44 & 46: Acute Kidney Injury and Chronic Kidney Disease, Assessment of Urinary System
Which statement by the nurse regarding continuous ambulatory peritoneal dialysis (CAPD) would be of highest priority when teaching a patient new to this procedure? A. "It is essential that you maintain aseptic technique to prevent peritonitis. B. "You will be allowed a more liberal protein diet once you complete CAPD." C."It is important for you to maintain a daily written record of blood pressure and weight." D."You will need to 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 preventing this from occurring. Although the other teaching statements are accurate, they do not have the potential for morbidity and mortality as does peritonitis, thus making that statement of highest priority.
The home care nurse visits a 34-year-old woman receiving peritoneal dialysis. Which statement, if made by the patient, indicates a need for immediate follow-up by the nurse? A. "Drain time is faster if I rub my abdomen." B."The fluid draining from the catheter is cloudy." C."The drainage is bloody when I have my period." D."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.
The clinical nurse educator on a nephrology unit of a large, urban hospital is orientating recent nursing graduates to the unit. Which of the following teaching points about acute tubular necrosis (ATN) should the educator include in the orientation session? a) "Trauma, burns and major surgery are common precursors to ATN." b) "The cardinal signs of ATN are oliguria and retention of potassium, creatinine and sulfates." c) "Ureteral and bladder outlet obstructions are often contributors to ATN." d) "Tubular epithelial cells are sensitive to ischemia and toxins, and damage is irreversible."
"Trauma, burns and major surgery are common precursors to ATN." ATN is often preceded by major surgery, burns or trauma. Many cases of ATN are nonoliguric, and obstructions that are postrenal in nature are not common causes of ATN. Damage to tubular epithelial cells is not necessarily irreversible.
A 72-year-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
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
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. Drink 1500 to 2000 mL of fluids 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 limited in patients requiring dialysis. Dairy products are high in phosphate and usually are limited
.
ANS: B
d. Acetaminophen (Tylenol) 650 mg
ANS: B
d. Blood urea nitrogen (BUN) 56 mg/dL
ANS: B
d. Determine the ultrafiltration rate for the hemodialysis.
ANS: B
d. Draw blood for complete blood count.
ANS: B
d. Educate the patient about the normal vascular response after AVG insertion.
ANS: B
d. Give sodium polystyrene sulfonate (Kayexalate).
ANS: B
d. phosphate.
ANS: B
A 38-year-old patient who had a kidney transplant 8 years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone). Which assessment data will be of most concern to the nurse? a. The blood glucose is 144 mg/dL. b. There is a nontender axillary lump. c. The patient's skin is thin and fragile. d. The patient's blood pressure is 150/92.
ANS: B 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
Before administration of captopril (Capoten) to a patient with stage 2 chronic kidney disease (CKD), the nurse will check the patient's a. glucose. b. potassium. c. creatinine. 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-year-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions 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
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 b. Phosphate level c. Neurologic status 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 immediately 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 has abdominal pain during the inflow phase. d. The patient's abdomen appears bloated after the inflow.
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 the human immunodeficiency virus.
ANS: B Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant
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 b. Urine output c. Creatinine clearance 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
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. Multivitamin with iron b. Magnesium hydroxide c. Acetaminophen (Tylenol) d. Calcium phosphate (PhosLo)
ANS: B 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.
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 b. rapid, deep respirations. c. bounding peripheral pulses. d. hot, flushed face and neck.
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
A 48-year-old patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which order for the patient will the nurse question? a. NPO for 6 hours before procedure b. Ibuprofen (Advil) 400 mg PO PRN for pain c. Dulcolax suppository 4 hours before procedure d. Normal saline 500 mL IV infused before procedure
ANS: B The contrast dye used in IVPs is potentially nephrotoxic, and concurrent use of other nephrotoxic medications such as the nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided. The suppository and NPO status are necessary to ensure adequate visualization during the IVP. IV fluids are used to ensure adequate hydration, which helps reduce the risk for contrast-induced renal failure
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-year-old female patient has been hospitalized for 8 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 <30 mL/min/1.73m2.
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
A 25-year-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 2.1 mg/dL b. Serum potassium level 6.5 mEq/L c. White blood cell count 11,500/µL d. Blood urea nitrogen (BUN) 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
A 74-year-old 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 intervention will be included in the plan of care for a male 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
During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Check patient's 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
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 collaborative treatment goal in the plan will be a. augmenting fluid volume. b. maintaining cardiac output. c. diluting nephrotoxic substances. 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
d. 1400
ANS: C
d. Blood pressure 98/56 mm Hg
ANS: C
d. Creatinine clearance
ANS: C
d. Dietary sodium and potassium are unrestricted because these levels are normalized by dialysis.
ANS: C
d. Dulcolax suppository 4 hours before IVP procedure
ANS: C
d. Give prescribed PRN antiemetic drugs.
ANS: C
d. Neurologic status
ANS: C
d. The LPN/LVN carries a tray containing low-protein foods into the patient's room.
ANS: C
d. The glomerular filtration rate is <30 mL/min/1.73m2.
ANS: C
d. The patient has a round, moonlike face.
ANS: C
d. The patient has level 8 (on a 10-point scale) incisional pain.
ANS: C
d. diluting nephrotoxic substances.
ANS: C
d. level of consciousness (LOC).
ANS: C
Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation? a. Postural hypotension b. Recurrent tachycardia c. Knee and hip joint pain 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 37-year-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 b. Creatinine level c. Glomerular filtration rate (GFR) 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
A 55-year-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 b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL 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 >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 (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check laboratory results for a. potassium level. b. total cholesterol. c. serum phosphate. d. serum creatinine.
ANS: C If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. The 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 64-year-old male 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. Unlimited fluids are allowed because retained fluid is removed during dialysis. c. More protein is allowed because urea and creatinine are removed by dialysis. d. Dietary potassium is not restricted because the level is normalized by dialysis.
ANS: C Once 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
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 70-year-old 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 would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be 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 b. Calcium level c. Cardiac rhythm 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
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. Check the medical record for most recent potassium level. d. Check the chart for the patient's current creatinine level.
ANS: C 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
Which statement by a 62-year-old 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 kidney 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 54-year-old 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
A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient's a. blood glucose. b. urine osmolality. c. serum creatinine. 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
.
ANS: D
d. Calculated glomerular filtration rate (GFR)
ANS: D
d. Check the chart for the most recent blood potassium level.
ANS: D
d. The patient cleans the catheter while taking a bath every day.
ANS: D
d. infuse a bolus of normal saline.
ANS: D
d. rapid respirations.
ANS: D
d. serum phosphate.
ANS: D
A patient complains of leg cramps during hemodialysis. The nurse should first a. massage the patient's legs. b. reposition the patient supine. c. give acetaminophen (Tylenol). 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.
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 is tachycardic 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
d. Acute tubular necrosis (ATN) is primarily the result of ischemia, nephrotoxins, or sepsis. Major surgery is most likely to cause severe kidney ischemia in the patient requiring a blood transfusion. A blood transfusion hemolytic reaction produces nephrotoxic injury if it occurs. Diabetes mellitus, hypertension, and acetaminophen overdose will not contribute to ATN.
Acute tubular necrosis (ATN) is the most common cause of intrarenal AKI. Which patient is most likely to develop ATN? a. Patient with diabetes mellitus b. Patient with hypertensive crisis c. Patient who tried to overdose on acetaminophen d. Patient with major surgery who required a blood transfusion
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 also is appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening bradycardia.
After noting lengthening QRS intervals in a patient with acute kidney injury (AKI), which action should the nurse take first? d. Check the chart for the most recent blood potassium level.
-B 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 decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.
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. Elevate the patient's arm above the level of the heart. b. Report the patient's symptoms to the health care provider. c. Remind the patient about the need to take a daily low-dose aspirin tablet. d. Educate the patient about the normal vascular response after AVG insertion.
A client who has developed stage 3 renal failure has been diagnosed with high phosphate levels. To avoid the development of osteodystrophy, the physician may prescribe a phosphate-binding agent that does not contain: a) Aluminum b) Sevelamer hydrochloride c) Calcium acetate d) Calcium carbonate
Aluminum Aluminum-containing antacids can contribute to the development of osteodystrophy, whereas calcium-containing phosphate binders can lead to hypercalcemia, thus worsening soft tissue calcification, especially in persons receiving vitamin D therapy. Sevelamer hydrochloride is a newer phosphate-binding agent that does not contain calcium or aluminum.
A frail 72-year-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? A.Aspirin B. Acetaminophen (Tylenol) C. Diphenhydramine (Benadryl) D.Aluminum hydroxide (Amphogel)
Aluminum hydroxide (Amphogel) 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.
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.
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. Nephrotoxic drugs e. Decreased cardiac output
A
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 a 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. the immunosuppressive therapy that is required following transplantation causes fatal malignancies in many patients D. hemodialysis replaces the normal functioning of the kidneys and patients do not have to live with the continual fear of rejection
A 78-year-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? A.Apple, green beans, and a roast beef sandwich B.Granola made with dried fruits, nuts, and seeds C.Watermelon and ice cream with chocolate sauce D.Bran cereal with ½ banana and milk and orange juice
Apple, green beans, and a roast beef sandwich Correct 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 52-year-old man with stage 2 chronic kidney disease is scheduled for an outpatient diagnostic procedure using contrast media. Which action should the nurse take? A.Assess skin turgor to determine hydration status. B.Insert a urinary catheter for the expected diuresis. C.Evaluate the patient's lower extremities for edema D. 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.
1 Numbness and burning sensation in the legs are manifestations of peripheral neuropathy caused by nitrogenous waste accumulation in the brain. A patient with a chronic kidney disease (CKD), increased blood urea nitrogen (BUN) levels, and a very low glomerular filtration rate of 10 mL/min should undergo dialysis to remove nitrogenous wastes and prevent fluid accumulation due to impaired excretion. Sodium polystyrene sulfonate treats hyperkalemia. Sodium bicarbonate treats metabolic acidosis. A patient with CKD must not take antacids containing magnesium or aluminum because they are excreted by the kidneys. Text Reference - p. 1110
Assessment findings of a patient with chronic kidney failure include a glomerular filtration rate (GFR) of 10 mL/min, numbness and burning sensation in the legs, and a blood urea nitrogen level (BUN) of 26 mg/dL. The nurse anticipates that which intervention will be included on the patient's plan of care? 1 Make a referral for dialysis. 2 Administer sodium polystyrene sulfonate. 3 Restrict sodium bicarbonate. 4 Provide a magnesium-containing antacid.
A 25-year-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 2.1 mg/dL b. Serum potassium level 6.5 mEq/L c. White blood cell count 11,500/µL d. Blood urea nitrogen (BUN) 56 mg/dL
B
A 48-year-old patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which order for the patient will the nurse question? a. NPO for 6 hours before procedure b. Ibuprofen (Advil) 400 mg PO PRN for pain c. Dulcolax suppository 4 hours before procedure d. Normal saline 500 mL IV infused before procedure
B
A 74-year-old 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."
B
A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2 L inflows. Which information should the nurse report immediately 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 has abdominal pain during the inflow phase. d. The patient's abdomen appears bloated after the inflow.
B
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.
B
Before administration of captopril (Capoten) to a patient with stage 2 chronic kidney disease (CKD), the nurse will check the patient's a. glucose. b. potassium. c. creatinine. d. phosphate.
B
During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Check patient's blood pressure (BP). c. Review the hematocrit (Hct) level. d. Give prescribed PRN antiemetic drugs.
B
One of the major advantages of peritoneal dialysis is that: A. no medications are required because of the enhanced efficiency of the peritoneal membranes in removing toxins B. the diet is less restricted and dialysis can be performed at home C. the dialysate is biocompatible and causes no long term consequences D. high glucose concentration of the dialysate causes a reduction in appetite promoting weight loss
B
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. Multivitamin with iron b. Magnesium hydroxide c. Acetaminophen (Tylenol) d. Calcium phosphate (PhosLo)
B
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 collaborative treatment goal in the plan will be a. augmenting fluid volume. b. maintaining cardiac output. c. diluting nephrotoxic substances. d. preventing systemic hypertension.
B
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 b. Phosphate level c. Neurologic status d. Creatinine clearance
B
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.
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).
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.
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
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.
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.
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.
B Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant.
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 b. Urine output c. Creatinine clearance d. Blood urea nitrogen (BUN) level
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.
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 b. rapid, deep respirations. c. hot, flushed face and neck. d. bounding peripheral pulses.
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.
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.
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
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.
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
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.
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."
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 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.
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.
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.
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.
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. b. maintaining cardiac output. c. diluting nephrotoxic substances. d. preventing systemic hypertension.
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.
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.
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.
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
B, D
12. Which patient should be taught preventive measures for CKD by the nurse because this patient is most likely to develop CKD? A. A 50-year-old white female with hypertension B. A 61-year-old Native American male with diabetes C. A 40-year-old Hispanic female with cardiovascular disease D. A 28-year-old African American female with a urinary tract infection
B. It is especially important for the nurse to teach CKD prevention to the 61-year-old Native American with diabetes. This patient is at highest risk because 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. 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.
4. A patient with a history of end-stage kidney disease secondary to diabetes mellitus has presented to the outpatient dialysis unit for his scheduled hemodialysis. Which assessments should the nurse prioritize before, during, and after his treatment? A. Level of consciousness B. Blood pressure and fluid balance C. Temperature, heart rate, and blood pressure D. Assessment for signs and symptoms of infection
B. Although all of the assessments are relevant to the care of a patient receiving hemodialysis, the nature of the procedure indicates a particular need to monitor the patient's blood pressure and fluid balance.
13. Diffusion, osmosis, and ultrafiltration occur in both hemodialysis and peritoneal dialysis. The nurse should know that ultrafiltration in peritoneal dialysis is achieved by which method? A. Increasing the pressure gradient B. Increasing osmolality of the dialysate C. Decreasing the glucose in the dialysate D. Decreasing the concentration of the dialysate
B. 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 is caring for a patient who has had acute blood loss from ruptured esophageal varices. Which of the following does the nurse recognize is an early sign of prerenal failure? a) Baseline blood pressure of 150/90 mm Hg that is now 130/80 mm Hg b) Baseline heart rate of 100 bpm that has increased to 120 bpm c) Foul smelling, cloudy urine d) Baseline urine output of 50 mL/hr that is now 10 mL/hr
Baseline urine output of 50 mL/hr that is now 10 mL/hr The kidney normally responds to a decrease in the glomerular filtration rate with a decrease in urine output. Thus, an early sign of prerenal failure is a sharp decrease in urine output.
C 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.
Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess the a. blood urea nitrogen (BUN) and creatinine. b. blood glucose level. c. patient's bowel sounds. d. level of consciousness (LOC).
D If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. The 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.
Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check the laboratory value for a. creatinine. b. potassium. c. total cholesterol. d. serum phosphate.
A patient with a history of end-stage kidney disease secondary to diabetes mellitus has presented to the outpatient dialysis unit for his scheduled hemodialysis. Which assessments should the nurse prioritize before, during, and after his treatment? A.Level of consciousness B. Blood pressure and fluid balance C.Temperature, heart rate, and blood pressure D.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, the nature of the procedure indicates a particular need to monitor the patient's blood pressure and fluid balance.
A 55-year-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 b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg
C
A 64-year-old male 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. Unlimited fluids are allowed because retained fluid is removed during dialysis. c. More protein is allowed because urea and creatinine are removed by dialysis. d. Dietary potassium is not restricted because the level is normalized by dialysis.
C
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.
C
A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient's a. blood glucose. b. urine osmolality. c. serum creatinine. d. serum potassium.
C
Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check laboratory results for a. potassium level. b. total cholesterol. c. serum phosphate. d. serum creatinine.
C
If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalance? A. hyperkalemia and hyponatremia B. hyperkalemia and hypernatremia C. hypokalemia and hyponatremia D. hypokalemia and hypernatremia
C
Measures indicated in the conservative therapy of chronic kidney disease include: A. decreased fluid intake, carbohydrate intake, and protein intake B. increased fluid intake, decreased carbohydrate intake and protein intake C. decreased fluid intake and protein intake, increased carbohydrate intake D. decreased fluid intake and carbohydrate intake, increased protein intake
C
To assess the patency of a newly places arteriovenous graft for dialysis, the nurse should: A. irrigate the graft daily with low-dose heparin B. monitor for any increase of BP in the affected arm C. listen with a stethoscope over the graft for presence of a bruit D. frequently monitor the pulses and neurovascular status distal to the graft
C
Which action by a 70-year-old 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.
C
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
C
Which statement by a 62-year-old 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."
C
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 b. Blood pressure is 150/92. c. A nontender axillary lump. d. Blood glucose is 144 mg/dL.
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 assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation? a. Postural hypotension b. Recurrent tachycardia c. Knee and hip joint pain d. Increased serum creatinine
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 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 b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level
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.
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 b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg
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.
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.
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 w/ iron
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 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.
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.
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
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
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."
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.
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.
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.
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.
16. 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? A. Hemodialysis (HD) 3 times per week B. Automated peritoneal dialysis (APD) C. Continuous venovenous hemofiltration (CVVH) D. Continuous ambulatory peritoneal dialysis (CAPD)
C. CVVH removes large volumes of water and solutes from the patient over a longer period of time by using ultrafiltration and convection. HD 3 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.
14. During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do for the patient? A. Administer hypertonic saline. B. Administer a blood transfusion. C. Decrease the rate of fluid removal. D. Administer antiemetic medications.
C. 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.
The patient has had type 1 diabetes mellitus for 25 years and is now reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse finds that the patient has newly developed hypertension and difficulty with blood glucose control. The nurse should know that which diagnostic study will be most indicative of chronic kidney disease (CKD) in this patient? A.Serum creatinine B.Serum potassium C.Microalbuminuria D.Calculated glomerular filtration rate (GFR)
Calculated glomerular filtration rate (GFR) The best study to determine kidney function or chronic kidney disease (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 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? A.Hemodialysis (HD) 3 times per week B.Automated peritoneal dialysis (APD) C.Continuous venovenous hemofiltration (CVVH) D. 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 3 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.
A client with a recently created vascular access for hemodialysis is being discharged. In planning discharge instructions, which information does the nurse include?
Correct 1 Avoiding venipuncture and blood pressure measurements in the affected arm
What are the main causes of end-stage kidney disease (ESKD)? Select all that apply.
Correct 1 Diabetes mellitus Correct 3 Hypertension
Which clients are at risk for acute kidney injury (AKI)? Select all that apply.
Correct 1 Football player in preseason practice Correct 2 Client who underwent contrast dye radiology Correct 3 Accident victim recovering from a severe hemorrhage Correct 5 Client in the intensive care unit on high doses of antibiotics Correct 6 Client recovering from gastrointestinal influenza NOT ACCOUNTANT
The nurse is teaching a client about preventing kidney problems. What does the nurse instruct the client? Select all that apply.
Correct 1 Reduce the intake of carbonated soft drinks. Correct 3 Report any discomfort with the passage of urine. Correct 4 Have kidney function checked at least once a year. Correct 5 Report any change in frequency or volume of urine.
The nurse assists a client with acute kidney injury (AKI) to modify the diet in which ways? Select all that apply.
Correct 1 Restricted protein Correct 3 Restricted fluids Correct 4 Low potassium
The classification of acute kidney injury (AKI) in a client is based on the five criteria called RIFLE (Risk, Injury, Failure, Loss and End-stage kidney disease). Which criteria are categorized as reversible severity levels? Select all that apply.
Correct 1 Risk Correct 2 Injury Correct 3 Failure
What must a client with hypertension do in order to prevent or delay the onset of chronic kidney disease (CKD)? Select all that apply.
Correct 1 Smoking cessation Correct 2 Adhere to medication and diet regimens Correct 3 Remain Physically active. ----
What types of nutritional therapy may be required for the client? Select all that apply.
Correct 1 Total parenteral nutrition (TPN) Correct 3 Fluid intake equal to urine output plus 500 mL
What laboratory changes does the nurse expect in a client with chronic kidney disease? Select all that apply. Increased serum calcium Elevated BUN Decreased serum potassium Elevated creatinine Elevated hemoglobin
Correct 2 --Elevated BUN Correct 4 -- Elevated creatinine
Which instruction does the nurse provide to a client with hypertension and diabetes to prevent or delay the onset of chronic kidney disease (CKD)?
Correct 2 Adhere to all drug and diet regimens
The nurse is caring for a client with chronic kidney disease. What are some complications the nurse should be aware of after hemodialysis? Select all that apply.
Correct 2 Infection. Correct 3 Muscle cramps and back pain. Correct 4 Hypotension
A client with an acute kidney injury will require continuing dialysis even after discharge. What does the nurse include in the discharge teaching?
Correct 2 Limit the intake of foods containing phosphorus
A client with acute kidney injury (AKI) will require dialysis even after discharge. What precautions are of importance to the client? Select all that apply.
Correct 2 Limiting the intake of foods containing phosphorus Correct 4 Reporting a daily weight gain of 2 pounds or more
The nurse is assessing a client with chronic kidney disease (CKD) and pericarditis. What manifestations of pericarditis does the nurse expect to find in the client? Select all that apply.
Correct 2 Low-grade fever Correct 4 Pericardial friction rub
A client is required to undergo hemodialysis. Which dialyzable drug does the nurse expect to be administered to the client after hemodialysis is performed?
Correct 3 Ganciclovir
The nurse is caring for a client who underwent placement of an arteriovenous fistula. What is the priority postoperative intervention for this client?
Correct 4 Instruct the client to elevate the extremity postoperatively.
A client with chronic kidney disease (CKD) wants to undergo peritoneal dialysis. What are the advantages of peritoneal dialysis? Select all that apply.
Correct 4 It provides better blood pressure control than hemodialysis. Correct 5 It requires fewer dietary and fluid restrictions than hemodialysis
Which problem excludes a client hoping to receive a kidney transplant from undergoing the procedure?
Correct 4 Presence of tuberculosis
A patient complains of leg cramps during hemodialysis. The nurse should first a. massage the patient's legs. b. reposition the patient supine. c. give acetaminophen (Tylenol). d. infuse a bolus of normal saline.
D
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
D
A patient complains of leg cramps during hemodialysis. The nurse should a. massage the patient's legs. b. reposition the patient supine. c. give acetaminophen (Tylenol). d. infuse a bolus of normal saline.
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.
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.
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.
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
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.
1. The nurse preparing to administer a dose of calcium acetate (PhosLo) to a patient with chronic kidney disease (CKD) should know that this medication should have a beneficial effect on which laboratory value? A. Sodium B. Potassium C. Magnesium D. Phosphorus
D. 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. PhosLo will not have an effect on sodium, potassium, or magnesium levels.
10. The patient has had type 1 diabetes mellitus for 25 years and is now reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse finds that the patient has newly developed hypertension and difficulty with blood glucose control. The nurse should know that which diagnostic study will be most indicative of chronic kidney disease (CKD) in this patient? A. Serum creatinine B. Serum potassium C. Microalbuminuria D. Calculated glomerular filtration rate (GFR)
D. The best study to determine kidney function or chronic kidney disease (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.
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
D. serum creatinine or urine output from baseline
As chronic kidney disease progresses, the second stage (renal insufficiency) is identified by: a) Decrease in GFR to 30 to 59 mL/minute/1.73 m2 b) Diminished GFR to less than 15 mL/minute/1.73 m2 c) Decrease in GFR of 60 to 89 mL/minute/1.73 m2 d) GFR decrease to 15 to 29 mL/minute/1.73 m2
Decrease in GFR of 60 to 89 mL/minute/1.73 m2 Diminished renal reserve is characteristic of renal insufficiency, when labs remain normal but there is renal insufficiency. Only the second stage, formerly known as renal insufficiency, is characterized by a decrease in GFR of 60 to 89 mL/minute/1.73 m2. The other choices represent stage 3, 4, and 5, respectfully.
During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do for the patient? A.Administer hypertonic saline. B.Administer a blood transfusion C.Decrease the rate of fluid removal. D.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.
The nurse knows the patient with AKI has entered the diuretic phase when what assessments occur (select all that apply)? A.Dehydration B.Hypokalemia C.Hypernatrimia D.BUN increases E.Serum Creatinine Increases
Dehydration, Hypokalemia Dehydration, hypokalemia, and hyponatremia occur in the diuretic phase of AKI because the nephrons can excrete wastes but not concentrate urine. Therefore the serum BUN and serum creatinine levels also begin to decrease.
The nurse is instructing a patient with advanced kidney disease (AKD) about a dietary regimen. Which of the following restrictions should the nurse be sure to include in the treatment plan to decrease the progress of renal impairment in people with AKD? a) Dietary protein b) Fats c) Foods high in calcium d) Carbohydrates
Dietary protein Restriction of dietary proteins may decrease the progress of renal impairment in people with advanced renal disease. Proteins are broken down to form nitrogenous wastes, and reducing the amount of protein in the diet lowers the blood urea nitrogen and reduces symptoms.
2 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. Text Reference - p. 1118
Diffusion, osmosis, and ultrafiltration occur in both hemodialysis and peritoneal dialysis. The nurse should know that ultrafiltration in peritoneal dialysis is achieved by which method? 1 Increasing the pressure gradient 2 Increasing osmolality of the dialysate 3 Decreasing the glucose in the dialysate 4 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.
Diffusion, osmosis, and ultrafiltration occur in both hemodialysis and peritoneal dialysis. The nurse should know that ultrafiltration in peritoneal dialysis is achieved by which method? A.Increasing the pressure gradient B.Increasing osmolality of the dialysate C.Decreasing the glucose in the dialysate D.Decreasing the concentration of the dialysate
The patient was diagnosed with prerenal AKI. The nurse should know that what is most likely the cause of the patient's diagnosis? A.IV tobramycin (Nebcin) B.Incompatible blood transfusion C.Poststreptococcal glomerulonephritis D.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 poststretpcoccal glomerulonephritis are intrarenal causes of AKI.
