46: Acute Kidney Injury and Chronic Kidney Disease

22. A client who is 2 days post-femoral vein cannulation begins to have difficulty with outflow of blood during dialysis. For which complication does the nurse assess? a. Hematoma at cannula insertion site b. Infection c. Oliguria d. Skin necrosis at cannula insertion site

ANS: A The puncture site of the femoral vein is prone to hematoma formation because positioning the extremity can cause movement of the cannula and subsequent bleeding at the site. The hematoma can compress the cannula, decreasing flow through it. The other complications would not diminish outflow.

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

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.

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

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).

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.

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.

16. A client with chronic hypertension is seen in the clinic. Which assessment indicates that the client's hypertension is not under control? a. Heart rate of 55 beats/min b. Serum creatinine level of 1.9 mg/dL c. Blood glucose level of 128 mg/dL d. Irregular heart sounds

ANS: B Increased blood pressure damages the delicate capillaries in the glomerulus and eventually results in acute kidney injury. An elevated serum creatinine level is a manifestation of this. Heart rate, blood glucose level, and irregular heart sounds are not correlated with acute kidney injury.

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."

"The fluid draining from the catheter is cloudy." The primary clinical manifestation of peritonitis is a cloudy peritoneal effluent. Blood may be present in the effluent of women who are menstruating, and no intervention is indicated. Daily catheter care may include washing around the catheter with soap and water. Drain time may be facilitated by gently massaging the abdomen.

The nurse is attending to a patient who is receiving hemodialysis for chronic kidney disease. The nurse understands that hemodialysis is associated with complications. Which complications should the nurse be observant for in the patient? Select all that apply. 1) Hypotension 2) Renal calculi 3) Hepatitis type B 4) Bladder infection 5) Muscle cramp

1) Hypotension 3) Hepatitis type B 5) Muscle cramp The patient on hemodialysis may have decreased blood pressure due to rapid removal of blood. Hepatitis type B is a blood-borne infection, and hemodialysis poses a high risk for transmission of hepatitis B. Muscle cramps are a common complication of hemodialysis. Factors associated with the development of muscle cramps in hemodialysis include hypotension, hypovolemia, a high ultrafiltration rate (large interdialytic weight gain), and low-sodium dialysis solution. Hemodialysis does not increase the risk of development of renal calculi; people who are on bed rest or have low urine output may be at risk. Bladder infection is not related to dialysis. Text Reference - p. 1122

The nurse is attending to a patient who receives regular hemodialysis. When teaching the patient about nutritional therapy during hemodialysis, which food items should the nurse tell the patient to avoid? Select all that apply. 1) Pasta 2) Cereal 3) Bananas 4) Pickled tuna 5) Barbecued red meat

3) Bananas 4) Pickled tuna 5) Barbecued red meat Pasta and cereal have a good amount of carbohydrates and hence should be encouraged. Bananas are high in potassium, pickled tuna is high in protein and sodium, and barbecued red meat is high in protein, sodium, and potassium. Therefore, these foods are to be avoided in this patient. Text Reference - p. 1115

An ESRD patient receiving hemodialysis is considering asking a relative to donate a kidney for transplantation. In assisting the patient to make a decision about treatment, the nurse informs the patient that: A. successful transplantation usually provides a better quality of life than that offered by dialysis B. if rejection of the transplanted kidney occurs, no further treatment for the renal failure is available C. the immunosuppressive therapy that is required following transplantation causes fatal malignancies in many patients D. hemodialysis replaces the normal functioning of the kidneys and patients do not have to live with the continual fear of rejection

A

A 72-yr-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.

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.

A patient with end-stage kidney disease is receiving continuous ambulatory peritoneal dialysis. The patient has a fever and the nurse suspects that it is due to peritonitis. What are the other manifestations that the nurse should monitor the patient for? Select all that apply. A) Vomiting B) Abdominal pain C) Bloody stools D) Weight loss E) Cloudy peritoneal effluent

A) Vomiting, B) Abdominal Pain, E) Cloudy peritoneal effluent Peritonitis may manifest as vomiting due to the inflammatory process in the peritoneum. The patient may have pain in the abdomen due to peritoneal irritation caused by the inflammatory process in the peritoneum. The primary clinical manifestations of peritonitis are abdominal pain and cloudy peritoneal effluent with a white blood cell (WBC) count greater than 100 cells/μL (more than 50% neutrophils). An activated immune response may attract WBCs, and an elevated level of WBC in the peritoneal fluid indicates peritonitis. Bloody stool or weight loss is not associated with peritonitis. Peritonitis may not cause hemorrhage; therefore, bloody stools may not be present. Weight loss is usually caused by malnutrition or fluid loss and therefore may not be seen in peritonitis; weight gain may occur due to fluid retention. Text Reference - p. 1119

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

8. A client in the intensive care unit is started on continuous venovenous hemofiltration (CVVH). Which finding is the cause of immediate action by the nurse? a. Blood pressure of 76/58 mm Hg b. Sodium level of 138 mEq/L c. Potassium level of 5.5 mEq/L d. Pulse rate of 90 beats/min

ANS: A Hypotension can be a problem with CVVH if replacement fluid does not provide enough volume to maintain blood pressure. The specially trained nurse needs to monitor for ongoing fluid and electrolyte replacement. The sodium level is normal and the potassium level is slightly elevated, which could be normal findings for someone with acute kidney injury. A pulse rate of 90 beats/min is normal.

15. A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern? a. Albumin level of 2.5 g/dL b. Phosphorus level of 5 mg/dL c. Sodium level of 135 mmol/L d. Potassium level of 5.5 mmol/L

ANS: A Protein restriction is necessary with chronic renal failure due to the buildup of waste products from protein breakdown. The nurse would be concerned with the low albumin level since this indicates that the protein in the diet is not enough for the client's metabolic needs. The electrolyte values are not related to the protein-restricted diet.

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.

During a hot summer day, an older adult client tells the clinic nurse, "I am not drinking or voiding that much these days." The nurse notes a heart rate of 100 beats/min and a blood pressure of 90/60 mm Hg. Which action does the nurse take first? a. Give the client something to drink. b. Insert an intravenous catheter. c. Teach the client to drink 2 to 3 liters a day. d. Perform a bladder scan to assess urine volume.

ANS: A Severe blood volume depletion can lead to kidney failure, even in those who have no kidney problem. The client is showing signs of mild volume depletion. The first action the nurse should take is to give the client something to drink. After that, the nurse should teach the client to avoid dehydration by drinking at least 2 to 3 L of fluid daily. The client does not need an IV at this time. Performing a bladder scan will not help prevent or reverse the client's problem.

37. A client has end-stage kidney disease (ESKD). The nurse observes tall, peaked T waves on the client's cardiac monitor. Which action by the nurse is best? a. Check the serum potassium level. b. Document the finding in the client's chart. c. Prepare to give sodium bicarbonate. d. Call the health care provider to request an electrocardiogram (ECG).

ANS: A Tall, peaked T waves are a manifestation of hyperkalemia. Thus, the nurse should check the potassium level. Afterward, the nurse should report findings to the provider. The client may need an ECG, but treatment may be based on monitor tracings and potassium levels. Sodium bicarbonate is not warranted. Documentation is important but is not the priority.

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.

A client is scheduled to have dialysis in 30 minutes and is due for the following medications: vitamin C, B-complex vitamin, and cimetidine (Tagamet). Which action by the nurse is best? a. Give medications with a small sip of water. b. Hold all medications until after dialysis. c. Give the supplements, but hold the Tagamet. d. Give the Tagamet, but hold the supplements.

ANS: B All three medications are dialyzable, meaning that they will be removed by the dialysis. They should be given after the treatment is over.

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

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.

The nurse is providing a client with a peritoneal dialysis exchange. The nurse notes the presence of cloudy peritoneal effluent. Which action by the nurse is most appropriate? a. Document the finding in the client's chart. b. Collect a sample to send to the laboratory. c. Reposition the client on the left side. d. Increase the free water content in the next bag. .

ANS: B Cloudy or opaque effluent is an early sign of peritonitis. The nurse should collect and send a sample for culture. Then the nurse should document the finding. The other two options are not appropriate

Which nursing action for a patient who has arrived for a scheduled hemodialysis session is most appropriate for the RN to delegate to a dialysis technician? a. Educate patient about fluid restrictions. b. Check blood pressure before starting dialysis. c. Assess for reasons for 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.

20. The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse? a. "My sodium level changes by movement from the blood into the dialysate." b. "Dialysis works by movement of wastes from lower to higher concentration." c. "Extra fluid can be pulled from the blood by osmosis." d. "The dialysate is similar to blood but without any toxins."

ANS: B Dialysis works using the passive transfer of toxins by diffusion. Diffusion is the movement of molecules from an area of higher concentration to an area of lower concentration. The other statements show a correct understanding about hemodialysis.

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.

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.

A client has been missing some scheduled hemodialysis sessions. Which intervention is most important for the nurse to implement? a. Discussing with the client his or her acceptance of the disease b. Discussing with the client the option of peritoneal dialysis c. Rescheduling the sessions to another day or another time d. Stressing to the client the importance of going to the sessions

ANS: A Some people on dialysis retreat into complete or partial denial of the disease and the need for treatment. They may deny the need for dialysis and/or may not adhere to drug therapy and diet restrictions. Providing support as the client struggles to accept the disease is an important step in ensuring compliance with the dialysis regimen. The nurse should explore scheduling options, but missing so many sessions cues the nurse that a bigger problem than just scheduling is involved. The nurse should provide education, but simply stressing the need for dialysis will not help the client accept it. Peritoneal dialysis, with its technical demands on the client and partner, probably is not an option for a client who appears noncompliant with hemodialysis.

A client has end-stage kidney disease (ESKD). The nurse observes tall, peaked T waves on the client's cardiac monitor. Which action by the nurse is best? a. Check the serum potassium level. b. Document the finding in the client's chart. c. Prepare to give sodium bicarbonate. d. Call the health care provider to request an electrocardiogram (ECG).

ANS: A Tall, peaked T waves are a manifestation of hyperkalemia. Thus, the nurse should check the potassium level. Afterward, the nurse should report findings to the provider. The client may need an ECG, but treatment may be based on monitor tracings and potassium levels. Sodium bicarbonate is not warranted. Documentation is important but is not the priority.

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)

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).

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.

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

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

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).

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.

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.

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

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.

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)

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.

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

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.

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.

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 client has a serum creatinine level of 2 mg/dL and a urine output of 1000 mL/day. How does the nurse categorize the client's kidney injury? a. Intrarenal b. Nonoliguric c. Prerenal d. Postrenal

ANS: B Some clients have a nonoliguric form of acute renal failure (ARF), in which urine output remains near-normal but creatinine rises. The other categories relate to the cause of acute kidney injury.

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 patient's 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.

21. A client is receiving continuous arteriovenous hemofiltration (CAVH). Which laboratory value does the nurse monitor most closely? a. Hemoglobin b. Glomerular filtration rate c. Sodium d. White blood cells

ANS: C CAVH is used for clients who have fluid volume overload. It continuously removes large quantities of plasma, water, waste, and electrolytes, such as sodium. Fluid removal can also affect the serum sodium level.

A client is receiving continuous arteriovenous hemofiltration (CAVH). Which laboratory value does the nurse monitor most closely? a. Hemoglobin b. Glomerular filtration rate c. Sodium d. White blood cells

ANS: C CAVH is used for clients who have fluid volume overload. It continuously removes large quantities of plasma, water, waste, and electrolytes, such as sodium. Fluid removal can also affect the serum sodium level.

A client has been diagnosed with acute postrenal kidney injury. Which assessment finding does the nurse assess most carefully for? a. Blood urea nitrogen (BUN), 35 mg/dL b. Creatinine, 2.5 mg/dL c. Feeling of urgency d. Weight gain and edema

ANS: C Postrenal kidney failure is identified by focusing on urinary obstructive problems. Symptoms include changes in the urine stream or difficulty starting urination. All the other distractors can be seen with prerenal and intrarenal kidney injury.

Usually fluid replacement should be based on the patient's measured output plus 600 mL/day for insensible losseA patient in the oliguric phase of acute renal failure has a 24-hour fluid output of 150 mL emesis and 250 mL urine. The nurse plans a fluid replacement for the following day of ___ mL. a. 400 b. 800 c. 1000 d. 1400s.

ANS: C Usually fluid replacement should be based on the patient's measured output plus 600 mL/day for insensible losses.

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.

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 patient's 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

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)

Aluminum hydroxide (Amphogel) Antacids (that contain magnesium and aluminum) should be avoided because patients with kidney disease are unable to excrete these substances. Also, some antacids contain high levels of sodium that further increase blood pressure. Acetaminophen and aspirin (if taken for a short period of time) are usually safe for patients with kidney disease. Antihistamines may be used, but combination drugs that contain pseudoephedrine may increase blood pressure and should be avoided.

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

Assess skin turgor to determine hydration status. 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 performed. Indwelling catheter use should be avoided whenever possible to decrease the risk of infection.

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

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.

A 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. More protein is allowed because urea and creatinine are removed by dialysis. c. Dietary potassium is not restricted because the level is normalized by dialysis. d. Unlimited fluids are allowed because retained fluid is removed during dialysis.

B When 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.

A patient with a history of end-stage kidney disease secondary to diabetes mellitus has presented to the outpatient dialysis unit for his scheduled hemodialysis. Which assessments should the nurse prioritize before, during, and after his treatment? A.Level of consciousness B. Blood pressure and fluid balance C.Temperature, heart rate, and blood pressure D.Assessment for signs and symptoms of infection

Blood pressure and fluid balance Although all of the assessments are relevant to the care of a patient receiving hemodialysis, the nature of the procedure indicates a particular need to monitor the patient's blood pressure and fluid balance.

