Renal

20. Which urine specific gravity value would indicate to the nurse that the patient is receiving excessive IV fluid therapy? a. 1.002 b. 1.010 c. 1.025 d. 1.033

a. A urine specific gravity of 1.002 is low, indicating dilute urine and the excretion of excess fluid. Fluid overload, diuretics, or lack of ADH can cause dilute urine. Normal urine specific gravity is 1.003 to 1.030. A high urine specific gravity indicates concentrated urine that would be seen in dehydration.

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. Dialysate 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. The dialysate fluid has no potassium so that potassium will diffuse into the dialysate from the blood.

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. Pericarditis b. Hyperkalemia c. Fluid overload d. Hypernatremia

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

The nurse identifies that a patient with chronic kidney disease (CKD) is at risk for which electrolyte disturbance?

A patient with CKD has hyperphosphatemia due to a decrease in elimination of phosphate by the kidneys. Hyperkalemia, rather than hypokalemia, is a serious electrolyte disturbance that occurs in the patient with CKD. Hypernatremia, rather than hyponatremia, leads to hypertension and fluid retention in a patient with CKD. Hypocalcemia, not hypercalcemia, occurs in the later stages of CKD due to the inability to absorb calcium in the absence of active vitamin D.

The nurse is caring for a patient who was transferred to the emergency department with severe burns. The laboratory values reveal a serum creatinine level of 5.2 mg/dL, and the glomerular filtration rate (GFR) has decreased by 75%. Which stage of acute kidney failure is the patient exhibiting?

As per the RIFLE (Risk, Injury, Failure, Loss, and End-stage) classification for staging acute kidney injury, this patient is at the failure stage. The criterion for failure is that serum creatinine increased by three times or GFR decreased by 75% or a serum creatinine >4 mg/dL with acute rise ≥0.5 mg/dL. When the GFR has decreased by 25%, the patient is at the risk stage. The patient with a GFR that has decreased by 50% is at the injury stage. The patient with persistent acute kidney failure experiences a complete loss of kidney function and is at the loss stage.

. A patient reports reduced urine output and abdominal pain. The nurse suspects acute kidney injury and anticipates that which diagnostic test will be prescribed as an initial test to confirm the diagnosis?

Aside from blood tests, the health care provider will first order a kidney ultrasound because it does not involve exposure to contrast agents. A renal biopsy is the best method for confirmation of intrarenal causes of acute kidney injury; however, it is not the preliminary test used to diagnose acute kidney injury. A CT scan can identify lesions, masses, obstructions, and vascular anomalies, but it is not primarily used to establish a diagnosis of acute kidney injury. MRI will be suggested later to examine the abnormalities in detail.

The nurse identifies that a patient with acute kidney injury (AKI) has entered the diuretic phase when which assessment findings are noted? Select all that apply.

During the diuretic phase of AKI, daily urine output is usually around 1 to 3 L but may reach 5 L or more. The nephrons are still not fully functional even as urine output increases. The high urine volume is caused by osmotic diuresis from the high urea concentration in the glomerular filtrate and the inability of the tubules to concentrate the urine. In this phase, the kidneys have recovered their ability to excrete wastes but not to concentrate the urine. Hypovolemia can occur from massive fluid losses. Large losses of fluid and electrolytes require patient monitoring for hyponatremia, hypokalemia, and dehydration. The diuretic phase may last one to three weeks. Near the end of this phase, the patient's acid-base, electrolyte, and waste product (BUN, creatinine) values stabilize.

26. What nursing responsibilities are done to obtain a clean-catch urine specimen from a patient (select all that apply)? a. Use sterile container. b. Must start the test with full bladder. c. Insert catheter immediately after voiding. d. Have the patient void, stop, and void in container. e. Have the patient clean the meatus before voiding.

a, d, e. A clean-catch urine specimen is obtained in a sterile container after cleaning the meatus. The patient will void a small amount in the toilet, stop, and then void in the container to catch the urine midstream. The first morning specimen is best for a urinalysis. A full bladder is necessary for a urine flow study. A urinary catheter is inserted immediately after voiding to assess residual urine.

25. Priority Decision: Following a renal biopsy, what is the nurse's priority? a. Offer warm sitz baths to relieve discomfort. b. Test urine for microscopic bleeding with a dipstick. c. Expect the patient to experience burning on urination. d. Monitor the patient for symptoms of a urinary infection.

b. Bleeding from the kidney following a biopsy is the most serious complication of the procedure and urine must be examined for both gross and microscopic blood, in addition to vital signs and hematocrit levels being monitored. Following a cystoscopy, the patient may have burning with urination, and warm sitz baths may be used. Urinary infections are a complication of any procedure requiring instrumentation of the bladder

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 (GFR) c. Degree of altered mental status d. Serum creatinine and urea levels

b. Stages of CKD are based on the GFR. No specific markers of urinary output, mental status, or azotemia classify the seriousness of CKD.

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 contribute to prerenal AKI in this patient (select all that apply)? a Anaphylaxis b. Renal stones c. Hypovolemia d. Nephrotoxic drugs e. Decreased cardiac output

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 renal stones would be a postrenal cause of AKI.

