassium. B Restrict fluids based on urine output. C Monitor output from peritoneal dialysis. D Offer high protein snacks between meals

B Fluid intake is monitored during the oliguric phase. Fluid is determined by adding all the losses for the previous 24 hours plus 600 mL.

6. Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurses teaching about management of CKD has been effective? a. I need to try to get more protein from dairy products. b. I will try to increase my intake of fruits and vegetables. c. I will measure my urinary output each day to help calculate the amount I can drink. d. I need to take the erythropoietin to boost my immune system and help prevent infection.

ANS: C The patient with end-stage renal disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD.

15. A patient is admitted to the critical care unit in congestive heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The nurse is assessing the peripheral edema. The nurse presses two fingers over the tibial area, and it takes 1 minute before the indention disappears. The nurse would chart the following result: a. +1 pitting edema. b. +2 pitting edema. c. +3 pitting edema. d. +4 pitting edema.

ANS: C The pitting edema scale includes +1 = 2-mm depth; +2 = 4-mm depth (lasting up to 15 sec); +3 = 6-mm depth (lasting up to 60 sec); and +4 = 8-mm depth (lasting longer than 60 sec).

3. A patient with severe heart failure develops elevated blood urea nitrogen (BUN) and creatinine levels. The nurse will plan care to meet the goal of a. replacing fluid volume. b. preventing hypertension. c. maintaining cardiac output. d. diluting nephrotoxic substances.

ANS: C The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patients heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct.

8. As serum osmolality rises, intravascular fluid equilibrium will be maintained by the release of a. ketones. b. glucagon. c. antidiuretic hormone. d. potassium.

11. A 37-year-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level

ANS: C GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.

12. A patient is admitted to the critical care unit in congestive heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The patient weight upon admission was 176 lb. The patient's weight the next day is 184 lb. What is the approximate amount of fluid retained with this weight gain? a. 800 mL c. 3600 mL b. 2200 mL d. 8000 mL

ANS: C One liter of fluid equals 1 kg, which is 2.2 pounds; 8 pounds equals 3.6 kg, which is 3.6 liters; 3.6 liters is equal to 3600 mL.

30. A licensed practical/vocational nurse (LPN/LVN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention? a. The LPN/LVN administers the erythropoietin subcutaneously. b. The LPN/LVN assists the patient to ambulate out in the hallway. c. The LPN/LVN administers the iron supplement and phosphate binder with lunch. d. The LPN/LVN carries a tray containing low-protein foods into the patient's room.

15. Which action by a 70-year-old patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient leaves the catheter exit site without a dressing. b. The patient plans 30 to 60 minutes for a dialysate exchange. c. The patient cleans the catheter while taking a bath each day. d. The patient slows the inflow rate when experiencing abdominal pain.

ANS: C Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis.

9. Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful? a. Split-pea soup, English muffin, and nonfat milk b. Oatmeal with cream, half a banana, and herbal tea c. Poached eggs, whole-wheat toast, and apple juice d. Cheese sandwich, tomato soup, and cranberry juice

ANS: C Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate.

10. A patient has been hospitalized for a subtotal gastrectomy. After the procedure, an infection developed that eventually had to be treated with gentamicin, an aminoglycoside antibiotic. After 3 days of administration, oliguria occurred, and subsequent laboratory values indicated elevated blood-urea-nitrogen and creatinine levels. The patient is transferred to the critical care unit with acute tubular necrosis. The patient is in the oliguric/anuric phase of acute tubular necrosis. Which statement best describes this phase? a. It is the period of time from insult until cell injury. A decrease in glomerular filtration rate (GFR) results and disrupts the integrity of the tubular epithelium. b. It is characterized by an increase in GFR in which the kidneys can clear volume and not solutes. c. It is referred to as the maintenance phase and lasts 5 to 8 days in a nonoliguric patient and 10 to 16 days in an oliguric patient. d. Renal function slowly returns to normal with a GFR at 70% to 80%.

ANS: C The oliguric/anuric phase, the second phase of acute tubular necrosis, lasts 5 to 8 days in a nonoliguric patient and 10 to 16 days in an oliguric patient. The accumulation of necrotic cellular debris in the tubular space blocks the flow of urine and causes damage to the tubular wall and basement membranes.