Measures indicated in the conservative therapy of chronic kidney disease include: A. decreased fluid intake, carbohydrate intake, and protein intake B. increased fluid intake, decreased carbohydrate intake and protein intake C. decreased fluid intake and protein intake, increased carbohydrate intake D. decreased fluid intake and carbohydrate intake, increased protein intake

C

To assess the patency of a newly places arteriovenous graft for dialysis, the nurse should: A. irrigate the graft daily with low-dose heparin B. monitor for any increase of BP in the affected arm C. listen with a stethoscope over the graft for presence of a bruit D. frequently monitor the pulses and neurovascular status distal to the graft

C

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

C 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.

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.

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.

Which action by a 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.

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.

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

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 is high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and cream is high in phosphate.

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 c. Cardiac rhythm b. Calcium level d. Neurologic status

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.

Which statement by a 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."

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.

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. 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.

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.

The patient has had type 1 diabetes mellitus for 25 years and is now reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse finds that the patient has newly developed hypertension and difficulty with blood glucose control. The nurse should know that which diagnostic study will be most indicative of chronic kidney disease (CKD) in this patient? A.Serum creatinine B.Serum potassium C.Microalbuminuria D.Calculated glomerular filtration rate (GFR)

Calculated glomerular filtration rate (GFR) The best study to determine kidney function or chronic kidney disease (CKD) that would be expected in the patient with diabetes is the calculated GFR that is obtained from the patient's age, gender, race, and serum creatinine. It would need to be abnormal for 3 months to establish a diagnosis of CKD. A creatinine clearance test done with a blood sample and a 24-hour urine collection is also important. Serum creatinine is not the best test for CKD because the level varies with different patients. Serum potassium levels could explain why the patient has an irregular heartbeat. The finding of microalbuminuria can alert the patient with diabetes about potential renal involvement and potentially failing kidneys. However, urine albumin levels are not used for diagnosis of CKD.

The physician has decided to use renal replacement therapy to remove large volumes of fluid from a patient who is hemodynamically unstable in the intensive care unit. The nurse should expect which treatment to be used for this patient? A.Hemodialysis (HD) 3 times per week B.Automated peritoneal dialysis (APD) C.Continuous venovenous hemofiltration (CVVH) D. Continuous ambulatory peritoneal dialysis (CAPD)

Continuous venovenous hemofiltration (CVVH) CVVH removes large volumes of water and solutes from the patient over a longer period of time by using ultrafiltration and convection. HD 3 times per week would not be used for this patient because fluid and solutes build up and then are rapidly removed. With APD (used at night instead of during the day) fluid and solutes build up during the day and would not benefit this patient as much. CAPD will not as rapidly remove large amounts of fluid as CVVH can do.

During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do for the patient? A.Administer hypertonic saline. B.Administer a blood transfusion C.Decrease the rate of fluid removal. D.administer antiemetic medications.

Decrease the rate of fluid removal. The patient is experiencing hypotension from a rapid removal of vascular volume. The rate and volume of fluid removal will be decreased, and 0.9% saline solution may be infused. Hypertonic saline is not used because of the high sodium load. A blood transfusion is not indicated. Antiemetic medications may help the nausea but would not help the hypovolemia.

The nurse knows the patient with AKI has entered the diuretic phase when what assessments occur (select all that apply)? A.Dehydration B.Hypokalemia C.Hypernatrimia D.BUN increases E.Serum Creatinine Increases

Dehydration, Hypokalemia Dehydration, hypokalemia, and hyponatremia occur in the diuretic phase of AKI because the nephrons can excrete wastes but not concentrate urine. Therefore the serum BUN and serum creatinine levels also begin to decrease.

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.

Restrict fluids based on urine output. Fluid intake is monitored during the oliguric phase. Fluid intake is determined by adding all losses for the previous 24 hours plus 600 mL. Potassium and protein intake may be limited in the oliguric phase to avoid hyperkalemia and elevated urea nitrogen. Hemodialysis, not peritoneal dialysis, is indicated in acute kidney injury if dialysis is needed.

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

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).

Which statement by the nurse regarding continuous ambulatory peritoneal dialysis (CAPD) would be of highest priority when teaching a patient new to this procedure? "It is essential that you maintain aseptic technique to prevent peritonitis." 2 "You will be allowed a more liberal protein diet once you complete CAPD." 3 "It is important for you to maintain a daily written record of blood pressure and weight." 4 "You will need to continue regular medical and nursing follow-up visits while performing CAPD."

"It is essential that you maintain aseptic technique to prevent peritonitis." Peritonitis is a potentially fatal complication of peritoneal dialysis, and thus it is imperative to teach the patient methods of preventing this from occurring by use of aseptic technique. Although the nurse will teach a patient he or she may be allowed more liberal protein, the importance of maintaining a weight and blood pressure record, and keeping follow-up appointments, these statements do not have the potential for morbidity and mortality as does peritonitis, thus making that statement of highest priority . Text Reference - p. 1119

Which statement by the nurse regarding continuous ambulatory peritoneal dialysis (CAPD) would be of highest priority when teaching a patient new to this procedure? A. "It is essential that you maintain aseptic technique to prevent peritonitis. B. "You will be allowed a more liberal protein diet once you complete CAPD." C."It is important for you to maintain a daily written record of blood pressure and weight." D."You will need to continue regular medical and nursing follow-up visits while performing CAPD."

"It is essential that you maintain aseptic technique to prevent peritonitis." Peritonitis is a potentially fatal complication of peritoneal dialysis, and thus it is imperative to teach the patient methods of preventing this from occurring. Although the other teaching statements are accurate, they do not have the potential for morbidity and mortality as does peritonitis, thus making that statement of highest priority.

A patient with chronic kidney disease is prescribed regular peritoneal dialysis (PD). What should the nurse inform the patient while teaching about PD? 1 Avoid high-protein diets. Take potassium supplements. 3 Restrict fluid intake, as in hemodialysis. 4 Avoid powdered breakfast drinks.

1 Avoid high-protein diets. The patient undergoing regular peritoneal dialysis (PD) does not need to restrict potassium intake; instead, this patient may be prescribed oral potassium supplementation because of hypokalemia caused by dialysis. The patient need not restrict protein diet or fluid intake. The patient should include enough protein in diet to compensate for loss of protein in dialysate. The patient may even take liquid or powdered breakfast drinks in case of inadequate protein intake. Patients on hemodialysis have a more restricted fluid intake than patients receiving peritoneal dialysis (PD). Text Reference - p. 1118

The nurse just received an urgent laboratory value on a patient in renal failure. The potassium level is 6.3. The telemetry monitor is showing peaked T waves. Which prescription from the primary health care provider should be implemented first? 1) Administer regular insulin intravenously (IV) 2) Restrict dietary potassium intake to 40 meq daily 3) Administer kayexalate enema 4) Educate the patient on dietary restriction of potassium

1) Administer regular insulin intravenously (IV) This patient is showing signs of hyperkalemia, which could be fatal and lead to myocardial damage. Regular insulin IV is needed to quickly force potassium into the cells. The kayexalate enema will take too long to excrete the potassium. Restricting oral intake and educating the patient will be needed when the crisis has resolved. Text Reference - p. 1112

The nurse is attending to a patient who is undergoing peritoneal dialysis. The dialysate solution is being infused to the patient. The nurse finds that the patient is developing symptoms of respiratory distress. What nursing interventions are necessary to prevent further respiratory complications? Select all that apply. 1) Auscultate the lungs. 2) Frequently reposition the patient. 3) Promote deep-breathing exercises. 4) Increase the rate of infusion of the dialysate. 5) Place the patient in a low Fowler's position.

1) Auscultate the lungs. 2) Frequently reposition the patient. 3) Promote deep-breathing exercises. Auscultation is very important to find the cause of respiratory distress. Decreased areas of ventilation suggest the presence of atelectasis, whereas adventitious sounds may suggest fluid overload, retained secretions, or infection. Frequent positioning will promote equal ventilation to all parts of the lungs. Deep-breathing exercises could help to promote proper expansion of lungs. Rapid infusion would cause more pressure on the diaphragm. The patient should be placed in the semi-Fowler's position for peritoneal dialysis; this allows inflow of fluid while not impinging on the thoracic cavity. Text Reference - p. 1119

A patient has end-stage kidney disease and is receiving hemodialysis. During dialysis the patient complains of nausea and a headache and appears confused. On examination, the nurse finds that the blood pressure is very low. What should the nurse do? Select all that apply. 1) Decrease the volume of fluids being removed. 2) Infuse 0.9% saline solution. 3) Infuse hypertonic glucose solution. 4) Avoid excess coagulation. 5) Transfuse blood, as ordered.

1) Decrease the volume of fluids being removed. 2) Infuse 0.9% saline solution. Hypotension is a complication of hemodialysis and may manifest as headache and nausea. The nurse should try to keep the intravascular volume adequate by decreasing the volume of fluids being removed and infusing 0.9% saline solution. Hypertonic glucose solutions are infused if the patient gets muscle cramps. Excess coagulation is avoided if the patient has blood loss. Blood is transfused if the patient has blood loss. Text Reference - p. 1122

Which process involves movement of fluid and molecules across a semipermeable membrane from one compartment to another? 1) Dialysis 2) Osmosis 3) Diffusion 4) Ultrafiltration

1) Dialysis Dialysis is the movement of fluid and molecules across a semipermeable membrane from one compartment to another. Substances move from the blood through a semipermeable membrane and into a dialysis solution in this process. Osmosis is the movement of fluid from an area of lesser concentration to an area of greater concentration of solutes. Diffusion is the movement of solutes from an area of greater concentration to an area of lesser concentration. Ultrafiltration occurs when there is a pressure gradient across the membrane. Text Reference - p. 1117

A nurse is delivering a lecture on organ donation. She is explaining about the selection criteria for kidney donors. What are the donor characteristics that the nurse should discuss with the group? Select all that apply. 1) Donors should not have diabetes. 2) Donors should be a first-degree relative of a recipient. 3) Donors should be approximately the same body size as the recipient. 4) Donors must have ABO compatibility with the recipient. 5) The donor and recipient should have matching leukocyte antigen complexes

1) Donors should not have diabetes. 4) Donors must have ABO compatibility with the recipient. 5) The donor and recipient should have matching leukocyte antigen complexes Diabetes is a major predisposing factor for development of kidney disease; hence, the donor should not be a diabetic. ABO compatibility is necessary for being a donor, although the exact blood type is not necessary. Human leukocyte antigen compatibility provides the most specific predictions of the body's tendency to accept or reject foreign tissue. Being a member of the same family is unsafe unless the family member has matching leukocyte antigen complexes. Being a member of the same family may increase the possibility of a match, but there is no guarantee that a family member will match. Differences in body size do not cause problems. Text Reference - p. 1124

When obtaining a health history for the patient with chronic kidney disease, the nurse notes the following medications on the patient's medication list. The patient will need further education on which medication? 1) Ibuprofen 2) Tylenol 3) Calcium supplements 4) PhosLo

1) Ibuprofen Ibuprofen, and other nonsteroidal anti-inflammatory drugs (NSAIDS), will cause further damage to the kidneys. Chronic kidney disease (CKD) patients should be taking Tylenol as prescribed for pain. CKD patients also could be consuming calcium supplements and PhosLo tablets as prescribed by the health care provider. Text Reference - p. 1107

Which continuous renal replacement therapy requires no fluid replacement? 1) Slow continuous ultrafiltration 2) Continuous venovenous hemodialysis 3) Continuous venovenous hemofiltration 4) Continuous venovenous hemodiafiltration

1) Slow continuous ultrafiltration Slow continuous ultrafiltration is a simplified version of continuous venovenous hemofiltration. No fluid replacement is required in this process. Continuous venovenous hemodialysis removes both fluids and solutes and requires both dialysate and replacement fluid. Continuous venovenous hemofiltration removes both fluids and solutes and requires replacement fluid. Continuous venovenous hemodiafiltration removes both fluids and solutes and requires both dialysate and replacement fluid. Text Reference - p. 1123

The nurse is attending to a patient who has received a kidney transplant. What parameters would indicate a successful transplant? Select all that apply. 1) The specific gravity of urine increases. 2) High blood pressure is corrected. 3) Serum potassium levels are elevated. 4) Serum creatinine levels are decreased. 5) Blood sodium levels are decreased

2) High blood pressure is corrected. 4) Serum creatinine levels are decreased. 5) Blood sodium levels are decreased The patient with end-stage kidney disease may have hypertension due to fluid retention; the hypertension is corrected after a successful transplant through adequate urine output. The serum creatinine levels decrease as the transplanted kidney starts eliminating the nitrogenous wastes. After the transplant, the sodium levels should be corrected as the fluid balance returns to normal. As more urine is produced by the transplanted kidney, the specific gravity and concentration of the urine will decrease. Following a transplant, the serum potassium levels are corrected as fluid balance is restored. Text Reference - p. 1127

Diffusion, osmosis, and ultrafiltration occur in both hemodialysis and peritoneal dialysis. The nurse should know that ultrafiltration in peritoneal dialysis is achieved by which method? 1) Increasing the pressure gradient 2) Increasing osmolality of the dialysate 3) Decreasing the glucose in the dialysate 4) Decreasing the concentration of the dialysate

2) Increasing osmolality of the dialysate Ultrafiltration in peritoneal dialysis is achieved by increasing the osmolality of the dialysate with additional glucose. In hemodialysis the increased pressure gradient from increased pressure in the blood compartment or decreased pressure in the dialysate compartment causes ultrafiltration. Decreasing the concentration of the dialysate in either peritoneal or hemodialysis will decrease the amount of fluid removed from the blood stream. Text Reference - p. 1118

A nurse has to determine the volume of fluid that must be administered to the patient with acute renal failure who is in the oliguric phase. The total urine output of the patient the previous day was 250 mL. What should be the fluid allocation for this patient on this day? Record your answer using a whole number. __ mL

250 + 600 = 850 mL The patient is at a risk of developing hypovolemia, and to prevent this, adequate fluid resuscitation should be done. To determine the volume for fluid resuscitation, the nurse adds together all losses during the previous 24 hours (e.g., urine, diarrhea, emesis, blood) and adds 600 mL for insensible losses (e.g., respiration, diaphoresis). Text Reference - p. 1105