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, partial pressure of carbon dioxide in arterial blood (PaCO2 ) 30 mm Hg, partial pressure of oxygen in arterial blood (PaO2 ) 86 mm Hg, HCO3 − 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 leve

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 temporarily shift the potassium back into the cells. A decrease in pH and the bicarbonate and partial pressure of carbon dioxide in arterial blood (PaCO2 ) levels would indicate worsening acidosis.

16. The patient with CKD is receiving dialysis, and the nurse observes excoriations on the patient's skin. What pathophysiologic changes in CKD most likely occur that 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 >200 mg/dL, which should not occur in a patient on dialysis; ureacrystallizes on the skin and also causes pruritus

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. Increased ammonia in saliva, from bacterial breakdown of urea, leads to stomatitis and mucosal ulcerations. Uremic fetor, or the urine odor of the breath, is caused by high urea content in the blood. 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.

D.B., a 46-year-old female, has CKD resulting from type 1 diabetes and hypertension. She underwent hemodialysis for 2 years and then received a deceased (cadaveric) renal transplant 1 year ago. She had 1 episode of acute rejection 3 months after transplant. Her baseline creatinine has been 1.2 to 1.3 mg/dL (106 to 115 mmol/L). She came to the clinic reporting decreased urinary output, fever, and tenderness at the transplant site. She is admitted to the hospital for testing and possible kidney biopsy 1. Explain the pathophysiology of acute rejection

1. The kidney is recognized as foreign and, as a foreign substance, stimulates activation of the immune system. T helper cells are activated to produce interleukin-2 (IL-2), and T cytotoxic lymphocytes are sensitized. After T cytotoxic lymphocytes proliferate, they attack the transplanted kidney, setting in process the activation of the inflammatory andcomplement systems. This usually occurs 4 days to 6 months after the transplant, but it may occur later. It is not uncommon to have at least 1 rejection episode

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

26. Which description accurately describes the care of the patient with CKD? a. Iron is a nutrient that is commonly supplemented for the patient on dialysis because it is dialyzable. 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 dialyzable nutrient supplemented for patients on dialysis is folic acid, although IV iron sucrose injections may be prescribed for anemia if the patient receives erythropoietin. 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 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 CKD 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 (PD) is less stressful for the cardiovascular system and requires fewer dietary restrictions. PD actually contributes to more protein loss and increased hyperlipidemia. The fluid and creatinine removal are slower with PD than hemodialysis (HD).

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 BP.

21. Priority Decision: After a patient had a renal arteriogram and is back on the clinical unit, what is the most important action by the nurse? a. Observe for gross bleeding in the urine. b. Place the patient in high Fowler's position. c. Monitor the patient for signs of allergy to the contrast mediumd. d. Assess peripheral pulses in the involved leg every 30 to 60 minutes

21. d. During a renal arteriogram, a catheter is inserted, most commonly in the femoral artery. Following the procedure, the patient is positioned with the affected leg extended with a pressure dressing applied. Peripheral pulse monitoring is essential to detect the development of thrombi around the insertion site, which may occlude blood supply to the leg. Gross bleeding in the urine is a complication of a renal biopsy. Allergy to the contrast medium should be established before the procedure

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

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

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 HD 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 HD occurs while the patient issleeping and is done up to 6 times per week. Continuous venovenous hemofiltration (CVVH) is a type of continuous RRT used to treat AKI. Continuous ambulatory peritoneal dialysis (CAPD) is dialysis that is done with exchanges of 2 to 3 L of dialysate at least 4 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. Exit site infection and peritonitis are common complications of 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 care 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 HD develops a thrombus of a subcutaneous arteriovenous graft (AVG), requiring its removal. While waiting for a replacement graft or fistula, the patient is most likely to have what done for treatment? a. PD b. Peripheral vascular access using radial artery c. Long-term cuffed 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 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. Because the patient has chosen HD, APD would not be started. The peripheral vessels and peripherally inserted central catheter (PICC) lines are not used for HD.

he nurse is preparing to perform peritoneal dialysis for a patient with chronic kidney disease. Which osmotic agent does the nurse obtain for the dialysis exchanges?

Dextrose is the most commonly used osmotic agent used in peritoneal dialysis. Normal saline solution is not used in peritoneal dialysis. Icodextrin and amino acid solutions are used as alternatives to dextrose.

The nursing instructor is teaching a nursing student about continuous renal replacement therapy (CRRT). Which statement by the student indicates effective learning?

CRRT is a physiologic therapy that simulates kidney function day and night. Several features of CRRT differ from HD. Fluid volume can be removed over days (24 hours to more than two weeks) versus hours (three to four hours). CRRT has a slower blood-flow rate than intermittent HD; the blood pump in CRRT runs at an average rate of 150 mL/min. CRRT involves the flow of blood from the body through a filter and carries an increased risk of clotting; thus an anticoagulant must be added. CRRT can be performed along with HD.

