Chapter 46: Acute Kidney Injury and Chronic Kidney Disease

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 with iron

ANS: 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 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.

Correct answer: a Rationale: Advantages of peritoneal dialysis include fewer dietary restrictions and the possibility of home dialysis.

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.

Correct answer: a 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.

During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do first? Administer hypertonic saline. Administer a blood transfusion. Decrease the rate of fluid removal. 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.

Diffusion, osmosis, and ultrafiltration occur in both hemodialysis and peritoneal dialysis. Which strategy is used to achieve ultrafiltration in peritoneal dialysis? Increasing the pressure gradient Increasing osmolality of the dialysate Decreasing the glucose in the dialysate 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.

The nurse preparing to administer a dose of calcium acetate to a patient with chronic kidney disease (CKD). Which laboratory result will the nurse monitor to determine if the desired effect was achieved? Sodium Potassium Magnesium 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. Calcium acetate will not have an effect on sodium, potassium, or magnesium levels.

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 c. hot, flushed face and neck. b. rapid, deep respirations. d. bounding peripheral pulses.

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

Which is a major complication in a child with chronic renal failure? a. Hypokalemia b. Metabolic alkalosis c. Water and sodium retention d. Excessive excretion of blood urea nitrogen

ANS: C Chronic renal failure leads to water and sodium retention, which contributes to edema and vascular congestion. Hyperkalemia, metabolic acidosis, and retention of blood urea nitrogen are complications of chronic renal failure.

Which is a common side effect of short-term corticosteroid therapy? a. Fever b. Hypertension c. Weight loss d. Increased appetite

ANS: D Side effects of short-term corticosteroid therapy include an increased appetite. Fever is not a side effect of therapy. It may be an indication of infection. Hypertension is not usually associated with initial corticosteroid therapy. Weight gain, not weight loss, is associated with corticosteroid therapy.

Which is the most common cause of acute renal failure in children? a. Pyelonephritis b. Tubular destruction c. Urinary tract obstruction d. Severe dehydration

ANS: D The most common cause of acute renal failure in children is dehydration or other causes of poor perfusion that may respond to restoration of fluid volume. Pyelonephritis and tubular destruction are not common causes of acute renal failure. Obstructive uropathy may cause acute renal failure, but it is not the most common cause.

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

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.

Which statement regarding continuous ambulatory peritoneal dialysis (CAPD) would be most important when teaching a patient new to the treatment? "Maintain a daily written record of blood pressure and weight." "It is essential that you maintain aseptic technique to prevent peritonitis." "You will be allowed a more liberal protein diet once you complete CAPD." "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 prevention. Although the other teaching statements are accurate, they do not have the potential for morbidity and mortality that peritonitis does.

The home care nurse visits a 34-yr-old woman receiving peritoneal dialysis. Which statement indicates a need for immediate follow-up by the nurse? "Drain time is faster if I rub my abdomen." "The fluid draining from the catheter is cloudy." "The drainage is bloody when I have my period." "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.

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

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.

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.

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.

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.

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.

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

Calcium carbonate is given with meals to a child with chronic renal disease. The purpose of this is to: a. prevent vomiting. b. bind phosphorus. c. stimulate appetite. d. increase absorption of fat-soluble vitamins.

ANS: B Oral calcium carbonate preparations combine with phosphorus to decrease gastrointestinal absorption and the serum levels of phosphate. Serum calcium levels are increased by the calcium carbonate, and vitamin D administration is necessary to increase calcium absorption. Calcium carbonate does not prevent vomiting, stimulate appetite, or increase the absorption of fat-soluble vitamins.

Which statement is descriptive of renal transplantation in children? a. It is an acceptable means of treatment after age 10 years. b. It is the preferred means of renal replacement therapy in children. c. Children can receive kidneys only from other children. d. The decision for transplantation is difficult because a relatively normal lifestyle is not possible.

ANS: B Renal transplant offers the opportunity for a relatively normal life and is the preferred means of renal replacement therapy in end-stage renal disease. Renal transplantation can be done in children as young as age 6 months. Both children and adults can serve as donors for renal transplant purposes. Renal transplantation affords the child a more normal lifestyle than dependence on dialysis.

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

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

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.

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

The nurse is conducting teaching for an adolescent being discharged to home after a renal transplant. The adolescent needs further teaching if which statement is made? a. "I will report any fever to my primary health care provider." b. "I am glad I only have to take the immunosuppressant medication for two weeks." c. "I will observe my incision for any redness or swelling." d. "I won't miss doing kidney dialysis every week."

ANS: B The immunosuppressant medications are taken indefinitely after a renal transplant, so they should not be discontinued after two weeks. Reporting a fever and observing an incision for redness and swelling are accurate statements. The adolescent is correct in indicating dialysis will not need to be done after the transplant.