6. Which statement by a 62-year-old patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? a. "I need to get most of my protein from low-fat dairy products." b. "I will increase my intake of fruits and vegetables to 5 per day." c. "I will measure my urinary output each day to help calculate the amount I can drink." d. "I need to take erythropoietin to boost my immune system and help prevent infection."

ANS: C The patient with end-stage kidney disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD.

21. A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient's a. blood glucose. b. urine osmolality. c. serum creatinine. d. serum potassium.

ANS: C When a patient at risk for chronic kidney disease (CKD) receives a potentially nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels. The other laboratory values would not be useful in assessing for the adverse effects of the gentamicin.

10. Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check the laboratory value for a. creatinine. b. potassium. c. total cholesterol. d. serum phosphate.

ANS: D If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. The calcium carbonate should not be given until the phosphate level is lowered. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered.

1. Which of the following assessment findings would indicate fluid volume excess? a. Venous filling of the hand veins greater than 5 seconds b. Distended neck veins in the supine position c. Presence of orthostatic hypotension d. Third heart sound

17. The patient is a gravida 6, para 1. She is admitted after a cesarean section after an amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less than 80 mm Hg. Her temperature is 38°C, and her condition has caused her to develop prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter, which was placed into her right femoral access, and started on vasopressors with a fair response (BP, 80/50 mm Hg; HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis, the patient was begun on CVVH. Why would this therapy be chosen for this patient? a. Hyperdynamic patients can better tolerate abrupt fluid and solute changes. b. It is the treatment of choice for patients with diminished renal perfusion who are unresponsive to diuretics. c. It is indicated for patients who require large-volume removal for severe uremia or critical acid-base imbalances. d. It is indicated for hemodynamically unstable patients, who are often intolerant of the abrupt fluid and solute changes that can occur with hemodialysis.

ANS: D Continuous venovenous hemodialysis is indicated for patients who require large-volume removal for severe uremia or critical acid-base imbalances or for those who are resistant to diuretics.

5. Which of the following is most indicative of renal failure? a. Elevated blood-urea-nitrogen c. Peripheral edema b. Congestive heart failure d. Elevated creatinine

ANS: D Creatinine is used as a measure of the glomerular filtration rate (GFR) because it is a waste product produced at a fairly constant rate by the muscles, is freely filtered by the glomerulus, and is minimally resorbed or secreted by the tubules. Therefore, most of the creatinine produced by the body is excreted by the kidneys, making the creatinine clearance a good screening and follow-up test for estimating the GFR. A creatinine clearance less than 100 mL/min reflects a GFR of less than 100 mL/min and is a signal of decreased kidney function. A creatinine clearance (and GFR) less than 20 mL/min results in symptoms of kidney failure.

12. A patient has been hospitalized for a subtotal gastrectomy. After the procedure, an infection developed that eventually had to be treated with gentamicin, an aminoglycoside antibiotic. After 3 days of administration, oliguria occurred, and subsequent laboratory values indicated elevated BUN and creatinine levels. The patient is transferred to the critical care unit with acute tubular necrosis. The fluid that is removed each hour is not called urine; it is known as a. convection. c. replacement fluid. b. diffusion. 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.

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 which kind of AKI? A Prerenal B Intrarenal C Postrenal D Both A and B

Answer: A Rationale: 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 AKI. Any condition that produces an ischemic or toxic insult directly at parenchymal nephron tissue places the patient at risk for development of intrarenal AKI. Any obstruction that hinders the flow of urine from beyond the kidney through the remainder of the urinary tract may lead to postrenal AKI.

2. Which of these values can be used to accurately assess the fluid volume status? (Choose all that apply.) a. Central venous pressure b. Intracranial pressure c. Pulmonary artery occlusion pressure d. Cardiac index e. Pulse oximetry f. Mean arterial pressure

Answer: A, C, D, F Body fluid status is accurately reflected in measurements of cardiovascular hemodynamics. Measurements such as central venous pressure (CVP), pulmonary artery occlusion pressure (PAOP), cardiac index (CI), and mean arterial pressure (MAP) provide pressure values that have traditionally been used to assess fluid volume status.