The physician has decided to use renal replacement therapy to remove large volumes of fluid from a patient who is hemodynamically unstable in the intensive care unit. The nurse should expect which treatment to be used for this patient? 1) Hemodialysis (HD) three times per week 2) Automated peritoneal dialysis (APD) 3) Continuous venovenous hemofiltration (CVVH) 4) Continuous ambulatory peritoneal dialysis (CAPD)

3) Continuous venovenous hemofiltration (CVVH) CVVH removes large volumes of water and solutes from the patient over a longer period of time by using ultrafiltration and convection. HD three times per week would not be used for this patient because fluid and solutes build up and then are removed rapidly. With APD (used at night instead of during the day) fluid and solutes build up during the day and would not benefit this patient as much. CAPD will not remove as rapidly large amounts of fluid as CVVH can do. Text Reference - p. 1123

A nurse is explaining the warning signs of organ rejection to a patient who had a kidney transplant. What are the signs of rejection that the nurse should explain to the patient? Select all that apply. 1) Weight loss 2) Subnormal temperature 3) Elevated blood pressure 4) Reduction in the amount of urine 5) Pain over the transplant site

3) Elevated blood pressure 4) Reduction in the amount of urine 5) Pain over the transplant site Hypertension is caused by hypervolemia because of the failure of the new kidney. A reduction in the amount of urine produced indicates ineffective functioning of the kidney. Pain in the site of transplant could be caused by any underlying kidney pathology, which could be a result of rejection. Weight gain, not loss, occurs with a rejection of the kidney because of fluid retention. The patient will have an elevated temperature exceeding 100°F with kidney rejection. Text Reference - p. 1127

The nurse reviews a plan of care for a patient with diagnosis of chronic kidney disease who is undergoing hemodialysis. Which part of the plan should the nurse question? 1) 2-g sodium diet 2) Oxygen via nasal cannula at 4 L/min 3) Furosemide (Lasix) 40 mg PO twice a day 4) IV of 0.9% sodium chloride at 125 mL/hour

4) IV of 0.9% sodium chloride at 125 mL/hour A patient with chronic kidney disease (CKD) should receive limited fluids because the kidneys are unable to remove excessive water. An IV solution of 0.9% sodium chloride at a rate of 125 mL/hr places this patient at high risk for complications such as fluid overload, electrolyte imbalance, and hypertension. A 2-g sodium diet, oxygen, and furosemide (Lasix) would be appropriate if prescribed for a patient with CKD. Text Reference - p. 1115

When caring for a patient during the oliguric phase of acute kidney injury (AKI), what is an appropriate nursing intervention? 1) Weigh patient three times weekly 2) Increase dietary sodium and potassium 3) Provide a low-protein, high-carbohydrate diet 4) Restrict fluids according to previous daily loss

4) Restrict fluids according to previous daily loss Patients in the oliguric phase of acute kidney injury will have fluid volume excess with potassium and sodium retention. Therefore, they will need to have dietary sodium, potassium, and fluids restricted. The patient also should be weighed daily, not just three times each week. Daily fluid intake is based on the previous 24-hour fluid loss (measured output plus 600 mL for insensible loss). The diet also needs to provide adequate, not low, protein intake to prevent catabolism. Text Reference - p. 1107

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?

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).

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.

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.

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).

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.

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.

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.

Which patient should be taught preventive measures for CKD by the nurse because this patient is most likely to develop CKD? A.A 50-year-old white female with hypertension B.A 61-year-old Native American male with diabetes C.A 40-year-old Hispanic female with cardiovascular disease D.A 28-year-old African American female with a urinary tract infection

A 61-year-old Native American male with diabetes It is especially important for the nurse to teach CKD prevention to the 61-year-old Native American with diabetes. This patient is at highest risk because diabetes causes about 50% of CKD. This patient is the oldest, and Native Americans with diabetes develop CKD 6 times more frequently than other ethnic groups. Hypertension causes about 25% of CKD. Hispanics have CKD about 1.5 times more than non-Hispanics. African Americans have the highest rate of CKD because hypertension is significantly increased in African Americans. A UTI will not cause CKD unless it is not treated or UTIs occur recurrently.

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. Restrict fluid intake to 1000 mL daily. c. Take phosphate binders with each meal. d. Choose high-protein foods for most meals. e. Have several servings of dairy products daily.

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 not limited unless weight and blood pressure are notmcontrolled. Dairy products are high in phosphate and usually are limited.

A client with acute kidney injury had normal assessments 1 hour ago. Now the nurse finds that the client's respiration rate is 44 breaths/min and the client is restless. Which assessment does the nurse perform? a. Obtain an oxygen saturation level. b. Send blood for a creatinine level. c. Assess the client for dehydration. d. Perform a bedside blood glucose.

ANS: A A complication of acute kidney injury is pulmonary edema. Manifestations of this include tachypnea; frothy, blood-tinged sputum; and tachycardia, anxiety, and crackles. The nurse needs to obtain an oxygen saturation, listen to the client's lungs, and notify the health care provider, so that treatment can be started. The other interventions are not helpful.

A client is admitted to the hospital with a serum creatinine level of 2 mg/dL. When taking the client's history, which question does the nurse ask first? a. "Do you take any nonprescription medications?" b. "Does anyone in your family have kidney disease?" c. "Do you have yearly blood work done?" d. "Is your diet low in protein?"

ANS: A Acute renal failure can be caused by certain medications considered to have a nephrotoxic effect, such as NSAIDs and acetaminophen. Asking the client whether he or she takes any nonprescription drugs can help determine which medication(s) might have contributed to the problem. A family history is important but is not as vital as assessing for nephrotoxic agents that the client may have ingested. Yearly blood work might reveal a trend in kidney function, but again would not be as important. A diet low in protein would not be an important factor to assess.

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.

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

Which client is most at risk for developing postrenal kidney failure? a. Client diagnosed with renal calculi b. Client with congestive heart failure c. Client taking NSAIDs for arthritis pain d. Client recovering from glomerulonephritis

ANS: A Causes of postrenal kidney failure include disorders that obstruct the flow of urine, such as renal calculi. Heart failure can lead to prerenal failure, which is due to decreased blood flow to the kidneys. Both NSAIDs and glomerulonephritis can damage the kidney, leading to intrarenal failure.

When evaluating the effects of a low-protein diet in a client with chronic kidney disease, the nurse is most concerned with which result? a. Albumin level of 2 g/dL b. Calcium level of 8.0 mg/dL c. Potassium level of 5.2 mmol/L d. Magnesium level of 3 mEq/L

ANS: A Clients with chronic kidney disease are placed on a low-protein diet. However, decreased serum albumin levels indicate that the protein they are taking in is not enough for their metabolic needs. The electrolyte levels in the other options are not related to protein

18. When evaluating the effects of a low-protein diet in a client with chronic kidney disease, the nurse is most concerned with which result? a. Albumin level of 2 g/dL b. Calcium level of 8.0 mg/dL c. Potassium level of 5.2 mmol/L d. Magnesium level of 3 mEq/L

ANS: A Clients with chronic kidney disease are placed on a low-protein diet. However, decreased serum albumin levels indicate that the protein they are taking in is not enough for their metabolic needs. The electrolyte levels in the other options are not related to protein.

24. Which response by a client indicates an understanding of measures to facilitate the flow of peritoneal dialysate fluid? a. "I will take my stool softeners every day." b. "I will keep the drainage bag at the level of my abdomen." c. "Flushing the catheter is needed with each exchange." d. "Warmed dialysate infusion increases the speed of flow."

ANS: A Constipation is the primary cause of inflow and outflow problems. To prevent constipation, clients are placed on a bowel regimen before placement of a peritoneal catheter. The drainage bag should be lower than the abdomen. Warming the fluid helps prevent discomfort during the procedure. Flushing the catheter will not facilitate the flow of dialysate.

Which response by a client indicates an understanding of measures to facilitate the flow of peritoneal dialysate fluid? a. "I will take my stool softeners every day." b. "I will keep the drainage bag at the level of my abdomen." c. "Flushing the catheter is needed with each exchange." d. "Warmed dialysate infusion increases the speed of flow."

ANS: A Constipation is the primary cause of inflow and outflow problems. To prevent constipation, clients are placed on a bowel regimen before placement of a peritoneal catheter. The drainage bag should be lower than the abdomen. Warming the fluid helps prevent discomfort during the procedure. Flushing the catheter will not facilitate the flow of dialysate.

16. The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates more teaching is needed? a. "I am thrilled that I can continue to eat fast food." b. "I will cut out bacon with my eggs every morning." c. "My cooking style will change by not adding salt." d. "I will probably lose weight by cutting out potato chips."

ANS: A Fast food restaurants usually serve food that is high in sodium. This statement indicates that more teaching needs to occur. The other statements show a correct understanding of the teaching.

12. A client is taking furosemide (Lasix) 40 mg/day for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best? a. Obtain daily weights of the client. b. Auscultate heart and breath sounds. c. Palpate the client's abdomen. d. Assess the client's diet history.

ANS: A Furosemide (Lasix) is a loop diuretic that helps reduce fluid overload and hypertension in clients with early stages of CKD. One kilogram of weight equals about 1 liter of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication. Heart and breath sounds should be assessed if there is fluid retention, as in heart failure. Palpation of the client's abdomen is not necessary, but the nurse should check for edema. The diet history of the client would be helpful to assess electrolyte replacement since potassium is lost with this diuretic, but this does not assess the effect of the medication.

6. During a hot summer day, an older adult client tells the clinic nurse, "I am not drinking or voiding that much these days." The nurse notes a heart rate of 100 beats/min and a blood pressure of 90/60 mm Hg. Which action does the nurse take first? a. Give the client something to drink. b. Insert an intravenous catheter. c. Teach the client to drink 2 to 3 liters a day. d. Perform a bladder scan to assess urine volume.

ANS: A Severe blood volume depletion can lead to kidney failure, even in those who have no kidney problem. The client is showing signs of mild volume depletion. The first action the nurse should take is to give the client something to drink. After that, the nurse should teach the client to avoid dehydration by drinking at least 2 to 3 L of fluid daily. The client does not need an IV at this time. Performing a bladder scan will not help prevent or reverse the client's problem.

11. A client has been missing some scheduled hemodialysis sessions. Which intervention is most important for the nurse to implement? a. Discussing with the client his or her acceptance of the disease b. Discussing with the client the option of peritoneal dialysis c. Rescheduling the sessions to another day or another time d. Stressing to the client the importance of going to the sessions

ANS: A Some people on dialysis retreat into complete or partial denial of the disease and the need for treatment. They may deny the need for dialysis and/or may not adhere to drug therapy and diet restrictions. Providing support as the client struggles to accept the disease is an important step in ensuring compliance with the dialysis regimen. The nurse should explore scheduling options, but missing so many sessions cues the nurse that a bigger problem than just scheduling is involved. The nurse should provide education, but simply stressing the need for dialysis will not help the client accept it. Peritoneal dialysis, with its technical demands on the client and partner, probably is not an option for a client who appears noncompliant with hemodialysis.

A client with acute kidney injury is placed on a fluid restriction. To determine whether outcomes related to fluid balance are being met, the nurse assesses for which finding? a. Absence of lung crackles b. Decreased serum creatinine level c. Decreased serum potassium level d. Increased muscle strength

ANS: A The client with chronic kidney disease is expected to achieve and maintain an acceptable fluid balance. Fluid restriction helps with this outcome. Absence of lung crackles can indicate that the client is not fluid overloaded. The other options are not related to fluid balance.

27. A client's temperature after dialysis is 99° F (37.2° C) and was normal before dialysis. Which is the nurse's best action? a. Continue to monitor the temperature. b. Encourage the client to drink fluids. c. Obtain a white blood cell count. d. Prepare to culture the fistula site.

ANS: A The client's temperature may be elevated because the dialysis machine warms the blood slightly. An excessive temperature elevation from baseline can signal sepsis. The nurse should inform the provider and obtain blood cultures if this happens. The other actions are not needed.

A client's temperature after dialysis is 99° F (37.2° C) and was normal before dialysis. Which is the nurse's best action? a. Continue to monitor the temperature. b. Encourage the client to drink fluids. c. Obtain a white blood cell count. d. Prepare to culture the fistula site.

ANS: A The client's temperature may be elevated because the dialysis machine warms the blood slightly. An excessive temperature elevation from baseline can signal sepsis. The nurse should inform the provider and obtain blood cultures if this happens. The other actions are not needed.

11. A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse? a. Discuss what the treatment regimen means to him. b. Refer the client to a mental health nurse practitioner. c. Reschedule the appointments to another date and time. d. Discuss the option of peritoneal dialysis.

ANS: A The initial action for the nurse is to assess anxiety, coping styles, and the client's acceptance of the required treatment for CKD. The client may be in denial of the diagnosis. While rescheduling hemodialysis appointments may help, and referral to a mental health practitioner and the possibility of peritoneal dialysis are all viable options, assessment of the client's acceptance of the treatment should come first.

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 patient's 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.

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.

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.

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.

6. A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse? a. Place the client on a cardiac monitor immediately. b. Teach the client to limit high-potassium foods. c. Continue to monitor the client's intake and output. d. Ask to have the laboratory redraw the blood specimen.

ANS: A The priority action by the nurse should be to check the cardiac status with a monitor. High potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.

A client who is 2 days post-femoral vein cannulation begins to have difficulty with outflow of blood during dialysis. For which complication does the nurse assess? a. Hematoma at cannula insertion site b. Infection c. Oliguria d. Skin necrosis at cannula insertion site

ANS: A The puncture site of the femoral vein is prone to hematoma formation because positioning the extremity can cause movement of the cannula and subsequent bleeding at the site. The hematoma can compress the cannula, decreasing flow through it. The other complications would not diminish outflow.