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."

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.

Which is an objective of care for a 10-year-old child with minimal change nephrotic syndrome? a. Reduce blood pressure. b. Reduce excretion of urinary protein. c. Increase excretion of urinary protein. d. Increase ability of tissues to retain fluid.

ANS: B The objectives of therapy for the child with minimal change nephrotic syndrome include reduction of the excretion of urinary protein, reduction of fluid retention, prevention of infection, and minimization of complications associated with therapy. Blood pressure is usually not elevated in minimal change nephrotic syndrome. Excretion of urinary protein and fluid retention are part of the disease process and must be reversed.

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.

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

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. c. diluting nephrotoxic substances. b. maintaining cardiac output. 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.

One of the clinical manifestations of chronic renal failure is uremic frost. Which best describes this term? a. Deposits of urea crystals in urine b. Deposits of urea crystals on skin c. Overexcretion of blood urea nitrogen d. Inability of body to tolerate cold temperatures

ANS: B Uremic frost is the deposition of urea crystals on the skin. The urea crystals are present on the skin, not in the urine. The kidneys are unable to excrete blood urea nitrogen, leading to elevated levels. There is no relation between cold temperatures and uremic frost.

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.

ANS: 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.

The nurse is teaching parents of a child with chronic renal failure (CRF) about the use of recombinant human erythropoietin (rHuEPO) subcutaneous injections. Which statement indicates the parents have understood the teaching? a. "These injections will help with the hypertension." b. "We're glad the injections only need to be given once a month." c. "The red blood cell count should begin to improve with these injections." d. "Urine output should begin to improve with these injections."

ANS: C Anemia in children with CRF is related to decreased production of erythropoietin. Recombinant human erythropoietin (rHuEPO) is being offered to these children as thrice-weekly or weekly subcutaneous injections and is replacing the need for frequent blood transfusions. The parents understand the teaching if they say that the red blood cell count will begin to improve with these injections.

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 c. Hemoglobin level 13 g/dL b. Oxygen saturation 89% 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 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.

ANS: 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.

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.

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.

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.

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

ANS: C Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup 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

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.

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."

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

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.

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.

The nurse notes that a child has lost 8 pounds after 4 days of hospitalization for acute glomerulonephritis. This is most likely the result of: a. poor appetite. b. increased potassium intake. c. reduction of edema. d. restriction to bed rest.

ANS: C This amount of weight loss in this period is a result of the improvement of renal function and mobilization of edema fluid. Poor appetite and bed rest would not result in a weight loss of 8 pounds in 4 days. Foods with substantial amounts of potassium are avoided until renal function is normalized.

Which clinical manifestation would be seen in a child with chronic renal failure? a. Hypotension b. Massive hematuria c. Hypokalemia d. Unpleasant "uremic" breath odor

ANS: D Children with chronic renal failure have a characteristic breath odor resulting from the retention of waste products. Hypertension may be a complication of chronic renal failure. With chronic renal failure, little or no urinary output occurs. Hyperkalemia is a concern in chronic renal failure.

The nurse is caring for an adolescent who has just started dialysis. The child seems always angry, hostile, or depressed. The nurse should recognize that this is most likely related to: a. neurologic manifestations that occur with dialysis. b. physiologic manifestations of renal disease. c. adolescents having few coping mechanisms. d. adolescents often resenting the control and enforced dependence imposed by dialysis.

ANS: D Older children and adolescents need control. The necessity of dialysis forces the adolescent into a dependent relationship, which results in these behaviors. These are a function of the child's age, not neurologic or physiologic manifestations of the dialysis. Feelings of anger, hostility, and depression are functions of the child's age, not neurologic or physiologic manifestations of the dialysis. Adolescents do have coping mechanisms, but they need to have some control over their disease management.

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.

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 is also appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening dysrhythmias.

A preschool child is being admitted to the hospital with dehydration and a urinary tract infection (UTI). Which urinalysis result should the nurse expect with these conditions? a. WBC <1; specific gravity 1.008 b. WBC <2; specific gravity 1.025 c. WBC >2; specific gravity 1.016 d. WBC >2; specific gravity 1.030

ANS: D WBC count in a routine urinalysis should be <1 or 2. Over that amount indicates a urinary tract inflammatory process. The urinalysis specific gravity for children with normal fluid intake is 1.016 to 1.022. When the specific gravity is high, dehydration is indicated. A low specific gravity is seen with excessive fluid intake, distal tubular dysfunction, or insufficient antidiuretic hormone secretion.