Patient-Centered Care: A 68-year-old man with a history of heart failure resulting from hypertension has AKI resulting from 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 bicarbonate (HCO3 − ) is 14 mEq/L (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 bicarbonated. d.Sodium polystyrene sulfonate (Kayexalate)

11. b. This patient has at least 3 of the 6 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 >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, c, and d), obstetric complications (c) cardiac failure (d) preexisting chronic kidney disease (CKD), 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 BP. c. Teach the patient to avoid high-potassium foods. d. Call the laboratory and request a redraw of the laboratory to verify results.

13. a. Dysrhythmias may occur with an elevated potassium level and are potentially lethal. Monitor the rhythm while contacting the HCP 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 must be monitored

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.

22. Which test is most specific for renal function? a. Renal scan b. Serum creatinine c. Creatinine clearance d. Blood urea nitrogen (BUN)

22. c. The rate at which creatinine is cleared from the blood and eliminated in the urine approximates the GFR and is the most specific test of renal function. The renal scan is useful in showing the location, size, and shape of the kidney and general blood perfusion. Serum creatinine is an end product of muscle and protein metabolism and may be elevated with body builders and decreased with older people. Blood urea nitrogen (BUN) can be altered with gastrointestinal (GI) bleeding, starvation, and hyper- or hypovolemia

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 sugars and starches (unless the patient is diabetic); hard candy is an appropriate snack and may help 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. What is the most likely reason that the BUN would be increased in a patient? a. Has impaired renal function b. Has not eaten enough protein c. Has decreased urea in the urine d. May have nonrenal tissue hypertrophy

23. a. BUN is increased in patients with renal problems. It may also be increased when there is rapid or extensive tissue damage from other causes. Very low protein intake may cause a low BUN

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. Both are used to treat hypertension. Nifedipine (Procardia) is a calcium channel blocker, and furosemide (Lasix) is a loop diuretic that can help decrease potassium

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

25. a, b, e. Cinacalcet (Sensipar), a calcimimetic agent to control secondary hyperparathyroidism; calcium acetate, a calcium-based phosphate binder, and sevelamer carbonate (Renvela), a non-calciumbased 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

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 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. Diabetes, hypertension, and acetaminophen overdose will not contribute to ATN.

34. A man with end-stage renal disease (ESRD) is scheduled for HD 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 may 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 2 lumens will be inserted into the fistula to send blood to and return it from the dialyzer

34. a. While patients are undergoing HD, they can perform quiet activities that do not require the limb that has the vascular access. BP is monitored frequently, and the dialyzer monitors dialysis function, but cardiac monitoring is not usually indicated. The HD machine continuously circulates both the blood and the dialysate past the semipermeable membrane in the machine. Graft and fistula access involve the insertion of 2 needles into the site: one to remove blood from and the other to return blood to the dialyzer. A double-lumen catheter is used for temporary access

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.

37. A patient rapidly progressing toward ESRD 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. Hepatitis B or C infection is not a contraindication. Coronary artery disease (CAD) may be treated with bypass surgery before transplantation, and transplantation can relieve hypertension

38. Priority Decision: During the immediate postoperative care of a recipient of a kidney transplant, what is a priority for the nurse 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 the priority 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 HCP should be notified. 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

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. Assessment of 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 in which urine output is <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 determine if the AKI has a prerenal, intrarenal, or postrenal cause by what is seen in the urine. With this patient's dehydration, it is thought to be prerenal to begin treatment

D.B., a 46-year-old female, has CKD resulting from type 1 diabetes and hypertension. She underwent hemodialysis for 2 years and then received a deceased (cadaveric) renal transplant 1 year ago. She had 1 episode of acute rejection 3 months after transplant. Her baseline creatinine has been 1.2 to 1.3 mg/dL (106 to 115 mmol/L). She came to the clinic reporting decreased urinary output, fever, and tenderness at the transplant site. She is admitted to the hospital for testing and possible kidney biopsy 5. Explain the long-term problems D.B. may face with a kidney transplan

5. Long-term problems include increased risk for infections and malignancies; increased risk for atherosclerosis, with CAD a major cause of death; joint necrosis from chronic corticosteroid therapy, if needed; psychologic adjustment (constant fear of rejection and wondering how long the transplant will last); and depression if there is failure and a return to dialysis.

5. Which statement accurately describes glomerular filtration rate (GFR)? a. The primary function of GFR is to excrete nitrogenous waste products. b. Decreased permeability in the glomerulus causes loss of proteins into theurine. c. The GFR is primarily dependent on adequate blood flow and adequate hydrostatic pressure. d. The GFR is decreased when prostaglandins cause vasodilation and increased renal blood flow.

5. c. GFR is primarily dependent on adequate blood flow and hydrostatic pressure. The glomerulus filters the blood. The GFR is the amount of blood filtered each minute by the glomeruli, which determines the concentration of urea in the blood. Increased permeability in the glomerulus from kidney diseases causes loss of proteins in the urine. The prostaglandins increase the GFR with increased renal blood flow

D.B., a 46-year-old female, has CKD resulting from type 1 diabetes and hypertension. She underwent hemodialysis for 2 years and then received a deceased (cadaveric) renal transplant 1 year ago. She had 1 episode of acute rejection 3 months after transplant. Her baseline creatinine has been 1.2 to 1.3 mg/dL (106 to 115 mmol/L). She came to the clinic reporting decreased urinary output, fever, and tenderness at the transplant site. She is admitted to the hospital for testing and possible kidney biopsy 6. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?

