Chapter 46: Acute Kidney Injury and Chronic Kidney Disease Question 1 of 21

Which statement about 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." Rationale: 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 patient 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." Rationale: The primary 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.

A frail 86-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 Rationale: Antacids (that contain magnesium and aluminum) should be avoided because patients with kidney disease are unable to excrete these substances. Also, some antacids contain high levels of sodium that further increase blood pressure. Acetaminophen and aspirin (if taken for a short period of time) are usually safe for patients with kidney disease. Antihistamines may be used, but combination drugs that contain pseudoephedrine may increase blood pressure and should be avoided.

a patient with stage 2 chronic kidney disease is scheduled for an outpatient diagnostic procedure using contrast media. Which priority action should the nurse perform? Assess the patient's 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 the patient's hydration status Rationale: 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 patient with end-stage renal disease (ESRD) secondary to diabetes 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 Rationale: Although all 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

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 Rationale: 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.

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

Decrease the rate of fluid removal. Rationale: The patient is having 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.

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 Rationale: 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 poststreptococcal glomerulonephritis are intrarenal causes of AKI.

A patient with type 2 diabetes and chronic kidney disease has a serum potassium level of 6.8 mEq/L. Which finding will the nurse monitor for? Fatigue Dysrhythmias Hypoglycemia Elevated triglycerides

Dysrhythmias Rationale: 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

A patient donated a kidney via a laparoscopic donor nephrectomy to a nonrelated recipient. The patient is having significant pain and refuses to get up to walk. How should the nurse respond? Allow the patient to rest and try again tomorrow. Encourage a short walk around the patient's room. Have the transplant psychologist convince her to walk. Tell the patient she is lucky she did not have an open nephrectomy.

Encourage a short walk around the patient's room. Rationale: 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. 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. Early ambulation should be encouraged, waiting until tomorrow is too long.

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

A patient is recovering in the intensive care unit (ICU) 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 Rationale: Patients often have diuresis in the hours and days immediately after 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. Rationale: The nurse's priority is to monitor the patient's cardiac status. With the rapidly progressing glomerulonephritis, renal function begins to fail and fluid, potassium, and hydrogen retention lead to hypervolemia, hyperkalemia, and metabolic acidosis. Excess fluid increases the workload of the heart, and hyperkalemia can lead to life-threatening dysrhythmias. Teaching about hand washing and observation of the patient are important nursing interventions but are not the priority. Electrolyte measurement is a collaborative intervention that will be done as ordered by the health care provider.

The nurse preparing to give 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 Rationale: 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 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. Rationale: 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.

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 28-yr-old black woman with a urinary tract infection A 40-yr-old Hispanic woman with cardiovascular disease

correct Answer: A 61-yr-old Native American man with diabetes Rationale: The nurse identifies the 61-year-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 6 times more frequently than other ethnic groups. Hypertension causes about 25% of CKD. Hispanics have CKD about 1.5 times more than non-Hispanics. Blacks have the highest rate of CKD because hypertension is significantly increased in blacks. A UTI will not cause CKD unless it is not treated or UTIs occur recurrently

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 fracture risk Elevated white blood cells

Anemia Hypertension Increased fracture risk Rationale: When the kidney fails, erythropoietin is not excreted, so anemia is expected. Dehydration and hypercalcemia are not expected in chronic renal disease. Fluid volume overload with hypertension and hypocalcemia are expected. Hypocalcemia from chronic renal disease stimulates the parathyroid to release parathyroid hormone, causing calcium liberation from bones increasing the risk of pathological fracture. 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 with stage 3 CKD 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 Rationale: When the patient selects an apple, green beans, and a roast beef sandwich, the patient shows understanding of the low-potassium diet. Granola, dried fruits, nuts and seeds, milk products, chocolate sauce, bran cereal, banana, and orange juice all have high levels of potassium, at or above 200 mg per 1/2 cup.

A patient with a 25-year history of type 1 diabetes is reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse notes newly developed hypertension and uncontrolled blood glucose levels. 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) Rationale: 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.

The provider 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) Rationale: 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

The nurse is caring for a patient who is in 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. Rationale: 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.