What is an advantage to teach to the family about continuous cycling peritoneal dialysis (CCPD) or continuous ambulatory peritoneal dialysis (CAPD) for adolescents who require dialysis? Hospitalization is only required several nights per week. Dietary restrictions are no longer necessary. Adolescents can carry out procedures themselves. Insertion of a catheter does not require surgical placement.

Adolescents can carry out procedures themselves. This type of dialysis provides the most independence for adolescents with end-stage renal disease and their families. Adolescents can carry out the procedure themselves, and the procedure is usually performed at night, enabling the adolescent to live life more normally during the day. CCPD and CAPD can be done at home. Dietary restrictions are still required but are less strict when an adolescent is on CCPD or CAPD. The catheter is surgically implanted in the abdominal cavity for both CCPD and CAPD.

A 78-yr-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? Apple, green beans, and a roast beef sandwich Granola made with dried fruits, nuts, and seeds Watermelon and ice cream with chocolate sauce Bran cereal with ½ banana and milk and orange juice

Apple, green beans, and a roast beef sandwich 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.

A 56-yr-old woman with type 2 diabetes mellitus and chronic kidney disease has a serum potassium level of 6.8 mEq/L. Which finding will the nurse monitor for? Fatigue Hypoglycemia Cardiac dysrhythmias 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. Hypoglycemia is a complication related to diabetes control, not hyperkalemia. However, administration of insulin and dextrose is an emergency treatment for hyperkalemia.

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? Hemodialysis (HD) three times per week Automated peritoneal dialysis (APD) Continuous venovenous hemofiltration (CVVH) 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 three 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.

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.

Correct answer: a 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.

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.

Correct answer: d 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.

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.

Correct answers: a, b, c 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. 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.

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.

Correct answers: a, b, d 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.

Correct answers: a, b, d, e 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).

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.

Correct answers: a, c 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.

To assess the patency 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.

Correct answers: c, d, e 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.

Which assessment findings would alert the nurse that the patient has entered the diuretic phase of acute kidney injury (AKI) (select all that apply.)? Dehydration Hypokalemia Hypernatremia BUN increases Urine output increases Serum creatinine increases

Dehydration Hypokalemia Urine output increases The hallmark of entering the diuretic phase is the production of copious amounts of urine. Dehydration, hypokalemia, and hyponatremia occur in the diuretic phase of AKI because the nephrons can excrete wastes but not concentrate urine. Serum BUN and serum creatinine levels begin to decrease.

Which patient diagnosis or treatment is most consistent with prerenal acute kidney injury (AKI)? IV tobramycin Incompatible blood transfusion 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 post-streptococcal glomerulonephritis are intrarenal causes of AKI.

A 24-yr-old woman donated a kidney via a laparoscopic donor nephrectomy to a nonrelated recipient. The patient is experiencing significant pain and refuses to get up to walk. How should the nurse respond? Have the transplant psychologist convince her to walk. Encourage even a short walk to avoid complications of surgery. Tell the patient that no other patients have ever refused to walk. 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; 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.

Parents of a newborn bring their male son to the emergency room. The infant appears fretful and the parents state that he has not voided in several hours. Inspection of the penis reveals edema and the nurse is unable to retract the foreskin. Based on this assessment, what would the nurse anticipate as the priority action? Perform an ultrasound to determine if there is urinary retention. Inform the ER physician of the patient's condition. Ask the parents specifically how long the infant has not voided. Continue to monitor the patient in the ER setting.

Inform the ER physician of the patient's condition. If the nurse cannot retract the foreskin and there is associated edema, paraphimosis is suspected which requires prompt medical evaluation. Ultrasound determination of bladder status is not the priority action. Even though having more precise information about the length of time that the infant has not voided, the priority is to initiate medical action.

The nurse is caring for a 68-yr-old man who had coronary artery bypass surgery 3 weeks ago. During the oliguric phase of acute kidney disease, which action would be appropriate to include in the plan of care? Provide foods high in potassium. Restrict fluids based on urine output. Monitor output from peritoneal dialysis. 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.

A nurse is caring for an infant with a suspected urinary tract infection (UTI). Based on the nurse's knowledge of UTIs, which clinical manifestation would be observed? Select all that apply. Vomiting Jaundice Swelling of the face Persistent diaper rash Failure to gain weight

Vomiting Persistent diaper rash Failure to gain weight Vomiting is a clinical manifestation observed in an infant with a urinary tract infection (UTI) and can be related to poor feeding. Persistent diaper rash is a clinical manifestation of UTI in an infant. Failure to gain weight is a clinical manifestation of UTI in an infant related to poor feeding and vomiting. Jaundice and swelling of the face are not clinical manifestations of UTI in an infant.