A client with chronic kidney disease (CKD) has developed asterixis. The nurse knows that asterixis is which of the following? a) Burning sensation in feet b) Dorsiflexion of hands and feet c) Demyelination of nerve fibers d) Unsteady gait
Dorsiflexion of hands and feet Asterixis, which is involuntary dorsiflexion of hands and feet, can develop as CKD worsens. -Burning sensation in feet, unsteady gait and demyelination of nerves can also accompany CKD, but are not part of asterixis.
The patient's complaints of nausea and dizziness suggest hypotension, so the initial action should be to check the BP. The other actions also may be appropriate, based on the blood pressure obtained.
During hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first? c. Check the patient's blood pressure.
c. The most common causes of CKD in the United States are diabetes mellitus and hypertension. The nurse should obtain information on long-term health problems that are related to kidney disease. The other disorders are not closely associated with renal disease.
During the nursing assessment of the patient with renal insufficiency, the nurse asks the patient specifically about a history of a. angina. b. asthma. c. hypertension. d. rheumatoid arthritis.
B, D
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
Following the diagnosis of acute renal failure, the nurse knows that one of the earliest manifestations of residual tubular damage is which of the following lab/diagnostic results? a) Elevated blood urea nitrogen (BUN). b) Serum creatinine elevation. c) Inability to concentrate urine. d) Reduced glomerular filtration rate.
Elevated blood urea nitrogen (BUN). Urine tests that measure urine osmolality, urinary sodium concentration, and fractional excretion of sodium help differentiate prerenal azotemia, in which the reabsorptive capacity of the tubular cells is maintained, from tubular necrosis, in which these functions are lost. One of the earliest manifestations of tubular damage is the inability to concentrate urine. Conventional markers of serum creatinine and urea nitrogen, fractional secretion of sodium to assess glomerular filtration rate (GFR), and urine output do not manifest for 1-2 days after the acute renal failure has begun.
A 24-year-old female donated a kidney via a laparoscopic donor nephrectomy to a non-related recipient. The patient is experiencing a lot of pain and refuses to get up to walk. How should the nurse handle this situation? A.Have the transplant psychologist convince her to walk. B. Encourage even a short walk to avoid complications of surgery. C.Tell the patient that no other patients have ever refused to walk. D.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, while 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.
c. The calcium-phosphorus imbalances that occur in CKD result in hypocalcemia, from a deficiency of active vitamin D and increased phosphorus levels. This leads to an increased rate of bone remodeling with a weakened bone matrix. Aluminum accumulation is also believed to contribute to the osteomalacia. Osteitis fibrosa involves replacement of calcium in the bone with fibrous tissue and is primarily a result of elevated levels of parathyroid hormone resulting from hypocalcemia.
For a patient with CKD the nurse identifies a nursing diagnosis of risk for injury: fracture related to alterations in calcium and phosphorus metabolism. What is the pathologic process directly related to the increased risk for fractures? a. Loss of aluminum through the impaired kidneys b. Deposition of calcium phosphate in soft tissues of the body c. Impaired vitamin D activation resulting in decreased GI absorption of calcium d. Increased release of parathyroid hormone in response to decreased calcium levels
1, 3, 5 The external shunt may come apart, external temperatures make clotting a potential hazard, and frequent handling increases the risk of infection. Infusions should not be in the extremity with the shunt or the fistula to avoid pressure from the tourniquet and to lessen the chance of phlebitis. Blood pressure readings should not be obtained in the extremity that has a shunt or fistula because of the pressure exerted on the circulatory system during the procedure. There are no respiratory complications of this procedure. The ends of the shunt cannula should be left exposed for rapid reconnection in the event of disruption. Test-Taking Tip: Being prepared reduces your stress or tension level and helps you maintain a positive attitude. Text Reference - p. 1120
Hemodialysis is planned for a patient who has end-stage kidney disease. The patient is scheduled for the creation of an internal arteriovenous fistula and the placement of an external arteriovenous shunt to be used until the fistula heals. What postoperative nursing care is appropriate for this patient? Select all that apply. 1 Regularly check the positioning of the external shunt. 2 Check for signs and symptoms of respiratory complications. 3 Ensure that intravenous fluids are not infused in the arm with the shunt. 4 Cover the ends of the shunt cannula with a dressing. 5 Do not take blood pressure on the extremity with the shunt
How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis? a. Palpate along both sides of the lumbar vertebral column. b. Strike a flat hand covering the costovertebral angle (CVA). c. Push fingers upward into the two lowest intercostal spaces. d. Percuss between the iliac crest and ribs at the midaxillary line. ANS: B
How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis? a. Palpate along both sides of the lumbar vertebral column. b. Strike a flat hand covering the costovertebral angle (CVA). c. Push fingers upward into the two lowest intercostal spaces. d. Percuss between the iliac crest and ribs at the midaxillary line. ANS: B
Which assessment finding is a consequence of the oliguric phase of AKI? A. Hypovolemia B. Hyperkalemia C. Hypernatremia D.Thrombocytopenia
Hyperkalemia In AKI the serum potassium levels increase because the normal ability of the kidneys to excrete potassium is impaired. Sodium levels are typically normal or diminished, whereas fluid volume is normally increased because of decreased urine output. Thrombocytopenia is not a consequence of AKI, although altered platelet function may occur in AKI.
C
If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalance? A. hyperkalemia and hyponatremia B. hyperkalemia and hypernatremia C. hypokalemia and hyponatremia D. hypokalemia and hypernatremia
A 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.
In a patient with acute kidney injury (AKI) who requires hemodialysis, a temporary vascular access is obtained by placing a catheter in the left femoral vein. Which intervention will be included in the plan of care? a. Place the patient on bed rest.
d. Measuring daily weights with the same scale at the same time each day allows for the evaluation and detection of excessive body fluid gains or losses. Infection is the leading cause of death in AKI, so meticulous aseptic technique is critical. The fluid limitation in the oliguric phase is 600 mL plus the prior day's measured fluid loss. Dietary sodium and potassium intake are managed according to the plasma levels.
In caring for the patient with AKI, what should the nurse be aware of? a. The most common cause of death in AKI is irreversible metabolic acidosis. b. During the oliguric phase of AKI, daily fluid intake is limited to 1000 mL plus the prior day's measured fluid loss. c. Dietary sodium and potassium during the oliguric phase of AKI are managed according to the patient's urinary output. d. One of the most important nursing measures in managing fluid balance in the patient with AKI is taking accurate daily weights.
b. Stages of chronic kidney disease are based on the GFR. No specific markers of urinary output, mental status, or azotemia classify the degree of chronic kidney disease (CKD).
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? b. Glomerular filtration rate
b. Automated peritoneal dialysis (APD) is the type of dialysis in which the patient dialyzes during sleep and leaves the fluid in the abdomen during the day. Long nocturnal hemodialysis occurs while the patient is sleeping and is done up to six times per week. Continuous venovenous hemofiltration (CVVH) is a type of continuous renal replacement therapy used to treat AKI. Continuous ambulatory peritoneal dialysis (CAPD) is dialysis that is done with exchanges of 1.5 to 3 L of dialysate at least four times daily.
In which type of dialysis does the patient dialyze during sleep and leave the fluid in the abdomen during the day? a. Long nocturnal hemodialysis b. Automated peritoneal dialysis (APD) c. Continuous venovenous hemofiltration (CVVH) d. Continuous ambulatory peritoneal dialysis (CAPD)
Diffusion, osmosis, and ultrafiltration occur in both hemodialysis and peritoneal dialysis. The nurse should know that ultrafiltration in peritoneal dialysis is achieved by which method? A.Increasing the pressure gradient B.Increasing osmolality of the dialysate C.Decreasing the glucose in the dialysate D.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.
A client has acute pyelonephritis. The nurse will monitor the client for development of which of the following? a) Prerenal failure b) Post renal failure c) Intrarenal failure d) Chronic kidney disease
Intrarenal failure Acute pyelonephritis, an active bacterial infection, can cause tubular cell necrosis and intrarenal failure. Acute pyelonephritis does not cause prerenal or postrenal failure or chronic kidney disease unless it is not treated
A
Kidney transplant recipient complains of having fever, chills, and dysuria over the course of the past 2 days, What is the first action the nurse should take? A. assess temperature and initiate workup to rule out infection B. provied warm cover for the patient and give 1 g acetaminophen orally C. reassure the patient that this is common after transplantation D. notify the nephrologist that the patient has developed symptoms of acute rejection
A patient is recovering in the intensive care unit (ICU) after receiving a kidney transplant approximately 24 hours ago. What is an expected assessment finding for this patient during this early stage of recovery? A.Hypokalemia B. Hyponatremia C.Large urine output D. 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.
C
Measures indicated in the conservative therapy of chronic kidney disease include: A. decreased fluid intake, carbohydrate intake, and protein intake B. increased fluid intake, decreased carbohydrate intake and protein intake C. decreased fluid intake and protein intake, increased carbohydrate intake D. decreased fluid intake and carbohydrate intake, increased protein intake
a. Metabolic acidosis occurs in AKI because the kidneys cannot synthesize ammonia or excrete acid products of metabolism, resulting in an increased acid load. Sodium is lost in urine because the kidneys cannot conserve sodium. Impaired excretion of potassium results in hyperkalemia. Bicarbonate is normally generated and reabsorbed by the functioning kidney to maintain acidbase balance.
Metabolic acidosis occurs in the oliguric phase of AKI as a result of impairment of a. ammonia synthesis. b. excretion of sodium. c. excretion of bicarbonate. d. conservation of potassium.
The patient has a form of glomerular inflammation that is progressing rapidly. She is gaining weight, and the urine output is steadily declining. What is the priority nursing intervention? A.Monitor the patient's cardiac status. B.Teach the patient about hand washing. C.Obtain a serum specimen for electrolytes. D. 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.
a. 3; b. 2; c. 1
Number the following in the order of the phases of exchange in PD. Begin with 1 and end with 3. a. Drain b. Dwell c. Inflow
B
One of the major advantages of peritoneal dialysis is that: A. no medications are required because of the enhanced efficiency of the peritoneal membranes in removing toxins B. the diet is less restricted and dialysis can be performed at home C. the dialysate is biocompatible and causes no long term consequences D. high glucose concentration of the dialysate causes a reduction in appetite promoting weight loss
A, B, D, E
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 dyslipiemia E. increased high-density lipoprotein levels
The nurse preparing to administer a dose of calcium acetate (PhosLo) to a patient with chronic kidney disease (CKD) should know that this medication should have a beneficial effect on which laboratory value? A.Sodium B.Potassium C. Magnesium D. 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. PhosLo will not have an effect on sodium, potassium, or magnesium levels.
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).
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 abruptio 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
b. IV administration of fluid and furosemide (Lasix) Injury is the stage of RIFLE classification when urine output is less than 0.5 mL/kg/hr for 12 hours, the serum creatinine is increased times two or the glomerular filtration rate (GFR) is decreased by 50%. This stage may be reversible by treating the cause or, in this patient, the dehydration by administering IV fluid and a low dose of a loop diuretic, furosemide (Lasix). Assessing the daily weight will be done to monitor fluid changes but it is not the first treatment the nurse should anticipate. IV administration of insulin and sodium bicarbonate would be used for hyperkalemia. Checking the urinalysis will help to determine if the AKI has a prerenal, intrarenal, or postrenal cause by what is seen in the urine but with this patient's dehydration, it is thought to be prerenal to begin treatment.
Priority Decision: A dehydrated patient is in the Injury stage of the RIFLE staging of AKI. What would the nurse first anticipate in the treatment of this patient? a. Assess daily weight b. IV administration of fluid and furosemide (Lasix) c. IV administration of insulin and sodium bicarbonate d. Urinalysis to check for sediment, osmolality, sodium, and specific gravity
a. 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.
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. Check the patient's blood pressure (BP). c. Instruct the patient to avoid high-potassium foods. d. Call the lab and request a redraw of the lab to verify results.
a. Fluid and electrolyte balance is critical in the transplant recipient patient, especially because diuresis often begins soon after surgery. Fluid replacement is adjusted hourly based on kidney function and urine output. Urine-tinged drainage on the abdominal dressing may indicate leakage from the ureter implanted into the bladder and the health care provider should be notified. The donor patient may have a flank or laparoscopic incision(s) where the kidney was removed. The recipient has an abdominal incision where the kidney was placed in the iliac fossa. The urinary catheter is usually used for 2 to 3 days to monitor urine output and kidney function.
Priority Decision: During the immediate postoperative care of a recipient of a kidney transplant, what should the nurse expect to do? a. Regulate fluid intake hourly based on urine output. b. Monitor urine-tinged drainage on abdominal dressing. c. Medicate the patient frequently for incisional flank pain. d. Remove the urinary catheter to evaluate the ureteral implant.
d. 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. Lewis, Sharon L.; Dirksen, Shannon Ruff; Bucher, Linda (2014-03-14). Study Guide for Medical-Surgical Nursing: Assessment and Management of Clinical Problems (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 413). Elsevier Health Sciences. Kindle Edition.
Priority Decision: What is the most appropriate snack for the nurse to offer a patient with stage 4 CKD? a. Raisins b. Ice cream c. Dill pickles d. Hard candy
D. serum creatinine or urine output from baseline
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
Which of the following phenomena contributes to the difficulties with absorption, distribution and elimination of drugs that is associated with kidney disease? a) Reductions in plasma proteins increase the amount of free drug and decrease the amount of protein-bound drug. b) Acute tubular necrosis is associated with impaired drug reabsorption through the tubular epithelium. c) Decreased retention by the kidneys often renders normal drug dosages ineffective. d) Dialysis removes active metabolites from circulation minimizing therapeutic effect.
Reductions in plasma proteins increase the amount of free drug and decrease the amount of protein-bound drug. A decrease in plasma proteins, particularly albumin, that occurs in many persons with renal failure results in less protein-bound drug and greater amounts of free drug. -Drug elimination problems do not stem as directly from impaired tubular reabsorption, decreased retention or the process of dialysis.
Neuromuscular disorders can be triggered by CKD. For those clients on dialysis, approximately two thirds suffer from what peripheral neuropathy? a) Raynaud syndrome b) Tingling and loss of sensation in lower limbs c) Burning hands and feet d) Restless legs syndrome
Restless legs syndrome Restless legs syndrome is a manifestation of peripheral nerve involvement and can be seen in as many as two thirds of clients on dialysis. The other answers are not correct.
The nurse is caring for a 68-year-old man who had coronary artery bypass surgery 3 weeks ago. If the patient is now is in the oliguric phase of acute kidney disease, which action would be appropriate to include in the plan of care? A.Provide foods high in potassium. B.Restrict fluids based on urine output. C.Monitor output from peritoneal dialysis D.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.
2, 3, 4 If routine urinalysis indicates moderate to severe proteinuria, the preferred way of determining kidney functions is by assessing the GFR. An ultrasound of the kidneys is usually done to detect any obstructions and to determine the size of the kidneys. A patient with diabetes needs to have a further examination of the urine for microalbuminuria. The patient may not have an increase in serum creatinine until there is a decrease of 50% or more in kidney function. MRA study with the contrast media gadolinium is generally not advised unless the ultrasound or computed tomography (CT) does not provide the information needed. Test-Taking Tip: Become familiar with reading questions on a computer screen. Familiarity reduces anxiety and decreases errors. Text Reference - p. 1104
Routine urinalysis for a diabetic patient reveals moderate proteinuria. What further tests help to identify decreased kidney function at an early stage? Select all that apply. 1 Serum creatinine 2 Glomerular filtration rate (GFR) 3 Renal ultrasound 4 Evaluation of microalbuminuria 5 Magnetic resonance angiography (MRA)
The GFR is considered to be the best measure of renal function. What is used to estimate the GFR? a) BUN b) Serum creatinine c) Serum protein d) Albumin level
Serum creatinine In clinical practice, GFR is usually estimated using the serum creatinine concentration. The other answers are not used to estimate the GFR.
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.
The RN observes an LPN/LVN carrying out all of the following actions while caring for a patient with stage 2 chronic kidney disease. Which action requires the RN to intervene? c. The LPN/LVN gives the iron supplement and phosphate binder with lunch.
3 A rapid removal of fluid results in reduced vascular volume, which can lead to a decreased cardiac output and decreased vascular resistance. Therefore, hemodialysis has the potential to cause hypotension during the process. Peritoneal dialysis is associated with hernias, lower back pain, and pneumonia, due to increased intraabdominal pressure while infusing the dialysate and decreased lung expansion caused by frequent upward displacement of the diaphragm. Text Reference - p. 1122
The dialysis nurse is administering hemodialysis to a patient with chronic kidney failure. For what common complication should the nurse carefully monitor in this patient? 1 Hernias 2 Pneumonia 3 Hypotension 4 Lower back pain
"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.
The home care nurse visits a 34-year-old woman receiving peritoneal dialysis. Which statement, if made by the patient, indicates a need for immediate follow-up by the nurse? A. "Drain time is faster if I rub my abdomen." B."The fluid draining from the catheter is cloudy." C."The drainage is bloody when I have my period." D."I wash around the catheter with soap and water."
The nurse assessing the urinary system of a 45-yr-old patient would use palpation to a. determine kidney function. c. check for ureteral peristalsis. b. identify renal artery bruits. d. assess for bladder distention. ANS: D
The nurse assessing the urinary system of a 45-yr-old patient would use palpation to a. determine kidney function. c. check for ureteral peristalsis. b. identify renal artery bruits. d. assess for bladder distention. ANS: D
The nurse caring for a patient after cystoscopy plans that the patient a. learns to request narcotics for pain. b. understands to expect blood-tinged urine. c. restricts activity to bed rest for 4 to 6 hours. d. remains NPO for 8 hours to prevent vomiting. ANS: B
The nurse caring for a patient after cystoscopy plans that the patient a. learns to request narcotics for pain. b. understands to expect blood-tinged urine. c. restricts activity to bed rest for 4 to 6 hours. d. remains NPO for 8 hours to prevent vomiting. ANS: B
1 The patient with heart failure has a decreased circulating blood volume. This causes autoregulatory mechanisms to preserve blood flow to essential organs. Laboratory data for this patient will likely demonstrate an elevation in BUN, creatinine, and potassium. Prerenal azotemia results in a reduction in the excretion of sodium, increased sodium and water retention, and decreased urine output. Text Reference - p. 1102
The nurse caring for a patient with heart failure notes the patient has decreased urine output of 200 mL/day. Which laboratory finding aids in the diagnosis of prerenal azotemia in this patient? 1 Elevated blood urea nitrogen (BUN) 2 Normal creatinine level 3 Decreased sodium level 4 Decreased potassium level
The nurse completing a physical assessment for a newly admitted patient is unable to feel either kidney on palpation. Which action should the nurse take? a. Obtain a urine specimen to check for hematuria. b. Document the information on the assessment form. c. Ask the patient about any history of recent sore throat. d. Ask the health care provider about scheduling a renal ultrasound. ANS: B
The nurse completing a physical assessment for a newly admitted patient is unable to feel either kidney on palpation. Which action should the nurse take? a. Obtain a urine specimen to check for hematuria. b. Document the information on the assessment form. c. Ask the patient about any history of recent sore throat. d. Ask the health care provider about scheduling a renal ultrasound. ANS: B
A Scrambled eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate.
The nurse has instructed a patient who is receiving hemodialysis about appropriate dietary choices. Which menu choice by the patient indicates that the teaching has been successful? a. Scrambled eggs, English muffin, and apple juice b. Oatmeal with cream, half a banana, and herbal tea c. Split-pea soup, whole-wheat toast, and nonfat milk d. Cheese sandwich, tomato soup, and cranberry juice
2 It is within the scope of practice of the UAP to obtain a finger stick blood glucose level. It is not within the UAP scope of practice to assess the intake and output during a peritoneal dialysis exchange. The patient postoperative day one will need a nursing assessment on his or her ability to ambulate, as well as a pain assessment. UAP do not report any results to health care providers. Text Reference - p. 1117
The nurse has the following tasks to perform. Which is an appropriate task to delegate to the unlicensed assistive personnel (UAP)? 1 Document intake and output on the patient performing bedside peritoneal dialysis 2 Obtain a finger stick blood sugar on the patient receiving hemodialysis 3 Ambulate the patient who is postoperative day one following a right-sided nephrectomy 4 Report the patient's potassium level of 5.2 to the primary health care provider
4 A patient with renal failure has a reduced ability to eliminate metabolites and drugs. Therefore, drugs like vancomycin, which are mainly excreted by the kidney, need to be used with caution and monitoring for accumulation and potential drug toxicity is necessary. Cinacalcet is a calcimimetic agent that helps to control secondary hyperparathyroidism. Paricalcitol is an active vitamin D supplement that helps to control elevated levels of parathyroid hormone and is used for treating secondary hyperparathyroidism in patients with end stage chronic kidney disease. Gemfibrozil helps to reduce triglyceride levels and increases high-density cholesterol in patients with chronic kidney disease. Text Reference - p. 1114
The nurse identifies that which drug should be used with caution in a patient with renal failure? 1 Cinacalcet 2 Paricalcitol 3 Gemfibrozil 4 Vancomycin
1 Yogurt is rich is phosphate and should be avoided by patients with hyperphosphatemia. The patient with hypernatremia and hypertension should avoid soy sauce, canned soups, and salad dressings because they are high in sodium. Text Reference - p. 1115
The nurse instructs a patient with hyperphosphatemia to avoid what food item? 1 Yogurt 2 Soy sauce 3 Canned soup 4 Salad dressing
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
The nurse is assessing a patient who is receiving peritoneal dialysis with 2 L inflows. Which information should be reported immediately to the health care provider? b. The patient's peritoneal effluent appears cloudy.
1, 3, 5 The patient on hemodialysis may have decreased blood pressure due to rapid removal of blood. Hepatitis type B is a blood-borne infection, and hemodialysis poses a high risk for transmission of hepatitis B. Muscle cramps are a common complication of hemodialysis. Factors associated with the development of muscle cramps in hemodialysis include hypotension, hypovolemia, a high ultrafiltration rate (large interdialytic weight gain), and low-sodium dialysis solution. Hemodialysis does not increase the risk of development of renal calculi; people who are on bed rest or have low urine output may be at risk. Bladder infection is not related to dialysis. Text Reference - p. 1122
The nurse is attending to a patient who is receiving hemodialysis for chronic kidney disease. For which complications should the nurse be observant in the patient? Select all that apply. 1 Hypotension 2 Renal calculi 3 Hepatitis type B 4 Bladder infection 5 Muscle cramps
1, 2, 3 Auscultation is very important to find the cause of respiratory distress. Decreased areas of ventilation suggest the presence of atelectasis, whereas adventitious sounds may suggest fluid overload, retained secretions, or infection. Frequent positioning will promote equal ventilation to all parts of the lungs. Deep-breathing exercises could help to promote proper expansion of lungs. Rapid infusion would cause more pressure on the diaphragm. The patient should be placed in the semi-Fowler's position for peritoneal dialysis; this allows inflow of fluid while not impinging on the thoracic cavity. Text Reference - p. 1119
The nurse is attending to a patient who is undergoing peritoneal dialysis. The nurse assesses the patient is developing symptoms of respiratory distress. What nursing interventions are necessary to prevent further respiratory complications? Select all that apply. 1 Auscultate the lungs. 2 Frequently reposition the patient. 3 Promote deep-breathing exercises. 4 Increase the rate of infusion of the dialysate. 5 Place the patient in a low Fowler's position.
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.
The nurse is caring for a 68-year-old man who had coronary artery bypass surgery 3 weeks ago. If the patient is now is in the oliguric phase of acute kidney disease, which action would be appropriate to include in the plan of care? A.Provide foods high in potassium. B.Restrict fluids based on urine output. C.Monitor output from peritoneal dialysis D.Offer high protein snacks between meals.
The nurse is caring for a hospitalized patient with a decreased glomerular filtration rate who is scheduled for an intravenous pyelogram (IVP). Which action will be included in the plan of care? a. Monitor the urine output after the procedure. b. Assist with monitored anesthesia care (MAC). c. Give oral contrast solution before the procedure. d. Insert a large size urinary catheter before the IVP. ANS: A Patients with
The nurse is caring for a hospitalized patient with a decreased glomerular filtration rate who is scheduled for an intravenous pyelogram (IVP). Which action will be included in the plan of care? a. Monitor the urine output after the procedure. b. Assist with monitored anesthesia care (MAC). c. Give oral contrast solution before the procedure. d. Insert a large size urinary catheter before the IVP. ANS: A Patients with
4 Peritonitis is caused by either a Staphylococcus aureus or a Staphylococcus epidermidis infection. It is manifested by abdominal pain, cloudy peritoneal effluent, and increased white blood cell count. Oliguria, hyperkalemia, and hyponatremia are complications associated with acute kidney injury. Text Reference - p. 1119
The nurse is caring for a patient undergoing peritoneal dialysis. What finding should the nurse report to the primary health care provider that would indicate peritonitis? 1 Oliguria 2 Hyperkalemia 3 Hyponatremia 4 Abdominal pain
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.