3. A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mL/dL. What question should the nurse ask first when taking this client's history? a. "Have you been taking any aspirin, ibuprofen, or naproxen recently?" b. "Do you have anyone in your family with renal failure?" c. "Have you had a diet that is low in protein recently?" d. "Has a relative had a kidney transplant lately?"

ANS: A There are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the client since both the serum creatinine and BUN are elevated, indicating some renal problems. A family history of renal failure and kidney transplantation would not be part of the questioning and could cause anxiety in the client. A diet high in protein could be a factor in an increased BUN.

18. A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best? a. Check the client's digoxin (Lanoxin) level. b. Administer an anti-nausea medication. c. Ask if the client is able to eat crackers. d. Get a referral to a gastrointestinal provider.

ANS: A These signs and symptoms are indications of digoxin (Lanoxin) toxicity. The nurse should check the level of this medication. Administering antiemetics, asking if the client can eat, and obtaining a referral to a specialist all address the client's symptoms but do not lead to the cause of the symptoms.

2. A marathon runner comes into the clinic and states "I have not urinated very much in the last few days." The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority? a. Give the client a bottle of water immediately. b. Start an intravenous line for fluids. c. Teach the client to drink 2 to 3 liters of water daily. d. Perform an electrocardiogram.

ANS: A This athlete is mildly dehydrated as evidenced by the higher heart rate and lower blood pressure. The nurse can start hydrating the client with a bottle of water first, followed by teaching the client to drink 2 to 3 liters of water each day. An intravenous line may be ordered later, after the client's degree of dehydration is assessed. An electrocardiogram is not necessary at this time.

6. A client is undergoing hemodialysis. The client's blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.) a. Adjust the rate of extracorporeal blood flow. b. Place the client in the Trendelenburg position. c. Stop the hemodialysis treatment. d. Administer a 250-mL bolus of normal saline. e. Contact the health care provider for orders.

ANS: A, B, D Hypotension occurs often during hemodialysis treatments as a result of vasodilation from the warmed dialysate. Modest decreases in blood pressure, as is the case with this client, can be maintained with rate adjustment, Trendelenburg positioning, and a fluid bolus. If the blood pressure drops considerably after two boluses and cooling dialysate, the hemodialysis can be stopped and the health care provider contacted.

7. A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? (Select all that apply.) a. "You will not need vascular access to perform PD." b. "There is less restriction of protein and fluids." c. "You will have no risk for infection with PD." d. "You have flexible scheduling for the exchanges." e. "It takes less time than hemodialysis treatments."

ANS: A, B, D PD is based on exchanges of waste, fluid, and electrolytes in the peritoneal cavity. There is no need for vascular access. Protein is lost in the exchange, which allows for more protein and fluid in the diet. There is flexibility in the time for exchanges, but the treatment takes a longer period of time compared to hemodialysis. There still is risk for infection with PD, especially peritonitis.

1. A client asks the nurse, "What are the advantages of peritoneal dialysis over hemodialysis?" Which response by the nurse is accurate? (Select all that apply.) a. "It will give you greater freedom in your scheduling." b. "You have less chance of getting an infection." c. "You need to do it only three times a week." d. "You do not need a machine to do it." e. "You will have fewer dietary restrictions."

ANS: A, D, E Although peritoneal dialysis is slower than hemodialysis, it does not require a specially trained registered nurse and can be done at home, allowing for greater flexibility in scheduling. Peritoneal dialysis is ambulatory, and a machine is not needed. Nursing implications for hemodialysis include vascular access care and diet restrictions, whereas peritoneal dialysis allows for a more flexible diet (abdominal catheter care is still necessary).

A client asks the nurse, "What are the advantages of peritoneal dialysis over hemodialysis?" Which response by the nurse is accurate? (Select all that apply.) a. "It will give you greater freedom in your scheduling." b. "You have less chance of getting an infection." c. "You need to do it only three times a week." d. "You do not need a machine to do it." e. "You will have fewer dietary restrictions."

ANS: A, D, E Although peritoneal dialysis is slower than hemodialysis, it does not require a specially trained registered nurse and can be done at home, allowing for greater flexibility in scheduling. Peritoneal dialysis is ambulatory, and a machine is not needed. Nursing implications for hemodialysis include vascular access care and diet restrictions, whereas peritoneal dialysis allows for a more flexible diet (abdominal catheter care is still necessary).

A client is 12 hours post-kidney transplantation. The nurse notes that the client has put out 2000 mL of urine in 10 hours. Which assessment does the nurse carry out first? a. Skin turgor b. Blood pressure c. Serum blood urea nitrogen (BUN) level d. Weight of the client

ANS: B After transplantation, the client may have diuresis. Excessive diuresis might cause hypotension. Hypotension needs to be prevented because it can reduce blood flow and oxygen to the new kidney, threatening graft survival. The other assessments can give information about fluid balance, but hypotension is the main concern here, so the nurse needs to check the client's blood pressure, then notify the provider.

17. A client is scheduled to have dialysis in 30 minutes and is due for the following medications: vitamin C, B-complex vitamin, and cimetidine (Tagamet). Which action by the nurse is best? a. Give medications with a small sip of water. b. Hold all medications until after dialysis. c. Give the supplements, but hold the Tagamet. d. Give the Tagamet, but hold the supplements.

ANS: B All three medications are dialyzable, meaning that they will be removed by the dialysis. They should be given after the treatment is over.

24. A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse? a. Warm the dialysate solution in a microwave before instillation. b. Take a sample of the effluent and send to the laboratory. c. Flush the tubing with normal saline to maintain patency of the catheter. d. Check the peritoneal catheter for kinking and curling.

ANS: B An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse. Checking the catheter for obstruction is a viable option but will not treat the peritonitis.

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.

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 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 also would 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.

The nurse is assessing a patient who is receiving peritoneal dialysis with 2 L inflows. Which information should be reported 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 complains of feeling 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

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.

40. The nurse is providing a client with a peritoneal dialysis exchange. The nurse notes the presence of cloudy peritoneal effluent. Which action by the nurse is most appropriate? a. Document the finding in the client's chart. b. Collect a sample to send to the laboratory. c. Reposition the client on the left side. d. Increase the free water content in the next bag.

ANS: B Cloudy or opaque effluent is an early sign of peritonitis. The nurse should collect and send a sample for culture. Then the nurse should document the finding. The other two options are not appropriate.

25. When providing care for a client receiving peritoneal dialysis, the nurse notices that the effluent is cloudy. Which intervention is most important for the nurse to carry out? a. Irrigate the peritoneal catheter with saline. b. Send a specimen for culture and sensitivity. c. Document the finding in the client's chart. d. Change the dialysate solution and catheter tubing.

ANS: B Cloudy or opaque effluent is the earliest sign of peritonitis. The health care provider should be notified, and a sample of the outflow should be sent for culture and sensitivity. Irrigating the catheter or changing the solution and tubing will not help reveal the cause of the problem so that appropriate treatment can be started. Documentation is important but is not the priority.

When providing care for a client receiving peritoneal dialysis, the nurse notices that the effluent is cloudy. Which intervention is most important for the nurse to carry out? a. Irrigate the peritoneal catheter with saline. b. Send a specimen for culture and sensitivity. c. Document the finding in the client's chart. d. Change the dialysate solution and catheter tubing.

ANS: B Cloudy or opaque effluent is the earliest sign of peritonitis. The health care provider should be notified, and a sample of the outflow should be sent for culture and sensitivity. Irrigating the catheter or changing the solution and tubing will not help reveal the cause of the problem so that appropriate treatment can be started. Documentation is important but is not the priority.

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.

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 ra

A client with acute kidney failure and on dialysis asks how much fluid will be permitted each day. Which is the nurse's best response? a. "This is based on the amount of damage to your kidneys." b. "You can drink an amount equal to your urine output, plus 700 mL." c. "It is based on your body weight and changes daily." d. "You can drink approximately 2 liters of fluid each day."

ANS: B For clients on dialysis, fluid intake is generally calculated to equal the amount of urine excreted plus 500 to 700 mL.

A client with chronic hypertension is seen in the clinic. Which assessment indicates that the client's hypertension is not under control? a. Heart rate of 55 beats/min b. Serum creatinine level of 1.9 mg/dL c. Blood glucose level of 128 mg/dL d. Irregular heart sounds

ANS: B Increased blood pressure damages the delicate capillaries in the glomerulus and eventually results in acute kidney injury. An elevated serum creatinine level is a manifestation of this. Heart rate, blood glucose level, and irregular heart sounds are not correlated with acute kidney injury.

9. The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding? a. Woman with a blood pressure of 158/90 mm Hg b. Client with Kussmaul respirations c. Man with skin itching from head to toe d. Client with halitosis and stomatitis

ANS: B Kussmaul respirations indicate a worsening of chronic kidney disease (CKD). The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs. Hypertension is common in most clients with CKD, and skin itching increases with calcium-phosphate imbalances, another common finding in CKD. Uremia from CKD causes ammonia to be formed, resulting in the common findings of halitosis and stomatitis.

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.

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 with CKD.

23. A client is admitted with a 3-day history of vomiting and diarrhea. The client's vital signs are blood pressure, 85/60 mm Hg and heart rate, 105 beats/min. Which intervention by the nurse takes priority? a. Obtain blood and urine cultures. b. Start an IV of normal saline as ordered. c. Administer antiemetic medications. d. Assess the client's recent travel history.

ANS: B Many types of problems can reduce kidney function. Severe hypotension from shock or dehydration reduces renal blood flow and leads to prerenal acute renal failure (ARF). Volume depletion leading to prerenal azotemia is the most common cause of ARF and usually is reversible with prompt intervention. The nurse should first initiate the ordered IV fluids. Obtaining cultures will help identify a possible cause of the client's symptoms and should be done quickly after the IV has been started. Attending to the client's discomfort would be next. Assessing for travel history, although important, can wait until after the other interventions have been accomplished.

A client is admitted with a 3-day history of vomiting and diarrhea. The client's vital signs are blood pressure, 85/60 mm Hg; and heart rate, 105 beats/min. Which intervention by the nurse takes priority? a. Obtain blood and urine cultures. b. Start an IV of normal saline as ordered. c. Administer antiemetic medications. d. Assess the client's recent travel history.

ANS: B Many types of problems can reduce kidney function. Severe hypotension from shock or dehydration reduces renal blood flow and leads to prerenal acute renal failure (ARF). Volume depletion leading to prerenal azotemia is the most common cause of ARF and usually is reversible with prompt intervention. The nurse should first initiate the ordered IV fluids. Obtaining cultures will help identify a possible cause of the client's symptoms and should be done quickly after the IV has been started. Attending to the client's discomfort would be next. Assessing for travel history, although important, can wait until after the other interventions have been accomplished.

A client who underwent kidney transplantation 7 days ago has developed the following signs: urine output, 50 mL/12 hr; temperature, 102.2° F (39° C); lethargy; serum creatinine, 2.1 mg/dL; blood urea nitrogen (BUN), 54 mg/dL; and potassium, 5.6 mEq/L. Which initial intervention does the nurse anticipate for this client? a. Immediate hemodialysis b. Increased dose of immune suppressive drugs c. Initiation of IV antibiotics after cultures are obtained d. Placement of a catheter for peritoneal dialysis

ANS: B Oliguria, lethargy, elevated temperature, and increases in serum electrolyte levels, BUN, and creatinine, 1 week to 2 years post-transplantation are hallmarks of acute rejection, which can be reversible with increased immune suppressive therapy. The client does not need hemodialysis, peritoneal dialysis, or antibiotics at this point.

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.

13. A client has a serum creatinine level of 2 mg/dL and a urine output of 1000 mL/day. How does the nurse categorize the client's kidney injury? a. Intrarenal b. Nonoliguric c. Prerenal d. Postrenal

ANS: B Some clients have a nonoliguric form of acute renal failure (ARF), in which urine output remains near-normal but creatinine rises. The other categories relate to the cause of 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.

When the nurse is caring for a patient who 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.

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.

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

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 patient's arm above the level of the heart. b. Report the patient's 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 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 decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.

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

ANS: B 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.

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.

The nurse is assessing a client with acute kidney injury and hears the following sound when auscultating the lungs. For what complication does the nurse plan care? Audio Clip a. Cardiac tamponade b. Pericarditis c. Pulmonary edema d. Myocardial Infarction

ANS: B The sound heard is a pericardial friction rub. This is heard in pericarditis because the pericardial sac becomes inflamed from uremic toxins. Other manifestations include low-grade fever, tachycardia, and chest pain. A tamponade would manifest as muffled heart tones. Pulmonary edema would manifest with crackles in the lungs. A myocardial infarction may or may not have abnormal chest sounds associated with it.

33. A client who is admitted to the hospital with a history of kidney disease begins to have difficulty breathing. Vital signs are as follows: blood pressure, 90/70 mm Hg heart rate, difficult to feel peripheral pulses. His heart sounds are difficult to hear. Which intervention does the nurse prepare for? a. Administration of digoxin (Lanoxin) b. Draining of pericardial fluid with a needle c. Emergency hemodialysis d. Placement of a pacemaker

ANS: B These signs and symptoms are of cardiac tamponade, an emergency situation in which fluid accumulates in the pericardial sac, making it difficult for the heart to pump normally. Treatment includes a pericardiocentesis, or withdrawing the fluid with a needle or catheter. The other interventions are not appropriate in this situation.

A client who is admitted to the hospital with a history of kidney disease begins to have difficulty breathing. Vital signs are as follows: blood pressure, 90/70 mm Hg; heart rate, difficult to feel peripheral pulses. His heart sounds are difficult to hear. Which intervention does the nurse prepare for? a. Administration of digoxin (Lanoxin) b. Draining of pericardial fluid with a needle c. Emergency hemodialysis d. Placement of a pacemaker

ANS: B These signs and symptoms are of cardiac tamponade, an emergency situation in which fluid accumulates in the pericardial sac, making it difficult for the heart to pump normally. Treatment includes a pericardiocentesis, or withdrawing the fluid with a needle or catheter. The other interventions are not appropriate in this situation.