6. Nursing diagnoses • Fluid imbalance; Etiology: inability of kidney to excrete fluid • Anxiety; Etiology: threat of loss of kidney • Risk for infection; Etiology: suppressed immune system • Difficulty coping; Etiology: possible future need for dialysis Collaborative problems Potential complications: hypertension, hyperkalemia with dysrhythmias, hyperglycemia, metabolic acidosis, infection

6. A patient with an obstruction of the renal artery causing renal ischemia has hypertension. What factor may contribute to the hypertension? a. Increased renin release b. Increased ADH secretion c. Decreased aldosterone secretion d. Increased synthesis and release of prostaglandins

6. a. Renin is released in response to decreased arterial BP, renal ischemia, decreased extracellular fluid (ECF), decreased serum Na + concentration, and increased urinary Na + concentration. It is the catalyst of the renin-angiotensin-aldosterone system, which raises BP when stimulated. ADH is secreted by the posterior pituitary in response to serum hyperosmolality and low blood volume. Aldosterone is secreted only after stimulation by angiotensin II. Kidney prostaglandins lower BP by causing vasodilation.

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 (>40 mEq/L).

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

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

8. What are common diagnostic studies done for a patient with severe renal colic (select all that apply)? a. CT scan b. Urinalysis c. Cystoscopy d. Ureteroscopy e. Abdominal ultrasound

8. a, b, e. Testing would include urinalysis to see crystals and look for red blood cells. Abdominal ultrasound and CT scan may also be done to look for renal calculi

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 AK

The nurse provides education for a group of nursing students about cardiovascular problems associated with chronic kidney disease (CKD). The nurse explains that arterial stiffness is related to which event?

A patient with CKD may have arterial stiffness due to calcium deposition in the vascular smooth layer of the blood vessels. Excessive sodium retention causes extracellular fluid accumulation that leads to hypertension and edema. Decrease in the sodium bicarbonate level in the body leads to metabolic acidosis. Accumulation of the nitrogenous waste products leads to neurologic complications.

A patient with a glomerular filtration rate (GFR) of 30 mL/min has a hemoglobin of 5 g/dL. The peripheral smear tests show that the red blood cells are normocytic and normochromic. The nurse suspects that which physiologic change led to this condition?

A patient with a GFR of 30 mL/min has stage 3 chronic kidney disease (CKD). Normocytic normochromic anemia is common in patients with CKD due to reduced production of the erythropoietin hormone by the kidneys. Erythropoietin stimulates precursor cells in the bone marrow and helps in production of red blood cells. The patient with CKD may have a high serum potassium level, which can cause fatal dysrhythmias. An increase in extracellular fluid volume may lead to hypertension in patients with CKD. Metabolic acidosis may occur in CKD patients with defective reabsorption and regeneration of bicarbonate.

A patient with a glomerular filtration rate (GFR) of 35 mL/min develops dyspnea, excess fatigue, tachycardia, palpitations, and chest pain. The nurse expects which to be included in the plan for treatment?

A patient with a GFR of 35 mL/min has chronic kidney disease (CKD) and is at an increased risk for anemia due to decreased production of erythropoietin. The additional symptoms of dyspnea, excess fatigue, tachycardia, palpitations, and chest pain indicate symptomatic anemia, which requires a blood transfusion. Darbepoetin alfa is a long-acting erythropoietin (EPO) that is helpful to treat anemia for patients with CKD, but it is not a primary treatment option for symptomatic anemia. Supplemental folic acid (1 mg/day) is indicated for patients with hemodialysis because folic acid depletes during dialysis. A sodium ferric gluconate complex in sucrose injection is a supplement for a patient on hemodialysis.

Which statement made by a nursing student indicates effective learning about which intervention is included in a plan of care for a patient with chronic kidney disease who is taking gluconate and calcium acetate?

A patient with chronic kidney disease who is taking oral iron salts (such as ferrous gluconate) and phosphate binders (such calcium acetate) may develop constipation and need to take a stool softener. Dialysis does not provide relief from constipation in patients with chronic kidney disease. Oral iron supplements should not be given at the same time as calcium-containing phosphate binders because they prevent iron absorption. Sodium polystyrene sulfonate helps to treat hyperkalemia but does not provide relief from constipation.

Which electrolyte, if abnormal, can result in decreased mental status, absence of reflexes, and respiratory failure for this patient?

A patient with hypermagnesemia, or an increase in the level of magnesium in the body, may have absence of reflexes, decreased mental status, cardiac dysrhythmias, hypotension, and respiratory failure. Sodium retention contributes to edema, hypertension, and heart failure in a patient with chronic kidney disease. Patients with hypocalcemia are at an increased risk for fractures. Hyperkalemia, or abnormally high potassium levels, is a serious electrolyte disorder in a patient with chronic renal failure that can lead to fatal dysrhythmias.

The nurse identifies that which drug should be used with caution in a patient with renal failure?

