Kidney Problems - Pretest

Which serum laboratory value indicates to the nurse that the patient's CKD is getting worse? a. Decreased creatinine b. Decreased calculated glomerular filtration rate (GFR) c. Decreased sodium d. Decreased BUN

B - Decreased calculated glomerular filtration rate (GFR) As GFR decreases, BUN and serum creatinine levels increase. Although elevated BUN and creatinine indicate that waste products are accumulating, the calculated GFR is considered a more accurate indicator of kidney function than BUN or serum creatinine.

What results in the edema associated with nephrotic syndrome? a. Hypercoagulability b. Decreased plasma oncotic pressure c. Decreased glomerular filtration rate d. Hyperalbuminemia

B - Decreased plasma oncotic pressure The massive proteinuria that results from increased glomerular membrane permeability in nephrotic syndrome leaves the blood without adequate proteins (hypoalbuminemia) to create an oncotic colloidal pressure to hold fluid in the vessels. Without oncotic pressure, fluid moves into the interstitium, causing severe edema. Hypercoagulability occurs in nephrotic syndrome but is not a factor in edema formation and glomerular filtration rate (GFR) is not necessarily affected in nephrotic syndrome

In replying to a patient's questions about the seriousness of her chronic kidney disease (CKD), the nurse knows that the stage of CKD is based on what? a. Total daily urine output b. Glomerular filtration rate c. Degree of altered mental status d. Serum creatinine and urea levels

B - Glomerular filtration rate Stages of chronic kidney disease are based on the GFR. No specific markers of urinary output, mental status, or azotemia classify the degree of chronic kidney disease (CKD)

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

B - Hyperkalemia Hyperkalemia can lead to life-threatening dysrhythmias. Hypocalcemia leads to an accelerated rate of bone remodeling and potentially to tetany. Hyponatremia may lead to confusion. Elevated sodium levels lead to edema, hypertension, and heart failure. Hypermagnesemia may decrease reflexes, mental status, and blood pressure.

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

B - They are caused by respiratory compensation for metabolic acidosis Kussmaul respirations occur with severe metabolic acidosis when the respiratory system is attempting to compensate by removing carbon dioxide with exhalations. Uremic pleuritis would cause a pleural friction rub. Decreased pulmonary macrophage activity increases the risk of pulmonary infection. Dyspnea would occur with pulmonary edema.

An 83-year-old female patient was found lying on the bathroom floor. She said she fell 2 days ago and has not been able to take her heart medicine or eat or drink anything since then. What conditions could be causing prerenal AKI in this patient (select all that apply)? a. Anaphylaxis b. Renal Calculi c. Hypovolemia d. Nephrotic Drugs e. Decreased Cardiac Output

C & E Because the patient has had nothing to eat or drink for 2 days, she is probably dehydrated and hypovolemic. Decreased cardiac output (CO) is most likely because she is older and takes heart medicine, which is probably for heart failure or hypertension. Both hypovolemia and decreased CO cause prerenal AKI. Anaphylaxis is also a cause of prerenal AKI but is not likely in this situation. Nephrotoxic drugs would contribute to intrarenal causes of AKI and renal calculi would be a postrenal cause of AKI.

The patient with chronic kidney disease is considering whether to use peritoneal dialysis (PD) or hemodialysis (HD). What are advantages of PD when compared to HD (select all that apply)? a. Less protein loss b. Rapid fluid removal c. Less cardiovascular stress d. Decreased hyperlipidemia e. Requires fewer dietary restrictions

C & E Peritoneal dialysis is less stressful for the cardiovascular system and requires fewer dietary restrictions. Peritoneal dialysis actually contributes to more protein loss and increased hyperlipidemia. The fluid and creatinine removal are slower with peritoneal dialysis than hemodialysis.