The nurse is caring for a patient who had kidney transplantation several years ago. Which assessment finding may indicate that the patient is experiencing adverse effects to the prescribed corticosteroid? a. Joint pain
3 An increased eosinophil level in the laboratory report is an indicator of atheroembolic renal disease, which supports the primary health care provider's conclusion. Increased levels of basophils, monocytes, and lymphocytes are not associated with atheroembolic renal disease. Test-Taking Tip: Patients with acute kidney injury have a risk of acquiring infection. Apply your knowledge and skill to answer the question. Text Reference - p. 1104
The nurse is caring for a patient with acute kidney injury and secondary hypertension. The urine output is 0.1 mL/kg/hr over 6 hours. The primary health care provider identifies atheroembolic renal disease. Which laboratory finding supports this conclusion? 1 Increased basophils 2 Increased monocytes 3 Increased eosinophils 4 Increased lymphocytes
1 Patients with chronic kidney disease undergoing hemodialysis should consume a diet low in protein and potassium. Calcium needs to be maintained in the diet to help prevent hyperphosphatemia. High protein diets should be avoided because they cause uremic toxicity. High potassium in the diet needs to be avoided because the increased serum potassium level can result in cardiac disturbances. Text Reference - p. 1130
The nurse is caring for a patient with chronic kidney disease who is undergoing hemodialysis. What is an appropriate diet for this patient? 1 High-protein and low-calcium 2 Low-protein and low-potassium 3 High-protein and high-potassium 4 Low-protein and high-phosphorus
3 As per the RIFLE (Risk, Injury, Failure, Loss, and End-stage) classification for staging acute kidney injury, this patient is at the Failure stage. When the GFR has decreased by 25%, the patient is at the Risk stage. The patient with a GFR that has decreased by 50% is at the Injury stage. The patient with persistent acute kidney failure experiences a complete loss of kidney function and is at the Loss stage. Text Reference - p. 110
The nurse is caring for a patient with severe burns in the emergency department. His laboratory values reveal serum creatinine level of 5 mg/dL, and the glomerular filtration rate (GFR) has decreased by 75%. What stage of acute kidney failure is this patient exhibiting? 1 Risk 2 Injury 3 Failure 4 Loss
2 Blood pressure fluctuates during dialysis and a change in vital signs can indicate rapid changes in blood pressure. Therefore, the nurse should record the vital signs every 30 to 60 minutes during dialysis. The patient's skin condition should be assessed before dialysis for determining the site for vascular access. The patient's weight should be recorded before and after the procedure to determine the amount of fluid to be removed. Blood pressure should not be checked from the same extremity with vascular access because this may cause clotting of the vascular access. Text Reference - p. 1122
The nurse is caring for the patient receiving hemodialysis. What action by the nurse is a priority? 1 Checking the patient's skin condition 2 Recording the vital signs every 30 to 60 minutes 3 Recording the patient's weight during the procedure 4 Checking the blood pressure from the extremity with vascular acces
3 Dacron cuffs acts as anchors and prevent the migration of microorganisms into the peritoneal cavity. Hemofilters in continuous renal replacement therapy (CRRT) remove nonprotein solutes and plasma water. Blood pumps are a part of CRRT; they are used to pump blood through the circuit. Grafts are used in hemodialysis to separate the blood from arteries and veins. Text Reference - p. 1118
The nurse is educating a patient about the insertion of a catheter with a Dacron cuff for delivery of peritoneal dialysis. What rationale should the nurse provide detailing the benefit of this type of catheter? 1 To remove nonprotein solutes 2 To propel blood through the circuit 3 To prevent the migration of microorganisms 4 To act as a bridge between arterial and venous blood
1 African Americans are at the greatest risk for develop kidney disease. Those of Asian descent, Caucasian males, and Hispanics are not at as great a risk. Text Reference - p. 1108
The nurse is planning an education program on chronic kidney disease. Which ethnic group would the nurse target for promoting this event? 1 African Americans 2 Asian descent 3 Caucasian males 4 Hispanics
1 Dextrose is the most commonly used osmotic agent used in peritoneal dialysis. Normal saline solution is not used in peritoneal dialysis. Icodextrin and amino acid solutions are used as alternatives to dextrose. Text Reference - p. 1118
The nurse is preparing to perform peritoneal dialysis for a patient with chronic kidney disease. Which osmotic agent will the nurse obtain for the dialysis exchanges? 1 Dextrose 2 Normal saline 3 Icodextrin solution 4 Amino acid solution
1 This patient is showing signs of hyperkalemia, which could be fatal and lead to myocardial damage. Regular insulin IV is needed to quickly force potassium into the cells. The kayexalate enema will take too long to excrete the potassium. Restricting oral intake and educating the patient will be needed when the crisis has resolved. Text Reference - p. 1112
The nurse just received an urgent laboratory value on a patient in renal failure. The potassium level is 6.3. The telemetry monitor is showing peaked T waves. Which prescription from the primary health care provider should be implemented first? 1 Administer regular insulin intravenously (IV) 2 Restrict dietary potassium intake to 40 meq daily 3 Administer kayexalate enema 4 Educate the patient on dietary restriction of potassium
4 Because the kidneys are not effectively removing waste products, including electrolytes, an increased potassium level (hyperkalemia) of more than 5.0 mEq/L is common in acute renal failure and places the patient at risk for cardiac arrhythmias. Patients usually experience anorexia, not an increase in hunger. Acute renal failure will likely manifest as hyponatremia. Hypotensive shock may be the result of a severe cardiac arrhythmia that is not treated. Text Reference - p. 1105
The nurse performs an admission assessment of a patient with acute renal failure. For which common complication does the nurse assess the patient? 1 Polyphagia 2 Hypernatremia 3 Hypotensive shock 4 Cardiac dysrhythmias
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. PhosLo will not have an effect on sodium, potassium, or magnesium levels.
The nurse preparing to administer a dose of calcium acetate (PhosLo) to a patient with chronic kidney disease (CKD) should know that this medication should have a beneficial effect on which laboratory value? A.Sodium B.Potassium C. Magnesium D. Phosphorus
4 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. Text Reference - p. 1113
The nurse preparing to administer a dose of calcium acetate to a patient with chronic kidney disease (CKD) should know that this medication should have a beneficial effect on which laboratory value? 1 Sodium 2 Potassium 3 Magnesium 4 Phosphorus
3 A patient with chronic kidney disease (CKD) develops anemia due to decreased production of erythropoietin (EPO). Exogenous erythropoietin helps replenish the erythropoietin demand. Iron supplements for a patient with low plasma ferritin levels prevent the patient from developing an iron deficiency from the increased demand for iron to support erythropoiesis. A folic acid supplement is given to patients on hemodialysis because it is required for red blood cell (RBC) formation, and is removed by dialysis. A high dosage of EPO should be avoided for a patient with anemia because of increased risk of thromboembolic events and death from cardiovascular effects. The recommendation is to use the lowest possible dose of EPO to treat anemia. EPO should be avoided for a patient with uncontrolled hypertension because it exacerbates hypertension by increasing blood viscosity. Text Reference - p. 1113 Topics
The nurse provides information to a nursing student about the administration of erythropoietin (EPO) therapy to a patient with chronic kidney disease (CKD). Which statement made by the nursing student indicates effective learning? 1 "EPO benefits a patient with plasma ferritin concentrations less than 100 mg/mL." 2 "EPO should be administered in higher doses to a patient with low hemoglobin levels." 3 "EPO, iron, sucrose, and folic acid of 1 mg/day should be administered to patients undergoing hemodialysis." 4 "EPO can be safely given to a patient that takes an antihypertensive and maintains a blood pressure of 150/90 mm Hg."
4 A patient with chronic kidney disease (CKD) may have arterial stiffness due to calcium deposition in the vascular smooth layer of the blood vessels. Excessive sodium retention causes extracellular fluid accumulation that leads to hypertension and edema. Decrease in the sodium bicarbonate level in the body leads to metabolic acidosis. Accumulation of the nitrogenous waste products leads to neurologic complications. Text Reference - p. 1110
The nurse recalls that the reason that patients with chronic kidney disease experience arterial stiffness is what? 1 Excessive sodium retention 2 Decrease in the sodium bicarbonate level 3 Increase in nitrogenous waste products 4 Excessive calcium deposition in vascular smooth layer
2 A patient with chronic kidney disease (CKD) must maintain good nutrition and should be referred to a dietitian for nutritional education and guidance. To avoid calorie-protein malnutrition, the patient should consume 25 to 35 kcal/kg/day, which includes calories from dialysate glucose absorption. Potassium is usually not restricted for a patient undergoing peritoneal dialysis. The patient needs to take iron supplements when on erythropoietin to prevent iron deficiency. Fluid intake in the patient who is undergoing peritoneal dialysis should be unrestricted if weight and blood pressure are in control. Therefore, it is not dependent upon urine output. Text Reference - p. 1114
The nurse recognizes that which intervention will likely be included in a treatment plan for a patient with chronic kidney disease (CKD) who is undergoing peritoneal dialysis? 1 Restricting potassium intake 2 Encouraging consumption of 25 to 35 kcal/kg/day 3 Avoiding iron supplements when taking erythropoietin 4 Calculating fluid restrictions based on urine output
1 The patient's symptoms of restless leg syndrome, altered mental ability, and irritability are manifestations of neurologic complications due to accumulation of nitrogenous wastes in the brain and nervous system. The patient has seizures and coma due to the high blood urea nitrogen (BUN) level of 35 mg/dL. Therefore, dialysis would improve central nervous system functions and slow the neuropathies. Calcium phosphate binders are administered in a patient with hyperphosphatemia. A blood transfusion is not preferred to treat anemia unless the patient experiences an acute blood loss or symptomatic anemia. Intravenous administration of 10% calcium gluconate helps to reduce hyperkalemia in a patient. Text Reference - p. 1110
The nurse recognizes that which intervention would help a patient with stage 5 chronic kidney disease who experiences restless leg syndrome, altered mental ability, seizures, coma, and a blood urea nitrogen (BUN) level of 35 mg/dL? 1 Refer the patient for dialysis. 2 Administer calcium phosphate binders. 3 Recommend that the patient receive a blood transfusion. 4 Administer 10% calcium gluconate intravenously
3 Hypertension is a common finding in a patient with kidney failure due to retention of sodium and water. This is treated with angiotensin receptor blockers. Magnesium antacids may aggravate hypermagnesemia in patients with kidney failure. Aluminum preparations should be used with caution in patients with chronic kidney disease because they are associated with bone diseases, such as osteomalacia. Nonsteroidal antiinflammatory agents are nephrotoxic, and should not be administered to patients with renal failure because they can cause acute kidney injury. Text Reference - p. 1113
The nurse recognizes that which medication is appropriate to give to patients with kidney failure? 1 Magnesium antacids 2 Aluminum preparations 3 Angiotensin receptor blockers 4 Nonsteroidal antiinflammatory agents
4 A patient with glycosylated hemoglobin of 5%, blood pressure of 140/95 mm Hg, and protein in the urine has hypertension with nondiabetic proteinuria. The patient can take angiotensin-receptor blockers and angiotensin-converting-enzyme (ACE) inhibitors. These medications help to decrease proteinuria and delay the progression of chronic kidney disease (CKD). Diuretics help control elevated blood pressure in patients with CKD but do not have an effect on proteinuria. Calcimimetic agents help to control secondary hyperparathyroidism by increasing the sensitivity of the calcium receptors in the parathyroid glands. They are not used for treatment of hypertension, diabetes, or proteinuria. Calcium channel blockers also do not have an effect on proteinuria. Text Reference - p. 1113
The nurse recognizes that which medication is the most appropriate for a patient with chronic kidney disease (CKD) who has a glycosylated hemoglobin of 5%, blood pressure of 140/95 mm Hg, and whose urinalysis reveals the presence of protein? 1 A diuretic 2 A calcimimetic agent 3 A calcium channel blocker 4 An angiotensin receptor blocker
2 A patient with chronic kidney disease who is prescribed phosphate binders, such as lanthanum carbonate, should take them with meals to reduce gastrointestinal side effects. The patient must avoid potassium-rich foods such as bananas, prunes, and raisins to prevent further aggravation of hyperkalemia. Patients with CKD have decreased urine output and fluid accumulation, so an appropriate fluid balance is important to prevent further complications such as edema and heart failure. The patient should take calcium supplements on an empty stomach for better absorption. Text Reference - p. 1116
The nurse recognizes that which recommendation is appropriate for a patient with chronic kidney disease (CKD)? 1 Eat prunes and raisins. 2 Take phosphate binders with meals. 3 Drink plenty of water. 4 Take calcium and iron supplements on an empty stomach.
4 A patient with chronic kidney disease (CKD) should receive limited fluids because the kidneys are unable to remove excessive water. An IV solution of 0.9% sodium chloride at a rate of 125 mL/hr places this patient at high risk for complications such as fluid overload, electrolyte imbalance, and hypertension. A 2-g sodium diet, oxygen, and furosemide (Lasix) would be appropriate if prescribed for a patient with CKD. Text Reference - p. 1115
The nurse reviews a plan of care for a patient with diagnosis of chronic kidney disease who is undergoing hemodialysis. Which part of the plan should the nurse question? 1 2-g sodium diet 2 Oxygen via nasal cannula at 4 L/min 3 Furosemide (Lasix) 40 mg PO twice a day 4 IV of 0.9% sodium chloride at 125 mL/hour
3 A patient with chronic kidney disease (CKD) may have low vitamin D levels. Vitamin D supplementation using cholecalciferol is recommended for patients who have vitamin D levels less than 30 mg/dL, but it can cause hypercalcemia. The laboratory reports of the patient show a calcium level of 13 mg/dL and a phosphorous level of 5 mg/dL, which are higher than normal values (calcium 8.6 to 10.2 mg/dL and phosphorous 2.4 to 4.4 mg/dL). Therefore, the patient should be given non-calcium-based phosphate binders such as sevelamer carbonate to lower the phosphate levels. Calcitriol is an activated form of vitamin D, which is indicated for severe hypocalcemia in CKD. It may further aggravate hypercalcemia and hyperphosphatemia on administration. Calcium acetate is a calcium-based phosphate binder, which may further increase calcium levels, leading to hypercalcemia. Polystyrene sulfonate is a potassium-binding agent used in patients with severe hyperkalemia. Text Reference - p. 1113
The nurse reviews the medical record of a patient with chronic kidney disease (CKD) and notes a history of taking cholecalciferal, a vitamin D level of 20 mg/mL, a calcium level of 13 mg/dL, and a phosphorous level of 5 mg/dL. Based on the laboratory results, the nurse anticipates that what medication will be prescribed? 1 Calcitriol 2 Calcium acetate 3 Sevelamer carbonate 4 Polystyrene sulfonate
2 A patient with chronic kidney disease (CKD) and hypertension has to monitor blood pressure at home regularly. Controlling blood pressure helps to slow the incidence of atherosclerosis that further impairs kidney function. The patient with CKD has an elevated level of serum potassium and ingestion of bananas may aggravate the condition and lead to fatal dysrhythmias. The patient should be in supine position while measuring blood pressure, not in prone position. The patient may develop hypermagnesemia from taking magnesium-containing laxatives. Text Reference - p. 1113
The nurse teaches safety measures to a patient with chronic kidney disease (CKD) who is experiencing constipation. The patient's blood pressure is 145/95 mm Hg. Which statement made by the patient indicates effective learning? 1 "I should eat three bananas after every meal." 2 "I should monitor my blood pressure regularly at home." 3 "I should rest in a prone position while recording my blood pressure." 4 "I should take magnesium-containing laxatives if I am experiencing constipation."
3 Creatinine is a waste product of muscle catabolism. Patients with acute kidney injury cannot remove body waste and it accumulates in the blood, which raises the serum creatinine level. Acute kidney injury is associated with an increased level of potassium, a decreased level of sodium, and a decreased level of blood urea nitrogen. Thus, the statements that the patient will have hypokalemia, hypernatremia, and decreased levels of blood urea nitrogen are incorrect. Text Reference - p. 1104
The nursing instructor asks the student nurse about fluid and electrolyte changes that occur in a patient with an acute kidney injury. Which statement by the student nurse indicates effective learning? 1 "The patient will have hypokalemia." 2 "The patient will have hypernatremia." 3 "The patient will have increased serum creatinine levels." 4 "The patient will have decreased levels of blood urea nitrogen."
1 Continuous renal replacement therapy (CRRT) is a physiologic therapy that simulates kidney function day and night. CRRT is done either by cannulating an artery and a vein or by cannulating two veins. CRRT is provided continuously for approximately 24 hours. CRRT involves the flow of blood from the body through a filter and carries an increased risk of clotting; thus an anticoagulant must be added. CRRT can be performed along with hemodialysis. CRRT has a slower blood flow rate than intermittent hemodialysis. Text Reference - p. 1106
The nursing instructor is teaching a student nurse about continuous renal replacement therapy (CRRT). Which statement by the student nurse indicates effective learning? 1 "CRRT is provided over approximately 24 hours." 2 "CRRT does not require the addition of an anticoagulant." 3 "CRRT cannot be used in conjunction with hemodialysis." 4 "CRRT has a faster blood flow rate than hemodialysis."
1 Sodium polystyrene sulfonate is used to correct hyperkalemia and is contraindicated in patients with a paralytic ileus because it causes bowel necrosis. Sodium polystyrene sulfonate can be administered in the form of an enema, which acts by exchanging potassium for sodium ions. It can also be administered after mixing it in water with sorbitol to facilitate the removal of potassium from the body. Text Reference - p. 1105
The nursing instructor is teaching a student nurse about sodium polystyrene sulfonate. Which statement by the student nurse indicates the need for further teaching? 1 "The drug is effective in treating a paralytic ileus." 2 "It can be administered as an enema." 3 "The drug helps exchange potassium for sodium." 4 "It is mixed in water with sorbitol and then administered."
4 Sodium polystyrene sulfonate is a cation-exchange resin that completely removes extra potassium; it is considered a permanent therapy. Insulin pushes potassium inside the cells, but with a decline in insulin levels, potassium exits the cell. Thus, insulin is a temporary therapy. Sodium bicarbonate and calcium gluconate are also considered temporary therapies because they shift potassium into the cells until their blood levels diminish, upon which potassium exits the cells. Text Reference - p. 1105
The nursing instructor is teaching a student nurse about the therapies for hyperkalemia associated with acute kidney injury. Which statement by the student nurse indicates effective learning? 1 "Insulin infusion is a permanent therapy." 2 "Sodium bicarbonate is a permanent therapy." 3 "Calcium gluconate infusion is a permanent therapy." 4 "Sodium polystyrene sulfonate is a permanent therapy."
Calculated glomerular filtration rate (GFR) The best study to determine kidney function or chronic kidney disease (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 patient has had type 1 diabetes mellitus for 25 years and is now reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse finds that the patient has newly developed hypertension and difficulty with blood glucose control. The nurse should know that which diagnostic study will be most indicative of chronic kidney disease (CKD) in this patient? A.Serum creatinine B.Serum potassium C.Microalbuminuria D.Calculated glomerular filtration rate (GFR)
1, 4, 5 During the diuretic phase of acute kidney injury, daily urine output is usually around 1 to 3 L but may reach 5 L or more. Hypovolemia and hypotension can occur from massive fluid losses. The diuretic phase may last one to three weeks. Near the end of this phase, the patient's acid-base, electrolyte, and waste product (blood urea nitrogen, creatinine) values begin to normalize. Although urine output is increasing, the nephrons are still not fully functional. The high urine volume is caused by osmotic diuresis from the high urea concentration in the glomerular filtrate and the inability of the tubules to concentrate the urine. In this phase the kidneys have recovered their ability to excrete wastes, but not to concentrate the urine. Because of the large losses of fluid and electrolytes, the patient must be monitored for hyponatremia, hypokalemia, and dehydration. Text Reference - p. 1104
The patient is in the diuretic phase of acute kidney injury. What education should the nurse provide to the patient regarding this phase? Select all that apply. 1 Urine output is increased. 2 The kidney has become fully functional. 3 The electrolyte imbalance will be normalized. 4 This phase will last no more than three weeks 5 There is a possibility that the fluid volume will be reduced in the body.
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 poststretpcoccal glomerulonephritis are intrarenal causes of AKI.
The patient was diagnosed with prerenal AKI. The nurse should know that what is most likely the cause of the patient's diagnosis? A.IV tobramycin (Nebcin) B.Incompatible blood transfusion C.Poststreptococcal glomerulonephritis D.Dissecting abdominal aortic aneurysm
b. Nifedipine (Procardia) is a calcium channel blocker and furosemide (Lasix) is a loop diuretic. Both are used to treat hypertension.
The patient with CKD asks why she is receiving nifedipine (Procardia) and furosemide (Lasix). The nurse understands that these drugs are being used to treat the patient's a. anemia. b. hypertension. c. hyperkalemia. d. mineral and bone disorder.
c. 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.
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. Uremic pleuritis is occurring. b. There is decreased pulmonary macrophage activity. c. They are caused by respiratory compensation for metabolic acidosis. d. Pulmonary edema from heart failure and fluid overload is occurring.
a, b, d. Pruritus is common in patients receiving dialysis. It causes scratching from dry skin, sensory neuropathy, and calcium-phosphate deposition in the skin. Vascular calcifications contribute to cardiovascular disease, not to itching skin. Uremic frost rarely occurs without BUN levels greater than 200 mg/dL, which should not occur in a patient on dialysis; urea crystallizes on the skin and also causes pruritis.
The patient with CKD is receiving dialysis, and the nurse observes excoriations on the patient's skin. What pathophysiologic changes in CKD can contribute to this finding (select all that apply)? a. Dry skin b. Sensory neuropathy c. Vascular calcifications d. Calcium-phosphate skin deposits e. Uremic crystallization from high BUN
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.
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
2, 3, 5 Any dialysis option would be appropriate for the patient. A nephrectomy is not going to cure the chronic kidney disease, and it is unknown whether the kidney has a tumor or cancer with this question. Kidney placement in place of dialysis at this point is too late. Dialysis needs to begin while awaiting a kidney transplant. Text Reference - p. 1117
The patient's glomerular filtration rate (GFR) is 15 mL/min. What are the treatment options the nurse would expect the health care provider to discuss with the patient? Select all that apply. 1 Nephrectomy 2 Hemodialysis 3 Peritoneal dialysis 4 Kidney transplant in place of dialysis 5 Continuous ambulatory peritoneal dialysis
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 3 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 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? A.Hemodialysis (HD) 3 times per week B.Automated peritoneal dialysis (APD) C.Continuous venovenous hemofiltration (CVVH) D. Continuous ambulatory peritoneal dialysis (CAPD)
3 A decrease in the urine output after healthy kidney transplantation indicates rejection, dehydration, or urinary leakage. This is a serious condition and should be reported to the primary health care provider. An increased urine output of 1 L/hour after kidney transplant indicates proper functioning of the transplanted kidney. Due to increased elimination, electrolyte imbalance can. Normal saline solution should be infused to the patient to rectify metabolic acidosis caused by delayed kidney function. Text Reference - p. 1127
The registered nurse is teaching a student nurse about physiologic changes in a kidney transplant recipient. Which statement made by the student nurse indicates the need for further teaching? 1 "The urinary output of the patient can be 1 L/hour." 2 "There may be an imbalance in the electrolyte levels." 3 "Decrease in the urine output after surgery can be neglected." 4 "Normal saline solution is infused to treat metabolic acidosis."
1, 3 The diuretic phase lasts for one to three weeks and hypovolemia and hypotension occur due to increased urinary output. In the diuretic phase, urine output increases because of the renal tubules' inability to concentrate urine. At the end of the diuretic phase, the creatinine, blood urine nitrogen, and electrolyte levels return to normal. Text Reference - p. 1104
The registered nurse is teaching a student nurse about physiologic changes in the diuretic phase of a patient with acute kidney disease. Which statement by the student nurse about the diuretic phase indicates effective learning? Select all that apply. 1 "The diuretic phase lasts for one to three weeks." 2 "Urine volume decreases in the diuretic phase." 3 "Hypovolemia occurs during the diuretic phase." 4 "The kidneys will have the ability to concentrate urine." 5 "The creatinine level increases drastically at the end of the diuretic phase."
3 The deceased donor should be free from active intravenous drug use. Donors with a long history of diabetes mellitus, autoimmune disorders, and defective cardiovascular functions cannot donate organs. Text Reference - p. 1125
The registered nurse is teaching a student nurse about the criteria for a deceased donor to donate an organ. Which student nurse's statement indicates effective learning? 1 "Diabetes mellitus has no effect on organ transplant." 2 "Immunocompromised donors can donate their organs." 3 "Donors should be free from active intravenous drug abuse." 4 "Donors with compromised cardiovascular health can be included."
4 Pericardial effusion is an abnormal accumulation of fluid inside the pericardial cavity; this condition is caused by increased blood volume. Renal replacement therapy (RRT) is recommended because the kidneys are unable to function properly. RRT is recommended in hyperkalemic, not hypokalemic, conditions. RRT does not alleviate the effects of metabolic acidosis. RRT is advised in patients with fluid overload, not hypovolemia. Test-Taking Tip: Renal replacement therapy is used in patients with impaired renal function, because the fluid volume increases in the body. Use this tip to answer the question. Text Reference - p. 1106
The registered nurse is teaching a trainee nurse about the use of renal replacement therapy (RRT). Which statement by the trainee nurse indicates effective learning? 1 "RRT is performed in patients with hypokalemia." 2 "RRT is advised for patients with metabolic acidosis." 3 "RRT is recommended in patients with hypovolemia." 4 "RRT is recommended if there is a pericardial effusion."
4 A blue catheter lumen returns blood from the dialyzer back to the patient. A hemofilter is a part of the continuous renal replacement therapy (CRRT), which removes nonprotein solutes and plasma water. A Dacron cuff is used to fix the catheter in place in peritoneal dialysis. A red catheter lumen is used to withdraw blood from the patient and send it to the dialyzer for purification. Text Reference - p. 1121
The student nurse is observing the administration of peritoneal dialysis by the dialysis nurse. What statement made by the student to the nurse demonstrates understanding about the dialysis process? 1 "The use of a hemofilter will return blood back to the patient." 2 "The Dacron cuff will return blood from the dialyzer back to the patient." 3 "The red catheter lumen will return blood from the dialyzer back to the patient." 4 "The blue catheter lumen will return blood from the dialyzer back to the patient."
C
To assess the patency of a newly places arteriovenous graft for dialysis, the nurse should: A. irrigate the graft daily with low-dose heparin B. monitor for any increase of BP in the affected arm C. listen with a stethoscope over the graft for presence of a bruit D. frequently monitor the pulses and neurovascular status distal to the graft
b. 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.
To prevent the most common serious complication of PD, what is important for the nurse to do? a. Infuse the dialysate slowly. b. Use strict aseptic technique in the dialysis procedures. c. Have the patient empty the bowel before the inflow phase. d. Reposition the patient frequently and promote deep breathing.
Bruising of the skin is a manifestation of bleeding disorders in patients with CKD. a) True b) False
True Bleeding disorders manifested by persons with CKD include epistaxis, menorrhagia, gastrointestinal bleeding, and bruising of skin and subcutaneous tissues.
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.