29. The nurse is providing dietary teaching to a client who was just started on peritoneal dialysis (PD). Which instruction does the nurse provide to this client regarding protein intake? a. "Your protein needs will not change, but you may take more fluids." b. "You will need more protein now because some protein is lost by dialysis." c. "Your protein intake will be adjusted according to your predialysis weight." d. "You no longer need to be on protein restriction."

ANS: B When renal disease has progressed and requires treatment with dialysis, increased protein is required in the diet to compensate for protein losses through peritoneal dialysis. The other statements are inaccurate.

The nurse is providing dietary teaching to a client who was just started on peritoneal dialysis (PD). Which instruction does the nurse provide to this client regarding protein intake? a. "Your protein needs will not change, but you may take more fluids." b. "You will need more protein now because some protein is lost by dialysis." c. "Your protein intake will be adjusted according to your predialysis weight." d. "You no longer need to be on protein restriction."

ANS: B When renal disease has progressed and requires treatment with dialysis, increased protein is required in the diet to compensate for protein losses through peritoneal dialysis. The other statements are inaccurate.

5. A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "I can continue to take antacids to relieve heartburn." b. "I need to ask for an antibiotic when scheduling a dental appointment." c. "I'll need to check my blood sugar often to prevent hypoglycemia." d. "The dose of my pain medication may have to be adjusted." e. "I should watch for bleeding when taking my anticoagulants."

ANS: B, C, D, E In discharge teaching, the nurse must emphasize that the client needs to have an antibiotic prophylactically before dental procedures to prevent infection. There may be a need for dose reduction in medications if the kidney is not excreting them properly (antacids with magnesium, antibiotics, antidiabetic drugs, insulin, opioids, and anticoagulants).

4. The nurse is teaching a client with diabetes mellitus how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.) a. "I need to decrease sodium, cholesterol, and protein in my diet." b. "My weight should be maintained at a body mass index of 30." c. "Smoking should be stopped as soon as I possibly can." d. "I can continue to take an aspirin every 4 to 8 hours for my pain." e. "I really only need to drink a couple of glasses of water each day."

ANS: B, D, E Weight should be maintained at a body mass index (BMI) of 22 to 25. A BMI of 30 indicates obesity. The use of nonsteroidal anti-inflammatory drugs such as aspirin should be limited to the lowest time at the lowest dose due to interference with kidney blood flow. The client should drink at least 2 liters of water daily. Diet adjustments should be made by restricting sodium, cholesterol, and protein. Smoking causes constriction of blood vessels and decreases kidney perfusion, so the client should stop smoking.

20. A client with chronic kidney disease is scheduled to be given the following medications: digoxin (Lanoxin) and epoetin alfa (Epogen). The client reports nausea and vomiting and wishes to wait to take the medications. Which action by the nurse is most appropriate? a. Administer both medications with soda crackers. b. Allow the client to wait an hour before taking the medications. c. Review today's potassium level and notify the health care provider. d. Call the health care provider to get an order for anti-nausea medication.

ANS: C Clients with kidney failure are particularly at risk for digoxin toxicity because the drug is excreted by the kidneys. When caring for clients with chronic kidney disease (CKD) who are receiving digoxin, monitor for signs of toxicity, such as nausea and vomiting. Potassium imbalances can alter digoxin levels as well. The nurse should hold the dose, check the current potassium level, and notify the provider. Giving the digoxin could be dangerous, so the nurse should not administer it with crackers, give it later, or ask for an anti-nausea medication.

A client with chronic kidney disease is scheduled to be given the following medications: digoxin (Lanoxin) and epoetin alfa (Epogen). The client reports nausea and vomiting and wishes to wait to take the medications. Which action by the nurse is most appropriate? a. Administer both medications with soda crackers. b. Allow the client to wait an hour before taking the medications. c. Review today's potassium level and notify the health care provider. d. Call the health care provider to get an order for anti-nausea medication.

ANS: C Clients with kidney failure are particularly at risk for digoxin toxicity because the drug is excreted by the kidneys. When caring for clients with chronic kidney disease (CKD) who are receiving digoxin, monitor for signs of toxicity, such as nausea and vomiting. Potassium imbalances can alter digoxin levels as well. The nurse should hold the dose, check the current potassium level, and notify the provider. Giving the digoxin could be dangerous, so the nurse should not administer it with crackers, give it later, or ask for an anti-nausea medication.

19. The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8° F (37.6° C). What is the most appropriate action by the nurse? a. Administer fluid to increase blood pressure. b. Check the white blood cell count. c. Monitor the client's temperature. d. Connect the client to an electrocardiographic (ECG) monitor.

ANS: C During hemodialysis, the dialysate is warmed to increase diffusion and prevent hypothermia. The client's temperature could reflect the temperature of the dialysate. There is no indication to check the white blood cell count or connect the client to an ECG monitor. The other vital signs are within normal limits.

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

ANS: C 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.

32. A client has end-stage kidney disease (ESKD). Which food selection by the client demonstrates understanding of a low-sodium, low-potassium diet? a. Bananas b. Ham c. Herbs and spices d. Salt substitutes

ANS: C Herbs and spices can be used in place of salt to enhance food flavor. Bananas are high in potassium. Ham is high in sodium. Many salt substitutes contain potassium chloride and should not be used.

A client has end-stage kidney disease (ESKD). Which food selection by the client demonstrates understanding of a low-sodium, low-potassium diet? a. Bananas b. Ham c. Herbs and spices d. Salt substitutes

ANS: C Herbs and spices can be used in place of salt to enhance food flavor. Bananas are high in potassium. Ham is high in sodium. Many salt substitutes contain potassium chloride and should not be used.

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

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.

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.

25. The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the client demonstrates a correct understanding of the teaching? a. "I should leave the drainage bag above the level of my abdomen." b. "I could flush the tubing with normal saline if the flow stops." c. "I should take a stool softener every morning to avoid constipation." d. "My diet should have low fiber in it to prevent any irritation."

ANS: C Inflow and outflow problems of the dialysate are best controlled by preventing constipation. A daily stool softener is the best option for the client. The drainage bag should be below the level of the abdomen. Flushing the tubing will not help with the flow. A diet high in fiber will also help with a constipation problem.

3. A client with a decreased glomerular filtration rate asks how to prevent further damage to the kidneys. Which is the nurse's best response? a. "The diuretics you are taking will prevent further damage." b. "Kidney damage is inevitable as you age." c. "Avoid taking NSAIDs." d. "You will need to follow a high-protein diet."

ANS: C Kidney failure causes many problems, including decreased glomerular filtration rate. Nephrotoxins can worsen renal failure, especially in someone who already has some loss of kidney function.

A client with a decreased glomerular filtration rate asks how to prevent further damage to the kidneys. Which is the nurse's best response? a. "The diuretics you are taking will prevent further damage." b. "Kidney damage is inevitable as you age." c. "Avoid taking NSAIDs." d. "You will need to follow a high-protein diet."

ANS: C Kidney failure causes many problems, including decreased glomerular filtration rate. Nephrotoxins can worsen renal failure, especially in someone who already has some loss of kidney function.

7. A client is taking furosemide (Lasix). To detect a common adverse effect, the nurse obtains which assessment as a priority? a. Breath sounds b. Heart sounds c. Intake and output d. Nutritional patterns

ANS: C Lasix is a diuretic that causes increased urine output. If too much urine output occurs, the client may be at risk for hypovolemia, which is a cause of prerenal kidney failure. A marked change in fluid balance seen in the intake and output measurement can help identify the client who may be at risk for hypovolemia. Heart sounds and breath sounds would be more important to assess if the client was receiving Lasix for fluid overload conditions, such as heart failure. Nutrition assessment is important to ensure that the client gets enough potassium, but dehydration is more common and needs more vigorous assessment.

A client is taking furosemide (Lasix). To detect a common adverse effect, the nurse obtains which assessment as a priority? a. Breath sounds b. Heart sounds c. Intake and output d. Nutritional patterns

ANS: C Lasix is a diuretic that causes increased urine output. If too much urine output occurs, the client may be at risk for hypovolemia, which is a cause of prerenal kidney failure. A marked change in fluid balance seen in the intake and output measurement can help identify the client who may be at risk for hypovolemia. Heart sounds and breath sounds would be more important to assess if the client was receiving Lasix for fluid overload conditions, such as heart failure. Nutrition assessment is important to ensure that the client gets enough potassium, but dehydration is more common and needs more vigorous assessment.

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.

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.

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.

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.

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.

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 patient's 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.

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.

39. The nurse is caring for a client who is receiving peritoneal dialysis (PD). Which nursing intervention has the greatest priority when a dialysis exchange is performed? a. Adding potassium and antibiotic to the dialysate bags b. Positioning the client on either side c. Using sterile technique when hooking up dialysate bags d. Warming the dialysate fluid in a microwave oven

ANS: C Peritonitis is the major complication of PD. The most common cause of peritonitis is connection site contamination. To prevent peritonitis, use meticulous sterile technique when caring for the PD catheter and when hooking up or clamping off dialysate bags. This safety precaution is the priority. Never warm dialysate fluid in the microwave. Positioning the client may help with the flow of fluid. Clients may need additives to their dialysate fluid, but potassium and antibiotics are not added together because interactions between them can reduce the effectiveness of the antibiotic.

The nurse is caring for a client who is receiving peritoneal dialysis (PD). Which nursing intervention has the greatest priority when a dialysis exchange is performed? a. Adding potassium and antibiotic to the dialysate bags b. Positioning the client on either side c. Using sterile technique when hooking up dialysate bags d. Warming the dialysate fluid in a microwave oven

ANS: C Peritonitis is the major complication of PD. The most common cause of peritonitis is connection site contamination. To prevent peritonitis, use meticulous sterile technique when caring for the PD catheter and when hooking up or clamping off dialysate bags. This safety precaution is the priority. Never warm dialysate fluid in the microwave. Positioning the client may help with the flow of fluid. Clients may need additives to their dialysate fluid, but potassium and antibiotics are not added together because interactions between them can reduce the effectiveness of the antibiotic.

12. Assessment findings reveal that a client with chronic kidney disease is refusing to take prescribed medications because of the "cost." The client also is having difficulty performing activities of daily living and prefers to sleep most of the day. To which health care team member does the nurse refer the client? a. Home health aide b. Physical therapist c. Psychiatric nurse practitioner d. Physician

ANS: C Professionals from many disciplines are resources for the client with renal failure. A psychiatric evaluation may be needed if depressive symptoms are present. Refusing treatment, having difficulty performing activities of daily living, and excessive sleeping could be signs of depression.

Assessment findings reveal that a client with chronic kidney disease is refusing to take prescribed medications because of the "cost." The client also is having difficulty performing activities of daily living and prefers to sleep most of the day. To which health care team member does the nurse refer the client? a. Home health aide b. Physical therapist c. Psychiatric nurse practitioner d. Physician

ANS: C Professionals from many disciplines are resources for the client with renal failure. A psychiatric evaluation may be needed if depressive symptoms are present. Refusing treatment, having difficulty performing activities of daily living, and excessive sleeping could be signs of depression.

10. Which staff member does the charge nurse assign to care for a client newly diagnosed with chronic kidney disease? a. Licensed practical nurse who usually works on the unit b. Registered nurse floated from the hemodialysis unit c. Registered nurse who has taken care of this client before d. Registered nurse with the most years of experience

ANS: C Provide continuity of care, whenever possible, by using a consistent nurse-client relationship to decrease anxiety and promote discussion of concerns.

Which staff member does the charge nurse assign to care for a client newly diagnosed with chronic kidney disease? a. Licensed practical nurse who usually works on the unit b. Registered nurse floated from the hemodialysis unit c. Registered nurse who has taken care of this client before d. Registered nurse with the most years of experience

ANS: C Provide continuity of care, whenever possible, by using a consistent nurse-client relationship to decrease anxiety and promote discussion of concerns.

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. patient's 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 nurse's decision to give the medication.

17. A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the client's fluid balance is stable at this time? a. Decreased calcium levels b. Increased phosphorus levels c. No adventitious sounds in the lungs d. Increased edema in the legs

ANS: C The absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the client's body. Decreased calcium levels and increased phosphorus levels are common findings with CKD. Edema would indicate a fluid imbalance.

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

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.

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.

10. The charge nurse of the medical-surgical unit is making staff assignments. Which staff member should be assigned to a client with chronic kidney disease who is exhibiting a low-grade fever and a pericardial friction rub? a. Registered nurse who just floated from the surgical unit b. Registered nurse who just floated from the dialysis unit c. Registered nurse who was assigned the same client yesterday d. Licensed practical nurse with 5 years' experience on this floor

ANS: C The client is exhibiting symptoms of pericarditis, which can occur with chronic kidney disease. Continuity of care is important to assess subtle differences in clients. Therefore, the registered nurse (RN) who was assigned to this client previously should again give care to this client. The float nurses would not be as knowledgeable about the unit and its clients. The licensed practical nurse may not have the education level of the RN to assess for pericarditis.

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.

Two hours after a kidney transplant, the nurse obtains all of the following data when assessing the patient. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The blood urea nitrogen (BUN) and creatinine levels are elevated. c. The patient's central venous pressure (CVP) is decreased. d. The patient has level 8 (on a 10-point scale) incisional pain.

ANS: C 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.

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.

21. The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? a. Palpating the access site for a bruit or thrill b. Using the right arm for a blood pressure reading c. Administering intravenous fluids through the AV fistula d. Checking distal pulses in the left arm

ANS: C The nurse should not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula. The AV fistula should be monitored by auscultating or palpating the access site. Checking the distal pulse would be an appropriate assessment.