A patient with renal failure has a reduced ability to eliminate metabolites and drugs. Therefore drugs like vancomycin, which are mainly excreted by the kidney, need to be used with caution and monitoring for accumulation and potential drug toxicity is necessary. Cinacalcet is a calcimimetic agent that helps to control secondary hyperparathyroidism. Paricalcitol is an active vitamin D supplement that helps to control elevated levels of parathyroid hormone and is used for treating secondary hyperparathyroidism in patients with end-stage chronic kidney disease. Gemfibrozil helps to reduce triglyceride levels and increases high-density cholesterol in patients with chronic kidney disease.

D.B., a 46-year-old female, has CKD resulting from type 1 diabetes and hypertension. She underwent hemodialysis for 2 years and then received a deceased (cadaveric) renal transplant 1 year ago. She had 1 episode of acute rejection 3 months after transplant. Her baseline creatinine has been 1.2 to 1.3 mg/dL (106 to 115 mmol/L). She came to the clinic reporting decreased urinary output, fever, and tenderness at the transplant site. She is admitted to the hospital for testing and possible kidney biopsy • Serum creatinine: 3.0 mg/dL (265 mmol/L) • BUN: 70 mg/dL (25 mmol/L) • Glucose: 404 mg/dL (22.4 mmol/L) • K + : 5.1 mEq/L (5.1 mmol/L) • HCO3 − : 18 mEq/L (18 mmol/L) 2. Identify the abnormal laboratory tests and explain why each would occur. What significance do the abnormal results have for nursing care?

All laboratory test results are abnormal, except potassium at high normal, and are typical of renal insufficiency that occurs during acute rejection: • Serum creatinine—decreased excretory function of kidneys • BUN—decreased ability of the kidney to excrete urea • Glucose—D.B. has diabetes, and the combination of this disease and the insulin resistance that occurs in CKD and stress response to the disease may be increasing the glucose levels. In addition, the corticosteroid therapy will increase glucose levels. • Potassium—decreased ability of the kidney to excrete potassium • Bicarbonate—impaired generation and reabsorption by the kidney, as it is being used to buffer acid load Nursing care includes monitoring for central nervous system (CNS) depression and skin and oral mucous breakdown from high urea; monitoring capillary blood glucose and administering insulin to keep glucose within normal range; monitoring for increasing weakness and cardiac changes related to hyperkalemia and for symptoms of metabolic acidosis, such as Kussmaul respirations

The nurse reviews laboratory tests that are prescribed for a patient with acute kidney injury. Which is the best indicator of renal function?

Creatinine is the best indicator of renal function. Creatinine is a waste product of the skeletal muscles and is excreted through the kidneys. In renal failure, the kidneys are unable to excrete creatinine, leading to a serum level greater than the normal range of 0.2 to 1.0 mL/dL. Potassium excretion and regulation are impaired in acute renal failure, and potassium may therefore be increased. However, potassium may be increased for reasons other than renal disease, whereas increased creatinine is specific to renal disease. BUN is also used to measure kidney function, but other disorders such as dehydration may cause an increase in BUN. ALT is related to liver dysfunction, not renal dysfunction

The nurse suspects that which electrolyte abnormality is a cause of cerebral edema in a patient with chronic kidney disease?

Damaged tubules cannot conserve sodium. Urinary sodium excretion may increase, resulting in normal or below-normal levels of serum sodium. Uncontrolled hyponatremia or water excess can lead to cerebral edema. Hyperkalemia can cause cardiac dysrhythmias. Hypermagnesemia may lead to absence of reflexes, decreased mental status, and hypotension. Hypophosphatemia can lead to bone weakness, fractures, and muscle damage.

A patient with chronic kidney failure is prescribed erythropoietin for treatment of anemia. The nurse would monitor the patient for indications of which adverse effect?

Erythropoietin is a hematopoietic agent that is prescribed for anemia in people with chronic kidney failure. Erythropoietin promotes erythropoiesis. An adverse effect of the medication is iron-deficiency anemia as a result of increased demand for iron to support erythropoiesis. Paralytic ileus is a side effect of sodium polystyrene sulfonate administered for the treatment of hyperkalemia. Hyperparathyroidism occurs in the patient with end-stage renal failure. Systemic lupus erythematosus leads to chronic renal failure.

A patient with kidney failure is scheduled for a diagnostic test in which a contrast media will be used. The nurse reviews the patient's history and notes diabetes and daily metformin use. The nurse reviews the patient's treatment plan and questions which item?

Having a diagnostic study with the contrast media gadolinium is not advised in patients with kidney failure. Giving gadolinium can be potentially fatal. In patients with kidney disease, contrast-induced nephropathy (CIN) can occur when contrast media for diagnostic studies causes nephrotoxic injury. In patients with diabetes receiving metformin, the drug should be held for 48 hours prior to and after the use of contrast media to decrease the risk for lactic acidosis. If contrast media must be given to a high-risk patient, the patient needs to have optimal hydration and the lowest possible dose of the contrast agent. Nursing interventions to ensure adequate fluid intake and hydration can decrease the risks associated with contrast media. After the procedure, blood tests are performed to evaluate kidney function, to determine the kidney's ability to eliminate the contrast from the body.

The nurse is notified that a patient with acute kidney injury has a very high potassium level. Which therapy does the nurse expect to be the most effective for this patient?

