Patho Chp 34: Acute Kidney Injury and Chronic Kidney Disease

The health care provider is reviewing laboratory results of a client. Select the diagnostic test that is considered the best measurement of overall kidney function. 1. Glomerular filtration rate (GFR) 2. Serum creatinine levels 3. Urine albumin levels 4. Blood urea nitrogen (BUN)

1. Glomerular filtration rate (GFR) GFR is the best overall measure of kidney function. GFR is usually estimated using the serum creatinine concentration. Creatinine, a by-product of muscle metabolism, is produced at a fairly constant rate, is freely filtered in the glomerulus, and is not reabsorbed in the renal tubules. Essentially all of the creatinine filtered by the kidneys is lost in the urine; therefore, serum creatinine is an indirect measure of GFR. Proteinuria serves as a key adjunctive tool for measuring nephron injury and repair. Urine normally contains small amounts of protein. Blood tests for BUN and creatinine provide information regarding the ability to remove nitrogenous wastes from the blood.

A geriatric nurse is caring for several clients. Which alterations in health should the nurse attribute to age-related physiologic changes? 1. A 90-year-old woman's blood urea nitrogen (BUN) is rising. 2. A 78-year-old woman's GFR has been steadily declining over several years. 3. A dipstick of an 80-year-old man's urine reveals protein is present.

2. A 78-year-old woman's GFR has been steadily declining over several years. A gradual decrease in GFR is considered a normal age-related change. Increased creatinine or BUN would warrant follow up, as would the presence of protein in a client's urine.

To maintain hematocrit levels in clients with kidney failure, the nurse should be prepared to perform which intervention?

Administer a subcutaneous injection of recombinant human erythropoietin (rhEPO). Recombinant human erythropoietin (rhEPO) helps maintain hematocrit levels in people with kidney failure. Secondary benefits include improvement in appetite, energy level, sexual function, skin color, hair and nail growth, and reduced cold intolerance.

Chronic kidney disease impacts many systems in the body. What is the most common hematologic disorder caused by CKD?

Anemia The most common hematologic disorder that accompanies CKD is anemia.

A client has been diagnosed with chronic kidney disease (CKD). Which drug category is usually administered to treat coexisting conditions that manifest early in CKD? Antihypertensive medications Antiarrhythmic medications

Antihypertensive medications

The nurse is caring for a client who has had acute blood loss from ruptured esophageal varices. What does the nurse recognize is an early sign of prerenal failure?

Baseline urine output of 50 mL/hr that is now 10 mL/hr The kidney normally responds to a decrease in the glomerular filtration rate with a decrease in urine output. Thus, an early sign of prerenal failure is a sharp decrease in urine output.

When acute tubular necrosis (ATN) is suspected, the nurse will likely see which laboratory findings on the urinalysis report? Select all that apply. Cast cells Glucose Sodium excess Protein Red blood cells

Cast cells Protein Red blood cells

A hospital client with a diagnosis of chronic renal failure has a prescription for measurement of serum electrolyte levels three times per week. Which statement best captures the relationship between renal failure and sodium regulation?

Clients with advanced renal failure are prone to hyponatremia because of impaired tubular reabsorption. The compromised ability of the tubular nephrons to reabsorb sodium predisposes renal clients to low serum sodium levels. A sodium restriction is thus not normally indicated

The nurse is instructing a client with advanced kidney disease (AKD) about a dietary regimen. Which restriction should the nurse be sure to include in the treatment plan to decrease the progress of renal impairment in people with AKD?

Dietary protein Restriction of dietary proteins may decrease the progress of renal impairment in people with advanced renal disease. Proteins are broken down to form nitrogenous wastes, and reducing the amount of protein in the diet lowers the blood urea nitrogen and reduces symptoms.

A client is beginning to recover from acute tubular necrosis. The nurse would likely be assessing which of the following manifestations of the recovery phase of ATN?

Diuresis

A client with chronic kidney disease (CKD) has developed asterixis. The nurse knows that asterixis is:

Dorsiflexion of hands and feet Asterixis, which is involuntary dorsiflexion of hands and feet, can develop as CKD worsens. Burning sensation in feet, unsteady gait and demyelination of nerves can also accompany CKD, but are not part of asterixis.