A client has a serum creatinine level of 2.5 mg/dL, a serum potassium level of 6 mmol/L, an arterial pH of 7.32, and a urine output of 250 mL/day. Which phase of acute kidney failure is the client experiencing? a. Intrarenal b. Nonoliguric c. Oliguric d. Postrenal

ANS: C The oliguric phase of acute kidney failure is characterized by the accumulation of nitrogenous wastes, resulting in increasing levels of serum creatinine and potassium, bicarbonate deficit, and decreased or no urine output. Intrarenal and postrenal refer to causes of kidney injury. Nonoliguric is not a classification.

14. A client has a serum creatinine level of 2.5 mg/dL, a serum potassium level of 6 mmol/L, an arterial pH of 7.32, and a urine output of 250 mL/day. Which phase of acute kidney failure is the client experiencing? a. Intrarenal b. Nonoliguric c. Oliguric d. Postrenal

ANS: C The oliguric phase of acute kidney failure is characterized by the accumulation of nitrogenous wastes, resulting in increasing levels of serum creatinine and potassium, bicarbonate deficit, and decreased or no urine output.Intrarenal and postrenal refer to causes of kidney injury. Nonoliguric is not a classification.

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.

During hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Obtain blood to check the blood urea nitrogen (BUN) level. c. Check the patient's blood pressure. d. Give prescribed PRN antiemetic drugs.

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

The patient's complaints of nausea and dizziness suggest hypotension, so the initial action should be to check the BP. The other actions also may be appropriate, based on the blood pressure obtained. a. Slow down the rate of dialysis. b. Obtain blood to check the blood urea nitrogen (BUN) level. c. Check the patient's blood pressure. d. Give prescribed PRN antiemetic drugs.

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

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.

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 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.

30. A client was just admitted to the emergency department for new-onset confusion. As the nurse starts the IV line, the client says he just finished a hemodialysis session. The IV site is bleeding briskly. What action by the nurse takes priority? a. Assess for a bruit and thrill over the vascular access site. b. Draw blood for coagulation studies and white blood cell count. c. Prepare to administer protamine sulfate. d. Hold constant firm pressure with a gauze pad for 5 minutes.

ANS: C To prevent blood clots from forming within the dialyzer or blood tubing, anticoagulation is needed during hemodialysis treatment. The drug used is heparin, which makes the client at risk for hemorrhage for the next 4 to 6 hours. Protamine sulfate is the antidote to heparin, and the nurse should prepare to administer it. Pressure may help, and someone else can apply it while the nurse is getting the medication. Laboratory studies are not needed because the client is at known risk for bleeding from heparin. Assessing the vascular access device does nothing to help the situation.

A client was just admitted to the emergency department for new-onset confusion. As the nurse starts the IV line, the client says he just finished a hemodialysis session. The IV site is bleeding briskly. What action by the nurse takes priority? a. Assess for a bruit and thrill over the vascular access site. b. Draw blood for coagulation studies and white blood cell count. c. Prepare to administer protamine sulfate. d. Hold constant firm pressure with a gauze pad for 5 minutes.

ANS: C To prevent blood clots from forming within the dialyzer or blood tubing, anticoagulation is needed during hemodialysis treatment. The drug used is heparin, which makes the client at risk for hemorrhage for the next 4 to 6 hours. Protamine sulfate is the antidote to heparin, and the nurse should prepare to administer it. Pressure may help, and someone else can apply it while the nurse is getting the medication. Laboratory studies are not needed because the client is at known risk for bleeding from heparin. Assessing the vascular access device does nothing to help the situation.

34. A client with chronic kidney disease states that he will be going to the dentist for a planned tooth extraction. Which is the nurse's best response? a. "Rinse your mouth with an antiseptic solution after the procedure." b. "Kidney disease is probably what caused your dental decay." c. "You should receive prophylactic antibiotics before any dental procedure." d. "You may take any medication for pain that the dentist prescribes."

ANS: C To prevent sepsis from oral cavity bacteria, the client should be given prophylactic antibiotics before any dental procedure. Rinsing the mouth with antiseptic solution would not be sufficient to prevent infection. Kidney disease may have contributed to the dental decay through loss of calcium from the teeth, but this cannot be confirmed. Clients with kidney disease should not take antibiotics known to be nephrotoxic. Dosage adjustments based on the client's kidney function may be needed.

A client with chronic kidney disease states that he will be going to the dentist for a planned tooth extraction. Which is the nurse's best response? a. "Rinse your mouth with an antiseptic solution after the procedure." b. "Kidney disease is probably what caused your dental decay." c. "You should receive prophylactic antibiotics before any dental procedure." d. "You may take any medication for pain that the dentist prescribes."

ANS: C To prevent sepsis from oral cavity bacteria, the client should be given prophylactic antibiotics before any dental procedure. Rinsing the mouth with antiseptic solution would not be sufficient to prevent infection. Kidney disease may have contributed to the dental decay through loss of calcium from the teeth, but this cannot be confirmed. Clients with kidney disease should not take antibiotics known to be nephrotoxic. Dosage adjustments based on the client's kidney function may be needed.

13. A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema? a. Maintaining oxygen saturation of 89% b. Minimal crackles and wheezes in lung sounds c. Maintaining a balanced intake and output d. Limited shortness of breath upon exertion

ANS: C With an optimal fluid balance, the client will be more able to eject blood from the left ventricle without increased pressure in the left ventricle and pulmonary vessels. Other ideal goals are oxygen saturations greater than 92%, no auscultated crackles or wheezes, and no demonstrated shortness of breath.

36. The nurse is caring for a client with chronic kidney disease who has developed uremia. Which assessment finding does the nurse correlate with this problem? a. Decreased breath sounds b. Foul-smelling urine c. Heart rate of 50 beats/min d. Respiratory rate of 40 breaths/min

ANS: D A client with uremia will also have metabolic acidosis. With severe metabolic acidosis, the client will develop hyperventilation, or Kussmaul respirations, as the body attempts to compensate for the falling pH. The other manifestations would not be associated with acidosis.

The nurse is caring for a client with chronic kidney disease who has developed uremia. Which assessment finding does the nurse correlate with this problem? a. Decreased breath sounds b. Foul-smelling urine c. Heart rate of 50 beats/min d. Respiratory rate of 40 breaths/min

ANS: D A client with uremia will also have metabolic acidosis. With severe metabolic acidosis, the client will develop hyperventilation, or Kussmaul respirations, as the body attempts to compensate for the falling pH. The other manifestations would not be associated with acidosis.

Which statement by a client who has undergone kidney transplantation indicates a need for more teaching? a. "I will need to continue to take insulin for my diabetes." b. "I will have to take my cyclosporine for the rest of my life." c. "I will take the antibiotics three times daily until the medication is finished." d. "My new kidney is working fine. I do not need to take medications any longer."

ANS: D A crucial role of the nurse in long-term follow-up of the kidney transplantation client involves maintenance of prescribed drug therapy. Such clients will need to take immune suppressants for the rest of their lives to prevent rejection of the kidney.

14. A client has a long history of hypertension. Which category of medications would the nurse expect to be ordered to avoid chronic kidney disease (CKD)? a. Antibiotic b. Histamine blocker c. Bronchodilator d. Angiotensin-converting enzyme (ACE) inhibitor

ANS: D ACE inhibitors stop the conversion of angiotensin I to the vasoconstrictor angiotensin II. This category of medication also blocks bradykinin and prostaglandin, increases renin, and decreases aldosterone, which promotes vasodilation and perfusion to the kidney. Antibiotics fight infection, histamine blockers decrease inflammation, and bronchodilators increase the size of the bronchi; none of these medications helps slow the progression of CKD in clients with hypertension.

4. A client who has chronic kidney disease is being discharged from the hospital after receiving treatment for a hip fracture. Which information is most important for the nurse to provide to the client before discharge? a. "Increase your intake of foods with protein." b. "Monitor your daily intake and output." c. "Maintain bedrest until the fracture is healed." d. "Take your aluminum hydroxide (Nephrox) with meals."

ANS: D Aluminum hydroxide lowers serum phosphate levels by binding phosphorus present in food. High blood phosphate levels cause hypocalcemia and osteodystrophy; this makes a client prone to fracture. Increasing protein may not be feasible for a client with chronic kidney disease and would not help prevent fracture. Intake and output will not be helpful for orthopedic problems. Bedrest will promote complications.

A client who has chronic kidney disease is being discharged from the hospital after receiving treatment for a hip fracture. Which information is most important for the nurse to provide to the client before discharge? a. "Increase your intake of foods with protein." b. "Monitor your daily intake and output." c. "Maintain bedrest until the fracture is healed." d. "Take your aluminum hydroxide (Nephrox) with meals."

ANS: D Aluminum hydroxide lowers serum phosphate levels by binding phosphorus present in food. High blood phosphate levels cause hypocalcemia and osteodystrophy; this makes a client prone to fracture. Increasing protein may not be feasible for a client with chronic kidney disease and would not help prevent fracture. Intake and output will not be helpful for orthopedic problems. Bedrest will promote complications.

Which intervention is most important for the nurse to implement in a client after kidney transplant surgery? a. Promote acceptance of new body image. b. Monitor magnesium levels daily. c. Place the client on protective isolation. d. Remove the indwelling (Foley) catheter as soon as possible.

ANS: D Because of increased risk for infection related to immune suppressive drugs given to prevent rejection, the catheter is removed as soon as possible to avoid infection, usually 3 to 7 days after surgery. The client may need assistance with changes in body image, but this is not the priority. The client does not require protective precautions. Laboratory values will be monitored frequently in a post-transplant client, but this is not as important as preventing a complication by removing the catheter.

23. A nurse is caring for a client who is scheduled for a dose of cefazolin and vitamins at this time. Hemodialysis for this client is also scheduled in 60 minutes. Which action by the nurse is best? a. Administer cefazolin since the level of the antibiotic must be maintained. b. Hold the vitamins but administer the cefazolin. c. Hold the cefazolin but administer the vitamins. d. Hold all medications since both cefazolin and vitamins are dialyzable.

ANS: D Both the cefazolin and the vitamins should be held until after the hemodialysis is completed because they would otherwise be removed by the dialysis process.

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.

26. During hemodialysis, a client with chronic kidney disease develops headache, nausea, vomiting, and restlessness. After notifying the health care provider, which action by the nurse is most appropriate? a. Administer a bolus of dextrose solution. b. Draw blood for sodium and potassium. c. Order a blood urea nitrogen level stat. d. Prepare to administer phenytoin (Dilantin),

ANS: D Headache, nausea, vomiting, and restlessness may be signs of dialysis disequilibrium syndrome. Rapid decreases in fluid and in blood urea nitrogen (BUN) level can cause cerebral edema and increased intracranial pressure (ICP). Early recognition and treatment of this syndrome are essential for preventing a life-threatening situation. Treatment includes administration of anticonvulsants (Dilantin) or barbiturates. Dextrose is not used to treat disequilibrium syndrome, and sodium and potassium levels are not helpful because the symptoms are related to changes in urea levels and increased intracranial pressure. Obtaining the BUN would provide useful information; however, it is more important to treat the problem.

During hemodialysis, a client with chronic kidney disease develops headache, nausea, vomiting, and restlessness. After notifying the health care provider, which action by the nurse is most appropriate? a. Administer a bolus of dextrose solution. b. Draw blood for sodium and potassium. c. Order a blood urea nitrogen level stat. d. Prepare to administer phenytoin (Dilantin).

ANS: D Headache, nausea, vomiting, and restlessness may be signs of dialysis disequilibrium syndrome. Rapid decreases in fluid and in blood urea nitrogen (BUN) level can cause cerebral edema and increased intracranial pressure (ICP). Early recognition and treatment of this syndrome are essential for preventing a life-threatening situation. Treatment includes administration of anticonvulsants (Dilantin) or barbiturates. Dextrose is not used to treat disequilibrium syndrome, and sodium and potassium levels are not helpful because the symptoms are related to changes in urea levels and increased intracranial pressure. Obtaining the BUN would provide useful information; however, it is more important to treat the problem.

22. A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the client's nose and around the intravenous catheter. What action by the nurse is the priority? a. Hold pressure over the client's nose for 10 minutes. b. Take the client's pulse, blood pressure, and temperature. c. Assess for a bruit or thrill over the arteriovenous fistula. d. Prepare protamine sulfate for administration.

ANS: D Heparin is used with hemodialysis treatments. The bleeding alerts the nurse that too much anticoagulant is in the client's system and protamine sulfate should be administered. Pressure, taking vital signs, and assessing for a bruit or thrill are not as important as medication administration.

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.

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.

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.

A patient complains of leg cramps during hemodialysis. The nurse should first a. reposition the patient. b. massage the patient's legs. 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.

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.

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.

28. The RN has assigned a client with a newly placed arteriovenous (AV) fistula in the right arm to an LPN. Which information about the care of this client is most important for the RN to provide to the LPN? a. "Avoid movement of the right extremity." b. "Place gentle pressure over the fistula site after blood draws." c. "Start any IV lines below the site of the fistula." d. "Take blood pressure in the left arm."

ANS: D Repeated compression of a fistula site can result in loss of vascular access. Therefore, avoid taking blood pressures and performing venipunctures or IV placement in the arm with the vascular access. The other statements are not appropriate.

The RN has assigned a client with a newly placed arteriovenous (AV) fistula in the right arm to an LPN. Which information about the care of this client is most important for the RN to provide to the LPN? a. "Avoid movement of the right extremity." b. "Place gentle pressure over the fistula site after blood draws." c. "Start any IV lines below the site of the fistula." d. "Take blood pressure in the left arm."

ANS: D Repeated compression of a fistula site can result in loss of vascular access. Therefore, avoid taking blood pressures and performing venipunctures or IV placement in the arm with the vascular access. The other statements are not appropriate.

35. A client hospitalized for worsening kidney injury suddenly becomes restless and agitated. Assessment reveals tachycardia and crackles bilaterally at the bases of the lungs. Which is the nurse's first intervention? a. Begin ultrafiltration. b. Administer an antianxiety agent. c. Place the client on mechanical ventilation. d. Place the client in high Fowler's position.