Two hours after a kidney transplant, the nurse obtains all of the following data when assessing the patient. Which information is most important to communicate to the health care provider? c. The patient's central venous pressure (CVP) is decreased.
d. In the patient with CKD, when serum calcium levels are increased, calcium-based phosphate binders are not used. The nutrient supplemented for patients on dialysis is folic acid. The various body system manifestations occur with uremia, which includes azotemia. Meperidine is contraindicated in patients with CKD related to possible seizures.
What accurately describes the care of the patient with CKD? a. A nutrient that is commonly supplemented for the patient on dialysis because it is dialyzable is iron. b. The syndrome that includes all of the signs and symptoms seen in the various body systems in CKD is azotemia. c. The use of morphine is contraindicated in the patient with CKD because accumulation of its metabolites may cause seizures. d. The use of calcium-based phosphate binders in the patient with CKD is contraindicated when serum calcium levels are increased.
d, 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.
What are intrarenal causes of acute kidney injury (AKI) (select all that apply)? a. Anaphylaxis b. Renal stones c. Bladder cancer d. Nephrotoxic drugs e. Acute glomerulonephritis f. Tubular obstruction by myoglobin
1, 3, 4 Hemodialysis is extracorporeal removal of waste products such as creatinine, urea, and free water from the blood during renal failure. The complications of hemodialysis include hepatitis, hypotension, muscle cramps, light-headedness and loss of blood. Hepatitis is common in patients who are undergoing dialysis due to the transmission of infection-causing organisms. Hypotension occurs due to rapid removal of vascular volume and decreased cardiac output. Muscle cramps are caused by hypotension, hypovolemia, or high ultrafiltration rate. Light-headedness is caused by a drop in blood pressure. Hemodialysis may cause hypotension and bleeding. Text Reference - p. 1122
What are the complications of hemodialysis? Select all that apply. 1 Hepatitis 2 Hypertension 3 Muscle cramps 4 Light-headedness 5 Excess coagulation of blood
1, 3, 5 Peritoneal dialysis is removal of waste products from the body when kidneys no longer work adequately. The complications of peritoneal dialysis include hernias, peritonitis, and exit site infection. Hernias are caused by increased intraabdominal pressure secondary to the dialysate infusion. Peritonitis results from contamination or from progression of an exit site or tunnel infection. Exit site infection is caused by infection of the peritoneal catheter. Hepatitis and hypotension are complications of hemodialysis. Text Reference - p. 1128
What are the complications of peritoneal dialysis? Select all that apply. 1 Hernias 2 Hepatitis 3 Peritonitis 4 Hypotension 5 Exit site infection
1, 2, 3 Renal calculi, trauma, and prostate cancer are postrenal causes of acute kidney injury. Intrarenal causes of acute kidney injury include kidney ischemia and myoglobin released from muscle cells. Text Reference - p. 1103
What are the postrenal causes of acute kidney injury? Select all that apply. 1 Renal calculi 2 Renal trauma 3 Prostate cancer 4 Kidney ischemia 5 Myoglobin release
2 Prerenal acute kidney injury can be caused by a reduced flow of blood to the kidneys. A release of nephrotoxins is an intrarenal cause of acute kidney injury. Urine reflux into the renal pelvis and the presence of extrarenal tumors are postrenal causes of acute kidney injury. Text Reference - p. 1103
What causes prerenal acute kidney injury? 1 Release of nephrotoxins 2 Reduced renal blood flow 3 Urine reflux into renal pelvis 4 Presence of extrarenal tumors
c. Uremic fetor, or the urine odor of the breath, is caused by high urea content in the blood. Increased ammonia from bacterial breakdown of urea leads to stomatitis and mucosal ulcerations. Irritation of the gastrointestinal (GI) tract from urea in CKD contributes to anorexia, nausea, and vomiting. Ingestion of iron salts and calcium-containing phosphate binders, limited fluid intake, and limited activity cause constipation.
What causes the gastrointestinal (GI) manifestation of stomatitis in the patient with CKD? a. High serum sodium levels b. Irritation of the GI tract from creatinine c. Increased ammonia from bacterial breakdown of urea d. Iron salts, calcium-containing phosphate binders, and limited fluid intake
c. 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.
What does the dialysate for PD routinely contain? a. Calcium in a lower concentration than in the blood b. Sodium in a higher concentration than in the blood c. Dextrose in a higher concentration than in the blood d. Electrolytes in an equal concentration to that of the blood
What glomerular filtration rate (GFR) would the nurse estimate for a 30-yr-old patient with a creatinine clearance result of 60 mL/min? a. 60 mL/min c. 120 mL/min b. 90 mL/min d. 180 mL/min ANS: A
What glomerular filtration rate (GFR) would the nurse estimate for a 30-yr-old patient with a creatinine clearance result of 60 mL/min? a. 60 mL/min c. 120 mL/min b. 90 mL/min d. 180 mL/min ANS: A
d. The blood urea nitrogen (BUN) and creatinine levels remain high during the oliguric and diuretic phases of AKI. The recovery phase begins when the glomerular filtration returns to a rate at which BUN and creatinine stabilize and then decrease. Urinary output of 3 to 5 L/ day, decreasing sodium and potassium levels, and fluid weight loss are characteristic of the diuretic phase of AKI.
What indicates to the nurse that a patient with AKI is in the recovery phase? a. A return to normal weight b. A urine output of 3700 mL/day c. Decreasing sodium and potassium levels d. Decreasing blood urea nitrogen (BUN) and creatinine levels
d. In prerenal oliguria, the oliguria is caused by a decrease in circulating blood volume and there is no damage yet to the renal tissue. It can be reversed by correcting the precipitating factor, such as fluid replacement for hypovolemia. Prerenal oliguria is characterized by urine with a high specific gravity and a low sodium concentration, whereas oliguria of intrarenal failure is characterized by urine with a low specific gravity and a high sodium concentration. Malignant hypertension causes damage to renal tissue and intrarenal oliguria.
What indicates to the nurse that a patient with oliguria has prerenal oliguria? a. Urine testing reveals a low specific gravity. b. Causative factor is malignant hypertension. c. Urine testing reveals a high sodium concentration. d. Reversal of oliguria occurs with fluid replacement.
4 Signs of nephrogenic systemic fibrosis include hyperpigmentation of the skin, induration, and joint contractures. Pruritus, urticaria, and scaling of the skin are not clinical signs of nephrogenic systemic fibrosis. Text Reference - p. 1103
What is a clinical manifestation of nephrogenic systemic fibrosis? 1 Pruritus 2 Urticaria 3 Scaling of skin 4 Hyperpigmentation
b. 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.
What is the most serious electrolyte disorder associated with kidney disease? a. Hypocalcemia b. Hyperkalemia c. Hyponatremia d. Hypermagnesemia
b. 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 is the primary way that a nurse will evaluate the patency of an AVF? a. Palpate for pulses distal to the graft site. b. Auscultate for the presence of a bruit at the site. c. Evaluate the color and temperature of the extremity. d. Assess for the presence of numbness and tingling distal to the site.
2 The movement of solutes from an area of higher concentration to an area of lower concentration is called diffusion. Osmosis is the movement of solutes from an area of lower concentration to an area of higher concentration. Dialysate is a solution used in dialysis, into which substances from the blood move out. Ultrafiltration is a technique that removes low-molecular solutes such as water and fluid from the semipermeable membrane. Text Reference - p. 1117
What is the term that describes the movement of solutes from a higher concentration area to a lower concentration area? 1 Osmosis 2 Diffusion 3 Dialysate 4 Ultrafiltration
Once 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.
When a patient who has had progressive chronic kidney disease (CKD) for several years is started on hemodialysis, which information about diet will the nurse include in patient teaching? c. More protein will be allowed because of the removal of urea and creatinine by dialysis.
When a patient's urine dipstick test indicates a small amount of protein, the nurse's next action should be to a. send a urine specimen to the laboratory to test for ketones. b. obtain a clean-catch urine for culture and sensitivity testing. c. inquire about which medications the patient is currently taking. d. ask the patient about any family history of chronic renal failure. ANS: C
When a patient's urine dipstick test indicates a small amount of protein, the nurse's next action should be to a. send a urine specimen to the laboratory to test for ketones. b. obtain a clean-catch urine for culture and sensitivity testing. c. inquire about which medications the patient is currently taking. d. ask the patient about any family history of chronic renal failure. ANS: C
Since 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.
When caring for a dehydrated patient with acute kidney injury who is oliguric, anemic, and hyperkalemic, which of the following prescribed actions should the nurse take first? b. Place the patient on a cardiac monitor
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 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. Check the fistula site for a bruit and thrill.
1 Ibuprofen, and other nonsteroidal antiinflammatory drugs (NSAIDS), will cause further damage to the kidneys. Chronic kidney disease (CKD) patients should be taking Tylenol as prescribed for pain. CKD patients also could be consuming calcium supplements and PhosLo tablets as prescribed by the health care provider. Text Reference - p. 1107
When obtaining a health history for the patient with chronic kidney disease, the nurse notes the following medications on the patient's medication list. The patient will need further education on which medication? 1 Ibuprofen 2 Acetaminophen 3 Calcium supplements 4 Calcium acetate
Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant.
When the nurse is taking a history for a patient who is a possible candidate for a kidney transplant, which information about the patient indicates that the patient is not an appropriate candidate for transplantation? a. The patient has metastatic lung cancer.
When working in the urology/nephrology clinic, which patient could the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Patient who is scheduled for a renal biopsy after a recent kidney transplant b. Patient who will need monitoring for several hours after a renal arteriogram c. Patient who requires teaching about possible post-cystoscopy complications d. Patient who will have catheterization to check for residual urine after voiding ANS: D
When working in the urology/nephrology clinic, which patient could the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Patient who is scheduled for a renal biopsy after a recent kidney transplant b. Patient who will need monitoring for several hours after a renal arteriogram c. Patient who requires teaching about possible post-cystoscopy complications d. Patient who will have catheterization to check for residual urine after voiding ANS: D
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 action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? d. The patient cleans the catheter while taking a bath every day.
Hyperkalemia In AKI the serum potassium levels increase because the normal ability of the kidneys to excrete potassium is impaired. Sodium levels are typically normal or diminished, whereas fluid volume is normally increased because of decreased urine output. Thrombocytopenia is not a consequence of AKI, although altered platelet function may occur in AKI.
Which assessment finding is a consequence of the oliguric phase of AKI? A. Hypovolemia B. Hyperkalemia C. Hypernatremia D.Thrombocytopenia
a. Erythropoietin is used to treat anemia, as it stimulates the bone marrow to produce red blood cells.
Which complication of chronic kidney disease is treated with erythropoietin (EPO)? a. Anemia b. Hypertension c. Hyperkalemia d. Mineral and bone disorder
1 A patient with glomerular filtration rate (GFR) of 10 mL/minute has chronic kidney disease (CKD), causing the BUN to rise above the normal BUN level of 6 to 20 mg/dL, which may be a result of uremia. Hypertension may result from hypernatremia in the patient with CKD; there is no sodium level information given. Dysrhythmias may occur in the patient with CKD due to hyperkalemia due to decreased excretion of potassium by the kidneys; however, this patient's potassium level of 4 mEq/L is a normal finding. An inability of the kidneys to excrete ammonia and generate bicarbonates leads to metabolic acidosis, indicated by a serum bicarbonate level lower than 15 mEq/L.; the patient's level is greater than 15 mEq/L. Text Reference - p. 1108
Which condition does the nurse suspect in a patient with a glomerular filtration rate (GFR) of 10 mL/minute, a blood urea nitrogen (BUN) level of 23 mg/dL, a potassium level of 4 mEq/L, and a serum bicarbonate level of 20 mEq/L? 1 Uremia 2 Hypertension 3 Dysrhythmias 4 Metabolic acidosis
4 Severe acidosis causes a patient to take deep and rapid breaths—called Kussmaul respirations—in an effort to increase the exhalation of carbon dioxide. Asterixis is a neurologic change associated with acute kidney injury due to the accumulation of metabolic waste in the brain and nervous system. Dysfunction of the glomerular membrane due to acute kidney injury leads to proteinuria. Hydronephrosis refers to dilation of the kidneys and is a postrenal cause of acute kidney injury. Text Reference - p. 1104
Which condition is a result of severe metabolic acidosis in patients with acute kidney injury? 1 Asterixis 2 Proteinuria 3 Hydronephrosis 4 Kussmaul respirations
3 Bilateral ureteral obstruction results in dilation of the kidneys, which is called hydronephrosis. Oliguria is a sign of acute kidney injury. Prostate cancer is a postrenal cause of acute kidney injury. Diabetic gastroaresis is a manifestation of chronic kidney disease. Text Reference - p. 1103
Which condition is seen in patients with bilateral ureteral obstruction? 1 Oliguria 2 Prostate cancer 3 Hydronephrosis 4 Diabetic gastroparesis
4 Chronic kidney disease mineral and bone disorder (CKD-MBD) is a common complication of CKD and results in both skeletal and extraskeletal complications. Osteomalacia is a skeletal complication. Calcium deposition in the eye may create irritation leading to uremic red eye, an extraskeletal complication. Asterixis (hand-flapping tremor) occurs due to motor neuropathy. Uremic frost is the crystallization of urea on the skin when blood urea nitrogen levels are elevated to 200 mg/dL. Gastroparesis (delayed gastric emptying) compounds the effect of malnutrition for patients with diabetes. Text Reference - p. 1111
Which condition should the nurse suspect in a patient with chronic kidney disease (CKD) who develops osteomalacia? 1 Asterixis 2 Uremic frost 3 Gastroparesis 4 Uremic red eye
1 Slow continuous ultrafiltration is a simplified version of continuous venovenous hemofiltration. No fluid replacement is required in this process. Continuous venovenous hemodialysis removes both fluids and solutes and requires both dialysate and replacement fluid. Continuous venovenous hemofiltration removes both fluids and solutes and requires replacement fluid. Continuous venovenous hemodiafiltration removes both fluids and solutes and requires both dialysate and replacement fluid. Text Reference - p. 1123
Which continuous renal replacement therapy requires no fluid replacement? 1 Slow continuous ultrafiltration 2 Continuous venovenous hemodialysis 3 Continuous venovenous hemofiltration 4 Continuous venovenous hemodiafiltration
A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result of chronic immunosuppressive therapy. The elevated glucose, moon face, 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 data obtained when assessing a patient who had a kidney transplant 8 years ago and who is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone) will be of most concern to the nurse? c. There is a nontender lump in the axilla.
a, b, d. Cinacalcet (Sensipar), a calcimimetic agent to control secondary hyperparathyroidism; sevelamer (Renagel), a noncalcium phosphate binder; and calcium acetate (PhosLo), a calcium-based phosphate binder are used to treat mineral and bone disorder in CKD. IV glucose and insulin and IV 10% calcium gluconate along with sodium polystyrene sulfonate (Kayexalate) are used to treat the hyperkalemia of CKD.
Which drugs will be used to treat the patient with CKD for mineral and bone disorder (select all that apply)? a. Cinacalcet (Sensipar) b. Sevelamer (Renagel) c. IV glucose and insulin d. Calcium acetate (PhosLo) e. IV 10% calcium gluconate
4 A urine output greater than 400 mL/day is a sign of nonoliguria. Thus a urine output of 500 mL/day indicates nonoliguria. A urine output of 200 or 300 mL/day indicates oliguria. A urine output of 400 mL per day indicates that the patient is at risk for oliguria. Text Reference - p. 1103
Which finding indicates nonoliguria? 1 Urinary output of 200 mL/day 2 Urinary output of 300 mL/day 3 Urinary output of 400 mL/day 4 Urinary output of 500 mL/day
1 A urinary output rate of less than 400 mL/day indicates oliguria; thus a urinary output of 350 mL/day suggests oliguria. Urine outputs of 450, 550, or 650 mL/day are considered normal. Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer. Text Reference - p. 1103
Which finding indicates oliguria? 1 Urinary output of 350 mL/day 2 Urinary output of 450 mL/day 3 Urinary output of 550 mL/day 4 Urinary output of 650 mL/day
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.
Which information about a patient who was admitted 10 days previously with acute kidney injury (AKI) caused by dehydration will be most important for the nurse to report to the health care provider? c. Urine output over an 8-hour period is 2500 mL.
Which information from a patient's urinalysis requires that the nurse notify the health care provider? a. pH 6.2 c. WBC 20 to 26/hpf b. Trace protein d. Specific gravity 1.021 ANS: C
Which information from a patient's urinalysis requires that the nurse notify the health care provider? a. pH 6.2 c. WBC 20 to 26/hpf b. Trace protein d. Specific gravity 1.021 ANS: C
D GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status. 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 information will be most useful to the nurse in evaluating improvement in kidney function for a patient who is hospitalized with acute kidney injury (AKI)? a. Blood urea nitrogen (BUN) level b. Urine output c. Creatinine level d. Calculated glomerular filtration rate (GFR)
1 Oliguria is a sign of acute kidney injury. Uremia, anemia, and pruritus are signs of chronic kidney injury. Text Reference - p. 1103
Which is a clinical manifestation of acute kidney injury? 1 Oliguria 2 Uremia 3 Anemia 4 Pruritus
4 The mildest form of acute kidney injury is characterized by increased serum creatinine levels. Kidney injury is associated with decreased urine output, not increased urine output. Increased levels of potassium and nitrogen are characteristics of a severe form of acute kidney injury. Text Reference - p. 1102
Which is a manifestation of a mild form of acute kidney injury? 1 Increased urine output 2 Increased nitrogen level 3 Increased potassium level 4 Increased serum creatinine level
Which medication taken at home by a patient with decreased renal function will be of most concern to the nurse? a. ibuprofen (Motrin) c. folic acid (vitamin B9) b. warfarin (Coumadin) d. penicillin (Bicillin C-R) ANS: A
Which medication taken at home by a patient with decreased renal function will be of most concern to the nurse? a. ibuprofen (Motrin) c. folic acid (vitamin B9) b. warfarin (Coumadin) d. penicillin (Bicillin C-R) ANS: A
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 nursing action for a patient who has arrived for a scheduled hemodialysis session is most appropriate for the RN to delegate to a dialysis technician? b. Check blood pressure before starting dialysis.
Which nursing action is essential for a patient immediately after a renal biopsy? a. Insert a urinary catheter and test urine for microscopic hematuria. b. Apply a pressure dressing and keep the patient on the affected side. c. Check blood glucose to assess for hyperglycemia or hypoglycemia. d. Monitor blood urea nitrogen (BUN) and creatinine to assess renal function. ANS: B
Which nursing action is essential for a patient immediately after a renal biopsy? a. Insert a urinary catheter and test urine for microscopic hematuria. b. Apply a pressure dressing and keep the patient on the affected side. c. Check blood glucose to assess for hyperglycemia or hypoglycemia. d. Monitor blood urea nitrogen (BUN) and creatinine to assess renal function. ANS: B
2 Patients with acute kidney injury experience mucous membrane irritation because of the production of ammonia in the saliva. Therefore, the nurse should provide oral care to prevent stomatitis. Spicy food should be avoided because it may aggravate the irritation. Because the patient has renal impairment, fluid intake should be limited. Ibuprofen, a nonsteroidal antiinflammatory drug, is nephrotoxic and may worsen the kidney injury. Text Reference - p. 1107
Which nursing interventions in a patient with kidney injury would be beneficial in providing safe and effective care? 1 Provide spicy food 2 Provide mouth care 3 Provide plenty of fluids 4 Provide ibuprofen if the patient experiences pain
A, C
Which of the following characterize acute kidney injury (select all that apply): A. primary cause of death is infection B. almost always affects older people C. disease course is potentially reversible D. most common cause is diabetic neuropathy E. cardiovascular disease is the most common cause of death
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 EPO is administered to a target hemoglobin of >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
Which of the following information obtained by the nurse who is caring for a patient with end-stage renal disease (ESRD) indicates the nurse should consult with the health care provider before giving the prescribed epoetin alfa (Procrit)? c. Hemoglobin level 13 g/dL
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.
Which parameter will be most important for the nurse to consider when titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation? c. Urine output
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
Which patient information will the nurse plan to obtain in order to determine the effectiveness of the prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance
A 61-year-old Native American male with diabetes It is especially important for the nurse to teach CKD prevention to the 61-year-old Native American with diabetes. This patient is at highest risk because 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. 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.
Which patient should be taught preventive measures for CKD by the nurse because this patient is most likely to develop CKD? A.A 50-year-old white female with hypertension B.A 61-year-old Native American male with diabetes C.A 40-year-old Hispanic female with cardiovascular disease D.A 28-year-old African American female with a urinary tract infection
d. 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.
Which serum laboratory value indicates to the nurse that the patient's CKD is getting worse? a. Decreased BUN b. Decreased sodium c. Decreased creatinine d. Decreased calculated glomerular filtration rate (GFR)
3 Prerenal oliguria is caused by a decrease in the circulatory volume due to dehydration and congestive cardiac failure. Parenchymal damage does not occur in prerenal oliguria. Prerenal azotemia results in decreased sodium excretion, which leads to increased sodium and water retention. Reduced systemic circulation is a prerenal cause that leads to a decrease in the blood flow to the kidneys. Therefore, the glomerular filtration rate also decreases. Text Reference - p. 1102
Which statement about acute kidney injury is correct? 1 Parenchymal damage occurs in prerenal oliguria. 2 Prerenal azotemia results in increased sodium excretion. 3 Prerenal oliguria is caused by decreased circulatory volume. 4 Prerenal causes of acute kidney injury increase the glomerular filtration rate.
Which statement by a patient who had a cystoscopy the previous day should be reported immediately to the health care provider? a. "My urine looks pink." c. "My sleep was restless." b. "My IV site is bruised." d. "My temperature is 101." ANS: D
Which statement by a patient who had a cystoscopy the previous day should be reported immediately to the health care provider? a. "My urine looks pink." c. "My sleep was restless." b. "My IV site is bruised." d. "My temperature is 101." ANS: D
"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 preventing this from occurring. Although the other teaching statements are accurate, they do not have the potential for morbidity and mortality as does peritonitis, thus making that statement of highest priority.
Which statement by the nurse regarding continuous ambulatory peritoneal dialysis (CAPD) would be of highest priority when teaching a patient new to this procedure? A. "It is essential that you maintain aseptic technique to prevent peritonitis. B. "You will be allowed a more liberal protein diet once you complete CAPD." C."It is important for you to maintain a daily written record of blood pressure and weight." D."You will need to continue regular medical and nursing follow-up visits while performing CAPD."
1 A patient with chronic kidney disease who is taking oral iron salts, such as ferrous gluconate, and phosphate binders, such calcium acetate, may develop constipation and need to take a stool softener. Dialysis does not provide relief from constipation in patients with chronic kidney disease. Oral iron supplements should not be given at the same time as calcium-containing phosphate binders because they prevent iron absorption. Sodium polystyrene sulfonate helps to treat hyperkalemia but does not provide relief from constipation. Text Reference - p. 1110
Which statement made by a nursing student indicates effective learning about what should be included on a plan of care for a patient with chronic kidney disease that is taking gluconate and calcium acetate? 1 Administer a stool softener. 2 Obtain consent for immediate dialysis. 3 Give both drugs at the same time. 4 Administer sodium polystyrene sulfonate
4 Peritoneal membranes allow the passage of amino acids, polypeptides, and plasma proteins. Glucose, creatinine, and fatty acids cannot permeate the peritoneal membrane. Text Reference - p. 1119
Which substance can pass through the peritoneal membrane? 1 Glucose 2 Creatinine 3 Fatty acids 4 Amino acids
1 Patients with acute kidney injury have impaired renal excretion cannot eliminate nitrogenous wastes; this will result in increased blood urea nitrogen (BUN) levels. Eating protein-rich food will increase the level of BUN and cause neurologic changes such as asterixis, which is characterized by flapping tremor upon extension of the wrist. A normal level of BUN is 120 mg/dL. Because the patient has asterixis and a BUN level of 125 mg/dL, the nurse suspects the consumption of protein-rich food to be the cause of this symptom. Text Reference - p. 1104
While caring for a patient with acute kidney injury, the nurse observes that the patient has hand tremors while extending the wrist. The patient's laboratory report shows a blood urea nitrogen (BUN) level of 123 mg/dL. Which action by the patient does the nurse suspect as the cause of this symptom? 1 Eating protein-rich food 2 Eating sodium-rich food 3 Eating potassium-rich food 4 Eating carbohydrate-rich food
d. Hyperkalemia is a potentially life-threatening complication of AKI in the oliguric phase. Muscle weakness and abdominal cramping are signs of the neuromuscular impairment that occurs with hyperkalemia. In addition, hyperkalemia can cause the cardiac conduction abnormalities of peaked T wave, prolonged PR interval, prolonged QRS interval, and depressed ST segment. Urine output of 300 mL/day is expected during the oliguric phase, as is the development of peripheral edema.
While caring for the patient in the oliguric phase of AKI, the nurse monitors the patient for associated collaborative problems. When should the nurse notify the health care provider? a. Urine output is 300 mL/day. b. Edema occurs in the feet, legs, and sacral area. c. Cardiac monitor reveals a depressed T wave and elevated ST segment. d. The patient experiences increasing muscle weakness and abdominal cramping.
1 Patients who have donated their kidney should be monitored for hematocrit levels to assess for bleeding. The nurse should monitor renal function to assess for impairment. The nurse should monitor for electrolytes to assess for hypokalemia and hyponatremia in kidney recipients. Text Reference - p. 1127
While providing postoperative care for a live kidney donor, the nurse monitors the hematocrit levels. What rationale does the nurse provide to the patient for this action? 1 To assess for bleeding 2 To assess for impairment 3 To assess for hypokalemia 4 To assess for hyponatremia
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 a decrease in urine output
a
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 abruptio 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).
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
a, c
Number the following in the order of the phases of exchange in PD. Begin with 1 and end with 3. a. Drain b. Dwell c. Inflow
a. 3; b. 2; c. 1
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
a. Assess temperature and initiate workup to rule out infection 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.
Which complication of chronic kidney disease is treated with erythropoietin (EPO)? a. Anemia b. Hypertension c. Hyperkalemia d. Mineral and bone disorder
a. Erythropoietin is used to treat anemia, as it stimulates the bone marrow to produce red blood cells.