Which dermatologic problem most often accompanies chronic kidney disease (CKD)? - Dry skin and pruritus - Petechiae and purpura

Dry skin and pruritus Dry, itchy skin is a common consequence of CKD

A client with significant burns on his lower body has developed sepsis on the 3rd day following his accident. Which of the following manifestations would the nurse anticipate for an ischemic acute tubular necrosis rather than prerenal failure?

GFR does not increase after restoration of renal blood flow

A client is diagnosed with renal failure. The nurse must monitor for failure of which functions? Select all that apply. Adrenal secretion Maintenance of body water Removal of metabolic waste from blood Acid-base balance Electrolyte balance

Maintenance of body water Removal of metabolic waste from blood Acid-base balance Electrolyte balance Functions of the kidney include removal of metabolic end products and regulation of body water, electrolyte balance, and acid-base balance. Although the adrenal glands are located above the kidneys, the kidneys are not directly involved in their regulation.

A client with postrenal acute kidney injury (AKI) exhibits oliguria and edema with laboratory results revealing increased levels of urea, potassium, and creatinine. Based on these data, which phase of AKI is this client most likely experiencing? Diuretic Phase Oliguric Phase

Oliguric phase The oliguric phase of AKI is characterized by marked decrease in glomerular filtration rate (GFR), causing sudden retention of endogenous metabolites, such as urea, potassium, sulfate, and creatinine, that normally are cleared by the kidneys. The urine output is usually lowest at this point. Fluid retention gives rise to edema, water intoxication, and pulmonary congestion. AKI typically progresses through four phases: 1. the onset phase, during which tubular injury is induced; 2. the oliguric phase, during which the GFR falls, nitrogenous wastes accumulate, and urine output ↓(oliguria) 3. the diuretic phase when the kidneys try to heal and urine output ↑ 4. the recovery phase, where tubular edema resolves and renal function improves. During recovery, there is normalization of fluid and electrolyte balance.

A client has an obstructive urine outflow related to benign prostatic hyperplasia. Due to the inability to excrete adequate amounts of urine, which type of renal failure should the nurse closely monitor for?

Postrenal failure

A client in renal failure has marked decrease in renal blood flow caused by hypovolemia, the result of gastrointestinal bleeding. The nurse is aware that this form of renal failure can be reversed if the bleeding is under control. Which form of acute renal injury does this client have?

Prerenal failure Prerenal failure, the most common form of acute renal failure, is characterized by a marked decrease in renal blood flow. It is reversible if the cause of the decreased renal blood flow can be identified and corrected before kidney damage occurs.

A 72-year-old client is scheduled for a kidney transplant. The nurse knows that which aspect of advanced age has a positive effect on the success of kidney transplant survival? Reduction in T-lymphocyte function Psychological maturity Acceptance of immunosuppressive therapy Decreased muscle mass

Reduction in T-lymphocyte function The general reduction in T-lymphocyte function with subsequent decrease in immune system activity that occurs with aging would foster transplant survival.

An 86-year-old female client has been admitted to the hospital for the treatment of dehydration and hyponatremia after she curtailed her fluid intake to minimize urinary incontinence. The client's admitting laboratory results are suggestive of prerenal failure. The nurse should be assessing this client for which early sign of prerenal injury?

Sharp decrease in urine output Dehydration and its consequent hypovolemia can result in acute renal failure that is prerenal in etiology. The kidney normally responds to a decrease in GFR with a decrease in urine output. Thus, an early sign of prerenal injury is a sharp decrease in urine output. Post-renal failure is obstructive in etiology, and intrinsic (or intrarenal) renal failure is reflective of deficits in the function of the kidneys themselves.

A client with chronic kidney disease (CKD) will be managed with peritoneal dialysis. Which description of this type of dialysis is most accurate?

Treatment involves the introduction into the peritoneum of a sterile dialyzing solution, which is drained after a specified time. peritoneal dialysis: a sterile dialyzing solution is instilled into the peritoneum through a catheter over approximately 10 minutes. The solution remains ("dwells") in the peritoneal cavity for a determined time interval, then drains into a sterile bag.