What is the primary way that a nurse will evaluate the patency of an arteriovenous fistula? a. Evaluate the color and temperature of the extremity. b. Assess for the presence of numbness and tingling distal to the site. c. Auscultate for the presence of a bruit at the site d. Palpate for pulses distal to the graft site.

C - Auscultate for the presence of a bruit at the site A patent arteriovenous fistula (AVF) creates turbulent blood flow that can be assessed by listening for a bruit or palpated for a thrill as the blood passes through the graft. Assessment of neurovascular status in the extremity distal to the graft site is important to determine that the graft does not impair circulation to the extremity but the neurovascular status does not indicate whether the graft is open.

What does the dialysate for PD routinely contain? a. Sodium in a higher concentration than in the blood b. Electrolytes in an equal concentration to that of the blood c. Dextrose in a higher concentration than in the blood d. Calcium in a lower concentration than in the blood

C - Dextrose in a higher concentration than in the blood Dextrose or icodextrin or amino acid is added to dialysate fluid to create an osmotic gradient across the membrane to remove excess fluid from the blood. The dialysate fluid has no potassium so that potassium will diffuse into the dialysate from the blood. Dialysate also usually contains higher calcium to promote its movement into the blood. Dialysate sodium is usually less than or equal to that of blood to prevent sodium and fluid retention.

Priority Decision: What is the most appropriate snack for the nurse to offer a patient with stage 4 CKD? a. Ice cream b. Dill pickles c. Hard candy d. Raisins

C - Hard candy A patient with CKD may have unlimited intake of sugars and starches (unless the patient is diabetic) and hard candy is an appropriate snack and may help to relieve the metallic and urine taste that is common in the mouth. Raisins are a high-potassium food. Ice cream contains protein and phosphate and counts as fluid. Pickled foods have high sodium content.

In which clinical situation would the increased release of erythropoietin be expected? a. Hyperkalemia b. Fluid overload c. Hypoxemia d. Hypotension

C - Hypoxemia Erythropoietin is released when the oxygen tension of the renal blood supply is low and stimulates production of red blood cells in the bone marrow. Hypotension causes activation of the renin-angiotensin-aldosterone system, as well as release of ADH. Hyperkalemia stimulates the release of aldosterone from the adrenal cortex and fluid overload does not directly stimulate factors affecting the erythropoietin release by the kidney.

Glomerulonephritis is characterized by glomerular damage caused by a. Growth of microorganisms in the glomeruli b. Release of bacterial substances toxic to the glomeruli c. Hemolysis of red blood cells circulating in the glomeruli d. Accumulation of immune complexes in the glomeruli

D - Accumulation of immune complexes in the glomeruli Glomerulonephritis is not an infection but rather an antibody-induced injury to the glomerulus, where either autoantibodies against the glomerular basement membrane (GBM) directly damage the tissue or antibodies reacting with nonglomerular antigens are randomly deposited as immune complexes along the GBM. Prior infection by bacteria or viruses may stimulate the antibody production but is not present or active at the time of glomerular damage.

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

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

A patient with AKI has a serum potassium level of 6.7 mEq/L (6.7 mmol/L) and the following arterial blood gas results: pH 7.28, PaCO 30 mm Hg, PaO 86 mm Hg, HCO − 18 mEq/L (18 mmol/L). The nurse recognizes that treatment of the acid-base problem with sodium bicarbonate would cause a decrease in which value? a. Bicarbonate level b. Creatinine level c. phH d. Potassium level

D - Potassium level During acidosis, potassium moves out of the cell in exchange for H+ ions, increasing the serum potassium level. Correction of the acidosis with sodium bicarbonate will help to shift the potassium back into the cells. A decrease in pH and the bicarbonate would indicate worsening acidosis.