In a non-potty-trained child with nephrotic syndrome, what is the best way to detect fluid retention? Weigh the child daily. Test the urine for hematuria. Measure the abdominal girth weekly. Count the number of wet diapers.

Weigh the child daily. A daily weight taken at the same time every day, with the child wearing the same clothing, is the most accurate way to determine fluid gains and losses. The presence or absence of blood in the urine will not help with the determination of fluid retention. The abdominal girth will reflect edema, but weekly measurements are too infrequent. The number of wet diapers reflects how often the diapers have been changed. The diapers should be weighed to reflect the fluid balance.

The nurse is caring for a 4-year-old girl with a history of frequent urinary tract infections (UTIs). What should the nurse be aware of before obtaining a urine sample? Select all that apply. a. To obtain a clean-catch urine specimen, have the child sit on the toilet facing backward toward the tank. b. Because children who have a UTI will have painful urination, have the child drink a large amount of fluid before obtaining the sample. c. The specimen must be fresh—less than 1 hour after voiding with storage at room temperature or less than 4 hours after voiding with refrigeration. d. If a urinalysis obtained by a bag specimen is negative, a specimen still needs to be obtained by catheterization or suprapubic aspiration. e. The key to distinguishing a true UTI from asymptomatic bacteriuria is the presence of pyuria (containing white blood cells or pus). f. Because the child is febrile, the nurse should immediately start an antimicrobial and then obtain a urine culture.

a, c, e

The parent of a child hospitalized with acute glomerulonephritis (AGN) asks the nurse why blood pressure readings are being taken so often. Based on the nurse's knowledge of AGN, the most appropriate response by the nurse is blood pressure fluctuations are a common side effect of antibiotic therapy. blood pressure fluctuations are a sign that the condition has become chronic. acute hypertension must be anticipated and identified. hypotension leading to sudden shock can develop at any time.

acute hypertension must be anticipated and identified. Vital signs, in particular the blood pressure, provide information about the severity of AGN and early signs of complications. Acute hypertension is anticipated and requires frequent monitoring for early intervention. Blood pressure does not commonly fluctuate with antibiotic therapy. Blood pressure fluctuations are not indicative of chronic disease. Most children with AGN fully recover. Hypertension, not hypotension, is more likely with AGN.

A 6-year-old child with acute renal failure (ARF) is being transferred out of the intensive care unit. Which children, considering their diagnoses, would be the most appropriate roommate for this child? 6-year-old child with pneumonia 4-year-old child with gastroenteritis 5-year-old child who has a fractured femur 7-year-old child who had surgery for a ruptured appendix

5-year-old child who has a fractured femur The 5-year-old orthopedic patient would be the best choice for a roommate. This child does not have an illness of viral or bacterial origin. A child with pneumonia has an illness of viral or bacterial origin and should not be placed in the same room as a child with ARF. A child with gastroenteritis has an illness of viral or bacterial origin and should not be placed in the same room as a child with ARF. A child who has had surgery for a ruptured appendix may have an illness of viral or bacterial origin and should not be placed in the same room as a child with ARF.

Which patient has the most significant risk factors for CKD? A 50-yr-old white woman with hypertension A 61-yr-old Native American man with diabetes A 40-yr-old Hispanic woman with cardiovascular disease A 28-yr-old African American woman with a urinary tract infection

A 61-yr-old Native American man with diabetes The nurse identifies the 61-yr-old Native American with diabetes as the most at risk. Diabetes causes about 50% of CKD. This patient is the oldest, and Native Americans with diabetes develop CKD six 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.

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

Which is instituted for the therapeutic management of minimal change nephrotic syndrome? a. Corticosteroids b. Antihypertensive agents c. Long-term diuretics d. Increased fluids to promote diuresis

ANS: A Corticosteroids are the first line of therapy for minimal change nephrotic syndrome. Response is usually seen within 7 to 21 days. Antihypertensive agents and long-term diuretic therapy are usually not necessary. A diet that has fluid and salt restrictions may be indicated.

A hospitalized child with minimal change nephrotic syndrome is receiving high doses of prednisone. Which is an appropriate nursing goal related to this? a. Prevent infection. b. Stimulate appetite. c. Detect evidence of edema. d. Ensure compliance with prophylactic antibiotic therapy.

ANS: A High-dose steroid therapy has an immunosuppressant effect. These children are particularly vulnerable to upper respiratory tract infections. A priority nursing goal is to minimize the risk of infection by protecting the child from contact with infectious individuals. Appetite is increased with prednisone therapy. The amount of edema should be monitored as part of the disease process, not necessarily related to the administration of prednisone. Antibiotics would not be used as prophylaxis.

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

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.