Hemodialysis is the most effective therapy for patients with hyperkalemia because it removes potassium ions in a short amount of time. Dietary restrictions are used to prevent recurrent elevations, but they are not used for acute elevations. Infusions of insulin and sodium bicarbonate are also beneficial but require more time to return the potassium levels to normal.

which mineral imbalance is ax w/ AKI?

Hyperkalemia is a complication associated with acute kidney injury. Foods rich in potassium will further increase the potassium level in the blood; these foods should not be included in the patient's diet plan. Foods rich in fiber do not cause any harm to the patient's health and can be included. There are no contraindications for patient with AKI to consume foods high in calcium or foods rich in carbohydrates.

A routine urinalysis for a patient with diabetes reveals moderate proteinuria. Which further tests help to identify decreased kidney function at an early stage? Select all that apply.

If routine urinalysis indicates moderate to severe proteinuria, the preferred way of determining kidney functions is by assessing the GFR. An ultrasound of the kidneys is usually done to detect any obstructions and to determine the size of the kidneys. A patient with diabetes needs to have a further examination of the urine for microalbuminuria. The patient may not have an increase in serum creatinine until there is a decrease of 50% or more in kidney function. MRA study with the contrast media gadolinium is generally not advised unless the ultrasound or CT does not provide the information needed.

D.B., a 46-year-old female, has CKD resulting from type 1 diabetes and hypertension. She underwent hemodialysis for 2 years and then received a deceased (cadaveric) renal transplant 1 year ago. She had 1 episode of acute rejection 3 months after transplant. Her baseline creatinine has been 1.2 to 1.3 mg/dL (106 to 115 mmol/L). She came to the clinic reporting decreased urinary output, fever, and tenderness at the transplant site. She is admitted to the hospital for testing and possible kidney biopsy 3. Explain the rationale for D.B.'s interprofessional care. How does each immunosuppressive medication work?

Immunosuppressive therapy is designed to reduce proliferation and action of T cytotoxic lymphocytes that are responsible for acute rejection. • Muromonab-CD3 (Orthoclone OKT3) is a monoclonal antibody that binds to CD3 receptors on T cells, causing cell lysis. It inhibits the function of T cells and is given via IV push to treat acute rejection. • Mycophenolate mofetil (CellCept) is a cytotoxic antiproliferative drug that inhibits purine synthesis and suppresses proliferation of T and B cells. • Methylprednisolone (Solu-Medrol) is a corticosteroid that suppresses inflammatory response. It inhibits cytokine production and T cell activation and proliferation. • Tacrolimus (Prograf) is a calcineurin inhibitor that prevents production and release of IL-2 and inhibits proliferation of T and B cells. Supportive therapy is designed to treat underlying disease and control the symptoms produced by renal insufficiency. • Furosemide (Lasix) is a loop diuretic that is not influenced by GFR and is used to promote sodium, potassium, and fluid loss through the kidney. It helps relieve hypervolemia and hypertension. Nifedipine (Procardia) is a calcium channel blocker that reduces cardiac output to control BP. • Sodium bicarbonate helps control the metabolic acidosis of renal insufficiency and replaces that which is not produced or reabsorbed by the kidney. • IV insulin will control the hyperglycemia resulting from diabetes and insulin resistance of CKD and/or corticosteroid use.

Which assessment finding is a consequence of the oliguric phase of acute kidney injury (AKI)?

In AKI, the serum potassium levels increase because the normal ability of the kidneys to excrete potassium is impaired. Impaired kidneys cannot excrete hydrogen ions or the acid products of metabolism. Serum bicarbonate (HCO3) production decreases from defective reabsorption and regeneration of HCO3 ions. The result is metabolic acidosis. Sodium levels are typically normal or diminished. Thrombocytopenia is not a consequence of AKI, although altered platelet function may occur in AKI.

A patient with chronic kidney disease is at risk for anemia. The nurse identifies that the events that lead to this condition occur in which order?

Increased PTH (made to compensate for low serum calcium levels) can inhibit erythropoiesis, shorten survival of RBCs, and cause bone marrow fibrosis, which can result in decreased numbers of hematopoietic cells.

The nurse reviews the plan of care for a patient in fluid volume overload due to chronic kidney disease. Furosemide and bumetanide have been ineffective. The nurse anticipates a prescription for which medication that is an osmotic diuretic?

Mannitol is an osmotic diuretic that promotes diuresis by increasing the concentration of filtrates in the kidney and blocking reabsorption of the water by the renal tubules. Chlorothiazide is a thiazide diuretic that inhibits the reabsorption of sodium (Na+) and chloride (Cl-) ions from the distal convoluted tubules. Ethacrynate is a loop diuretic that inhibits sodium (Na+), potassium (K+), and chloride (Cl-) reabsorption. Spironolactone is a potassium-sparing diuretic.

The nurse planning care for a patient with acute kidney injury (AKI) recognizes that the interventions of highest priority are directly related to which nursing diagnosis?