ANS: D Restlessness, anxiety, tachycardia, dyspnea, and crackles at the bases of the lungs are early manifestations of pulmonary edema, which is a complication of kidney failure. Initial treatment of pulmonary edema consists of placing the client in high Fowler's position and administering oxygen. Mechanical ventilation and ultrafiltration may be indicated if symptoms become worse. An antianxiety agent would not be helpful. Morphine, however, has both vasoactive and sedating effects.

A client hospitalized for worsening kidney injury suddenly becomes restless and agitated. Assessment reveals tachycardia and crackles bilaterally at the bases of the lungs. Which is the nurse's first intervention? a. Begin ultrafiltration. b. Administer an antianxiety agent. c. Place the client on mechanical ventilation. d. Place the client in high Fowler's position.

ANS: D Restlessness, anxiety, tachycardia, dyspnea, and crackles at the bases of the lungs are early manifestations of pulmonary edema, which is a complication of kidney failure. Initial treatment of pulmonary edema consists of placing the client in high Fowler's position and administering oxygen. Mechanical ventilation and ultrafiltration may be indicated if symptoms become worse. An antianxiety agent would not be helpful. Morphine, however, has both vasoactive and sedating effects.

7. A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse? a. Use the catheter for the next laboratory blood draw. b. Monitor the central venous pressure through this line. c. Access the line for the next intravenous medication. d. Place a heparin or heparin/saline dwell after hemodialysis.

ANS: D The central line should have a heparin or heparin/saline dwell after hemodialysis treatment. The central line catheter used for dialysis should not be used for blood sampling, monitoring central venous pressures, or giving drugs or fluids.

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 patient's health care provider. c. Look at the patient's 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 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 also is appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening bradycardia.

26. A client with chronic kidney disease states, "I feel chained to the hemodialysis machine." What is the nurse's best response to the client's statement? a. "That feeling will gradually go away as you get used to the treatment." b. "You probably need to see a psychiatrist to see if you are depressed." c. "Do you need help from social services to discuss financial aid?" d. "Tell me more about your feelings regarding hemodialysis treatment."

ANS: D The nurse needs to explore the client's feelings in order to help the client cope and enter a phase of acceptance or resignation. It is common for clients to be discouraged because of the dependency of the treatment, especially during the first year. Referrals to a mental health provider or social services are possibilities, but only after exploring the client's feelings first. Telling the client his or her feelings will go away is dismissive of the client's concerns.

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

38. Which assessment parameter does the nurse monitor in a client with chronic kidney disease to determine fluid and sodium retention status? a. Capillary refill b. Intake and output c. Muscle strength d. Weight and blood pressure

ANS: D Weight and blood pressure are helpful in estimating fluid and sodium retention. Weight and blood pressure rise with excess fluid and sodium. Weight is the most accurate noninvasive assessment for fluid status and therefore sodium status. Capillary refill also gives information on perfusion and oxygenation so is not specific for fluid status. Intake and output are part of the assessment for fluid status but do not account for insensitive water losses. Muscle strength is unrelated.

Which assessment parameter does the nurse monitor in a client with chronic kidney disease to determine fluid and sodium retention status? a. Capillary refill b. Intake and output c. Muscle strength d. Weight and blood pressure

ANS: D Weight and blood pressure are helpful in estimating fluid and sodium retention. Weight and blood pressure rise with excess fluid and sodium. Weight is the most accurate noninvasive assessment for fluid status and therefore sodium status. Capillary refill also gives information on perfusion and oxygenation so is not specific for fluid status. Intake and output are part of the assessment for fluid status but do not account for insensitive water losses. Muscle strength is unrelated.

A 78-year-old patient has Stage 3 CKD and is being taught about a low potassium diet. The nurse knows the patient understands the diet when the patient selects which foods to eat? A.Apple, green beans, and a roast beef sandwich B.Granola made with dried fruits, nuts, and seeds C.Watermelon and ice cream with chocolate sauce D.Bran cereal with ½ banana and milk and orange juice

Apple, green beans, and a roast beef sandwich Correct When the patient selects an apple, green beans, and a roast beef sandwich, the patient demonstrates understanding of the low potassium diet. Granola, dried fruits, nuts and seeds, milk products, chocolate sauce, bran cereal, banana, and orange juice all have elevated levels of potassium, at or above 200 mg per 1/2 cup.

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

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.

A 42-yr-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action 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).

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.

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 c. Neurologic status b. Phosphate level d. Creatinine clearance

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.

A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2-L inflows. Which information should the nurse report promptly 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's abdomen appears bloated after the inflow. d. The patient has abdominal pain during the inflow phase.

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.

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.

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.

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 human immunodeficiency virus.

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

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

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.

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. hot, flushed face and neck. d. bounding peripheral pulses.

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.

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.

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.

A 62-yr-old female patient has been hospitalized for 4 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. d. The glomerular filtration rate is less than 30 mL/min/1.73 m2

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.

A 25-yr-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 of 2.1 mg/dL b. Serum potassium level of 6.5 mEq/L c. White blood cell count of 11,500/μL d. Blood urea nitrogen (BUN) of 56 mg/dL

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.

A 74-yr-old patient 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."

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.

Which intervention will be included in the plan of care for a 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.

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.

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 treatment goal in the plan will be a. augmenting fluid volume. b. maintaining cardiac output. c. diluting nephrotoxic substances. d. preventing systemic hypertension.

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.

One of the major advantages of peritoneal dialysis is that: A. no medications are required because of the enhanced efficiency of the peritoneal membranes in removing toxins B. the diet is less restricted and dialysis can be performed at home C. the dialysate is biocompatible and causes no long term consequences D. high glucose concentration of the dialysate causes a reduction in appetite promoting weight loss

B Rationale: Advantages of peritoneal dialysis include fewer dietary restrictions and the possibility of home dialysis.

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

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.

A 37-yr-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

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.

A 55-yr-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

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 greater than 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.

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

C If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. 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.

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. Acetaminophen c. Magnesium hydroxide b. Calcium phosphate d. Multivitamin w/ iron

C 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.

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

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.

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

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.

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. Review the chart for the patient's current creatinine level. d. Check the medical record for the most recent potassium level.

D 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.

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

D The patient who has tachycardia 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.

The patient was diagnosed with prerenal acute kidney injury (AKI). The nurse should know that what is most likely the cause of the patient's diagnosis? 1 Intravenous (IV) tobramycin (Nebcin) 2 Incompatible blood transfusion 3 Poststreptococcal glomerulonephritis Dissecting abdominal aortic aneurysm

Dissecting abdominal aortic aneurysm A dissecting abdominal aortic aneurysm is a prerenal cause of AKI because it can decrease renal artery perfusion and therefore the glomerular filtrate rate. Aminoglycoside antibiotic administration, a hemolytic blood transfusion reaction, and poststretpcoccal glomerulonephritis are intrarenal causes of AKI. Text Reference - p. 1102

The patient was diagnosed with prerenal AKI. The nurse should know that what is most likely the cause of the patient's diagnosis? A.IV tobramycin (Nebcin) B.Incompatible blood transfusion C.Poststreptococcal glomerulonephritis D.Dissecting abdominal aortic aneurysm

Dissecting abdominal aortic aneurysm A dissecting abdominal aortic aneurysm is a prerenal cause of AKI because it can decrease renal artery perfusion and therefore the glomerular filtrate rate. Aminoglycoside antibiotic administration, a hemolytic blood transfusion reaction, and poststretpcoccal glomerulonephritis are intrarenal causes of AKI.

A 24-year-old female donated a kidney via a laparoscopic donor nephrectomy to a non-related recipient. The patient is experiencing a lot of pain and refuses to get up to walk. How should the nurse handle this situation? A.Have the transplant psychologist convince her to walk. B. Encourage even a short walk to avoid complications of surgery. C.Tell the patient that no other patients have ever refused to walk. D.Tell the patient she is lucky she did not have an open nephrectomy.

Encourage even a short walk to avoid complications of surgery Because ambulating will improve bowel, lung, and kidney function with improved circulation, even a short walk with assistance should be encouraged after pain medication. The transplant psychologist or social worker's role is to determine if the patient is emotionally stable enough to handle donating a kidney, while postoperative care is the nurse's role. Trying to shame the patient into walking by telling her that other patients have not refused and telling the patient she is lucky she did not have an open nephrectomy (implying how much more pain she would be having if it had been open) will not be beneficial to the patient or her postoperative recovery.

Which assessment finding is a consequence of the oliguric phase of AKI? A. Hypovolemia B. Hyperkalemia C. Hypernatremia D.Thrombocytopenia

Hyperkalemia In AKI the serum potassium levels increase because the normal ability of the kidneys to excrete potassium is impaired. Sodium levels are typically normal or diminished, whereas fluid volume is normally increased because of decreased urine output. Thrombocytopenia is not a consequence of AKI, although altered platelet function may occur in AKI.

Diffusion, osmosis, and ultrafiltration occur in both hemodialysis and peritoneal dialysis. The nurse should know that ultrafiltration in peritoneal dialysis is achieved by which method? A.Increasing the pressure gradient B.Increasing osmolality of the dialysate C.Decreasing the glucose in the dialysate D.Decreasing the concentration of the dialysate

Increasing osmolality of the dialysate Ultrafiltration in peritoneal dialysis is achieved by increasing the osmolality of the dialysate with additional glucose. In hemodialysis the increased pressure gradient from increased pressure in the blood compartment or decreased pressure in the dialysate compartment causes ultrafiltration. Decreasing the concentration of the dialysate in either peritoneal or hemodialysis will decrease the amount of fluid removed from the blood stream.

A patient is recovering in the intensive care unit (ICU) after receiving a kidney transplant approximately 24 hours ago. What is an expected assessment finding for this patient during this early stage of recovery? A.Hypokalemia B. Hyponatremia C.Large urine output D. Leukocytosis with cloudy urine output

Large urine output Patients frequently experience diuresis in the hours and days immediately following a kidney transplant. Electrolyte imbalances and signs of infection are unexpected findings that warrant prompt intervention.

The patient has a form of glomerular inflammation that is progressing rapidly. She is gaining weight, and the urine output is steadily declining. What is the priority nursing intervention? A.Monitor the patient's cardiac status. B.Teach the patient about hand washing. C.Obtain a serum specimen for electrolytes. D. Increase direct observation of the patient.

Monitor the patient's cardiac status The nurse's priority is to monitor the patient's cardiac status. With the rapidly progressing glomerulonephritis, renal function begins to fail and fluid, potassium, and hydrogen retention lead to hypervolemia, hyperkalemia, and metabolic acidosis. Excess fluid increases the workload of the heart, and hyperkalemia can lead to life-threatening dysrhythmias. Teaching about hand washing and observation of the patient are important nursing interventions but are not the priority. Electrolyte measurement is a collaborative intervention that will be done as ordered by the health care provider.

The nurse preparing to administer a dose of calcium acetate (PhosLo) to a patient with chronic kidney disease (CKD) should know that this medication should have a beneficial effect on which laboratory value? A.Sodium B.Potassium C. Magnesium D. Phosphorus

Phosphorus 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. PhosLo will not have an effect on sodium, potassium, or magnesium levels.

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

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).

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

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.

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

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.

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

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.

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

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.

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

a. 3; b. 2; c. 1

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

a. 3; b. 2; c. 1

A kidney transplant recipient complains of having fever, chills, and dysuria over the past 2 days. What is the first action that the nurse should take? a. Assess temperature and initiate workup to rule out infection b. Reassure the patient that this is common after transplantation c. Provide warm cover for the patient and give 1 g acetaminophen orally d. Notify the nephrologist that the patient has developed symptoms of acute rejection

a. Assess temperature and initiate workup to rule out infection Rationale: The nurse must be astute in the observation and assessment of kidney transplant recipients because prompt diagnosis and treatment of infections can improve patient outcomes. Fever, chills, and dysuria indicate an infection. The temperature should be assessed, and the patient should undergo diagnostic testing to rule out an infection.

Kidney transplant recipient complains of having fever, chills, and dysuria over the course of the past 2 days, What is the first action the nurse should take? A. assess temperature and initiate workup to rule out infection B. provied warm cover for the patient and give 1 g acetaminophen orally C. reassure the patient that this is common after transplantation D. notify the nephrologist that the patient has developed symptoms of acute rejection

a. Assess temperature and initiate workup to rule out infection Rationale: The nurse must be astute in the observation and assessment of kidney transplant recipients because prompt diagnosis and treatment of infections can improve patient outcomes. Fever, chills, and dysuria indicate an infection. The temperature should be assessed, and the patient should undergo diagnostic testing to rule out an infection.

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.

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.

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.

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.

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

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

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

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

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

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.

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.

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.

Nutritional support and management are essential across the entire continuum of chronic kidney disease. Which statements would be considered true related to nutritional therapy (select all that apply)? a. Fluid is not usually restricted for patients receiving peritoneal dialysis b. Sodium and potassium may be restricted in someone with advanced CKD c. Decreased fluid intake and a low-potassium diet are hallmarks of the diet for a patient receiving hemodialysis d. Decreased fluid intake and a low-potassium diet are hallmarks of the diet for a patient receiving peritoneal dialysis e. Decreased fluid intake and a diet with phosphate-rich foods are hallmarks of a diet for a patient receiving hemodialysis

a. Fluid is not usually restricted for patients receiving peritoneal dialysis b. Sodium and potassium may be restricted in someone with advanced CKD c. Decreased fluid intake and a low-potassium diet are hallmarks of the diet for a patient receiving hemodialysis Rationale: Water and any other fluids are not routinely restricted before Stage 5 end-stage renal disease (ESRD). Patients receiving hemodialysis have a more restricted diet than do patients receiving peritoneal dialysis. Patients receiving hemodialysis are frequently educated about the need for a dietary restriction of potassium- and phosphate-rich foods. However, patients receiving peritoneal dialysis may actually require replacement of potassium because of the higher losses of potassium with peritoneal dialysis. Sodium and salt restriction is common for all patients with CKD. For those receiving hemodialysis, as their urinary output diminishes, fluid restrictions are enhanced. Intake depends on the daily urine output. In general, 600 mL (from insensible loss) plus an amount equal to the previous day's urine output is allowed for a patient receiving hemodialysis. Patients are advised to limit fluid intake so that weight gains between dialysis sessions (i.e., interdialytic weight gain) are no more than 1 to 2 kg. For the patient who is undergoing dialysis, protein is not routinely restricted. The beneficial role of protein restriction in CKD stages 1 through 4 as a means to reduce the decline in kidney function is controversial. Historically, dietary counseling often encouraged restriction of protein for individuals with CKD. Although there is some evidence that protein restriction has benefits, many patients find these diets difficult to adhere to. For CKD stages 1 through 4, many clinicians encourage a diet with normal protein intake. However, patients must be taught to avoid high-protein diets and supplements because they may overstress the diseased kidneys.