With the increased risk of drug toxicity among chronically ill older adults, which statement by the nurse explains why the older adult's kidney is vulnerable to toxic injury?

"The kidney is rich in blood supply and can concentrate toxins in high levels in the medullary portion of the kidney." Alterations in pharmacokinetics occur with advancing age and increase the likelihood of toxic reactions. The kidney is rich in blood supply and can concentrate toxins in high levels in the medullary portion of the kidney. The toxic effects, which cause some minor necrosis, are generally limited to the proximal tubule

A 45-year-old client with chronic kidney disease (CKD) voices concern about her dialysis treatment. The client would like to work and spend time with her family. Which type of dialysis will best fit this client's lifestyle? 1. Continuous cyclic peritoneal dialysis 2. Nocturnal intermittent peritoneal dialysis (NIPD) 3. Continuous ambulatory peritoneal dialysis 4. Hemodialysis

2. Nocturnal intermittent peritoneal dialysis (NIPD) In NIPD, the client is given 10 hours of automatic cycling each night, with the abdomen left dry during the day. This is the most beneficial for this client. Individual preference, manual ability, lifestyle, knowledge of the procedure, and physiologic response to treatment are used to determine the type of dialysis that is used CAPD involves exchanging the dialysate four to six times per day. In CCPD, the last exchange remains in the abdomen during the day.

Accumulation of nitrogenous wastes such as urea in the circulatory system is an early sigh of chronic kidney disease (CKD). The nurse knows that normal levels of urea in blood are approximately:

20 mg/dL (7.14 mmol/L) Normal levels of blood urea nitrogen are approximately 20 mg/dL or less. The level increases as CKD worsens and can go as high as 800 mg/dL (285.60 mmol/L).

A client with a history of chronic kidney disease (CKD) is experiencing increasing fatigue, lethargy, and activity intolerance. The care team has established that the client's glomerular filtration rate (GFR) remains at a low, but stable, level. Which laboratory assessments will most likely be prescribed to help determine the cause of these new symptoms?

Blood work for hemoglobin, red blood cells, and hematocrit Anemia is a frequent and debilitating consequence of CKD. The anemia may be due to chronic blood loss, hemolysis, bone marrow suppression due to retained uremic factors, and decrease in red cell production due to impaired production of erythropoietin and iron deficiency.

Following kidney transplantation, the client is prescribed maintenance immunosuppressive therapy consisting of prednisone, azathioprine, and cyclosporine. While educating the client about the immunosuppressive therapy, which side effects should the nurse include in the teaching plan? Select all that apply. Ringing or buzzing in the ears Nephrotoxicity of newly transplanted kidney Increased risk of developing cancer Development of metabolic dysfunction Cardiovascular complications

Cardiovascular complications Increased risk of developing cancer Development of metabolic dysfunction Most immunosuppressive drugs have serious side effects such as cardiovascular complications, metabolic dysfunction, and cancer. Rarely do these medications harm the newly transplanted kidney. Development of moon face and buffalo hump are classic signs and symptoms of Cushing syndrome and can be associated with steroids like prednisone. Ringing or buzzing in the ears can be associated with ibuprofen intake.

A client is beginning to recover from acute tubular necrosis. During which phase of acute kidney injury will the nurse assess an increase in urine output?

Diuretic phase

Several urine tests can be useful in establishing a diagnosis of acute renal failure (ARF). The nurse must consider that fractional excretion of sodium can be particularly affected by administration of which type of drug?

Diuretics Diuretics, which directly affect renal excretion of sodium, can alter the fractional excretion of sodium.

Disorders of phosphate and calcium metabolism frequently occur in clients with chronic kidney disease (CKD). The nurse recognizes which statement regarding phosphate and calcium imbalances is correct? 1. Hypercalcemia can lead to osteodystrophy of CKD, which predisposes clients to cardiovascular disorders. 2. Consumption of foods high in phosphate content like beef and salmon are encouraged in clients with CKD. 3. Aluminum-containing antacids can decrease risk of osteodystrophy. 4. Calcitriol will decrease gastrointestinal absorption of calcium.