The issue of excess fluid volume is the primary problem of AKI and the highest priority for the nurse in this situation. When urine output decreases, fluid retention occurs. The severity of the manifestations depends on the extent of the fluid overload. In the case of reduced urine output (anuria and oliguria), the neck veins may become distended with a bounding pulse. Edema and hypertension may develop. Fluid overload can eventually lead to heart failure (HF), pulmonary edema, and pericardial and pleural effusions. The nursing diagnosis of ineffective coping is due to the acute severity of the illness. The nursing diagnosis of activity intolerance is related to the various AKI clinical manifestations. The nursing diagnosis of imbalanced nutrition, less than body requirements, is due to a decrease in appetite as a result of AKI

D.B., a 46-year-old female, has CKD resulting from type 1 diabetes and hypertension. She underwent hemodialysis for 2 years and then received a deceased (cadaveric) renal transplant 1 year ago. She had 1 episode of acute rejection 3 months after transplant. Her baseline creatinine has been 1.2 to 1.3 mg/dL (106 to 115 mmol/L). She came to the clinic reporting decreased urinary output, fever, and tenderness at the transplant site. She is admitted to the hospital for testing and possible kidney biopsy 4. What clinical manifestations may develop because of the increased immunosuppressive therapy? What nursing care is indicated?

Many side effects may occur from immunosuppressive therapy, but the most common is decreased resistance to infection and increased incidence of cancer because of depression of T cytotoxic lymphocytes. • Muromonab-CD3 causes fever, chills, dyspnea, chest pain, nausea, and vomiting. Anaphylactic reactions include pulmonary edema and cardiac or respiratory arrest. • Mycophenolate mofetil causes GI toxicity with diarrhea, nausea, and vomiting; neutropenia; thrombocytopenia; increased risks of infection and malignancy. • As a corticosteroid, methylprednisolone may cause Cushing syndrome with sodium and water retention, muscle weakness with protein wasting, hyperglycemia, hypertension, osteoporosis, delayed healing, easy bruising, and increased risk of infection. • Tacrolimus is nephrotoxic, hepatotoxic, and neurotoxic with headaches, seizures, and tremors; hypertension; hirsutism; leukopenia; gingival hyperplasia; and lymphoma. • Nursing care must include aseptic technique, thorough assessments, monitoring blood glucose, monitoring for and treatment of side effects; teaching patient and family about possible side effects and to report them

When assessing a patient with chronic kidney disease (CKD), the nurse recognizes that which neurologic change is common as the disease progresses?

Neurologic changes are expected as kidney disease progresses. They are the result of increased nitrogenous waste products, electrolyte imbalances, metabolic acidosis, and atrophy and demyelination of nerve fibers. The central nervous system (CNS) becomes depressed, resulting in lethargy, apathy, decreased ability to concentrate, fatigue, irritability, and altered mental ability. Anger, delirium, and restlessness are not commonly associated with CKD.

Which finding corresponds with nonoliguric acute kidney injury (AKI)

Nonoliguric AKI has a urine output greater than 400 mL/day. About 50% of patients with AKI will be nonoliguric, making the initial diagnosis more difficult. A urine output of less than 400 mL/day indicates oliguric AKI.

A patient with chronic kidney disease (CKD) experiences peripheral neuropathy, specifically asterixis. Which assessment finding does the nurse expect?

Peripheral neuropathy initially manifests as a slowing of nerve conduction to the extremities. Asterixis is a tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. This motor disorder is characterized by an inability to maintain a position, which is demonstrated by jerking movements of the outstretched hands when bent upward at the wrist. The patient may describe a burning sensation in the feet and legs, which are paresthesias. Asterixis is not bilateral foot drop or muscle jerking.

Which are complications of peritoneal dialysis? Select all that apply.

Peritoneal dialysis is removal of waste products from the body when kidneys no longer work adequately. The complications of peritoneal dialysis include hernias, peritonitis, and exit-site infection. Hernias are caused by increased intraabdominal pressure secondary to the dialysate infusion. Peritonitis results from contamination or from progression of an exit site or tunnel infection. Exit-site infection is caused by infection of the peritoneal catheter. Hepatitis and hypotension are complications of hemodialysis

The nurse preparing to administer a dose of calcium acetate to a patient with chronic kidney disease (CKD) recalls that the medication should have a beneficial effect on which laboratory value?

Phosphorus and calcium have inverse or reciprocal relationships, meaning that when phosphorus levels are high, calcium levels tend to be low. Therefore administration of calcium should help to reduce a patient's abnormally high phosphorus level, as seen with CKD. Calcium acetate will not affect sodium, potassium, or magnesium levels.

The nurse provides education for a group of nursing students about prerenal causes of acute kidney injury and includes which information

Prerenal oliguria is caused by a decrease in the circulatory volume due to dehydration and congestive cardiac failure. Parenchymal damage does not occur in prerenal oliguria. Prerenal azotemia results in decreased sodium excretion, which leads to increased sodium and water retention. Reduced systemic circulation is a prerenal cause that leads to a decrease in the blood flow to the kidneys. Therefore the glomerular filtration rate also decreases.

Which are postrenal causes of acute kidney injury? Select all that apply.

Renal calculi, spinal cord disease, and BPH are postrenal causes of acute kidney injury. Intrarenal causes of acute kidney injury include kidney ischemia and myoglobin released from muscle cells.