The nurse is conducting an admission assessment on a school-age child with acute renal failure. Which are the primary clinical manifestations the nurse expects to find with this condition? a. Oliguria and hypertension b. Hematuria and pallor c. Proteinuria and muscle cramps d. Bacteriuria and facial edema

ANS: A The principal feature of acute renal failure is oliguria; hypertension is a nonspecific clinical manifestation. Hematuria and pallor, proteinuria and muscle cramps, and bacteriuria and facial edema are not principal features of acute renal failure.

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.

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

A school-age child is admitted to the hospital with acute glomerulonephritis and oliguria. Which dietary menu items should be allowed for this child? (Select all that apply.) a. Apples b. Bananas c. Cheese d. Carrot sticks e. Strawberries

ANS: A, D, E Moderate sodium restriction and even fluid restriction may be instituted for children with acute glomerulonephritis. Foods with substantial amounts of potassium are generally restricted during the period of oliguria. Apples, carrot sticks, and strawberries would be items low in sodium and allowed. Bananas are high in potassium and cheese is high in sodium. Those items would be restricted.

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.

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 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).

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 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 c. Creatinine clearance b. Urine output d. Blood urea nitrogen (BUN) level

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

A school-age child with chronic renal failure is admitted to the hospital with a serum potassium level of 5.2 mEq/L. Which prescribed medication should the nurse plan to administer? a. Spironolactone (Aldactone) b. Sodium polystyrene sulfonate (Kayexalate) c. Lactulose (Cephulac) d. Calcium carbonate (Calcitab)

ANS: B Normal serum potassium levels in a school-age child are 3.5 to 5 mEq/L. Sodium polystyrene sulfonate is administered to reduce serum potassium levels. Spironolactone is a potassium sparing diuretic and should not be used if the serum potassium is elevated. Lactulose is administered to reduce ammonia levels in patients with liver disease. Calcium carbonate may be prescribed as a calcium supplement, but it will not reduce serum potassium levels.

Which is included in the diet of a child with minimal change nephrotic syndrome? a. High protein b. Salt restriction c. Low fat d. High carbohydrate

ANS: B Salt is usually restricted (but not eliminated) during the edema phase. The child has little appetite during the acute phase. Favorite foods are provided (with the exception of high-salt ones) in an attempt to provide nutritionally complete meals.

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.

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.

A child is admitted with acute glomerulonephritis. The nurse should expect the urinalysis during this acute phase to show: a. bacteriuria, hematuria. b. hematuria, proteinuria. c. bacteriuria, increased specific gravity. d. proteinuria, decreased specific gravity.

ANS: B Urinalysis during the acute phase characteristically shows hematuria and proteinuria. Bacteriuria and changes in specific gravity are not usually present during the acute phase.

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

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

A school-age child has been admitted to the hospital with an exacerbation of nephrotic syndrome. Which clinical manifestations should the nurse expect to assess? (Select all that apply.) a. Weight loss b. Facial edema c. Cloudy smoky brown-colored urine d. Fatigue e. Frothy-appearing urine

ANS: B, D, E A child with nephrotic syndrome will present with facial edema, fatigue, and frothy-appearing urine (proteinuria). Weight gain, not loss, is expected because of the fluid retention. Cloudy smoky brown-colored urine is seen with acute glomerulonephritis but not with nephrotic syndrome because there is no gross hematuria associated with nephrotic syndrome.

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. c. A nontender axillary lump. b. Blood pressure is 150/92. d. Blood glucose is 144 mg/dL.

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, 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.

Which should the nurse recommend for the diet of a child with chronic renal failure? a. High in protein b. Low in vitamin D c. Low in phosphorus d. Supplemented with vitamins A, E, and K

ANS: C Dietary phosphorus is controlled by the reduction of protein and milk intake to prevent or control the calcium-phosphorus imbalance. Protein should be limited in chronic renal failure to decrease intake of phosphorus. Vitamin D therapy is administered in chronic renal failure to increase calcium absorption. Supplementation of vitamins A, E, and K is not part of dietary management in chronic renal disease.

The nurse is teaching the parent about the diet of a child experiencing severe edema associated with acute glomerulonephritis. Which information should the nurse include in the teaching? a. "You will need to decrease the number of calories in your child's diet." b. "Your child's diet will need an increased amount of protein." c. "You will need to avoid adding salt to your child's food." d. "Your child's diet will consist of low-fat, low-carbohydrate foods."

ANS: C For most children, a regular diet is allowed, but it should contain no added salt. The child should be offered a regular diet with favorite foods. Severe sodium restrictions are not indicated.