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

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.

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

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.

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.

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

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.

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 acidbase balance.

Which descriptions characterize acute kidney injury (select all that apply)? a. Primary cause of death is infection b. It almost always affects older people c. Disease course is potentially reversible d. Most common cause is diabetic nephropathy e. Cardiovascular disease is most common cause of death

a. Primary cause of death is infection c. Disease course is potentially reversible Rationale: Acute kidney injury (AKI) is potentially reversible. AKI has a high mortality rate, and the primary cause of death in patients with AKI is infection. The primary cause of death in patients with chronic kidney failure is cardiovascular disease. Most commonly, AKI follows severe, prolonged hypotension or hypovolemia or exposure to a nephrotoxic agent. Older adults are more susceptible to AKI because the number of functioning nephrons decrease with age, but AKI can occur at any age.

Which of the following characterize acute kidney injury (select all that apply): A. primary cause of death is infection B. almost always affects older people C. disease course is potentially reversible D. most common cause is diabetic neuropathy E. cardiovascular disease is the most common cause of death

a. Primary cause of death is infection c. Disease course is potentially reversible Rationale: Acute kidney injury (AKI) is potentially reversible. AKI has a high mortality rate, and the primary cause of death in patients with AKI is infection. The primary cause of death in patients with chronic kidney failure is cardiovascular disease. Most commonly, AKI follows severe, prolonged hypotension or hypovolemia or exposure to a nephrotoxic agent. Older adults are more susceptible to AKI because the number of functioning nephrons decrease with age, but AKI can occur at any age.

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.

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.

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.

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.

Patients with chronic kidney disease experience an increased incidence of cardiovascular disease related to (select all that apply) a. hypertension b. vascular calcifications c. a genetic predisposition d. hyperinsulinemia causing dyslipidemia e. increased high-density lipoprotein levels

a. hypertension b. vascular calcifications d. hyperinsulinemia causing dyslipidemia Rationale: CKD patients have traditional cardiovascular (CV) risk factors, such as hypertension and elevated lipids. Hyperinsulinemia stimulates hepatic production of triglycerides. Most patients with uremia develop dyslipidemia. CV disease may be related to nontraditional CV risk factors, such as vascular calcification and arterial stiffness, which are major contributors to CV disease in CKD. Calcium deposits in the vascular medial layer are associated with stiffening of the blood vessels. The mechanisms involved are multifactorial and incompletely understood, but they include (1) change of vascular smooth muscle cells into chondrocytes or osteoblast-like cells, (2) high total-body amounts of calcium and phosphate as a result of abnormal bone metabolism, (3) impaired renal excretion, and (4) drug therapies to treat the bone disease (e.g., calcium phosphate binders).

Patients with chronic kidney disease experience an increased incidence of cardiovascular disease related to (select all that apply): A. hypertension B. vascular calcifications C. a genetic predisposition D. hyperinsulinemia causing dyslipiemia E. increased high-density lipoprotein levels

a. hypertension b. vascular calcifications d. hyperinsulinemia causing dyslipidemia Rationale: CKD patients have traditional cardiovascular (CV) risk factors, such as hypertension and elevated lipids. Hyperinsulinemia stimulates hepatic production of triglycerides. Most patients with uremia develop dyslipidemia. CV disease may be related to nontraditional CV risk factors, such as vascular calcification and arterial stiffness, which are major contributors to CV disease in CKD. Calcium deposits in the vascular medial layer are associated with stiffening of the blood vessels. The mechanisms involved are multifactorial and incompletely understood, but they include (1) change of vascular smooth muscle cells into chondrocytes or osteoblast-like cells, (2) high total-body amounts of calcium and phosphate as a result of abnormal bone metabolism, (3) impaired renal excretion, and (4) drug therapies to treat the bone disease (e.g., calcium phosphate binders).

Nurses must teach patients at risk for developing chronic kidney disease. Individuals considered to be at increased risk include (select all that apply) a. older African Americans b. patients more than 60 years old c. those with a history of pancreatitis d. those with a history of hypertension e. those with a history of type 2 diabetes

a. older African Americans b. patients more than 60 years old d. those with a history of hypertension e. those with a history of type 2 diabetes Rationale: Risk factors for CKD include diabetes mellitus, hypertension, age older than 60 years, cardiovascular disease, family history of CKD, exposure to nephrotoxic drugs, and ethnic minority (e.g., African American, Native American).

A patient is admitted to the hospital with chronic kidney disease. The nurse understands that this condition is characterized by a. progressive irreversible destruction of the kidneys b. a rapid decrease in urine output with an elevated BUN c. an increasing creatinine clearance with a decrease in urine output d. prostration, somnolence, and confusion with coma and imminent death

a. progressive irreversible destruction of the kidneys Rationale: Chronic kidney disease (CKD) involves progressive, irreversible loss of kidney function.

A patient is admitted to the hospital with chronic kidney disease. The nurse understands that this condition is characterized by: A. progressive irreversible destruction of the kidneys B. a rapid decrease in urinary output and an elevated BUN C. an increasing creatinine clearance with a decrease in urinary output D. prostration, somnolence and confusion with coma and imminent death

a. progressive irreversible destruction of the kidneys Rationale: Chronic kidney disease (CKD) involves progressive, irreversible loss of kidney function.

An ESRD patient receiving hemodialysis is considering asking a relative to donate a kidney for transplantation. In assisting the patient to make a decision about treatment, the nurse informs the patient that a. successful transplantation usually provides better quality of life than that offered by dialysis b. if rejection of the transplanted kidney occurs, no further treatment for the renal failure is available c. hemodialysis replaces the normal functions of the kidneys, and patients do not have to live with the continual fear of rejection d. the immunosuppressive therapy following transplantation makes the person ineligible to receive other forms of treatment if the kidney fails

a. successful transplantation usually provides better quality of life than that offered by dialysis Rationale: Kidney transplantation is extremely successful, with 1-year graft survival rates of about 90% for deceased donor organs and 95% for live donor organs. An advantage of kidney transplantation over dialysis is that it reverses many of the pathophysiologic changes associated with renal failure when normal kidney function is restored. It also eliminates the dependence on dialysis and the need for the accompanying dietary and lifestyle restrictions. Transplantation is less expensive than dialysis after the first year.

A major advantage of peritoneal dialysis is a. the diet is less restricted and dialysis can be performed at home b. the dialysate is biocompatible and causes no long-term consequences c. high glucose concentrations of the dialysate cause a reduction in appetite, promoting weight loss d. no medications are required because of the enhanced efficiency of the peritoneal membrane in removing toxins

a. the diet is less restricted and dialysis can be performed at home Rationale: Advantages of peritoneal dialysis include fewer dietary restrictions and the possibility of home dialysis.

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.

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.

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.

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.

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)

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).

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)

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.

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)

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.

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, PaCO2 30 mm Hg, 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 level

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.

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, PaCO2 30 mm Hg, 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 level

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.

During the oliguric phase of AKI, the nurse monitors the patient for (select all that apply) a. hypotension b. ECG changes c. hypernatremia d. pulmonary edema e. urine with high specific gravity

b. ECG changes d. pulmonary edema Rationale: The nurse monitors the patient in the oliguric phase of acute renal injury for the following: -Hypertension and pulmonary edema: When urinary output decreases, fluid retention occurs. The severity of the symptoms depends on the extent of the fluid overload. In the case of reduced urine output (i.e., anuria, 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. -Hyponatremia: Damaged tubules cannot conserve sodium. Consequently, the urinary excretion of sodium may increase, which results in normal or below-normal serum levels of sodium. -Electrocardiographic changes and hyperkalemia: Initially, clinical signs of hyperkalemia are apparent on electrocardiogram (ECG) demonstrating peaked T waves, widening of the QRS complex, and ST-segment depression. -Urinary specific gravity: Urinary specific gravity is fixed at about 1.010.

During the oliguric phase of AKI, the nurse monitors the patient for (select all that apply): A. hypotension B. ECG changes C. hypernatremia D. pulmonary edema E. urine with high specific gravity

b. ECG changes d. pulmonary edema Rationale: The nurse monitors the patient in the oliguric phase of acute renal injury for the following: -Hypertension and pulmonary edema: When urinary output decreases, fluid retention occurs. The severity of the symptoms depends on the extent of the fluid overload. In the case of reduced urine output (i.e., anuria, 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. -Hyponatremia: Damaged tubules cannot conserve sodium. Consequently, the urinary excretion of sodium may increase, which results in normal or below-normal serum levels of sodium. -Electrocardiographic changes and hyperkalemia: Initially, clinical signs of hyperkalemia are apparent on electrocardiogram (ECG) demonstrating peaked T waves, widening of the QRS complex, and ST-segment depression. -Urinary specific gravity: Urinary specific gravity is fixed at about 1.010.

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

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.

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

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.

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

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.

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

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.

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.

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

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.

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.

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.

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.

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 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 bicarbonate d. Sodium polystyrene sulfonate (Kayexalate)

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.

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 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 bicarbonate d. Sodium polystyrene sulfonate (Kayexalate)

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.

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

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.

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

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.

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

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.

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

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.

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

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.

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

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.

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

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.

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

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.

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

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.

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

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.

If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalance? A. hyperkalemia and hyponatremia B. hyperkalemia and hypernatremia C. hypokalemia and hyponatremia D. hypokalemia and hypernatremia

c. Hypokalemia and hyponatremia Rationale: In the diuretic phase of AKI, the kidneys have recovered the ability to excrete wastes but not the ability to concentrate urine. Hypovolemia and hypotension can result from massive fluid losses. Because of the large losses of fluid and electrolytes, the patient must be monitored for hyponatremia, hypokalemia, and dehydration.

If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalances? a. Hyperkalemia and hyponatremia b. Hyperkalemia and hypernatremia c. Hypokalemia and hyponatremia d. Hypokalemia and hypernatremia

c. Hypokalemia and hyponatremia Rationale: In the diuretic phase of AKI, the kidneys have recovered the ability to excrete wastes but not the ability to concentrate urine. Hypovolemia and hypotension can result from massive fluid losses. Because of the large losses of fluid and electrolytes, the patient must be monitored for hyponatremia, hypokalemia, and dehydration.

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.

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.

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

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.

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

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.

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.

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.

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

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.

To assess the potency of a newly placed arteriovenous graft for dialysis, the nurse should (select all that apply) a. monitor the BP in the affected arm b. irrigate the graft daily with low-dose heparin c. palpate the area of the graft to feel a normal thrill d. listen with a stethoscope over the graft to detect a bruit e. frequently monitor the pulses and neurovascular status distal to the graft

c. palpate the area of the graft to feel a normal thrill d. listen with a stethoscope over the graft to detect a bruit e. frequently monitor the pulses and neurovascular status distal to the graft Rationale: A thrill can be felt on palpation of the area of anastomosis of the arteriovenous graft, and a bruit can be heard with a stethoscope. The bruit and thrill are created by arterial blood rushing into the vein. The BP should not be taken in the arm with the AV graft.

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.

cardiac dysrhythmias. Hyperkalemia is the most serious electrolyte disorder associated with kidney disease. Fatal dysrhythmias can occur when the serum potassium level reaches 7 to 8 mEq/L. Fatigue and hypertriglyceridemia may be present but do not require urgent intervention. Tenderness or pain over the kidneys is not expected in CKD.

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

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.

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

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.

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

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.

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

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. Lewis, Sharon L.; Dirksen, Shannon Ruff; Bucher, Linda (2014-03-14). Study Guide for Medical-Surgical Nursing: Assessment and Management of Clinical Problems (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 413). Elsevier Health Sciences. Kindle Edition.

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

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

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

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.

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)

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.

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

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.

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.

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.

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, whereas oliguria of intrarenal failure is characterized by urine with a low specific gravity and a high sodium centration. Malignant hypertension causes damage to renal tissue and intrarenal oliguria.

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, 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.

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.

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.

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 calciumlevels are increased.

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.

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.

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.

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.

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.

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

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.

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

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.

RIFLE defines three stages of AKI based on changes in a. blood pressure and urine osmolality b. fractional excretion of urinary sodium c. estimation of GFR with the MDRD equation d. serum creatinine or urine output from baseline

d. serum creatinine or urine output from baseline Rationale: The RIFLE classification is used to describe the stages of AKI. RIFLE standardizes the diagnosis of AKI. Risk (R) is the first stage of AKI, followed by injury (I), which is the second stage, and then increasing in severity to the final or third stage of failure (F). The two outcome variables are loss (L) and end-stage renal disease (E). The first three stages are characterized by the serum creatinine level and urine output.

RIFLE defines three stages of AKI based on changes in: A. blood pressure and urine osmolality B. fractional excretion of urinary sodium C. estimation of GFR with the MDRD equation D. serum creatinine or urine output from baseline

d. serum creatinine or urine output from baseline Rationale: The RIFLE classification is used to describe the stages of AKI. RIFLE standardizes the diagnosis of AKI. Risk (R) is the first stage of AKI, followed by injury (I), which is the second stage, and then increasing in severity to the final or third stage of failure (F). The two outcome variables are loss (L) and end-stage renal disease (E). The first three stages are characterized by the serum creatinine level and urine output.