24. What impairment in kidney function would cause the following laboratory findings in a patient with kidney disease? Laboratory Finding Serum Ca 2 + : 7.2 mg/dL (1.8 mmol/L) Hemoglobin (Hgb): 9.6 g/dL (96 g/L) Serum creatinine: 3.2 mg/dL (283 mmol/L

Serum Ca 2 + : 7.2 mg/dL (1.8 mmol/L) Impaired conversion of inactive vitamin D to active vitamin D results in poor calcium absorption from the bowel, resulting in hypocalcemia. normal 8.6-10.3 mg/dL: 2.2-2.6 mmol/L Hgb: 9.6 g/dL (96 g/L) Loss of cells that produce erythropoietin results in lack of stimulation of bone marrow to produce RBCs. , normal 13.5 to 17.5 grams per deciliter Serum creatinine: 3.2 mg/dL (This serum creatinine level is high, indicating the loss of tubular secretion (passage of substances from the blood into the tubule) by the kidney.mmol/L) normal 0.7 to 1.2

A patient had the surgical creation of a subcutaneous arteriovenous fistula (AVF) for the administration of hemodialysis. The nurse monitors for which complication?

Surgical creation of AVF access for hemodialysis has several risks. These include distal ischemia (steal syndrome) and pain because too much arterial blood is being shunted or "stolen" from the distal extremity. Manifestations of steal syndrome are pain distal to the access site, numbness or tingling of fingers that may worsen during dialysis, and poor capillary refill. With an AVF, a bruit (rushing sound) is normal; it can be heard with a stethoscope. The thrill and bruit are created by arterial blood moving at a high velocity through the vein. The AVF is placed under the skin surface; bulging is expected. The AVF is designed to allow arterial blood to flow through the vein.

The nurse provides immediate postoperative care for a patient who received a kidney during transplant surgery. Which interventions does the nurse perform? Select all that apply.

The nurse caring for the kidney transplant recipient should record central venous pressure readings to monitor postoperative fluid status. The patient should be monitored for hyponatremia and hypokalemia, which are often associated with rapid diuresis. The health care provider should be notified in case of a sudden decrease in urine output in the early postoperative period; it may be due to dehydration, rejection, a urine leak, or obstruction. Urine output during this phase may be as high as 1 L/hr and may gradually decrease as the blood urea nitrogen (BUN) and serum creatinine levels return toward normal. Urine output is replaced with fluids mL for mL hourly for the first 12 to 24 hours. Dehydration must be avoided to prevent subsequent renal hypoperfusion and renal tubular damage.

what kind of protein diet should a renal pt follow?

The patient on peritoneal dialysis would ensure a protein intake of 1.2 to 1.3 g/kg/day. Pre-end stage renal disease patients should follow a low-protein diet. Patients on hemodialysis do not necessarily need to strictly monitor protein. Renal patients should not follow a high-protein diet.

The nurse provides education about maintenance hemodialysis (HD) for a group of nursing students and states that which is the leading cause of death for these patients?

The yearly death rate of patients receiving maintenance HD is around 19% to 24%. Cardiovascular disease (stroke, myocardial infarction [MI]) causes most deaths. Adaptation to maintenance HD varies considerably. At first, many patients feel positive about the dialysis because it makes them feel better and keeps them alive, but there is often great ambivalence about whether it is worthwhile. Dependence on a machine is a reality. In response to their illness, dialysis patients may be nonadherent or depressed and show suicidal tendencies. Infectious complications are the second leading cause of death. Respiratory complications are not the leading cause of death.

7. In which clinical situation would the increased release of erythropoietin be expected? a. Hypoxemia b. Hypotension c. Hyperkalemia d. Fluid overloa

a. Erythropoietin is released when the oxygen tension of the renal blood supply is low and stimulates production of red blood cells in the bone marrow. Hypotension causes activation of the renin-angiotensinaldosterone system, as well as release of ADH. Hyperkalemia stimulates the release of aldosterone from the adrenal cortex and fluid overload does not directly stimulate factors affecting the erythropoietin release by the kidney.

30. Number the following in the order of the phases of exchange in PD. Begin with 1 and end with 3. ______ a. Drain ______ b. Dwell ______ c. Inflow

c b a

21. The nurse identifies that a patient with CKD is at risk for fractures because of alterations in calcium and phosphorus metabolism. What is the pathologic process directly related to the increased risk for fractures? Number the processes beginning with 1 and ending with 6. ______ a. Bone remodeling causes weakened bone matrix ______ b. Bone demineralization for calcium and phosphate release ______ c. Decalcification of the bone and replacement of bone tissue with fibrous tissue ______ d. Impaired vitamin D activation resulting in decreased GI absorption of calcium ______ e. Increased release of parathyroid hormone in response to decreased calcium levels ______ f. Hyperphosphatemia decreases serum calcium levels and reduces kidney's vitamin D activation

d e b f a c

9. Patient-Centered Care: 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 (HCP)? 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 develops increasing muscle weakness and abdominal cramping.

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

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

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, 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.

10. In caring for the patient with AKI, of what should the nurse be aware? 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

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.