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 c. Glomerular filtration rate (GFR) b. Creatinine level d. Blood urea nitrogen (BUN) level

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

Which is the most appropriate nursing diagnosis for the child with acute glomerulonephritis? a. Risk for Injury related to malignant process and treatment b. Fluid Volume Deficit related to excessive losses c. Fluid Volume Excess related to decreased plasma filtration d. Fluid Volume Excess related to fluid accumulation in tissues and third spaces

ANS: C Glomerulonephritis has a decreased filtration of plasma, which results in an excessive accumulation of water and sodium that expands plasma and interstitial fluid volumes, leading to circulatory congestion and edema. No malignant process is involved in acute glomerulonephritis. A fluid volume excess is found. The fluid accumulation is secondary to the decreased plasma filtration.

The nurse is admitting a school-age child in acute renal failure with reduced glomerular filtration rate. Which urine test is the most useful clinical indication of glomerular filtration rate? a. pH b. Osmolality c. Creatinine d. Protein level

ANS: C The most useful clinical indication of glomerular filtration is the clearance of creatinine. It is a substance that is freely filtered by the glomerulus and secreted by the renal tubule cells. The pH and osmolality are not estimates of glomerular filtration. Although protein in the urine demonstrates abnormal glomerular permeability, it is not a measure of filtration rate.

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.

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

A mother asks the nurse what would be the first indication that acute glomerulonephritis is improving. The nurse's best response should be that the: a. blood pressure will stabilize. b. the child will have more energy. c. urine will be free of protein. d. urinary output will increase.

ANS: D An increase in urinary output may signal resolution of the acute glomerulonephritis. If blood pressure is elevated, stabilization usually occurs with the improvement in renal function. The child having more energy and the urine being free of protein are related to the improvement in urinary output.

The nurse is caring for a child with acute renal failure. Which clinical manifestation should the nurse recognize as a sign of hyperkalemia? a. Dyspnea b. Seizure c. Oliguria d. Cardiac arrhythmia

ANS: D Hyperkalemia is the most common threat to the life of the child. Signs of hyperkalemia include electrocardiograph anomalies such as prolonged QRS complex, depressed ST segments, peaked T waves, bradycardia, or heart block. Dyspnea, seizure, and oliguria are not manifestations of hyperkalemia.

A patient complains of leg cramps during hemodialysis. The nurse should a. massage the patient's legs. c. give acetaminophen (Tylenol). b. reposition the patient supine. 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 is an advantage of peritoneal dialysis? a. Treatments are done in hospitals. b. Protein loss is less extensive. c. Dietary limitations are not necessary. d. Parents and older children can perform treatments.

ANS: D Peritoneal dialysis is the preferred form of dialysis for parents, infants, and children who wish to remain independent. Parents and older children can perform the treatments themselves. Treatments can be done at home. Protein loss is not significantly different. The dietary limitations are necessary, but they are not as stringent as those for hemodialysis.

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 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.

A frail 72-yr-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? Aspirin Acetaminophen Diphenhydramine Aluminum hydroxide

Aluminum hydroxide 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.

Which findings will the nurse expect when caring for a patient with chronic kidney disease (CKD) (select all that apply.)? Anemia Dehydration Hypertension Hypercalcemia Increased risk for fractures Elevated white blood cells

Anemia Hypertension Increased risk for fractures When the kidney fails, erythropoietin in not excreted, so anemia is expected. Hypocalcemia from chronic renal disease stimulates the parathyroid to release parathyroid hormone, causing calcium liberation from bones increasing the risk of pathological fracture. Dehydration and hypercalcemia are not expected in chronic renal disease. Fluid volume overload and hypocalcemia are expected. Although impaired immune function should be expected, elevated white blood cells would indicate inflammation or infection not associated with chronic renal failure itself but a complication.

A 52-yr-old man with stage 2 chronic kidney disease is scheduled for an outpatient diagnostic procedure using contrast media. Which priority action should the nurse perform? Assess skin turgor to determine hydration status. Insert a urinary catheter for the expected diuresis. Evaluate the patient's lower extremities for edema. 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.

A child in renal failure has hyperkalemia. Which foods should be avoided? Cold cuts, chips, and canned foods Hamburger on a bun and lime Jell-O Spaghetti with meat sauce and breadsticks Bananas, carrots, and green leafy vegetables

Bananas, carrots, and green leafy vegetables are high in potassium. Cold cuts, chips, and canned foods are high in sodium but not necessarily in potassium. A hamburger on a bun and lime Jell-O is an acceptable choice for a low-potassium diet. Spaghetti with meat sauce and breadsticks is an acceptable choice for a low-potassium diet.

A patient with end-stage renal disease (ESRD) secondary to diabetes mellitus has arrived at the outpatient dialysis unit for hemodialysis. Which assessments should the nurse perform as a priority before, during, and after the treatment? Level of consciousness Blood pressure and fluid balance Temperature, heart rate, and blood pressure 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, fluid removal during the procedure will require monitoring blood pressure and fluid balance prior, during, and after.

