Ch 47: Nursing Management Acute Kidney Injury and Chronic Kidney Disease

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

3, 2, 1

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 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 patients history and cause of increased potassium, instruct the patient about dietary sources of potassium, this wouldn't help at this point. the nurse may want to recheck the value but until then the heart rhythm needs to be monitored.

Prevention of AKI is important because of high mortality rate. Which patients are at increased risk for AKI (select all that apply)? a. 86 yr old woman scheduled for cardiac catheterization b. 48 yr old man with multiple injuries from a motor vehicle accident c. 32 yr old woman following a C section delivery from abruptio placentae d. 64 year old woman with chronic heart failure admitted with bloody stools e. 58 yr 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 (b and c), obsteric complications c), cardiac failure d), preexisting CKD, 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)

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 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 calcification contribute to CVD, not to itching skin. Uremic frost rarely occurs without BUN levels greater than 200 mg/dL, which shouldn't occur in patient on dialysis; urea crystallizes on the skin and also causes pruritis.

A man with ESKD is scheduled for hemodialysis following healing of an AV fistula (AVF). What should nurse explain to him that'll 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 20-30 mins to remove 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.

A patient received kidney transplant last month. B/c of the effects of immunosuppressive drugs and CKD, what complications of transplantation should the nurse be assessing the patient for to decrease the risk of morality? a. infection b. rejection c. malignancy d. CVD

a.

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.

which complications of CKD is treated with erythropoietin (EPO)? a. Anemia b. hypertension c. hyperkalemia d. mineral and bone disorder

a.

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 b/c the kidneys can't synthesize ammonia or excrete acid products of metabolism, resulting in an increased acid load. Sodium is lost in urine because the kidneys can't conserve sodium. Impaired excretion of potassium results in hyperkalemia. Bicarbonate id normally generated and reabsorbed by functioning kidney to maintain acid-base balance

A patient with AKI has a serum potassium level of 6.7 mEq/L and the following arterial blood gas results: pH 7.28, PaCO2 30mm Hg, PaO2 86 mm Hg, HCO3 18 mEq/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.

In replying to a patients questions about the seriousness of her chronic kidney disease, the nurse knows that the stage of CKD is based on what? a. total daily urine output b. glomerular filration 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 CKD.

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

b.

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 inflow phase d. reposition the patient frequently and promote deep breathing

b.

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 sire c. evaluate the color and temp of the extremity d. assess for the presence of numbness and tingling distal to site

b.

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.

what is the most serious electrolyte disorder associated with kidney disease? a. hypocalcemia b. hyperkalemia c. hyponatremia d. hypermagnesemia

b.

A dehydrated patient is in the INJURY stage of RIFLE staging of AKI. What would the nurse first anticipate in treatment of this patient? a. assess daily weight b. IV admin of fluid and furosemide (Lasix) c. IV admin of insulin and sodium bicarbonate d. reversal of oliguria occurs with fluid replacement

b. Injury is the stage of RIFLE when urine output is less than 0.5 mL/kg/hr for 12 hours, the serum creatinine is increased times two or the GFR decreased by 50 %. this stage may be reversible by treating the cause or for this patient, the dehydration by admin IV fluid and low dose of a loop diuretic (Lasix). Assessing the daily weight will be done to monitor fluid changes but its not the first treatment the nurse should anticipate. IV admin 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 whats seen in urine but with this patients dehydration, its thought to be prerenal to begin treatment.

In a patient with AKI, which laboratory urinalysis results indicate 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

b. a urine specific gravity thats consistently 1.010 and a urine osmolality of about 300 mOsm/kg is same SG 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 high sodium concentration (greater than 40 mEq/L)

A 68 yr 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 with cardiac changes, his BUN is 108 mg/dL, his serum creatinine is 4.1 mg/dL and his serum HCO3- is 14 mEq/L. He is somnolent and disoriented. Which treatment should the nurse expect to be used for him? a. loop diuretic b. renal replacement therapy c. insulin and sodium bicarbonate d. sodium polystyrene sulftonate (Kayexalate)

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

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

c)

What causes the GI manifestations of stomatitis in the patient with CKD? a. high serum sodium levels b. irritation of GI tract from creatinine c. increased ammonia from bacterial breakdown of urea d. iron salts, calcium-containing phosphate binders and limited fluid intake

c)

The patient with CKD is considering whether to use peritoneal dialysis (PD) or hemodialysis (HD). What are advantages of PD when compared to HD (select all that apply)? a. less protein loss b. rapid fluid removal c. less cardiovascular stress d. decreased hyperlipidemia e. requires fewer dietary restrictions

c,e:

An 83 yr old female patient was found lying on the bathroom floor. She said she fell 2 days ago and hasn't been able to take her heart meds or eat/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: b/c the patient has had nothing to eat/drink for 2 days, she is probably dehydrated and hypovolemic. Decreased CO is most likely b/c she is older and takes heart meds, 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 isn't likely in this situation. Nephrotoxic drugs would contribute to intrarenal causes of AKI and renal calculi would be postrenal cause of AKI

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.

What does the dialysate for PD routinely contain? a. calcium in a lower concentration than in blood b. sodium in a higher concentration than in blood c. dextrose in a higher concentration than in the blood d. electrolytes in an equal concentration to that of blood

c.

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 more 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 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.

for a patient with CKD the nurse id's a nursing diagnosis of risk for injury, fracture related to alterations in calcium and phosphorus metabolism. Whats the pathologic process directly related to the increased risk for fractures? a. loss of aluminum thru the impaired kidneys b. deposition of calcium phosphate in sot tissues of body c. impaired vitamin D activation resulting in decreased GI absoprtion of calcium d. increased release of PTH in response to decreased calcium levels

c.

What are intrarenal causes of acute kidney injury? (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 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 postrenal causes of AKI

A patient rapidly progressing toward ESKD 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.

What accurately describes the care of the patient with CKD? a. a nutrient that is commonly supplemented for the patient on dialysis b/c it is dialyzable ir 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 bc 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.

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.

Which serum lab 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.

Acute tubular necrosis (ATN) is the most common cause of intrarenal AKI. Which patient is most likely to develop ATN? a. patient w/ 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 likely to cause severe kidney ischemia in patient requiring blood transfusion. a blood transfusion hemolytic rxn produces nephrotoxic injury if it occurs. Diabetes mellitus, hypertension and acetaminophen overdose will not contribute to ATN.

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 HCP? a. urine output is 300mL/day b. edema occurs in feet, legs and sacral area c. cardiac monitor reveals a decreased 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 neuromuscular impairment that occurs with hyperkalemia. In addition, hyperkalemia can cause cardiac conduction abnormalities of peaked T wave, prolonged PR interval, prolonged QRS interval, and depressed ST seg. 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 theres 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 high specific gravity and 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.

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

d. measuring daily weights with the same scale at the asme time of day allows for eval and detection of excessive body fluid gains/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 days measured fluid loss. Dietary sodium and potassium intake are managed according to 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 3700mL/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 3-5 L/day, decreasing sodium and potassium levels, and fluid weight loss are characteristics of diuretic phase of AKI.