A 1-kg weight gain over 24 hours represents how many units of additional fluid retention? A. 10 mL B. 100 mL C. 1000 mL D. 2000 mL

Answer: C Rationale: A 1-kg weight gain over 24 hours represents 1000 mL (1 liter) of additional fluid retention.

The resorption that takes place in the proximal convoluted tubules is caused by active and passive transport. Which statement(s) is/are true concerning active and passive transport? A Diffusion is an active process that involves the movement of particles across a semipermeable membrane and is active. B Osmosis is a passive process that involves the movement of water across a semipermeable membrane and is passive. C Active transport requires the presence of adenosine triphosphate (ATP). D Only substances below the threshold in the plasma occur in the urine. E Transport maximum is the maximum rate at which substances can be resorbed.

B C E

A nurse is assessing a patient with end-stage kidney disease (ESKD) and notices that the patient's left cheek is twitching, the patient's gums are bleeding, and the patient is irritable. Which electrolyte disturbance should the nurse suspect the patient is experiencing? Hypernatremia Hyperkalemia Hypocalcemia Hypermagnesemia

AN additional influence on fluid and electrolyte regulation comes from the synthesis of ANP. This hormone is secreted from cells in the atria of the heart in response to which stimulus? A Hyperkalemia B Hypokalemia C Hypernatremia D Hyponatermia

An additional influence on fluid and electrolyte regulation comes from the synthesis of atrial natriuretic peptide (ANP). This hormone is secreted from cells in the atria of the heart in response to which condition? A Hyperkalemia B Hypokalemia C Hypernatremia D Hyponatermia

Hypophosphatemia is characterized by what clinical findings? A Vomiting, spasticity, altered mentation B Anorexia, decreased platelet aggregation, postural hypotension C Nausea, hemolytic anemia, depressed white cell function D Diarrhea, cardiac dysrhythmias, deep bone pain

The hemoglobin and hematocrit levels can indicate increases or decreases in intravascular fluid volume. If the hematocrit value is decreasing but the hemoglobin concentration remains constant, what is the most likely cause? A Fluid volume deficit B Fluid volume overload C Red blood cell, anemia D Liver Damage

The nurse is educating the patient on starting oral furosemide. Which of the following statements signifies that the teaching was successful? A "I must count my pulse before taking the medication each morning." B "I need to rinse my mouth after taking this drug." C "I need to get up slowly from a sitting or lying position." D "I need to avoid eating cheese and red wine with this medication."

16. When the nurse is taking a history for a patient who is a possible candidate for a kidney transplant, which information about the patient indicates that the patient is not an appropriate candidate for transplantation? a. The patient has metastatic lung cancer. b. The patient has poorly controlled type 1 diabetes. c. The patient has a history of chronic hepatitis C infection. d. The patient is infected with the human immunodeficiency virus.

ANS: A Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant.

22. A patient with renal failure reports all of the following during the medical history. Which is most likely to have precipitated the patients renal failure? a. Recent computed tomography of the brain with and without contrast b. A recent bout of congestive heart failure after an acute myocardial infarction c. Twice-daily prescription of Lasix 40 mg by mouth d. A recent bout of benign prostatic hypertrophy and transurethral resection of the prostate

ANS: A Intravenous contrast media can be nephrotoxic, especially with the patients pre-existing cardiac disease. The other choices, although possible causes, are less likely than the intravenous contrast media

18. What is a continuous venovenous hemodialysis filter permeable to? a. Electrolytes c. Protein b. Red blood cells d. Lipids

ANS: A A continuous venovenous hemodialysis filter is permeable to solutes such as urea, creatinine, uric acid, sodium, potassium, ionized calcium, and drugs not bound by proteins.

9. A patient who receives peritoneal dialysis is seen in the intensive care unit with a 3-day history of flulike symptoms, including muscle cramps and low blood pressure. Which complication of peritoneal dialysis is the most likely problem for this patient? a. Dehydration c. Fluid obstruction b. Peritonitis d. Hernias

ANS: A This patient has dehydration. This patient is showing signs and symptoms of muscle cramps and low blood pressure.