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

Correct answer: c 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.

A patient with a 25-year history of type 1 diabetes mellitus is reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse notes newly developed hypertension and uncontrolled blood sugars. Which diagnostic study is most indicative of chronic kidney disease (CKD)? Serum creatinine Serum potassium Microalbuminuria Calculated glomerular filtration rate (GFR)

Calculated glomerular filtration rate (GFR) The best study to determine kidney function or 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.

In teaching a group of nursing students about factors that could lead to the development of urinary tract infections, which critical aspect should the nursing instructor focus on? Concept of urinary stasis Over distention of the bladder Urinary frequency Maintaining proper hydration

Concept of urinary stasis Urinary stasis is the primary factor leading to the occurrence of urinary tract infections as retaining urine serves as an excellent medium for bacterial growth. Over distention of the bladder is a direct result of urinary stasis. Urinary frequency as a clinical symptom rather than an etiologic cause is of concern as is the intervention of maintaining proper hydration to help flush components through the urinary tract system.

A patient is recovering in the intensive care unit (ICU) 24 hours after receiving a kidney transplant. What is an expected assessment finding during the earliest stage of recovery? Hypokalemia Hyponatremia Large urine output 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 rapidly progressing glomerular inflammation. Weight has increased and urine output is steadily declining. What is the priority nursing intervention? Monitor the patient's cardiac status. Teach the patient about hand washing. Obtain a serum specimen for electrolytes. 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.

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

Restrict fluids according to previous daily loss. Patients in the oliguric phase of AKI will have fluid volume excess with potassium and sodium retention. Therefore, they will need to have dietary sodium, potassium, and fluids restricted. 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. The patient should also be weighed daily, not just three times each week.

A child with periorbital edema, decreased urine output, pallor, and fatigue is admitted to the pediatric unit. The child is being examined for acute glomerular nephritis. Which of the following nursing measures should be considered? Select all that apply. a. On examination, there is usually a mild to moderate elevation in blood pressure compared with normal values for age, although severe hypertension may be present. b. Urinalysis during the acute phase characteristically shows hematuria, proteinuria, and increased specific gravity, c. The primary objective is to reduce the excretion of urinary protein and maintain protein-free urine. d. Assessment of the child's appearance for signs of cerebral complications is an important nursing function because the severity of the acute phase is variable and unpredictable. e. Because these children are particularly vulnerable to upper respiratory tract infection, protect them from contact with infected roommates, family, or visitors.

a, b, d

When caring for a child with acute renal failure, which nursing measure requires immediate attention? a. Serum potassium concentrations in excess of 7 mEq/L b. Sodium level of 135 c. Transfusion for hemoglobin of 8 d. Mannitol and furosemide for a urine output of 2 ml/kg/hr

a. Serum potassium concentrations in excess of 7 mEq/L

Urine specimen results for a pediatric patient note greater than 100,000 colony forming units (CFUs) but the patient denies any complaints with urination. Based on this information the nurse would suspect that the patient has subacute pyelonephritis. pyuria. asymptomatic bacteriuria. febrile UTI.

asymptomatic bacteriuria. Presence of a significant amount of CFUs without clinical symptoms indicate that the patient has asymptomatic bacteriuria. Subacute pyelonephritis would refer to a chronic infection of both upper and lower urinary tract. Pyuria refers to the presence of white blood cells in the urine. Febrile UTI refers to bacteriuria in the presence of fever with other associated clinical signs.

The nurse closely monitors the temperature of a child with minimal change nephrotic syndrome. The purpose of this assessment is to detect an early sign of which possible complication? a. Infection b. Hypertension c. Encephalopathy d. Edema

ANS: A Infection is a constant source of danger to edematous children and those receiving corticosteroid therapy. An increased temperature could be an indication of an infection. Temperature is not an indication of hypertension or edema. Encephalopathy is not a complication usually associated with minimal change nephrotic syndrome. The child will most likely have neurologic signs and symptoms.

A toddler is hospitalized with acute renal failure (ARF) secondary to severe dehydration. The nurse should assess the child for what possible complications? Hypotension Hypokalemia Hypernatremia Water intoxication

Water intoxication The child with acute renal failure has the tendency to develop water intoxication or hyponatremia. Control of water balance requires careful monitoring of intake, output, body weight, and electrolytes. The child needs to be monitored for hypertension, not hypotension, when hospitalized with acute renal failure. Hyperkalemia, not hypokalemia, is a concern in acute renal failure.