Priority Decision: During the immediate postoperative care of a recipient of a kidney transplant, what should the nurse expect to do? a. Regulate fluid intake hourly based on urine output. b. Monitor urine-tinged drainage on abdominal dressing. c. Medicate the patient frequently for incisional flank pain. d. Remove the urinary catheter to evaluate the ureteral implant.
a. Fluid and electrolyte balance is critical in the transplant recipient patient, especially because diuresis often begins soon after surgery. Fluid replacement is adjusted hourly based on kidney function and urine output. Urine-tinged drainage on the abdominal dressing may indicate leakage from the ureter implanted into the bladder and the health care provider should be notified. The donor patient may have a flank or laparoscopic incision(s) where the kidney was removed. The recipient has an abdominal incision where the kidney was placed in the iliac fossa. The urinary catheter is usually used for 2 to 3 days to monitor urine output and kidney function.
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
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 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. The beneficial role of protein restriction in CKD stages 1 through 4 as a means to reduce the decline in kidney function is controversial. Historically, dietary counseling often encouraged restriction of protein for individuals with CKD. Although there is some evidence that protein restriction has benefits, many patients find these diets difficult to adhere to. 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.
A patient received a kidney transplant last month. Because of the effects of immunosuppressive drugs and CKD, what complication of transplantation should the nurse be assessing the patient for to decrease the risk of mortality? a. Infection b. Rejection c. Malignancy d. Cardiovascular disease
a. Infection is a significant cause of morbidity and mortality after transplantation because the surgery, the immunosuppressive drugs, and the effects of CKD all suppress the body's normal defense mechanisms, thus increasing the risk of infection. The nurse must assess the patient as well as use aseptic technique to prevent infections. Rejection may occur but for other reasons. Malignancy occurrence increases later due to immunosuppressive therapy. Cardiovascular disease is the leading cause of death after renal transplantation but this would not be expected to cause death within the first month after transplantation.
Metabolic acidosis occurs in the oliguric phase of AKI as a result of impairment of a. ammonia synthesis. b. excretion of sodium. c. excretion of bicarbonate. d. conservation of potassium.
a. Metabolic acidosis occurs in AKI because the kidneys cannot synthesize ammonia or excrete acid products of metabolism, resulting in an increased acid load. Sodium is lost in urine because the kidneys cannot conserve sodium. Impaired excretion of potassium results in hyperkalemia. Bicarbonate is normally generated and reabsorbed by the functioning kidney to maintain acidbase balance.
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
a. Primary cause of death is infection c. Disease course is potentially reversible 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.
A man with end-stage kidney disease is scheduled for hemodialysis following healing of an arteriovenous fistula (AVF). What should the nurse explain to him that will occur during dialysis? a. He will be able to visit, read, sleep, or watch TV while reclining in a chair. b. He will be placed on a cardiac monitor to detect any adverse effects that might occur. c. The dialyzer will remove and hold part of his blood for 20 to 30 minutes to remove the waste products. d. A large catheter with two lumens will be inserted into the fistula to send blood to and return it from the dialyzer.
a. While patients are undergoing hemodialysis, they can perform quiet activities that do not require the limb that has the vascular access. Blood pressure is monitored frequently and the dialyzer monitors dialysis function but cardiac monitoring is not usually indicated. The hemodialysis machine continuously circulates both the blood and the dialysate past the semipermeable membrane in the machine. Graft and fistula access involve the insertion of two needles into the site: one to remove blood from and the other to return blood to the dialyzer.
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
a. hypertension b. vascular calcifications d. hyperinsulinemia causing dyslipidemia 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
a. older African Americans b. patients more than 60 years old d. those with a history of hypertension e. those with a history of type 2 diabetes 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).
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
a. progressive irreversible destruction of the kidneys Rationale: Chronic kidney disease (CKD) involves progressive, irreversible loss of kidney function.
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
a. successful transplantation usually provides better quality of life than that offered by dialysis 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.
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
a. the diet is less restricted and dialysis can be performed at home Rationale: Advantages of peritoneal dialysis include fewer dietary restrictions and the possibility of home dialysis.
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
b, d
What is the primary way that a nurse will evaluate the patency of an AVF? a. Palpate for pulses distal to the graft site. b. Auscultate for the presence of a bruit at the site. c. Evaluate the color and temperature of the extremity. d. Assess for the presence of numbness and tingling distal to the site.
b. 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 is the primary way that a nurse will evaluate the patency of an AVF? a. Palpate for pulses distal to the graft site. b. Auscultate for the presence of a bruit at the site. c. Evaluate the color and temperature of the extremity. d. Assess for the presence of numbness and tingling distal to the site.
b. 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.
In a patient with AKI, which laboratory urinalysis result indicates tubular damage? a. Hematuria b. Specific gravity fixed at 1.010 c. Urine sodium of 12 mEq/L (12 mmol/L) d. Osmolality of 1000 mOsm/kg (1000 mmol/kg)
b. A urine specific gravity that is consistently 1.010 and a urine osmolality of about 300 mOsm/kg is the same specific gravity and osmolality as plasma. This indicates that tubules are damaged and unable to concentrate urine. Hematuria is more common with postrenal damage. Tubular damage is associated with a high sodium concentration (greater than 40 mEq/L).
In which type of dialysis does the patient dialyze during sleep and leave the fluid in the abdomen during the day? a. Long nocturnal hemodialysis b. Automated peritoneal dialysis (APD) c. Continuous venovenous hemofiltration (CVVH) d. Continuous ambulatory peritoneal dialysis (CAPD)
b. Automated peritoneal dialysis (APD) is the type of dialysis in which the patient dialyzes during sleep and leaves the fluid in the abdomen during the day. Long nocturnal hemodialysis occurs while the patient is sleeping and is done up to six times per week. Continuous venovenous hemofiltration (CVVH) is a type of continuous renal replacement therapy used to treat AKI. Continuous ambulatory peritoneal dialysis (CAPD) is dialysis that is done with exchanges of 1.5 to 3 L of dialysate at least four times daily.
In which type of dialysis does the patient dialyze during sleep and leave the fluid in the abdomen during the day? a. Long nocturnal hemodialysis b. Automated peritoneal dialysis (APD) c. Continuous venovenous hemofiltration (CVVH) d. Continuous ambulatory peritoneal dialysis (CAPD)
b. Automated peritoneal dialysis (APD) is the type of dialysis in which the patient dialyzes during sleep and leaves the fluid in the abdomen during the day. Long nocturnal hemodialysis occurs while the patient is sleeping and is done up to six times per week. Continuous venovenous hemofiltration (CVVH) is a type of continuous renal replacement therapy used to treat AKI. Continuous ambulatory peritoneal dialysis (CAPD) is dialysis that is done with exchanges of 1.5 to 3 L of dialysate at least four times daily.
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, PaCO2 30 mm Hg, PaO2 86 mm Hg, HCO3 − 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. pH b. Potassium level c. Bicarbonate level d. Carbon dioxide level
b. During acidosis, potassium moves out of the cell in exchange for H+ ions, increasing the serum potassium level. Correction of the acidosis with sodium bicarbonate will help to shift the potassium back into the cells. A decrease in pH and the bicarbonate and PaCO2 levels would indicate worsening acidosis.
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
b. ECG changes d. pulmonary edema 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.
What is the most serious electrolyte disorder associated with kidney disease? a. Hypocalcemia b. Hyperkalemia c. Hyponatremia d. Hypermagnesemia
b. 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.
Priority Decision: A dehydrated patient is in the Injury stage of the RIFLE staging of AKI. What would the nurse first anticipate in the treatment of this patient? a. Assess daily weight b. IV administration of fluid and furosemide (Lasix) c. IV administration of insulin and sodium bicarbonate d. Urinalysis to check for sediment, osmolality, sodium, and specific gravity
b. Injury is the stage of RIFLE classification when urine output is less than 0.5 mL/kg/hr for 12 hours, the serum creatinine is increased times two or the glomerular filtration rate (GFR) is decreased by 50%. This stage may be reversible by treating the cause or, in this patient, the dehydration by administering IV fluid and a low dose of a loop diuretic, furosemide (Lasix). Assessing the daily weight will be done to monitor fluid changes but it is not the first treatment the nurse should anticipate. IV administration of insulin and sodium bicarbonate would be used for hyperkalemia. Checking the urinalysis will help to determine if the AKI has a prerenal, intrarenal, or postrenal cause by what is seen in the urine but with this patient's dehydration, it is thought to be prerenal to begin treatment.
To prevent the most common serious complication of PD, what is important for the nurse to do? a. Infuse the dialysate slowly. b. Use strict aseptic technique in the dialysis procedures. c. Have the patient empty the bowel before the inflow phase. d. Reposition the patient frequently and promote deep breathing.
b. 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.
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. 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).
A 68-year-old man with a history of heart failure resulting from hypertension has AKI as a result of the effects of nephrotoxic diuretics. Currently his serum potassium is 6.2 mEq/L (6.2 mmol/L) with cardiac changes, his BUN is 108 mg/dL (38.6 mmol/L), his serum creatinine is 4.1 mg/dL (362 mmol/L), and his serum HCO3 − is 14 mEq/L (14 mmol/L). He is somnolent and disoriented. Which treatment should the nurse expect to be used for him? a. Loop diuretics b. Renal replacement therapy c. Insulin and sodium bicarbonate d. Sodium polystyrene sulfonate (Kayexalate)
b. This patient has at least three of the six common indications for renal replacement therapy (RRT), including (1) high potassium level, (2) metabolic acidosis, and (3) changed mental status. The other indications are (4) volume overload, resulting in compromised cardiac status (this patient has a history of hypertension), (5) BUN greater than 120 mg/dL, and (6) pericarditis, pericardial effusion, or cardiac tamponade. Although the other treatments may be used, they will not be as effective as RRT for this older patient. Loop diuretics and increased fluid are used if the patient is dehydrated. Insulin and sodium bicarbonate can be used to temporarily drive the potassium into the cells. Sodium polystyrene sulfonate (Kayexalate) is used to actually decrease the amount of potassium in the body.
If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalance? a. hyperkalemia and hyponatremia b. hyperkalemia and hypernatremia c. hypokalemia and hyponatremia d. hypokalemia and hypernatremia
c
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. Nephrotoxic 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.
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.
A patient on hemodialysis develops a thrombus of a subcutaneous arteriovenous (AV) graft, requiring its removal. While waiting for a replacement graft or fistula, the patient is most likely to have what done for treatment? a. Peritoneal dialysis b. Peripheral vascular access using radial artery c. Silastic catheter tunneled subcutaneously to the jugular vein d. Peripherally inserted central catheter (PICC) line inserted into subclavian vein
c. A more permanent, soft, flexible Silastic double-lumen catheter is used for long-term access when other forms of vascular access have failed. These catheters are tunneled subcutaneously and have Dacron cuffs that prevent infection from tracking along the catheter.
A patient on hemodialysis develops a thrombus of a subcutaneous arteriovenous (AV) graft, requiring its removal. While waiting for a replacement graft or fistula, the patient is most likely to have what done for treatment? a. Peritoneal dialysis b. Peripheral vascular access using radial artery c. Silastic catheter tunneled subcutaneously to the jugular vein d. Peripherally inserted central catheter (PICC) line inserted into subclavian vein
c. A more permanent, soft, flexible Silastic double-lumen catheter is used for long-term access when other forms of vascular access have failed. These catheters are tunneled subcutaneously and have Dacron cuffs that prevent infection from tracking along the catheter.
A patient with AKI is a candidate for continuous renal replacement therapy (CRRT). What is the most common indication for use of CRRT? a. Azotemia b. Pericarditis c. Fluid overload d. Hyperkalemia
c. Continuous renal replacement therapy (CRRT) is indicated for the patient with AKI as an alternative or adjunct to hemodialysis to slowly remove solutes and fluid in the hemodynamically unstable patient. It is especially useful for treatment of fluid overload, but hemodialysis is indicated for treatment of hyperkalemia, pericarditis, or other serious effects of uremia.
A patient with AKI is a candidate for continuous renal replacement therapy (CRRT). What is the most common indication for use of CRRT? a. Azotemia b. Pericarditis c. Fluid overload d. Hyperkalemia
c. Continuous renal replacement therapy (CRRT) is indicated for the patient with AKI as an alternative or adjunct to hemodialysis to slowly remove solutes and fluid in the hemodynamically unstable patient. It is especially useful for treatment of fluid overload, but hemodialysis is indicated for treatment of hyperkalemia, pericarditis, or other serious effects of uremia.
What does the dialysate for PD routinely contain? a. Calcium in a lower concentration than in the blood b. Sodium in a higher concentration than in the blood c. Dextrose in a higher concentration than in the blood d. Electrolytes in an equal concentration to that of the blood
c. 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.
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
c. Hypokalemia and hyponatremia 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.
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. Uremic pleuritis is occurring. b. There is decreased pulmonary macrophage activity. c. They are caused by respiratory compensation for metabolic acidosis. d. Pulmonary edema from heart failure and fluid overload is occurring.
c. 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.
For a patient with CKD the nurse identifies a nursing diagnosis of risk for injury: fracture related to alterations in calcium and phosphorus metabolism. What is the pathologic process directly related to the increased risk for fractures? a. Loss of aluminum through the impaired kidneys b. Deposition of calcium phosphate in soft tissues of the body c. Impaired vitamin D activation resulting in decreased GI absorption of calcium d. Increased release of parathyroid hormone in response to decreased calcium levels
c. The calcium-phosphorus imbalances that occur in CKD result in hypocalcemia, from a deficiency of active vitamin D and increased phosphorus levels. This leads to an increased rate of bone remodeling with a weakened bone matrix. Aluminum accumulation is also believed to contribute to the osteomalacia. Osteitis fibrosa involves replacement of calcium in the bone with fibrous tissue and is primarily a result of elevated levels of parathyroid hormone resulting from hypocalcemia.
During the nursing assessment of the patient with renal insufficiency, the nurse asks the patient specifically about a history of a. angina. b. asthma. c. hypertension. d. rheumatoid arthritis.
c. The most common causes of CKD in the United States are diabetes mellitus and hypertension. The nurse should obtain information on long-term health problems that are related to kidney disease. The other disorders are not closely associated with renal disease.
During the nursing assessment of the patient with renal insufficiency, the nurse asks the patient specifically about a history of a. angina. b. asthma. c. hypertension. d. rheumatoid arthritis.
c. The most common causes of CKD in the United States are diabetes mellitus and hypertension. The nurse should obtain information on long-term health problems that are related to kidney disease. The other disorders are not closely associated with renal disease.
To assess the potency 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
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 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.
A 56-year-old woman with type 2 diabetes mellitus and chronic kidney disease has a serum potassium level of 6.8 mEq/L. The nurse should assess the patient for A.fatigue. B. flank tenderness. C.cardiac dysrhythmias. D.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. Tenderness or pain over the kidneys is not expected in CKD.
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
d
What are intrarenal causes of acute kidney injury (AKI) (select all that apply)? a. Anaphylaxis b. Renal stones c. Bladder cancer d. Nephrotoxic drugs e. Acute glomerulonephritis f. Tubular obstruction by myoglobin
d, e, f. Intrarenal causes of 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.
Acute tubular necrosis (ATN) is the most common cause of intrarenal AKI. Which patient is most likely to develop ATN? a. Patient with diabetes mellitus b. Patient with hypertensive crisis c. Patient who tried to overdose on acetaminophen d. Patient with major surgery who required a blood transfusion
d. Acute tubular necrosis (ATN) is primarily the result of ischemia, nephrotoxins, or sepsis. Major surgery is most likely to cause severe kidney ischemia in the patient requiring a blood transfusion. A blood transfusion hemolytic reaction produces nephrotoxic injury if it occurs. Diabetes mellitus, hypertension, and acetaminophen overdose will not contribute to ATN.
A patient rapidly progressing toward end-stage kidney disease asks about the possibility of a kidney transplant. In responding to the patient, the nurse knows that what is a contraindication to kidney transplantation? a. Hepatitis C infection b. Coronary artery disease c. Refractory hypertension d. Extensive vascular disease
d. Extensive vascular disease is a contraindication for renal transplantation, primarily because adequate blood supply is essential for the health of the new kidney. Other contraindications include disseminated malignancies, refractory or untreated cardiac disease, chronic respiratory failure, chronic infection, or unresolved psychosocial disorders. Coronary artery disease (CAD) may be treated with bypass surgery before transplantation and transplantation can relieve hypertension. Hepatitis B or C infection is not a contraindication.
A patient rapidly progressing toward end-stage kidney disease asks about the possibility of a kidney transplant. In responding to the patient, the nurse knows that what is a contraindication to kidney transplantation? a. Hepatitis C infection b. Coronary artery disease c. Refractory hypertension d. Extensive vascular disease
d. Extensive vascular disease is a contraindication for renal transplantation, primarily because adequate blood supply is essential for the health of the new kidney. Other contraindications include disseminated malignancies, refractory or untreated cardiac disease, chronic respiratory failure, chronic infection, or unresolved psychosocial disorders. Coronary artery disease (CAD) may be treated with bypass surgery before transplantation and transplantation can relieve hypertension. Hepatitis B or C infection is not a contraindication.
While caring for the patient in the oliguric phase of AKI, the nurse monitors the patient for associated collaborative problems. When should the nurse notify the health care provider? a. Urine output is 300 mL/day. b. Edema occurs in the feet, legs, and sacral area. c. Cardiac monitor reveals a depressed T wave and elevated ST segment. d. The patient experiences increasing muscle weakness and abdominal cramping.
d. Hyperkalemia is a potentially life-threatening complication of AKI in the oliguric phase. Muscle weakness and abdominal cramping are signs of the neuromuscular impairment that occurs with hyperkalemia. In addition, hyperkalemia can cause the cardiac conduction abnormalities of peaked T wave, prolonged PR interval, prolonged QRS interval, and depressed ST segment. Urine output of 300 mL/day is expected during the oliguric phase, as is the development of peripheral edema.
What indicates to the nurse that a patient with oliguria has prerenal oliguria? a. Urine testing reveals a low specific gravity. b. Causative factor is malignant hypertension. c. Urine testing reveals a high sodium concentration. d. Reversal of oliguria occurs with fluid replacement.
d. In prerenal oliguria, the oliguria is caused by a decrease in circulating blood volume and there is no damage yet to the renal tissue. It can be reversed by correcting the precipitating factor, such as fluid replacement for hypovolemia. Prerenal oliguria is characterized by urine with a high specific gravity and a low sodium concentration, whereas oliguria of intrarenal failure is characterized by urine with a low specific gravity and a high sodium concentration. Malignant hypertension causes damage to renal tissue and intrarenal oliguria.
What accurately describes the care of the patient with CKD? a. A nutrient that is commonly supplemented for the patient on dialysis because it is dialyzable is iron. b. The syndrome that includes all of the signs and symptoms seen in the various body systems in CKD is azotemia. c. The use of morphine is contraindicated in the patient with CKD because accumulation of its metabolites may cause seizures. d. The use of calcium-based phosphate binders in the patient with CKD is contraindicated when serum calcium levels are increased.
d. In the patient with CKD, when serum calcium levels are increased, calcium-based phosphate binders are not used. The nutrient supplemented for patients on dialysis is folic acid. The various body system manifestations occur with uremia, which includes azotemia. Meperidine is contraindicated in patients with CKD related to possible seizures.
What accurately describes the care of the patient with CKD? a. A nutrient that is commonly supplemented for the patient on dialysis because it is dialyzable is iron. b. The syndrome that includes all of the signs and symptoms seen in the various body systems in CKD is azotemia. c. The use of morphine is contraindicated in the patient with CKD because accumulation of its metabolites may cause seizures. d. The use of calcium-based phosphate binders in the patient with CKD is contraindicated when serum calciumlevels are increased.
d. In the patient with CKD, when serum calcium levels are increased, calcium-based phosphate binders are not used. The nutrient supplemented for patients on dialysis is folic acid. The various body system manifestations occur with uremia, which includes azotemia. Meperidine is contraindicated in patients with CKD related to possible seizures.
In caring for the patient with AKI, what should the nurse be aware of? a. The most common cause of death in AKI is irreversible metabolic acidosis. b. During the oliguric phase of AKI, daily fluid intake is limited to 1000 mL plus the prior day's measured fluid loss. c. Dietary sodium and potassium during the oliguric phase of AKI are managed according to the patient's urinary output. d. One of the most important nursing measures in managing fluid balance in the patient with AKI is taking accurate daily weights.
d. Measuring daily weights with the same scale at the same time each day allows for the evaluation and detection of excessive body fluid gains or losses. Infection is the leading cause of death in AKI, so meticulous aseptic technique is critical. The fluid limitation in the oliguric phase is 600 mL plus the prior day's measured fluid loss. Dietary sodium and potassium intake are managed according to the plasma levels.
What indicates to the nurse that a patient with AKI is in the recovery phase? a. A return to normal weight b. A urine output of 3700 mL/day c. Decreasing sodium and potassium levels d. Decreasing blood urea nitrogen (BUN) and creatinine levels
d. The blood urea nitrogen (BUN) and creatinine levels remain high during the oliguric and diuretic phases of AKI. The recovery phase begins when the glomerular filtration returns to a rate at which BUN and creatinine stabilize and then decrease. Urinary output of 3 to 5 L/ day, decreasing sodium and potassium levels, and fluid weight loss are characteristic of the diuretic phase of AKI.
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
d. serum creatinine or urine output from baseline 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.
To assess whether there is any improvement in a patient's dysuria, which question will the nurse ask? a. "Do you have to urinate at night?" b. "Do you have blood in your urine?" c. "Do you have to urinate frequently?" d. "Do you have pain when you urinate?" ANS: D
vTo assess whether there is any improvement in a patient's dysuria, which question will the nurse ask? a. "Do you have to urinate at night?" b. "Do you have blood in your urine?" c. "Do you have to urinate frequently?" d. "Do you have pain when you urinate?" ANS: D
Sexual dysfunction in people with CKD is thought to be multifactorial. What are thought to be causes of sexual dysfunction in people with CKD? (Select all that apply.) a) Uremic toxins b) Antihypertensive drugs c) Psychological factors d) Inability to vasodilate veins e) High incidence of sexually transmitted diseases
• Antihypertensive drugs • Psychological factors • Uremic toxins The cause of sexual dysfunction in men and women with CKD is unclear. The cause probably is multifactorial and may result from high levels of uremic toxins, neuropathy, altered endocrine function, psychological factors, and medications (e.g., antihypertensive drugs). The other answers do not apply in this situation.
A client is diagnosed with decreased gomerular filtration rate but has no renal damage. The nurse recognizes that this can occur with which of the following? Select all that apply. a) Carbohydrate diet b) Heart failure c) Dehydration d) Cirrhosis e) Removal of one kidney
• Cirrhosis • Heart failure • Removal of one kidney • Dehydration Chronic reduction in glomerular filtration rate with no renal damage can be the result of depleted body fluid, removal of one kidney, and conditions such as heart failure and cirrhosis which decrease renal perfusion. A carbohydrate diet should not affect GFR.
A patient is diagnosed with chronic kidney disease (CKD). The nurse recognizes that this patient will experience which of the following? Select all that apply. a) Decreased tubular reabsorption b) Hypophospatemia c) Decreased glomerular filtration d) Proliferation of nephrons e) Decreased renal endocrine function
• Decreased renal endocrine function • Decreased tubular reabsorption • Decreased glomerular filtration Chronic kidney disease results in loss of nephrons, with a decrease in tubular reabsorption, glomerular filtration, and endocrine function. -Phosphate accumulates in the blood, as the kidneys lose their ability to excrete this electrolyte.
The nurse is preparing to assess a client who has just been admitted to the hospital with a diagnosis of prerenal failure. Which would the nurse expect the client to manifest? Select all that apply. a) BUN-to-serum creatinine ratio of greater than 20:1 b) Increased urinary output c) Decreased urinary output d) Increased BUN e) Decreased BUN f) BUN to serum creatinine ratio of 10:1
• Decreased urinary output • Increased BUN • BUN-to-serum creatinine ratio of greater than 20:1 Prerenal injury is manifested by a sharp decrease in urine output and a disproportionate elevation of blood urea nitrogen (BUN) in relation to serum creatinine levels. Consequently, there also is a disproportionate elevation in the ratio of BUN to serum creatinine, from a normal value of 10:1 to a ratio greater than 20:1.
Glomerular filtration rate (GFR) is the best indicator of renal function. The nurse knows that GFR can vary with which of the following factors? Select all that apply. a) Age b) Body size c) Diet d) Ethnicity e) Gender
• Gender • Age • Body size • Ethnicity GFR, the best indicator of overall renal function, varies with age, gender, body size, and ethnicity. Equations are available for calculating GFR based on serum creatinine and these variables. Diet, if it includes sufficient fluid intake to maintain hydration, should not affect GFR.
A child has received a kidney transplant at the age of 3. Knowing he will be on immunosuppressive agents like corticosteroids, the nurse should educate the parents about which long-term side effects? Select all that apply. a) Growth retardation b) Excess weight loss c) Development of cataracts d) Hypertension e) Frequent hematuria
• Hypertension • Growth retardation • Development of cataracts Early transplantation in young children is regarded as the best way to promote physical growth, improve cognitive function, and foster psychosocial development. Immunosuppressive therapy in children is similar to that used in adults. All immunosuppressive agents have side effects, including increased risk for infection. Corticosteroids carry the risk for hypertension, orthopedic complications (especially aseptic necrosis), cataracts, and growth retardation. Steroids usually are associated with weight gain. -Frequent hematuria is caused by something other than steroids and should be reported.
The nurse knows that a child with chronic kidney disease (CKD) may experience which of these manifestations? Select all that apply. a) Mental retardation b) Severe growth deficit c) High bone turnover d) Early sexual maturity e) Bladder incontinence
• Severe growth deficit • High bone turnover Childhood CKD is manifested by delays in growth and sexual maturity as a result of the uremic effects on endocrine function and bone growth. High bone turnover is related to secondary hyperparathyroidism. -Intelligence and control of urinary tract function are not directly affected by renal failure.