To prevent the most common serious complication of PD, what is important for the nurse to do? a. Have the patient empty the bowel before the inflow phase. b. Reposition the patient frequently and promote deep breathing. c. Infuse the dialysate slowly. d. Use strict aseptic technique in the dialysis procedures

D - Use strict aseptic technique in the dialysis procedures Peritonitis is a common complication of peritoneal dialysis (PD) and may require catheter removal and termination of dialysis. Infection occurs from contamination of the dialysate or tubing or from progression of exit-site or tunnel infections and strict sterile technique must be used by health professionals as well as the patient to prevent contamination. Too-rapid infusion may cause shoulder pain and pain may be caused if the catheter tip touches the bowel. Difficulty breathing, atelectasis, and pneumonia may occur from pressure of the fluid on the diaphragm, which may be prevented by elevating the head of the bed and promoting repositioning and deep breathing.

What are intrarenal causes of acute kidney injury (AKI) (select all that apply)? a. Anaphylaxis b. Renal Stones c. Bladder Cancer d. Nephrotic Drugs e. Acute Glomerulonephritis f. Tubular Obstruction by Mygoblobin

D, E, F Intrarenal causes of acute kidney injury (AKI) include conditions that cause direct damage to the kidney tissue, including nephrotoxic drugs, acute glomerulonephritis, and tubular obstruction by myoglobin, or prolonged ischemia. Anaphylaxis and other prerenal problems are frequently the initial cause of AKI. Renal stones and bladder cancer are among the postrenal causes of AKI.

Which test is most evaluating function of the kidneys? a. Blood urea nitrogen (BUN) b. Renal scan c. Urine output d. Creatinine clearance

D - Creatinine Clearance The rate at which creatinine is cleared from the blood and eliminated in the urine approximates the GFR and is the most specific test of renal function. Looking at serum creatinine would be the next best test.

A patient with an obstruction of the renal artery causing renal ischemia exhibits hypertension. What is one factor that may contribute to the hypertension? a. Increased renin release b. Increased synthesis and release of prostaglandins. c. Increased ADH secretion d. Decreased aldosterone secretion

A - Increased Renin Release Renin is released in response to decreased arterial blood pressure (BP), renal ischemia, decreased extracellular fluid (ECF), decreased serum Na+ concentration, and increased urinary Na+ concentration. It is the catalyst of the renin- angiotensin-aldosterone system, which raises BP when stimulated. ADH is secreted by the posterior pituitary in response to serum hyperosmolality and low blood volume. Aldosterone is secreted only after stimulation by angiotensin II. Kidney prostaglandins lower BP by causing vasodilation.

Priority Decision: A patient on a medical unit has a potassium level of 6.8 mEq/L. What is the priority action that the nurse should take? a. Place the patient on a cardiac monitor. b. Call the lab and request a redraw of the lab to verify results. c. Check the patient's blood pressure (BP). d. Instruct the patient to avoid high-potassium foods.

A - Place the patient on a cardiac monitor Dysrhythmias may occur with an elevated potassium level and are potentially lethal. Monitor the rhythm while contacting the physician or calling the rapid response team. Vital signs should be checked. Depending on the patient's history and cause of increased potassium, instruct the patient about dietary sources of potassium; however, this would not help at this point. The nurse may want to recheck the value but until then the heart rhythm needs to be monitored.

Prevention of AKI is important because of the high mortality rate. Which patients are at increased risk for AKI (select all that apply)? a. An 86-year-old woman scheduled for a cardiac catheterization b. A 48-year-old man with multiple injuries from a motor vehicle accident c. A 32-year-old woman following a C-section delivery for abruption of placentae d. A 64-year-old woman with chronic heart failure admitted with bloody stools e. A 58-year-old man with prostate cancer undergoing preoperative workup for prostatectomy

A, B, C, D, E High-risk patients include those exposed to nephrotoxic agents and advanced age (a), massive trauma (b), prolonged hypovolemia or hypotension (possibly b and c), obstetric complications (c), cardiac failure (d), preexisting chronic kidney disease, extensive burns, or sepsis. Patients with prostate cancer may have obstruction of the outflow tract, which increases risk of postrenal AKI (e).