Hypercalcemia can lead to osteodystrophy of CKD, which predisposes clients to cardiovascular disorders. Bone demineralization of CKD can lead to calcification and stiffness of arteries, and left ventricular hypertrophy. Hyperphosphatemia occurs frequently in clients with CKD, so foods rich in phosphates are discouraged. Calcitriol increases gastrointestinal absorption of both calcium and phosphate.

A nurse is assessing a client for early manifestations of chronic kidney disease (CKD). Which would the nurse expect the client to display? Impotence Terry nails Hypertension Asterixis

Hypertension Hypertension is commonly an early manifestation of CKD. The mechanisms that cause the hypertension are multifactorial: they include increased vascular volume, increased peripheral vascular resistance, decreased levels of renal vasodilator prostaglandins, and increased activity of the renin-angiotensin-aldosterone system. -Impotence occurs in as many as 56% of males on dialysis. -Terry nails are a dark band just behind the leading edge of a fingernail followed by a white band that occurs in the late stages. -Asterixis, a sign of hepatic encephalopathy, is due to the inability of the liver to metabolize ammonia to urea. Causes dorsiflexion of hands and feet

The client with substance use disorder was found unconscious after overdosing on heroin 2 days prior. Because of prolonged pressure on the muscles the client has developed myoglobinuria, causing which complication?

Obstruction of the renal tubules with myoglobin and damaged tubular cells Myoglobin normally is not found in the serum or urine. It has a low molecular weight; if it escapes into the circulation, it is rapidly filtered in the glomerulus. A life-threatening condition known as rhabdomyolysis occurs when increasing myoglobinuria levels cause myoglobin to precipitate in the renal tubules, leading to obstruction and damage to surrounding tubular cells. Myoglobinuria most commonly results from muscle trauma but may result from exertion, hyperthermia, sepsis, prolonged seizures, and alcoholism or drug abuse.

A client with chronic kidney disease has developed cardiac calcification. On admission the priority assessment would be for the nurse to: listen to the heart for extra clicking sounds. place on a heart monitor to watch for arrhythmias. assess for pulses in the feet bilaterally. check the BP in both arms and compare.

place on a heart monitor to watch for arrhythmias. Visceral calcification may be found in the myocardium, lungs, and stomach. In cardiac calcification, the deposits usually develop in the conduction system and may result in serious cardiac arrhythmias. priority.watching for arrhythmias The other assessments are valid

Vitamin D metabolism is deranged in clients with chronic kidney disease (CKD). The nurse recognizes that which statement regarding vitamin D is correct?

Kidneys convert inactive vitamin D to its active form, calcitriol. Inactive vitamin D is converted to active calcitriol in the kidneys. Calcitriol enhances gastrointestinal absorption of calcium, and suppresses release of PTH. Elevated levels of PTH are characteristic of CKD as blood levels of phosphate rise and levels of calcium fall.

The nurse recognizes that acute renal injury is characterized by which of the following?

Rapid decline in renal function Acute renal injury is a rapid decline in kidney function. BUN rises as nitrogenous wastes are not removed from the circulation. If the cause can be ameliorated, the injury is usually reversible. Most at risk are seriously ill clients; the mortality rate is between 40% and 90% in these clients.

The nurse caring for four male clients recognizes which client is at highest risk for developing postrenal kidney failure? - Client with acute pyelonephritis - Client with prostatic hyperplasia

Client with prostatic hyperplasia most common cause of postrenal kidney failure is prostatic hyperplasia.

The primary care provider for a newly admitted hospital client has added the glomerular filtration rate (GFR) to the blood work scheduled for this morning. The client's GFR results return as 50 mL/minute/1.73 m2. The nurse explains to the client that this result represents: - a loss of over half the client's normal kidney function. - diagnostic for concentrated urine

a loss of over half the client's normal kidney function. In clinical practice, GFR is usually estimated using the serum creatinine concentration. A GFR below 60 mL/minute/1.73 m2 represents a loss of one half or more of the level of normal adult kidney function. The GFR is not diagnostic for concentrated urine or the need to drink more water.