A client with chronic kidney disease (CKD) is anemic. The nurse will attempt to alleviate the anemia in order to prevent which of the following? Select all that apply. a) Decreased myocardial oxygen b) Increased blood viscosity c) Hypersomnia d) Tachycardia e) Fatigue
• Tachycardia • Fatigue • Decreased myocardial oxygen Uncorrected anemia provokes fatigue and insomnia, a decrease in blood viscosity, a decrease in myocardial oxygen supply, and tachycardia as the heart attempts to supply sufficient oxygen to the heart and brain
The nurse is planning care for a client with chronic kidney disease (CKD). The nurse determines that an allowable fluid intake would be: a) 500 to 800 mL/day b) 1050 to 1200 mL/day c) 400 to 600 mL/day d) 850 to 1000 mL/day
500 to 800 mL/day It is a common practice to allow 500 to 800 mL, which is equal to insensible water loss plus a quantity equal to the 24-hour urine output. -Fluid intake in excess of what the kidneys can excrete causes circulatory overload, edema, and water intoxication. -Inadequate intake, on the other hand, causes volume depletion and hypotension and can cause further decreases in the already compromised GFR.
A patient in the oliguric phase after an acute kidney injury has had a 250 mL urine output and an emesis of 100 mL in the past 24 hours. What is the patient's fluid restriction for the next 24 hours?
950 mL
A patient in the oliguric phase after an acute kidney injury has had a 250-mL urine output and an emesis of 100 mL in the past 24 hours. What is the patient's fluid restriction for the next 24 hours?
950 mL The general rule for calculating fluid restrictions is to add all fluid losses for the previous 24 hours, plus 600 mL for insensible losses: (250 + 100 + 600 = 950 mL).
A 72-year-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.
A
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 urinary output and an elevated BUN C. an increasing creatinine clearance with a decrease in urinary output D. prostration, somnolence and confusion with coma and imminent death
A
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.
A
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 a 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. the immunosuppressive therapy that is required following transplantation causes fatal malignancies in many patients D. hemodialysis replaces the normal functioning of the kidneys and patients do not have to live with the continual fear of rejection
A
Kidney transplant recipient complains of having fever, chills, and dysuria over the course of the past 2 days, What is the first action the nurse should take? A. assess temperature and initiate workup to rule out infection B. provied warm cover for the patient and give 1 g acetaminophen orally C. reassure the patient that this is common after transplantation D. notify the nephrologist that the patient has developed symptoms of acute rejection
A
Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the a. bowel sounds. b. blood glucose. c. blood urea nitrogen (BUN). d. level of consciousness (LOC).
A
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.
A
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.
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.
Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the a. bowel sounds. b. blood glucose. c. blood urea nitrogen (BUN). d. level of consciousness (LOC).
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.
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.
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.
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.
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 52-year-old man with stage 2 chronic kidney disease is scheduled for an outpatient diagnostic procedure using contrast media. Which action should the nurse take? A.Assess skin turgor to determine hydration status. B.Insert a urinary catheter for the expected diuresis. C.Evaluate the patient's lower extremities for edema D. Check the patient's urine for the presence of ketones
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. Tenderness or pain over the kidneys is not expected in CKD.
A 56-year-old woman with type 2 diabetes mellitus and chronic kidney disease has a serum potassium level of 6.8 mEq/L. The nurse should assess the patient for A.fatigue. B. flank tenderness. C.cardiac dysrhythmias. D.elevated triglycerides.
Which patient should be taught preventive measures for CKD by the nurse because this patient is most likely to develop CKD? A.A 50-year-old white female with hypertension B.A 61-year-old Native American male with diabetes C.A 40-year-old Hispanic female with cardiovascular disease D.A 28-year-old African American female with a urinary tract infection
A 61-year-old Native American male with diabetes It is especially important for the nurse to teach CKD prevention to the 61-year-old Native American with diabetes. This patient is at highest risk because 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. 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.
b. This patient has at least three of the six common indications for renal replacement therapy (RRT), including (1) high potassium level, (2) metabolic acidosis, and (3) changed mental status. The other indications are (4) volume overload, resulting in compromised cardiac status (this patient has a history of hypertension), (5) BUN greater than 120 mg/dL, and (6) pericarditis, pericardial effusion, or cardiac tamponade. Although the other treatments may be used, they will not be as effective as RRT for this older patient. Loop diuretics and increased fluid are used if the patient is dehydrated. Insulin and sodium bicarbonate can be used to temporarily drive the potassium into the cells. Sodium polystyrene sulfonate (Kayexalate) is used to actually decrease the amount of potassium in the body.
A 68-year-old man with a history of heart failure resulting from hypertension has AKI as a result of the effects of nephrotoxic diuretics. Currently his serum potassium is 6.2 mEq/L (6.2 mmol/L) with cardiac changes, his BUN is 108 mg/dL (38.6 mmol/L), his serum creatinine is 4.1 mg/dL (362 mmol/L), and his serum HCO3− is 14 mEq/L (14 mmol/L). He is somnolent and disoriented. Which treatment should the nurse expect to be used for him? a. Loop diuretics b. Renal replacement therapy c. Insulin and sodium bicarbonate d. Sodium polystyrene sulfonate (Kayexalate)
29.5 The Cockcroft-Gault formula estimates glomerular filtration rate (GFR): [(140 - Age) x (weight in kilograms) x (0.85 if female)]/(72 x Creatinine (Cr) mg/dL) = GFR. Using this formula, a female patient of 70 years weighing 50 kg with serum creatinine level of 1.4 mg/dL has a GFR of 29.5 mL/min as shown by ((140 - 70) x (50 kg) x 0.85 if female))/(72 x (1.4 mg/dL) = 29.5. Text Reference - p. 1112
A 70-year-old female patient weighs 50 kg and has a serum creatinine level of 1.4 mg/dL. Using the Cockcroft-Gault rule, what should the nurse document as the patient's glomerular filtration rate (GFR)? Record the answer using one decimal place. ____________ mL/min
Apple, green beans, and a roast beef sandwich Correct 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 78-year-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? A.Apple, green beans, and a roast beef sandwich B.Granola made with dried fruits, nuts, and seeds C.Watermelon and ice cream with chocolate sauce D.Bran cereal with ½ banana and milk and orange juice
A 79-yr-old patient has been admitted with benign prostatic hyperplasia. What is most appropriate to include in the nursing plan of care? a. Limit fluid intake to no more than 1000 mL/day. b. Leave a light on in the bathroom during the night. c. Ask the patient to use a urinal so that urine can be measured. d. Pad the patient's bed to accommodate overflow incontinence. ANS: B
A 79-yr-old patient has been admitted with benign prostatic hyperplasia. What is most appropriate to include in the nursing plan of care? a. Limit fluid intake to no more than 1000 mL/day. b. Leave a light on in the bathroom during the night. c. Ask the patient to use a urinal so that urine can be measured. d. Pad the patient's bed to accommodate overflow incontinence. ANS: B
1 Heparin is added to the blood to prevent clotting when the patient's blood contacts a foreign substance. Dextrose and icodextrin are used as osmotic agents during dialysis. Saline solution is used to flush the dialyzer. Text Reference - p. 1121
A dialysis nurse is performing hemodialysis for a patient with chronic kidney disease. Which action by the nurse will prevent blood clotting during the procedure? 1 Addition of heparin to the blood 2 Addition of dextrose to the blood 3 Addition of icodextrin to the blood 4 Addition of saline solution to the blood
A female patient being admitted with pneumonia has a history of neurogenic bladder as a result of a spinal cord injury. Which action will the nurse plan to take first? a. Ask about the usual urinary pattern and any measures used for bladder control. b. Assist the patient to the toilet at scheduled times to help ensure bladder emptying. c. Check the patient for urinary incontinence every 2 hours to maintain skin integrity. d. Use intermittent catheterization on a regular schedule to avoid the risk of infection. ANS: A
A female patient being admitted with pneumonia has a history of neurogenic bladder as a result of a spinal cord injury. Which action will the nurse plan to take first? a. Ask about the usual urinary pattern and any measures used for bladder control. b. Assist the patient to the toilet at scheduled times to help ensure bladder emptying. c. Check the patient for urinary incontinence every 2 hours to maintain skin integrity. d. Use intermittent catheterization on a regular schedule to avoid the risk of infection. ANS: A
A female patient with a suspected urinary tract infection (UTI) is to provide a clean-catch urine specimen for culture and sensitivity testing. To obtain the specimen, the nurse will a. have the patient empty the bladder completely; then obtain the next urine specimen that the patient is able to void. b. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup. c. insert a short sterile "mini" catheter attached to a collecting container into the urethra and bladder to obtain the specimen. d. clean the area around the meatus with a povidone-iodine (Betadine) swab and then have the patient void into a sterile container. ANS: B
A female patient with a suspected urinary tract infection (UTI) is to provide a clean-catch urine specimen for culture and sensitivity testing. To obtain the specimen, the nurse will a. have the patient empty the bladder completely; then obtain the next urine specimen that the patient is able to void. b. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup. c. insert a short sterile "mini" catheter attached to a collecting container into the urethra and bladder to obtain the specimen. d. clean the area around the meatus with a povidone-iodine (Betadine) swab and then have the patient void into a sterile container. ANS: B
Aluminum hydroxide (Amphogel) 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 frail 72-year-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? A.Aspirin B. Acetaminophen (Tylenol) C. Diphenhydramine (Benadryl) D.Aluminum hydroxide (Amphogel)
A hospitalized patient with possible renal insufficiency after coronary artery bypass surgery is scheduled for a creatinine clearance test. Which item will the nurse need to obtain? a. Urinary catheter c. Cleansing towelettes b. Sterile specimen cup d. Large urine container ANS: D
A hospitalized patient with possible renal insufficiency after coronary artery bypass surgery is scheduled for a creatinine clearance test. Which item will the nurse need to obtain? a. Urinary catheter c. Cleansing towelettes b. Sterile specimen cup d. Large urine container ANS: D
A male patient in the clinic provides a urine sample that is red-orange in color. Which action should the nurse take? a. Notify the patient's health care provider. b. Teach correct midstream urine collection. c. Ask the patient about current medications. d. Question the patient about urinary tract infection (UTI) risk factors. ANS: C
A male patient in the clinic provides a urine sample that is red-orange in color. Which action should the nurse take? a. Notify the patient's health care provider. b. Teach correct midstream urine collection. c. Ask the patient about current medications. d. Question the patient about urinary tract infection (UTI) risk factors. ANS: C
a. While patients are undergoing hemodialysis, they can perform quiet activities that do not require the limb that has the vascular access. Blood pressure is monitored frequently and the dialyzer monitors dialysis function but cardiac monitoring is not usually indicated. The hemodialysis machine continuously circulates both the blood and the dialysate past the semipermeable membrane in the machine. Graft and fistula access involve the insertion of two needles into the site: one to remove blood from and the other to return blood to the dialyzer.
A man with end-stage kidney disease is scheduled for hemodialysis following healing of an arteriovenous fistula (AVF). What should the nurse explain to him that will occur during dialysis? a. He will be able to visit, read, sleep, or watch TV while reclining in a chair. b. He will be placed on a cardiac monitor to detect any adverse effects that might occur. c. The dialyzer will remove and hold part of his blood for 20 to 30 minutes to remove the waste products. d. A large catheter with two lumens will be inserted into the fistula to send blood to and return it from the dialyzer.
When a patient at risk for chronic kidney disease (CKD) receives a nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels. The other laboratory values would not be useful in determining the effect of the gentamicin
A new order for IV gentamicin (Garamycin) 60 mg BID is received for a patient with diabetes who has pneumonia. When evaluating for adverse effects of the medication, the nurse will plan to monitor the patient's d. blood urea nitrogen (BUN) and creatinine.
850 The patient is at a risk of developing hypovolemia, and to prevent this, adequate fluid resuscitation should be done. To determine the volume for fluid resuscitation, the nurse adds together all losses during the previous 24 hours (e.g., urine, diarrhea, emesis, blood) and adds 600 mL for insensible losses (e.g., respiration, diaphoresis). Text Reference - p. 1105
A nurse has to determine the volume of fluid that must be administered to the patient with acute renal failure who is in the oliguric phase. The total urine output of the patient the previous day was 250 mL. What should be the fluid allocation for this patient on this day? Record your answer using a whole number. __ mL
1, 4, 5 Diabetes is a major predisposing factor for development of kidney disease; hence, the donor should not be a diabetic. ABO compatibility is necessary for being a donor, although the exact blood type is not necessary. Human leukocyte antigen compatibility provides the most specific predictions of the body's tendency to accept or reject foreign tissue. Being a member of the same family is unsafe unless the family member has matching leukocyte antigen complexes. Being a member of the same family may increase the possibility of a match, but there is no guarantee that a family member will match. Differences in body size do not cause problems. Text Reference - p. 1124
A nurse is delivering a lecture on organ donation. She is explaining about the selection criteria for kidney donors. What are the donor characteristics that the nurse should discuss with the group? Select all that apply. 1 Donors should not have diabetes. 2 Donors should be a first-degree relative of a recipient. 3 Donors should be approximately the same body size as the recipient. 4 Donors must have ABO compatibility with the recipient. 5 The donor and recipient should have matching leukocyte antigen complexes.
1, 2 A chronic renal failure patient on continuous ambulatory peritoneal dialysis is encouraged to have a high-calorie diet to meet the increased demands of the body. A good amount of protein should be consumed to replace that lost during dialysis. Foods containing high amounts of potassium and phosphorus should be avoided in patients with chronic renal failure. High potassium can cause hyperkalemia and related complications, especially cardiac complications. High phosphorus may deteriorate bone health. Usually there is a modest restriction of fluids when the patient is on dialysis. Text Reference - p. 1115
A nurse is giving dietary advice to a patient who is on continuous ambulatory peritoneal dialysis for chronic renal failure. Which dietary instructions are appropriate for this patient? Select all that apply. 1 High-calorie foods 2 High-protein foods 3 High-potassium content 4 High-phosphorus content 5 High-fluid intake
2 The issue of excess fluid volume is the primary problem of acute renal failure and the highest priority for the nurse in this situation. The major problem with acute renal failure is altered fluid and electrolyte balance, which, if not managed, can lead to permanent renal damage, cardiac complications, and death. The nursing diagnosis of ineffective coping is due to the acute severity of the illness. The nursing diagnosis of impaired gas exchange is related to excess fluid volume, such as in the development of pulmonary edema. The nursing diagnosis of imbalanced nutrition, less than body requirements, is due to a decrease in appetite as a result of the acute renal failure. Text Reference - p. 1106
A nurse planning care for a patient with acute renal failure recognizes that the interventions of highest priority are directly related to: 1 Ineffective coping 2 Excess fluid volume 3 Impaired gas exchange 4 Imbalanced nutrition: less than body requirements
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.
A patient complains of leg cramps during hemodialysis. The nurse should first d. infuse a bolus of normal saline.
1 Pedal edema and urine output less than 0.5 mL/kg/hr for 12 hours indicate acute kidney injury. Glomerulonephritis is one of the intrarenal causes of acute kidney injury. A kidney biopsy is the best method to confirm intrarenal causes of kidney injury. A kidney ultrasound is the first diagnostic test used to establish acute kidney injury. A computed tomography scan is used to identify lesions, masses, lesions, and vascular anomalies. Magnetic resonance imaging is not advised in patients with renal failure unless necessary due to the development of nephrogenic systemic fibrosis. Text Reference - p. 1105
A patient complains of pedal edema. The laboratory reports show 0.4 mL/kg/hr of urine output for the past 12 hours. The patient has a history of acute glomerulonephritis. Which method is the best to confirm acute glomerulonephritis as a cause of acute kidney injury in this patient? 1 Kidney biopsy 2 Kidney ultrasound 3 Computed tomographic scan 4 Magnetic resonance imaging
2 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, whereas postoperative care is the nurse's role. Trying to shame the patient into walking by telling him or her that other patients have not refused and telling the patient he or she is lucky not to have had an open nephrectomy (implying how much more pain the patient would be having if it had been open) will not be beneficial to the patient or to the postoperative recovery. Text Reference - p. 1127
A patient donated a kidney via a laparoscopic donor nephrectomy to a nonrelated recipient. The patient is experiencing a lot of pain and refuses to get up to walk. How should the nurse handle this situation? 1 Have the transplant psychologist convince the patient to walk. 2 Encourage even a short walk to avoid complications of surgery. 3 Tell the patient that no other patients have ever refused to walk. 4 Tell the patient that he or she is lucky it was not necessary to have an open nephrectomy.
A patient gives the admitting nurse health information before a scheduled intravenous pyelogram (IVP). Which item requires the nurse to intervene before the procedure? a. The patient has not had food or drink for 8 hours. b. The patient lists allergies to shellfish and penicillin. c. The patient complains of costovertebral angle (CVA) tenderness. d. The patient used a bisacodyl (Dulcolax) tablet the previous night. ANS: B
A patient gives the admitting nurse health information before a scheduled intravenous pyelogram (IVP). Which item requires the nurse to intervene before the procedure? a. The patient has not had food or drink for 8 hours. b. The patient lists allergies to shellfish and penicillin. c. The patient complains of costovertebral angle (CVA) tenderness. d. The patient used a bisacodyl (Dulcolax) tablet the previous night. ANS: B
1, 2 Hypotension is a complication of hemodialysis and may manifest as headache and nausea. The nurse should try to keep the intravascular volume adequate by decreasing the volume of fluids being removed and infusing 0.9% saline solution. Hypertonic glucose solutions are infused if the patient gets muscle cramps. Excess coagulation is avoided if the patient has blood loss. Blood is transfused if the patient has blood loss. Text Reference - p. 1122
A patient has end-stage kidney disease and is receiving hemodialysis. During dialysis the patient complains of nausea and a headache and appears confused. On examination, the nurse finds that the blood pressure is very low. What is the priority action by the nurse? Select all that apply. 1 Decrease the volume of fluids being removed. 2 Infuse 0.9% saline solution. 3 Infuse hypertonic glucose solution. 4 Avoid excess coagulation. 5 Transfuse blood, as ordered
2 Renal failure, whether acute or chronic, causes an increase in serum urea, creatinine, and blood urea nitrogen. Renal failure may also cause hyperkalemia and anemia and decrease serum albumin. However, it does not cause decreased blood urea nitrogen or increased serum albumin. Text Reference - p. 1102
A patient has renal failure. The nurse, reviewing the lab results, recognizes which finding as indicative of the diminished renal function associated with the diagnosis? 1 Hypokalemia 2 Increased serum urea and serum creatinine 3 Anemia and decreased blood urea nitrogen 4 Increased serum albumin and hyperkalemia
Usually fluid replacement should be based on the patient's measured output plus 600 mL/day for insensible losses.
A patient in the oliguric phase of acute renal failure has a 24-hour fluid output of 150 mL emesis and 250 mL urine. The nurse plans a fluid replacement for the following day of ___ mL. c. 1000
A
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 urinary output and an elevated BUN C. an increasing creatinine clearance with a decrease in urinary output D. prostration, somnolence and confusion with coma and imminent death
4 The nurse should report changes to the health care provider in the ECG, such as peaked T waves and widened QRS complexes; dialysis may be required to remove excess potassium. Monitoring for iron overload is a consideration for blood transfusions, but not for administration of sodium polystyrene sulfonate. The nurse should warn the patient that this treatment will often cause diarrhea because the preparation contains sorbitol, a sugar alcohol that has an osmotic laxative action. Magnesium-containing antacids should not be prescribed for patients with chronic kidney disease because magnesium is excreted by the kidneys. Text Reference - p. 1112
A patient is being administered 15 g sodium polystyrene sulfonate (Kayexalate) orally for hyperkalemia. Which intervention should the nurse perform? 1 Observe the patient for iron overload. 2 Inform the patient that constipation is an expected side effect. 3 Provide magnesium-containing antacids. 4 Report peaked T waves in electrocardiogram (ECG)
3 Patients frequently experience diuresis (a large volume of urine output) in the hours and days immediately following a kidney transplant. Hypokalemia, hyponatremia, and signs of infection are unexpected findings that warrant prompt intervention. Text Reference - p. 1127
A patient is recovering in the intensive care unit (ICU) after receiving a kidney transplant approximately 24 hours ago. What is an expected assessment finding for this patient during this early stage of recovery? 1 Hypokalemia 2 Hyponatremia 3 Large urine output 4 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.
A patient is recovering in the intensive care unit (ICU) after receiving a kidney transplant approximately 24 hours ago. What is an expected assessment finding for this patient during this early stage of recovery? A.Hypokalemia B. Hyponatremia C.Large urine output D. Leukocytosis with cloudy urine output
A 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
A patient needing vascular access for hemodialysis asks the nurse what the differences are between an arteriovenous (AV) fistula and a graft. The nurse explains that one advantage of the fistula is that it a. is much less likely to clot. b. increases patient mobility. c. can accommodate larger needles. d. can be used sooner after surgery.
c. A more permanent, soft, flexible Silastic double-lumen catheter is used for long-term access when other forms of vascular access have failed. These catheters are tunneled subcutaneously and have Dacron cuffs that prevent infection from tracking along the catheter.
A patient on hemodialysis develops a thrombus of a subcutaneous arteriovenous (AV) graft, requiring its removal. While waiting for a replacement graft or fistula, the patient is most likely to have what done for treatment? a. Peritoneal dialysis b. Peripheral vascular access using radial artery c. Silastic catheter tunneled subcutaneously to the jugular vein d. Peripherally inserted central catheter (PICC) line inserted into subclavian vein
A patient passing bloody urine is scheduled for a cystoscopy with cystogram. Which description of the procedure by the nurse is accurate? a. "Your doctor will place a catheter into an artery in your groin and inject a dye to visualize the blood supply to the kidneys." b. "Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted through the tube into your kidney." c. "Your doctor will insert a lighted tube in the bladder through your urethra, inspect the bladder, and instill dye that will outline your bladder on x-ray." d. "Your doctor will inject a radioactive solution into a vein in your arm, then the distribution of the isotope in your kidneys and bladder will be visible." ANS: C
A patient passing bloody urine is scheduled for a cystoscopy with cystogram. Which description of the procedure by the nurse is accurate? a. "Your doctor will place a catheter into an artery in your groin and inject a dye to visualize the blood supply to the kidneys." b. "Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted through the tube into your kidney." c. "Your doctor will insert a lighted tube in the bladder through your urethra, inspect the bladder, and instill dye that will outline your bladder on x-ray." d. "Your doctor will inject a radioactive solution into a vein in your arm, then the distribution of the isotope in your kidneys and bladder will be visible." ANS: C
d. Extensive vascular disease is a contraindication for renal transplantation, primarily because adequate blood supply is essential for the health of the new kidney. Other contraindications include disseminated malignancies, refractory or untreated cardiac disease, chronic respiratory failure, chronic infection, or unresolved psychosocial disorders. Coronary artery disease (CAD) may be treated with bypass surgery before transplantation and transplantation can relieve hypertension. Hepatitis B or C infection is not a contraindication.
A patient rapidly progressing toward end-stage kidney disease asks about the possibility of a kidney transplant. In responding to the patient, the nurse knows that what is a contraindication to kidney transplantation? a. Hepatitis C infection b. Coronary artery disease c. Refractory hypertension d. Extensive vascular disease
a. Infection is a significant cause of morbidity and mortality after transplantation because the surgery, the immunosuppressive drugs, and the effects of CKD all suppress the body's normal defense mechanisms, thus increasing the risk of infection. The nurse must assess the patient as well as use aseptic technique to prevent infections. Rejection may occur but for other reasons. Malignancy occurrence increases later due to immunosuppressive therapy. Cardiovascular disease is the leading cause of death after renal transplantation but this would not be expected to cause death within the first month after transplantation.
A patient received a kidney transplant last month. Because of the effects of immunosuppressive drugs and CKD, what complication of transplantation should the nurse be assessing the patient for to decrease the risk of mortality? a. Infection b. Rejection c. Malignancy d. Cardiovascular disease
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.
A patient who has acute glomerulonephritis is hospitalized with acute kidney injury (AKI) and hyperkalemia. Which information will the nurse obtain to evaluate the effectiveness of the prescribed calcium gluconate IV? a. Urine output b. Calcium level c. Cardiac rhythm d. Neurologic status
2, 5 Creatinine, urea, uric acid, and electrolytes such as sodium and potassium are filtered by the semipermeable membrane during hemodialysis. RBCs do not pass through the semipermeable membrane during hemodialysis because of their molecular weight. Glucose does not pass through the semipermeable membrane during hemodialysis due to the osmotic difference of the dialysate. Bacteria do not pass through the semipermeable membrane during hemodialysis due to their high molecular weight. Text Reference - p. 1117
A patient who has been on hemodialysis for several weeks asks the nurse what substances are being removed by the dialysis. What substances should the nurse tell the patient are passing through the membrane during hemodialysis? Select all that apply. 1 Red blood cells (RBCs) 2 Creatinine 3 Glucose 4 Bacteria 5 Sodium
A patient who has elevated blood urea nitrogen (BUN) and serum creatinine levels is scheduled for a renal arteriogram. Which bowel preparation order would the nurse question for this patient? a. Fleet enema c. Senna/docusate (Senokot-S) b. Tap-water enema d. Bisacodyl (Dulcolax) tablets ANS: A
A patient who has elevated blood urea nitrogen (BUN) and serum creatinine levels is scheduled for a renal arteriogram. Which bowel preparation order would the nurse question for this patient? a. Fleet enema c. Senna/docusate (Senokot-S) b. Tap-water enema d. Bisacodyl (Dulcolax) tablets ANS: A
b. During acidosis, potassium moves out of the cell in exchange for H+ ions, increasing the serum potassium level. Correction of the acidosis with sodium bicarbonate will help to shift the potassium back into the cells. A decrease in pH and the bicarbonate and PaCO2 levels would indicate worsening acidosis.
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, PaCO2, 30 mm Hg, PaO2 86 mm Hg, HCO3− 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. pH b. Potassium level c. Bicarbonate level d. Carbon dioxide level
c. Continuous renal replacement therapy (CRRT) is indicated for the patient with AKI as an alternative or adjunct to hemodialysis to slowly remove solutes and fluid in the hemodynamically unstable patient. It is especially useful for treatment of fluid overload, but hemodialysis is indicated for treatment of hyperkalemia, pericarditis, or other serious effects of uremia.