Which urine test would be considered abnormal? pH: 4 Specific gravity: 1.020 Protein level: absent Glucose level: absent

pH: 4 The expected pH of urine is 4.8 to 7.8. A specific gravity of 1.020 is within the normal specific gravity range of 1.015 to 1.030. Protein should not be present in the urine. It would indicate an abnormality in glomerular filtration. Glucose should not be present in the urine. If present, it could indicate diabetes mellitus, glomerulonephritis, or a response to infusion of fluids with high glucose concentrations.

A 5-year-old child has been sent to the school nurse for urinary incontinence three times in the past 2 days. The nurse should recommend to the child's parent that the first action is to have the child evaluated for school phobia. emotional causes. possible urinary tract infection. possible structural defects of urinary tract.

possible urinary tract infection. Incontinence in a previously toilet-trained child can be an indication of a urinary tract infection. A physical cause of the problem needs to be eliminated before a psychological cause is considered. Emotional causes should be investigated only once a physical cause has been ruled out. Possible structural defects would be explored as a cause after a urinary tract infection is confirmed.

A child is receiving cyclosporine following a kidney transplant. The child's parents ask the nurse the reason for the cyclosporine. The nurse's response is based on the knowledge that the medication's purpose is to decrease pain. boost immunity. suppress rejection. improve circulation to the kidney.

suppress rejection. Cyclosporine is given to suppress rejection. It does not decrease pain, boost immunity or improve circulation.

Which best describes acute glomerulonephritis? a. Occurs after a urinary tract infection b. Occurs after a streptococcal infection c. Associated with renal vascular disorders d. Associated with structural anomalies of genitourinary tract

ANS: B Acute glomerulonephritis is an immune-complex disease that occurs after a streptococcal infection with certain strains of the group A â-hemolytic streptococcus. Acute glomerulonephritis usually follows streptococcal pharyngitis and is not associated with renal vascular disorders or genitourinary tract structural anomalies.

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.

Correct answer: a Rationale: Chronic kidney disease (CKD) involves progressive, irreversible loss of kidney function.

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 a child has chronic renal failure, the progressive deterioration produces a variety of clinical and biochemical disturbances that eventually are manifested in the clinical syndrome known as: a. uremia. b. oliguria. c. proteinuria. d. pyelonephritis.

ANS: A Uremia is the retention of nitrogenous products, producing toxic symptoms. Oliguria is diminished urinary output. Proteinuria is the presence of protein, usually albumin, in the urine. Pyelonephritis is an inflammation of the kidney and renal pelvis.

What is an appropriate nursing intervention while the child with nephrotic syndrome is confined to bed? Restrain the child as necessary. Discourage the parents from holding the child. Do passive range-of-motion exercises once a day. Adjust activities to the child's tolerance level.

Adjust activities to the child's tolerance level. The child will have a variable level of tolerance for activity. The activity tolerance will also be affected by the labile moods associated with steroid administration. The nurse should assist the family in adjusting activities for the child that are age appropriate. Restraints should not be used to confine children to bed, unless they are a potential threat to themselves or others. Parents should be encouraged to hold the child. The child should be encouraged to move all extremities while in bed to prevent the potential complications of immobility.

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.

Correct answers: b, d 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.

In addition to presenting symptoms, what laboratory finding indicates nephrosis? Hypoalbuminemia Low specific gravity Decreased hematocrit Decreased hemoglobin

Hypoalbuminemia is a result of the large amounts of protein that leak through the glomerular membrane into the urine in a child with nephrosis. The specific gravity is increased due to the large amount of protein in a child with nephrosis. Both the hematocrit and the hemoglobin would be elevated in a child with a clinical diagnosis of nephrosis secondary to hypovolemia.

What is an important nursing consideration when caring for a child with end-stage renal disease (ESRD)? Children with ESRD usually adapt well to the minor inconveniences of treatment. Children with ESRD require extensive support until they outgrow the condition. Multiple stresses are placed on children with ESRD and their families until the illness is cured. Multiple stresses are placed on children with ESRD and their families because their lives are maintained by drugs and artificial means.

Multiple stresses are placed on children with ESRD and their families because their lives are maintained by drugs and artificial means. ESRD is a chronic, progressive illness with dependence on technology. Families need to arrange for continuing examinations and procedures that are often painful and may require hospitalization. ESRD is a complex disease process that requires substantial medical intervention and is not minor in its treatment modalities. ESRD cannot be outgrown. Dialysis is necessary until renal transplantation is performed. ESRD cannot be cured. Dialysis is necessary until renal transplantation is performed.

An appropriate nursing intervention for a child with nephrotic syndrome on bed rest is to restrain the child as necessary. discourage the parents from holding the child. do passive range-of-motion exercises once a day. adjust activities to the child's tolerance level.

adjust activities to the child's tolerance level.