18. A 38-year-old patient who had a kidney transplant 8 years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone). Which assessment data will be of most concern to the nurse? a. The blood glucose is 144 mg/dL. b. There is a nontender axillary lump. c. The patient's skin is thin and fragile. d. The patient's blood pressure is 150/92.

ANS: B A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result of chronic immunosuppressive therapy. The elevated glucose, skin change, and hypertension are possible side effects of the prednisone and should be addressed, but they are not as great a concern as the possibility of a malignancy.

11. A patient has been hospitalized for a subtotal gastrectomy. After the procedure, an infection developed that eventually had to be treated with gentamicin, an aminoglycoside antibiotic. After 3 days of administration, oliguria occurred, and subsequent laboratory values indicated elevated BUN and creatinine levels. The patient is transferred to the critical care unit with acute tubular necrosis. Which dialysis method would be most appropriate for the patient's condition? a. Peritoneal dialysis b. Hemodialysis c. Continuous renal replacement therapy d. Continuous venovenous hemodialysis (CVVH)

16. The patient complains of a metallic taste and loss of appetite. The nurse is concerned that the patient has developed a. glycosuria. c. myoglobin. b. proteinuria. d. uremia.

15. A patient is admitted to the critical care unit in congestive heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The nurse is assessing the peripheral edema. The nurse presses two fingers over the tibial area, and it takes 1 minute before the indention disappears. The nurse would chart the following result: a. +1 pitting edema. c. +3 pitting edema. b. +2 pitting edema. d. +4 pitting edema.

ANS: C The pitting edema scale includes +1 = 2-mm depth; +2 = 4-mm depth (lasting up to 15 sec); +3 = 6-mm depth (lasting up to 60 sec); and +4 = 8-mm depth (lasting longer than 60 sec).

Blood enters the kidneys through the renal arteries, which branch bilaterally from the abdominal aorta. Because of this, the kidneys are highly vascular and receive approximately how much of the cardiac output? A 10% B 20% C 30% D 50%

The patient has a serum sodium level of 145 and potassium of 3.7. What is the approximate serum osmolality? A 293.7 mOsm/L B 290 mOsm/L C 141 mOsm/L D 153 mOsm/L

What is creatinine? a. A byproduct of protein and amino acid metabolism b. A byproduct of muscle and normal cell metabolism c. The concentration or dilution of vascular fluid and measures the dissolved particles in the serum d. Measures how well the kidneys remove creatinine in the urine

Answer: B Rationale: Blood urea nitrogen (BUN), also known as the serum urea, is a byproduct of protein and amino acid metabolism. Creatinine is a by-product of muscle and normal cell metabolism, and it appears in serum in amounts generally proportional to the body muscle mass. The serum osmolality reflects the concentration or dilution of vascular fluid and measures the dissolved particles in the serum. The creatinine clearance measures how well the kidneys remove creatinine in the urine.

A 56-year-old woman with type 2 diabetes mellitus and chronic kidney disease has a serum potassium level of 6.8 mEq/L. The nurse should assess the patient for A fatigue. B flank tenderness. C cardiac dysrhythmias. D elevated triglycerides.

C Hyperkalemia is the most serious electrolyte disorder associated with kidney disease.

Renin is converted to angiotensin I, which is further converted to angiotensin II as the blood circulates through the lungs. Angiotensin II is responsible for which pathophysiologic mechanism? A Afferent arteriole vasodilation B Decreased arterial blood pressure C Increased renin secretion D Increased systemic vascular resistance

The patient has a blood sugar level of 350 and an anion gap of 17. The nurse is aware that this is indicative of which disorder? A Respiratory acidosis B Metabolic alkalosis C Respiratory alkalosis D Metabolic acidosis

What is the physiologic effect of angiotensin II? A Afferent arteriole vasodilation? B Decreased arterial blood pressure? C Increased Renin D Increased Systemic vascular resistance ?

A frail 72-year-old woman with stage 3 chronic kidney disease is cared for at home by her family. The patient has a history of taking many over- the-counter medications. Which over-the-counter medications should the nurse teach the patient to avoid? A Aspirin B Acetaminophen (Tylenol) C Diphenhydramine (Benadryl) D Aluminum Hydroxide (Amphogel)

D client's with kidney disease are unable to excrete these substances. Some contain high levels of sodium that further increase B/P

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