A patient with AKI is a candidate for continuous renal replacement therapy (CRRT). What is the most common indication for use of CRRT? a. Azotemia b. Pericarditis c. Fluid overload d. Hyperkalemia
4 A patient with a glomerular filtration rate (GFR) of 30 mL/min has stage 3 chronic kidney disease (CKD). Normocytic normochromic anemia is common in patients with CKD due to reduced production of the erythropoietin hormone by the kidneys. Erythropoietin stimulates precursor cells in the bone marrow and helps in production of red blood cells. The patient with CKD may have a high serum potassium level, which can cause fatal dysrhythmias. An increase in extracellular fluid volume may lead to hypertension in patients with CKD. Metabolic acidosis may occur in CKD patients with defective reabsorption and regeneration of bicarbonate. Text Reference - p. 1109
A patient with a glomerular filtration rate (GFR) of 30 mL/min has a hemoglobin of 5 g/dL. The peripheral smear tests show that the red blood cells are normocytic and normochromic. The nurse suspects that which physiologic change led to this condition? 1 Reduced excretion of potassium 2 Increased extracellular fluid volume 3 Defective reabsorption of bicarbonate 4 Decreased production of erythropoietin
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.
A patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and an elevated blood urea nitrogen (BUN) and creatinine. Which of these prescribed therapies should the nurse implement first? b. Insert retention catheter.
Blood pressure and fluid balance Although all of the assessments are relevant to the care of a patient receiving hemodialysis, the nature of the procedure indicates a particular need to monitor the patient's blood pressure and fluid balance.
A patient with a history of end-stage kidney disease secondary to diabetes mellitus has presented to the outpatient dialysis unit for his scheduled hemodialysis. Which assessments should the nurse prioritize before, during, and after his treatment? A.Level of consciousness B. Blood pressure and fluid balance C.Temperature, heart rate, and blood pressure D.Assessment for signs and symptoms of infection
2 Although monitoring level of consciousness, temperature, heart rate, and blood pressure and assessing for signs of infection are relevant to the care of a patient receiving hemodialysis, the nature of the procedure indicates a particular need to monitor the patient's blood pressure and fluid balance. Text Reference - p. 1122
A patient with a history of end-stage kidney disease secondary to diabetes mellitus has presented to the outpatient dialysis unit for the scheduled hemodialysis. Which assessments should the nurse prioritize before, during, and after the treatment? 1 Level of consciousness 2 Blood pressure and fluid balance 3 Temperature, heart rate, and blood pressure 4 Assessment for signs and symptoms of infection
ANS: D 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.
A patient with acute kidney injury (AKI) has an arterial blood pH of 7.30. The nurse will assess the patient for a. vasodilation. b. poor skin turgor. c. bounding pulses. d. rapid respirations.
2, 3, 5 ECG readings for this patient are indicative of cardiac changes due to hyperkalemia induced by acute kidney injury. Regular insulin, administered intravenously, helps the potassium to move into the cells. Sodium bicarbonate corrects the acidosis and causes the potassium to shift into the cells. Calcium gluconate raises the threshold for excitation, protecting the heart. The potassium intake should be limited to 40 mEq/day. Diuretics are not effective in hyperkalemia. Text Reference - p. 1105
A patient with acute kidney injury has been admitted to the hospital, and the nurse observes the electrocardiogram (ECG) reading shows tall peaked T waves, ST depression, and QRS widening. What nursing interventions should the nurse perform for this patient?? Select all that apply. 1 Ensure potassium intake of 50 mEq/day. 2 Administer regular insulin intravenously. 3 Administer sodium bicarbonate. 4 Administer diuretics as ordered. 5 Administer calcium gluconate intravenously.
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 patient with chronic kidney disease (CKD) brings all home medications to the clinic to be reviewed by the nurse. Which medication being used by the patient indicates that patient teaching is required? b. Milk of magnesia 30 mL
4 The arteriovenous (AV) graft is an artificial connection between an artery and vein to provide access for hemodialysis. Thrombosis may occur; therefore the need to determine patency is an essential assessment. Palpation of the site should indicate a thrill, which also indicates that the graft is patent. Listening over the AV graft should reveal a bruit sound, indicating patency. A bruit sounds similar to the impulse beat heard when measuring blood pressure. The arm that has the AV graft site should not be put through range-of-motion movements or exercises. Clubbing is not a complication observed in the fingers of a patient with an AV graft. Comparing the left radial pulse with the pulse on the AV graft site is not an accurate patency assessment procedure. Text Reference - p. 1120
A patient with chronic kidney disease has an arteriovenous (AV) graft in the right forearm. What is the nurse's priority in determining the patency of the graft? 1 Determine the range of motion of the right arm and shoulder 2 Observe for clubbing of the fingers on the right hand of the AV graft site 3 Compare radial pulses by checking the right and left pulses simultaneously 4 Check for a bruit by listening over the right arm AV graft site with a stethoscope
2, 5 Uremic pericarditis is one of the cardiac complications of chronic renal failure. Uremia can cause qualitative defects in platelet function, thereby predisposing the patient to hemorrhages. Anemia is caused by decreased production of erythropoietin from the kidneys. Hypertension is caused by sodium retention and increased extracellular fluid volume. Pulmonary edema could be a consequence of both fluid overload and hypertension. Text Reference - p. 1117
A patient with chronic kidney disease has developed uremic syndrome. What complications should the nurse anticipate due to an increase in blood urea levels? Select all that apply. 1 Anemia 2 Pericarditis 3 Hypertension 4 Pulmonary edema 5 Hemorrhagic tendencies
1, 2, 5 PD has many advantages over hemodialysis. The procedure is simple and home-based, with easy equipment setup. The patient can perform peritoneal dialysis. Because the dialysis is done through the peritoneal membrane, PD does not require a special water system or a vascular access device, as in hemodialysis. Text Reference - p. 1120
A patient with chronic kidney disease is advised to undergo peritoneal dialysis (PD). What advantages of PD over hemodialysis should the nurse explain to the patient? Select all that apply. 1 It is a simple procedure. 2 It is home-based. 3 It requires special water systems. 4 It needs a vascular access device. 5 Equipment setup is simple
2, 3, 4, 1 Elevated levels of PTH, produced to compensate for low serum calcium levels, can inhibit erythropoiesis, shorten the survival of RBCs, and cause bone marrow fibrosis, which can result in a decrease in hematopoietic cells. Text Reference - p. 1109
A patient with chronic kidney disease is at risk for anemia. Arrange the events in the order in which they lead to anemia caused by chronic kidney disease. 1. Bone marrow fibrosis 2. Elevated levels of parathyroid hormone (PTH) 3. Inhibition of erythropoiesis 4. Shortened survival of red blood cells (RBCs)
2 The patient undergoing regular peritoneal dialysis (PD) does not need to restrict potassium intake; instead, this patient may be prescribed oral potassium supplementation because of hypokalemia caused by dialysis. The patient need not restrict protein or fluid intake. The patient should include enough protein in the diet to compensate for loss of protein in dialysate. The patient may even take liquid or powdered breakfast drinks in case of inadequate protein intake. Patients on hemodialysis have a more restricted fluid intake than patients receiving peritoneal dialysis (PD). Text Reference - p. 1118
A patient with chronic kidney disease is prescribed regular peritoneal dialysis (PD). What should the nurse inform the patient while teaching about PD? 1 Avoid high-protein diets. 2 Take potassium supplements. 3 Restrict fluid intake, as in hemodialysis. 4 Avoid powdered breakfast drinks
1, 2, 5 Peritonitis may manifest as vomiting due to the inflammatory process in the peritoneum. The patient may have pain in the abdomen due to peritoneal irritation caused by the inflammatory process in the peritoneum. The primary clinical manifestations of peritonitis are abdominal pain and cloudy peritoneal effluent with a white blood cell (WBC) count greater than 100 cells/μL (more than 50% neutrophils). An activated immune response may attract WBCs, and an elevated level of WBC in the peritoneal fluid indicates peritonitis. Bloody stool or weight loss is not associated with peritonitis. Peritonitis may not cause hemorrhage; therefore, bloody stools may not be present. Weight loss is usually caused by malnutrition or fluid loss and therefore may not be seen in peritonitis; weight gain may occur due to fluid retention. Text Reference - p. 1119
A patient with end-stage kidney disease is receiving continuous ambulatory peritoneal dialysis. The patient has a fever and the nurse suspects that it is due to peritonitis. For what are other manifestations that the nurse should monitor the patient? Select all that apply. 1 Vomiting 2 Abdominal pain 3 Bloody stools 4 Weight loss 5 Cloudy peritoneal effluent
1, 2, 3 Preparation of the patient for catheter insertion includes emptying the bladder and bowel, weighing the patient, and obtaining a signed consent form. The bladder should be emptied to prevent accidental puncture of the bladder by the needle. Weighing the patient before and after the procedure is important to determine the effectiveness of dialysis. Because it is an invasive procedure, the nurse should explain about the risks and benefits, and informed consent should be obtained. Other factors are not contraindications for CAPD. Monitoring of cardiac and respiratory signs is essential but does not directly affect the procedure. Text Reference - p. 1118
A patient with end-stage kidney disease is to begin continuous ambulatory peritoneal dialysis (CAPD). What are the preparations to be done by the nurse before starting the catheter insertion for this patient? Select all that apply. 1 Ask patient to empty the bladder and bowel. 2 Note the patient's weight. 3 Obtain a signed consent form. 4 Monitor for abnormal cardiac signs and symptoms. 5 Monitor for abnormal respiratory signs and symptoms
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 also would be monitored in patients with CKD but would not affect whether the captopril was given or not.
A patient with hypertension and stage 2 chronic kidney disease (CKD) is receiving captopril (Capoten). Before administration of the medication, the nurse will check the patient's b. potassium.
ANS: C 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.
A patient with severe heart failure develops elevated blood urea nitrogen (BUN) and creatinine levels. The nurse will plan care to meet the goal of a. replacing fluid volume. b. preventing hypertension. c. maintaining cardiac output d. diluting nephrotoxic substances.
ANS: C The contrast dye used in IVPs is potentially nephrotoxic, and concurrent use of other nephrotoxic medications such as the NSAIDs should be avoided. The suppository and NPO status are necessary to ensure adequate visualization during the IVP. IV fluids are used to ensure adequate hydration, which helps reduce the risk for contrast-induced renal failure.
A patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which of these orders for the patient will the nurse question? a. NPO for 6 hours before IVP procedure b. Normal saline 500 mL IV before procedure c. Ibuprofen (Advil) 400 mg PO PRN for pain d. Dulcolax suppository 4 hours before IVP procedure
3 Nephrogenic systemic fibrosis is caused by the administration of gadolinium to patients with kidney failure; signs include hyperpigmentation of the skin and joint contractures. Asterixis is characterized by a tremor-like condition upon stretching of the wrist. Hydronephrosis is caused by bilateral ureteral obstruction. Contrast-induced nephropathy is a kidney injury caused by the injection of contrast agents during surgery or diagnostic testing. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 1105
A primary health care provider has ordered frequent magnetic resonance imaging using a gadolinium contrast agent in a patient with kidney failure. The patient reports darkness of the skin, joint pain, and limited joint movement. What condition does the nurse suspect? 1 Asterixis 2 Hydronephrosis 3 Nephrogenic systemic fibrosis 4 Contrast-induced nephropathy
4 Acute kidney injury is associated with dry mouth and inflammation and is caused by increased levels of ammonia in the saliva. The nurse should examine the mouth for inflammation and dryness. Therefore, the trainee nurse's statement about examining the mouth for a change in color indicates a need for further teaching. Because of renal impairment, fluid can accumulate in the lungs and result in difficulty breathing. Therefore, the nurse should auscultate the patient's lung sounds. Recording the patient's input and output will help to determine the efficacy of the treatment. Acute kidney injury is also associated with hyperpigmentation; thus the nurse should assess for changes in the patient's skin color. Test-Taking Tip: Acute kidney injury is associated with increased amounts of nitrogenous waste in blood and secretions. Use this tip to answer the above question. Text Reference - p. 1106
A registered nurse is teaching a trainee nurse about the parameters to be assessed in a patient with acute kidney injury who is undergoing dialysis. Which statement by the trainee nurse indicates a need for further teaching? 1 "I should auscultate patient's lung sounds." 2 "I should record the patient's input and output." 3 "I should assess for any change in the patient's skin color." 4 "I should examine the patient's mouth for a change in color."
A young adult who is employed as a hairdresser and has a 15 pack-year history of cigarette smoking is scheduled for an annual physical examination. The nurse will plan to teach the patient about the increased risk for a. renal failure. c. pyelonephritis. b. kidney stones. d. bladder cancer. ANS: D
A young adult who is employed as a hairdresser and has a 15 pack-year history of cigarette smoking is scheduled for an annual physical examination. The nurse will plan to teach the patient about the increased risk for a. renal failure. c. pyelonephritis. b. kidney stones. d. bladder cancer. ANS: D
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 dyslipiemia E. increased high-density lipoprotein levels
A, B, D, E
Which of the following characterize acute kidney injury (select all that apply): A. primary cause of death is infection B. almost always affects older people C. disease course is potentially reversible D. most common cause is diabetic neuropathy E. cardiovascular disease is the most common cause of death
A, C
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. Drink 1500 to 2000 mL of fluids daily. c. Take phosphate-binders with each meal. d. Choose high-protein foods for most meals. e. Have several servings of dairy products daily.
A, C, D
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.
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 notmcontrolled. Dairy products are high in phosphate and usually are limited.
3. Which statement by the nurse regarding continuous ambulatory peritoneal dialysis (CAPD) would be of highest priority when teaching a patient new to this procedure? A. "It is essential that you maintain aseptic technique to prevent peritonitis." B. "You will be allowed a more liberal protein diet once you complete CAPD." C. "It is important for you to maintain a daily written record of blood pressure and weight." D. "You will need to continue regular medical and nursing follow-up visits while performing CAPD."
A. Peritonitis is a potentially fatal complication of peritoneal dialysis, and thus it is imperative to teach the patient methods of preventing this from occurring. Although the other teaching statements are accurate, they do not have the potential for morbidity and mortality as does peritonitis, thus making that statement of highest priority.
11. A 78-year-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? A. Apple, green beans, and a roast beef sandwich B. Granola made with dried fruits, nuts, and seeds C. Watermelon and ice cream with chocolate sauce D. Bran cereal with ½ banana and milk and orange juice
A. 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 patient in the oliguric phase after an acute kidney injury has had a 250 mL urine output and an emesis of 100 mL in the past 24 hours. What is the patient's fluid restriction for the next 24 hours?
ANS: 950 mL The general rule for calculating fluid restrictions is to add all fluid losses for the previous 24 hours, plus 600 mL for insensible losses: (250 + 100 + 600 = 950 mL).
.
ANS: A
d. Cheese sandwich, tomato soup, and cranberry juice
ANS: A
d. Increase in creatinine level
ANS: A
d. Irrigate the fistula site with saline every 8 to 12 hours.
ANS: A
d. Restrict the patient's oral protein intake.
ANS: A
d. The patient is infected with the human immunodeficiency virus.
ANS: A
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
Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the a. bowel sounds. b. blood glucose. c. blood urea nitrogen (BUN). 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 35-year-old client is diagnosed with acute kidney injury (AKI) and is started on hemodialysis. The client is concerned with the diagnosis and wants to know what to expect in the progression of this disorder. Which statement best addresses the client's concern? a) "You will need to have a renal transplant to live a productive, healthy life." b) "Once your condition improves you can be placed on peritoneal dialysis for the rest of your life." c) "The occurrence of acute kidney injury will always eventually result in chronic renal failure." d) "Acute kidney injury is abrupt in onset and often reversible if recognized early and treated appropriately."
"Acute kidney injury is abrupt in onset and often reversible if recognized early and treated appropriately." AKI is the result of a rapid decline in kidney function that increases blood levels of nitrogenous wastes. Once the underlying cause is treated, AKI is potentially reversible if the precipitating factors can be corrected or removed before permanent damage occurs.
A 42 year-old male has been diagnosed with renal failure secondary to diabetes mellitus and is scheduled to begin dialysis soon. Which of the following statements by the client reflects an accurate understanding of the process of hemodialysis? a) "I won't be able to go about my normal routine during treatment." b) "It's stressful knowing that committing to dialysis means I can't qualify for a kidney transplant." c) "Changing my schedule to accommodate 3 or 4 hours of hemodialysis each day will be difficult." d) "I know I'll have to go to a hospital or dialysis center for treatment."
"I won't be able to go about my normal routine during treatment." Hemodialysis requires the client to remain connected to dialysis machinery, whereas peritoneal dialysis allows for activity during treatment. -Dialysis does not disqualify an individual from receiving a transplant. -Dialysis does not require attendance at a dialysis center, patients can be taught to perform the dialysis in their home with a family member in attendance. -Hemodialysis is normally conducted 3 times weekly, not once per day.
A nurse educator is performing client education with a 51 year-old man who has been recently diagnosed with chronic kidney disease. Which of the following statements by the client would the nurse most likely want to correct or clarify? a) "My heart rate might go up because of my kidney disease and my blood might be a lot thinner than it should be." b) "My kidney problems increase my chance of developing high blood pressure or diabetes." c) "I'll be prone to anemia, since I'm not producing as much of the hormone that causes my bones to produce red blood cells." d) "I'll have a risk of either bleeding too easily or possibly clotting too quickly, though dialysis can help minimize these effects."
"My kidney problems increase my chance of developing high blood pressure or diabetes." While high blood pressure can be causative of- or consequent to- renal failure, diabetes is not normally a result of existing CKD. Persons with renal failure are indeed prone to anemia, increased heart rate, decreased blood viscosity, and coagulopathies. The risk of bleeding and thrombotic disorders can be partially mitigated by dialysis
A nurse is collecting a urine specimen prior to measuring the albumin level in a client's urine. A colleague questions the rationale for the test, stating, "I thought albumin was related to liver function, not kidney function." How can the nurse best respond to this statement? a) "A urine test for albumin allows us to estimate the client's GFR quite accurately." b) "Urine should normally be free of any proteins, and albumin is one of the more common proteins to be excreted in chronic renal failure." c) "Urine albumin levels are useful for diagnosing diabetic kidney disease." d) "A urine dipstick test will tell us exactly how much albumin is being spilled by the client's kidneys."
"Urine albumin levels are useful for diagnosing diabetic kidney disease." In clients with diabetes, albumin tests are useful adjunctive test of nephron injury and repair. -Urine is not normally completely free of proteins and a urine dipstick does not allow for the quantification of how much albumin is in a sample. -Albumin tests do not allow for an accurate indirect indication of GFR.
A nurse is collecting a urine specimen prior to measuring the albumin level in a client's urine. A colleague questions the rationale for the test, stating, "I thought albumin was related to liver function, not kidney function." How can the nurse best respond to this statement?
"Urine albumin levels are useful for diagnosing diabetic kidney disease." Explanation: In clients with diabetes, albumin tests are useful adjunctive test of nephron injury and repair. Urine is not normally completely free of proteins and a urine dipstick does not allow for the quantification of how much albumin is in a sample. Albumin tests do not allow for an accurate indirect indication of GFR.
A family physician is providing care for a 61 year-old obese male who has a history of diabetes and hypertension. Blood work has indicated that the man has a GFR of 51 mL/min with elevated serum creatinine levels. Which of the following statements will the physician most likely provide to the client in light of these results? a) "You're in kidney failure and I'll be starting dialysis treatment immediately." b) "Your chronic kidney disease has likely been caused by your diabetes and high blood pressure." c) "You likely have chronic kidney disease and there may be urine in your blood until it is controlled." d) "We will regularly monitor your kidney function, but most likely your kidneys will be able to compensate on their own and intervention is not required."
"Your chronic kidney disease has likely been caused by your diabetes and high blood pressure." Diabetes and hypertension are conditions that can cause chronic kidney disease (CKD). While the kidneys do have a remarkable ability to compensate for impaired function, this fact does not mean that treatment would not be undertaken. -Hematuria is not a common manifestation of CKD and the clients GFR of 51 mL/min does not indicate kidney failure or the need for dialysis.
The nurse knows that a patient with which glomerular filtration rate (GFR) would be classified as "decreased GFR"? a) 120 mL/min b) 70 mL/min c) 100 mL/min d) 40 mL/min
70 mL/min Normal GFR is 120-130 mL/min. Persons with a GFR of 60-89 mL/min who have no discernible renal damage are classified as "decreased GFR." Causes for this condition include removal of one kidney, fluid volume depletion, and advanced age. GFR below 60 mL/min for greater than three months is defined as chronic kidney disease
A patient has prerenal failure. The nurse knows that this type of failure is characterized by which relationship of blood urea nitrogen (BUN) to serum creatinine levels? a) An elevated BUN level and decreased creatinine level b) A BUN to creatinine level ratio of 20:1 c) A BUN to creatinine level ratio of 10:1 d) An elevated creatinine level and decreased BUN level
A BUN to creatinine level ratio of 20:1 In prerenal failure, glomerular filtration rate (GFR) decreases, allowing more filtered urea to be reabsorbed into the circulatory system. Creatinine is filtered but remains in the forming urine. Thus the BUN to creatinine ratio rises to 20:1. A ratio of 10:1 is normal.
The primary care provider for a newly admitted hospital client has added the glomerular filtration rate (GFR) to the blood work scheduled for this morning. The client's GFR results return as 50 mL/minute/1.73 m2. The nurse explains to the client that this result represents: a) Concentrated urine b) A loss of over half the client's normal kidney function c) A need to increase water intake d) The kidneys are functioning normally
A loss of over half the client's normal kidney function In clinical practice, GFR is usually estimated using the serum creatinine concentration. A GFR below 60 mL/minute/1.73 m2 represents a loss of one half or more of the level of normal adult kidney function. -The GFR is not diagnostic for concentrated urine or the need to drink more water
A hospital client with a diagnosis of chronic renal failure has orders for measurement of her serum electrolyte levels three times per week. Which of the following statements best captures the relationship between renal failure and sodium regulation? a) Clients with renal failure often maintain high sodium levels because of decreased excretion. b) Clients with advanced renal failure are prone to hyponatremia because of impaired tubular reabsorption. c) Renal clients often require a sodium-restricted diet to minimize the excretion load on remaining nephrons. d) Restricting sodium intake helps to preserve nephron function and has the additional benefit of lowering blood pressure.
Clients with advanced renal failure are prone to hyponatremia because of impaired tubular reabsorption. The compromised ability of the tubular nephrons to reabsorb sodium predisposes renal clients to low serum sodium levels. A sodium restriction is thus not normally indicated.
A 1-year-old baby boy with renal dysplasia risks end-stage renal disease unless intervention occurs. Which of the following treatment options is his care team most likely to reject? a) Dietary restriction plus erythropoietin b) Renal transplantation c) Continuous cyclic peritoneal dialysis d) Continuous ambulatory peritoneal dialysis
Dietary restriction plus erythropoietin Renal transplantation and dialysis are recommended for children; of these, transplantation is the preferred treatment. Conservative measures are inappropriate in this age group because of the importance of fostering proper bone growth, especially in the first two years, and appropriate cognitive development, which is at risk due to issues such as uremic encephalopathy and the effect of renal failure upon the central nervous system of the developing child.
A nurse is assessing a client for early manifestations of chronic kidney disease (CKD). Which would the nurse expect the client to display? a) Terry nails b) Hypertension c) Asterixis d) Impotence
Hypertension Hypertension is commonly an early manifestation of CKD. The mechanisms that cause the hypertension are multifactorial; they include increased vascular volume, increased peripheral vascular resistance, decreased levels of renal vasodilator prostaglandins, and increase activity of the renin-angiotensin-aldosterone system. -Impotence occurs in as many as 56% of males on dialysis. -Terry nails are dark band just behind the leading edge of a fingernail followed by a white band that occur in the late stages. -Asterixis, a sign of hepatic encephalopathy, is due to the inability of the liver to metabolize ammonia to urea.
Which serum laboratory value indicates to the nurse that the patient's CKD is getting worse? a. Decreased BUN b. Decreased sodium c. Decreased creatinine d. Decreased calculated glomerular filtration rate (GFR)
d. 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.
Which of the following data would a clinician consider as most indicative of acute renal failure? a) Decreased serum creatinine and blood urea nitrogen (BUN); decreased potassium and calcium levels b) Decreased urine output; hematuria; increased GFR c) Alterations in blood pH; peripheral edema d) Increased nitrogenous waste levels; decreased glomerular filtration rate (GFR).
Increased nitrogenous waste levels; decreased glomerular filtration rate (GFR). The hallmark of acute renal injury is azotemia, an accumulation of nitrogenous wastes such as creatinine, urea nitrogen, and uric acid plus a decrease in the GFR of the kidneys. While pH alterations, edema, electrolyte imbalances and decreased urine output may accompany acute renal failure, they are all potentially attributable to other pathologies. Creatinine, GFR and BUN would be unlikely to rise during renal failure.
Vitamin D metabolism is deranged in clients with chronic kidney disease (CKD). The nurse recognizes that which of the following statements regarding vitamin D is correct? a) Calcitriol stimulates release of parathyroid hormone (PTH). b) Calcitriol blocks gastrointestinal absorption of calcium. c) Suppression of parathyroid hormone release is characteristic of CKD. d) Kidneys convert inactive vitamin D to its active form, calcitriol.
Kidneys convert inactive vitamin D to its active form, calcitriol. Inactive vitamin D is converted to active calcitriol in the kidneys. Calcitriol enhances gastrointestinal absorption of calcium, and suppresses release of PTH. Elevated levels of PTH are characteristic of CKD as blood levels of phosphate rise and levels of calcium fall.
A patient has a marked decrease in the glomerular filtration rate (GFR) and has elevations in blood urea nitrogen, potassium, and creatinine levels. The patient's urine output has decreased to 10 mL/hr and has 3+ pitting edema in the lower extremities. In which of the following phases of acute tubular necrosis does the nurse determine the patient is in relating to this assessment data? a) Maintenance phase b) Onset phase c) Initiating phase d) Recovery phase
Maintenance phase The maintenance phase of acute tubular necrosis is characterized by a marked decrease in the GFR causing sudden retention of endogenous metabolites—such as urea, potassium, sulfate, and creatinine—that normally are cleared by the kidneys. Urine output usually is lowest at this point. Fluid retention gives rise to edema, water intoxication, and pulmonary congestion. If the period of oliguria is prolonged, hypertension frequently develops and with it signs of uremia.
The health care provider has prescribed an aminoglycoside (gentamicin) for a client. The nurse is aware that the client is at risk for: a) Ischemic acute tubular necrosis b) Nephrotoxic acute tubular necrosis c) Postrenal failure d) Chronic kidney disease
Nephrotoxic acute tubular necrosis Pharmacologic agents that are directly toxic to the renal tubule include aminoglycosides (e.g., gentamicin), cancer chemotherapeutic agents such as cystplastin and ifosfamide, and radiocontrast agents. Nephrotoxic agents cause tubular injury by inducing varying combinations of renal vasoconstriction, direct tubular damage, or intratubular obstruction. -Postrenal failure results from obstruction of outflow of the kidneys. -CKD and its treatment can interfere with the absorption, distribution, and elimination of drugs. -Acute tubular necrosis (ATN) occurs most frequently in clients who have major trauma, severe hypovolemia, overwhelming sepsis, trauma, or burns.
A 45-year-old client with chronic kidney disease (CKD) voices concern about her dialysis treatment. The client would like to work and spend time with her family. Which type of dialysis will best fit this client's lifestyle? a) Hemodialysis b) Continuous ambulatory peritoneal dialysis c) Nocturnal intermittent peritoneal dialysis (NIPD) d) Continuous cyclic peritoneal dialysis
Nocturnal intermittent peritoneal dialysis (NIPD) In NIPD, the client is given 10 hours of automatic cycling each night, with the abdomen left dry during the day. This is the most beneficial for this client. Individual preference, manual ability, lifestyle, knowledge of the procedure, and physiologic response to treatment are used to determine the type of dialysis that is used. Hemodialysis is generally three times a week for 3 to 4 hours a day. CAPD involves exchanging the dialysate four to six times per day. In CCPD, the last exchange remains in the abdomen during the day
A drug abuser was found unconscious after shooting up heroin 2 days prior. Because of the pressure placed on the hip and arm, the client has developed rhabdomyolysis. The nurse knows this can: a) Be cured by administering an anticoagulant immediately b) Cause the kidney to develop renal stones due to stasis c) Cause compartment syndrome in the lower extremities d) Obstruct the renal tubules with myoglobin and damage tubular cells
Obstruct the renal tubules with myoglobin and damage tubular cells Myoglobin normally is not found in the serum or urine. It has a low molecular weight; if it escapes into the circulation, it is rapidly filtered in the glomerulus. A life-threatening condition known as rhabdomyolysis occurs when increasing myoglobinuria levels cause myoglobin to precipitate in the renal tubules, leading to obstruction and damage to surrounding tubular cells. Myoglobinuria most commonly results from muscle trauma but may result from exertion, hyperthermia, sepsis, prolonged seizures, and alcoholism or drug abuse. -Rhabdomyolysis is not cured with anticoagulation administration nor does it cause kidney stones. -Compartment syndrome occurs when there is insufficient blood supply to muscles and nerves due to increased pressure within one of the body's compartments.
While assessing a peritoneal dialysis client in his or her home, the nurse notes that the fluid draining from the abdomen is cloudy, is white in color, and contains a strong odor. The nurse suspects this client has developed a serious complication known as: a) Bladder erosion b) Bowel perforation c) Peritonitis d) Too much sugar in the dialysis solution
Peritonitis Potential problems with peritoneal dialysis include infection, catheter malfunction, dehydration, hyperglycemia, and hernia. -Bowel perforation can occur, but the fluid would be stool colored. -The client may develop hyperglycemia; however, this will not cause the fluid to be cloudy. -If bladder erosion had occurred, the fluid would look like urine and not be cloudy and white.
The nurse knows that one of the earliest manifestations of acute renal failure (ARF) is which of the following? a) Elevated plasma uric acid b) Polyuria c) Elevated urinary glucose d) Hypokalemia
Polyuria One of the earliest signs of ARF is loss of ability to concentrate urine. The other answer selections are not notable markers of early renal failure; however, they may develop as renal failure progresses.
A patient has an obstructive urine outflow related to benign prostatic hyperplasia. Due to the inability to excrete adequate amounts of urine, which of the following types of renal failure should the nurse closely monitor for? a) Postrenal failure b) Intrarenal failure c) Prerenal failure d) Chronic renal failure
Postrenal failure Postrenal failure results from obstruction of urine outflow from the kidneys. The obstruction can occur in the ureter, bladder, or urethra. Due to the increased urine not being able to be excreted due to the obstruction, retrograde pressure occurs throughout the tubules and nephrons, which ultimately damages the nephrons. Prostatic hyperplasia is the most common underlying problem
A patient in renal failure has marked decrease in renal blood flow caused by hypovolemia, caused by gastrointestinal bleeding. The nurse is aware that this form of renal failure can be reversed if the bleeding is under control. Which of the following forms of acute renal injury does this patient have? a) Postrenal failure b) Chronic renal failure c) Prerenal failure d) Intrarenal failure
Prerenal failure Prerenal failure, the most common form of acute renal failure, is characterized by a marked decrease in renal blood flow. It is reversible if the cause of the decreased renal blood flow can be identified and corrected before kidney damage occurs.
The nurse is reviewing the diagnosis of four male clients. Select the diagnosis that places the clients at risk for developing postrenal kidney failure. a) Severe hypovolemia b) Acute pyelonephritis c) Intratubular obstruction d) Prostatic hyperplasia
Prostatic hyperplasia The most common cause of postrenal kidney failure is prostatic hyperplasia. Postrenal failure results from conditions that obstruct urine outflow. The obstruction can occur in the ureter, bladder, or urethra. -Intratubular obstruction and acute pyelonephritis are intrarenal causes of kidney failure, and severe hypovolemia is a prerenal cause.
The nurse recognizes that acute renal injury is characterized by which of the following? a) Rapid decline in renal function b) Irreversible damage to nephrons c) Decreased blood urea nitrogen (BUN) d) Low incidence of mortality
Rapid decline in renal function Acute renal injury is a rapid decline in kidney function. BUN rises as nitrogenous wastes are not removed from the circulation. If the cause can be ameliorated, the injury is usually reversible. Most at risk are seriously ill clients; the mortality rate is between 40% and 90% in these clients.
A 72-year-old patient is scheduled for a kidney transplant. The nurse knows that which aspect of advanced age has a positive effect on the success of kidney transplant survival? a) Decreased muscle mass b) Psychological maturity c) Reduction in T-lymphocyte function d) Acceptance of immunosuppressive therapy
Reduction in T-lymphocyte function The general reduction in T-lymphocyte function with subsequent decrease in immune system activity that occurs with aging would foster transplant survival. The other options would not have a direct effect on rejection of the transplant. -Acceptance of immunosuppressive therapy is not a specific characteristic of advanced age. -Psychological maturity and decreased muscle mass have little to no effect on transplant survival.
A client diagnosed with chronic kidney disease (CKD) is experiencing nausea and vomiting. Which would be the best instruction for the nurse to provide? a) Restrict intake of dietary fat b) Increase intake of fruit juice c) Increase intake of carbohydrates d) Restrict intake of dietary protein
Restrict intake of dietary protein Early morning nausea is common in CKD. Nausea and vomiting often improve with the restriction of dietary protein and after initiation of dialysis and disappears after kidney transplant. The other options will not improve the symptoms.
An 86-year-old female client has been admitted to the hospital for the treatment of dehydration and hyponatremia after she curtailed her fluid intake to minimize urinary incontinence. The client's admitting laboratory results are suggestive of prerenal failure. The nurse should be assessing this client for which of the following early signs of prerenal injury? a) Intermittent periods of confusion b) Excessive voiding of clear urine c) Acute hypertensive crisis d) Sharp decrease in urine output
Sharp decrease in urine output Dehydration and its consequent hypovolemia can result in acute renal failure that is prerenal in etiology. The kidney normally responds to a decrease in GFR with a decrease in urine output. Thus, an early sign of prerenal injury is a sharp decrease in urine output. Post-renal failure is obstructive in etiology, and intrinsic (or intrarenal) renal failure is reflective of deficits in the function of the kidneys themselves.
A client has experienced severe hemorrhage and is in prerenal failure. The nurse anticipates the laboratory results of the client's BUN and serum creatinine to identify: a) BUN elevates and creatinine decreases. b) Creatinine level rises and BUN decreases. c) The BUN-to-creatinine ratio is 20:1. d) The BUN-to-creatinine ratio is 10:1.
The BUN-to-creatinine ratio is 20:1. Prerenal injury is manifested by a sharp decrease in urine output and a disproportionate elevation of blood urea nitrogen (BUN) in relation to serum creatinine levels. The kidney normally responds to a decrease in the GFR with a decrease in urine output. An early sign of prerenal injury is a sharp decrease in urine output. A low GFR allows more time for small particles such as urea to be reabsorbed into the blood. Creatinine, which is larger and nondiffusible, remains in the tubular fluid, and the total amount of creatinine that is filtered, although small, is excreted in the urine. Consequently, there also is a disproportionate elevation in the ratio of BUN to serum creatinine, from a normal value of 10:1 to a ratio greater than 20:1.
Which drugs will be used to treat the patient with CKD for mineral and bone disorder (select all that apply)? a. Cinacalcet (Sensipar) b. Sevelamer (Renagel) c. IV glucose and insulin d. Calcium acetate (PhosLo) e. IV 10% calcium gluconate
a, b, d. Cinacalcet (Sensipar), a calcimimetic agent to control secondary hyperparathyroidism; sevelamer (Renagel), a noncalcium phosphate binder; and calcium acetate (PhosLo), a calcium-based phosphate binder are used to treat mineral and bone disorder in CKD. IV glucose and insulin and IV 10% calcium gluconate along with sodium polystyrene sulfonate (Kayexalate) are used to treat the hyperkalemia of CKD.
The patient with CKD is receiving dialysis, and the nurse observes excoriations on the patient's skin. What pathophysiologic changes in CKD can contribute to this finding (select all that apply)? a. Dry skin b. Sensory neuropathy c. Vascular calcifications d. Calcium-phosphate skin deposits e. Uremic crystallization from high BUN
a, b, d. Pruritus is common in patients receiving dialysis. It causes scratching from dry skin, sensory neuropathy, and calcium-phosphate deposition in the skin. Vascular calcifications contribute to cardiovascular disease, not to itching skin. Uremic frost rarely occurs without BUN levels greater than 200 mg/dL, which should not occur in a patient on dialysis; urea crystallizes on the skin and also causes pruritis.
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. Check the patient's blood pressure (BP). c. Instruct the patient to avoid high-potassium foods. d. Call the lab and request a redraw of the lab to verify results.
a. Dysrhythmias may occur with 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.
Priority Decision: During the immediate postoperative care of a recipient of a kidney transplant, what should the nurse expect to do? a. Regulate fluid intake hourly based on urine output. b. Monitor urine-tinged drainage on abdominal dressing. c. Medicate the patient frequently for incisional flank pain. d. Remove the urinary catheter to evaluate the ureteral implant.
a. Fluid and electrolyte balance is critical in the transplant recipient patient, especially because diuresis often begins soon after surgery. Fluid replacement is adjusted hourly based on kidney function and urine output. Urine-tinged drainage on the abdominal dressing may indicate leakage from the ureter implanted into the bladder and the health care provider should be notified. The donor patient may have a flank or laparoscopic incision(s) where the kidney was removed. The recipient has an abdominal incision where the kidney was placed in the iliac fossa. The urinary catheter is usually used for 2 to 3 days to monitor urine output and kidney function.
A patient received a kidney transplant last month. Because of the effects of immunosuppressive drugs and CKD, what complication of transplantation should the nurse be assessing the patient for to decrease the risk of mortality? a. Infection b. Rejection c. Malignancy d. Cardiovascular disease
a. Infection is a significant cause of morbidity and mortality after transplantation because the surgery, the immunosuppressive drugs, and the effects of CKD all suppress the body's normal defense mechanisms, thus increasing the risk of infection. The nurse must assess the patient as well as use aseptic technique to prevent infections. Rejection may occur but for other reasons. Malignancy occurrence increases later due to immunosuppressive therapy. Cardiovascular disease is the leading cause of death after renal transplantation but this would not be expected to cause death within the first month after transplantation.
A man with end-stage kidney disease is scheduled for hemodialysis following healing of an arteriovenous fistula (AVF). What should the nurse explain to him that will occur during dialysis? a. He will be able to visit, read, sleep, or watch TV while reclining in a chair. b. He will be placed on a cardiac monitor to detect any adverse effects that might occur. c. The dialyzer will remove and hold part of his blood for 20 to 30 minutes to remove the waste products. d. A large catheter with two lumens will be inserted into the fistula to send blood to and return it from the dialyzer.
a. While patients are undergoing hemodialysis, they can perform quiet activities that do not require the limb that has the vascular access. Blood pressure is monitored frequently and the dialyzer monitors dialysis function but cardiac monitoring is not usually indicated. The hemodialysis machine continuously circulates both the blood and the dialysate past the semipermeable membrane in the machine. Graft and fistula access involve the insertion of two needles into the site: one to remove blood from and the other to return blood to the dialyzer.
The nurse recognizes that renal failure has many underlying causes, including which of the following? Select all that apply a) Renal disease b) Malnutrition c) Systemic disease d) Hepatic disease e) Nonrenal urological abnormalities
• Systemic disease • Renal disease • Nonrenal urological abnormalities Underlying causes of renal failure include renal or systemic disease and nonrenal urologic abnormalities. -Hepatic disease and malnutrition might gradually influence renal function as they can influence many body functions, but are not considered direct causes of renal failure.
The patient with CKD asks why she is receiving nifedipine (Procardia) and furosemide (Lasix). The nurse understands that these drugs are being used to treat the patient's a. anemia. b. hypertension. c. hyperkalemia. d. mineral and bone disorder.
b. Nifedipine (Procardia) is a calcium channel blocker and furosemide (Lasix) is a loop diuretic. Both are used to treat hypertension.
To prevent the most common serious complication of PD, what is important for the nurse to do? a. Infuse the dialysate slowly. b. Use strict aseptic technique in the dialysis procedures. c. Have the patient empty the bowel before the inflow phase. d. Reposition the patient frequently and promote deep breathing.
b. 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 does the dialysate for PD routinely contain? a. Calcium in a lower concentration than in the blood b. Sodium in a higher concentration than in the blood c. Dextrose in a higher concentration than in the blood d. Electrolytes in an equal concentration to that of the blood
c. 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.
What causes the gastrointestinal (GI) manifestation of stomatitis in the patient with CKD? a. High serum sodium levels b. Irritation of the GI tract from creatinine c. Increased ammonia from bacterial breakdown of urea d. Iron salts, calcium-containing phosphate binders, and limited fluid intake
c. Uremic fetor, or the urine odor of the breath, is caused by high urea content in the blood. Increased ammonia from bacterial breakdown of urea leads to stomatitis and mucosal ulcerations. Irritation of the gastrointestinal (GI) tract from urea in CKD contributes to anorexia, nausea, and vomiting. Ingestion of iron salts and calcium-containing phosphate binders, limited fluid intake, and limited activity cause constipation.
Priority Decision: What is the most appropriate snack for the nurse to offer a patient with stage 4 CKD? a. Raisins b. Ice cream c. Dill pickles d. Hard candy
d. 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. Lewis, Sharon L.; Dirksen, Shannon Ruff; Bucher, Linda (2014-03-14). Study Guide for Medical-Surgical Nursing: Assessment and Management of Clinical Problems (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 413). Elsevier Health Sciences. Kindle Edition.
A client with chronic kidney disease has developed cardiac calcification. On admission the priority assessment would be for the nurse to: a) place on a heart monitor to watch for arrhythmias. b) assess for pulses in the feet bilaterally. c) listen to the heart for extra clicking sounds. d) check the BP in both arms and compare.
place on a heart monitor to watch for arrhythmias. Visceral calcification may be found in the myocardium, lungs, and stomach. In cardiac calcification, the deposits usually develop in the conduction system and may result in serious cardiac arrhythmias. -The other assessments are valid, however watching for arrhythmias is the priority.
A patient with a recent diagnosis of renal failure that will require hemodialysis is being educated by the nurse in the dietary management of the disease. Which of the patient's following statements shows an accurate understanding of this component of treatment? Select all that apply. a) "I'm going to try a high-protein, low-carbohydrate diet." b) "I've made a list of high-phosphate foods so that I can try to avoid them." c) "I don't think I've been drinking enough, so I want to include 8 to 10 glasses of water each day." d) "I'll increase the carbohydrates in my diet to provide sufficient energy." e) "I'm making a point of trying to eat lots of bananas and other food rich in potassium."
• "I'll increase the carbohydrates in my diet to provide sufficient energy." • "I've made a list of high-phosphate foods so that I can try to avoid them." Persons with chronic kidney disease (CKD) are usually encouraged to limit their dietary phosphorus as a means of preventing secondary hyperparathyroidism, renal osteodystrophy, and hypocalcemia. Excessive protein, potassium, and fluids can be detrimental in individuals whose kidney disease requires hemodialysis. Because protein intake is limited, carbohydrate consumption should increase to meet daily energy requirements.
Which of the following patients scheduled for an interventional radiology procedure requiring administration of radiocontrast dye would be considered high risk for nephrotoxicity? Select all that apply. a) 25 year old with a history of glomerular nephritis who is complaining of severe flank pain. b) 14 year old with severe abdominal pain. c) 67 year old diabetic undergoing diagnostic testing for new-onset proteinuria. d) 45 year old with elevated liver enzymes possibly due to fatty liver cirrhosis. e) 53 year old male undergoing biopsy for a suspicious "spot" on their chest x-ray.
• 25 year old with a history of glomerular nephritis who is complaining of severe flank pain. • 67 year old diabetic undergoing diagnostic testing for new-onset proteinuria. Radiocontrast media-induced nephrotoxicity is thought to result from direct tubular toxicity and renal ischemia. The risk for renal damage caused by radiocontrast media is greatest in older adults and those with pre-existing kidney disease, volume depletion, diabetes mellitus, and recent exposure to other nephrotoxic agents
The nurse knows that a patient with chronic kidney disease (CKD) may develop renal osteodystrophy (skeletal damage). Which of the following are characteristic of both high-bone-turnover and low-bone-turnover osteodystrophy? Select all that apply. a) Decreased osteoblast and osteoclast proliferation b) Bone marrow fibrosis c) Defective bone remodeling d) Abnormal bone resorption e) Increased osteoblast and osteoclast proliferation
• Abnormal bone resorption • Defective bone remodeling Abnormal bone resorption and defective bone remodeling are characteristic of both high-bone-turnover and low-bone-turnover osteodystrophy. In high-turnover, there is increased osteoblast and osteoclast proliferation while in low-turnover there is decreased proliferation. Bone marrow fibrosis is characteristic of high-bone turnover.
A patient has developed chronic kidney disease (CKD). The nurse will advise the patient to be alert for the development of which hematologic signs and symptoms of this disorder? Select all that apply. a) Fatigue b) Bradycardia c) Gastrointestinal bleeding d) Bruising e) Intravascular clotting
• Bruising • Gastrointestinal bleeding • Fatigue Explanation: In CKD, platelet function is impaired and bruising and gastrointestinal bleeding can occur. Intravascular clotting usually does not happen. Decreased renal production of erythropoietin results in decreased synthesis of red blood cells, resulting in anemia and fatigue. Decrease in red cells also decreases blood viscosity and decreases cerebral oxygen delivery, both of which contribute to tachycardia rather than bradycardia.
If a CKD client is developing uremic encephalopathy, the earliest manifestations may include: Select all that apply. a) Delirium and hallucinations b) New-onset seizures c) Diminished awareness d) Decreased alertness
• Decreased alertness • Diminished awareness Reductions in alertness and awareness are the earliest and most significant indications of uremic encephalopathy. - Late in the disease process, the client may develop delirium, coma, and seizures.
Anemia frequently occurs in clients with chronic kidney disease (CKD). The nurse will monitor these clients for which of the following contributors to anemia? Select all that apply. a) Decreased erythropoietin production b) Chronic blood loss c) Iron overload d) Anorexia e) Bone marrow suppression
• Decreased erythropoietin production • Anorexia • Bone marrow suppression • Chronic blood loss Production of erythropoietin, which stimulates red cell synthesis, becomes deficient as the kidneys fail. Iron deficiency can develop as anorexia decreases ingestion of foods containing this mineral. Bone marrow production of red cells is suppressed as uremia develops. Clients on dialysis will experience chronic blood loss
A child is diagnosed with chronic kidney disease (CKD). The nurse knows that which of the following statements regarding supportive renal therapy in children are true? Select all that apply.
• Early transplantation is the preferred treatment when considering long-term effects. • Children older than 12 years will benefit from hemodialysis. • Peritoneal dialysis is generally most appropriate for children younger than 6. Children between birth and 5 years of age often are managed with peritoneal dialysis. -For those older than 12 years of age hemodialysis is usually preferred. -Early transplantation in young children is the best choice to promote physical growth, improve cognitive function, and foster psychosocial development. -Immunosuppressive therapy in children is similar to that required in adults. -Corticosteroids such as prednisone have risk for growth retardation.
The nurse knows that uremia or "urine in the blood" is often used to describe the clinical manifestations of chronic kidney disease (CKD). Which of the following are early signs and symptoms of uremia? Select all that apply. a) Elevated blood glucose b) Nausea c) Apathy d) Fatigue e) Weakness
• Fatigue • Nausea • Apathy • Weakness As nitrogenous wastes accumulate in the circulatory system, symptoms of fatigue, nausea, apathy, and weakness will appear. CKD does not immediately affect blood glucose.
Which of the following have the potential to cause chronic kidney disease? (Select all that apply.)
• Hypertension • Diabetes • Glomerulonephritis CKD can result from a number of conditions including diabetes, hypertension, glomerulonephritis as well as systemic lupus erythematosus, and polycystic kidney disease. These conditions slowly but steadily destroy renal tissue resulting in irreversible loss of function. Cardiomyopathies do not cause renal failure; they cause heart failure.
Chronic kidney disease (CKD) can cause derangement of calcium and phosphate metabolism. The nurse will monitor a client with CKD for which of the following? Select all that apply. a) Decreased blood levels of phosphate b) Decreased blood levels of calcium c) Excess calcium deposits in bone d) Decreased release of parathyroid hormone (PTH) e) Impaired phosphate excretion
• Impaired phosphate excretion • Decreased blood levels of calcium In CKD, renal ability to excrete phosphate declines. As blood levels of phosphate increase, levels of calcium inversely related to phosphate, fall. This provokes an increase in PTH, which stimulates mobilization of calcium from bone.
A client is diagnosed with acute renal injury. The nurse will evaluate the client for which of the following possible causes for this disorder? Select all that apply. a) Hormonal imbalance b) Ischemic injury c) Obstruction of urinary outflow d) Nephrotoxic substances e) Nonischemic reduced renal blood flow
• Ischemic injury • Nonischemic reduced renal blood flow • Obstruction of urinary outflow • Nephrotoxic substances Acute renal injury can result from ischemia, reduced renal blood without ischemia, nephrotoxic substances including some drugs, and obstruction of urinary outflow. Hormonal imbalance usually does not cause renal injury.
A client is diagnosed with renal failure. The nurse must monitor for failure of which of the following functions? Select all that apply. a) Electrolyte balance b) Removal of metabolic waste from blood c) Adrenal secretion d) Acid-base balance e) Maintenance of body water
• Maintenance of body water • Electrolyte balance • Acid-base balance • Removal of metabolic waste from blood Functions of the kidney include removal of metabolic end products and regulation of body water, electrolyte balance and acid-base balance. -Although the adrenal glands are located above the kidneys, the kidneys are not directly involved in their regulation.
A chronic kidney disease client who has renal osteodystrophy should be assessed for which of the following complications? Select all that apply. a) Stress fractures b) Bone pain c) Muscle weakness d) Urosepsis e) Kidney stones
• Muscle weakness • Bone pain • Stress fractures Both types of renal osteodystrophy are manifested by abnormal absorption and defective bone remodeling. Renal osteodystrophy is typically accompanied by reductions in bone mass, alterations in bone microstructure, bone pain, and skeletal fracture. There are changes in bone turnover, mineralization, and bone volume, accompanied by bone pain and muscle weakness, risk of fractures, and other skeletal complications. -Kidney stones and urosepsis are not associated with renal osteodystrophy.
A client is diagnosed with chronic kidney disease (CKD). The nurse recognizes that which of the following statements regarding CKD are correct? Select all that apply. a) Functioning nephrons compensate for those that are damaged. b) The rate of nephron destruction is the same in all clients. c) Signs and symptoms develop gradually. d) There is a reduction in glomerular filtration rate (GFR) as nephrons are destroyed. e) Nephron destruction takes place over many months.
• Nephron destruction takes place over many months. • Signs and symptoms develop gradually. • Functioning nephrons compensate for those that are damaged. • There is a reduction in glomerular filtration rate (GFR) as nephrons are destroyed. In CKD, the rate of nephron destruction occurs over many months and is different among clients. Signs and symptoms develop gradually as nephrons are destroyed and functioning nephrons gradually lose the ability to compensate for this. As nephrons are destroyed, GFR declines. (
As nitrogenous wastes increase in the blood, the CKD client may exhibit which of the following clinical manifestations? Select all that apply. a) Pruritis b) Extremely low platelet counts c) Photophobia d) Numbness in lower extremities e) Restless leg syndrome
• Numbness in lower extremities • Restless leg syndrome • Pruritis The uremic state is characterized by signs and symptoms of altered neuromuscular function (e.g., fatigue, peripheral neuropathy, restless leg syndrome, sleep disturbances, uremic encephalopathy); gastrointestinal disturbances such as anorexia and nausea; white blood cell and immune dysfunction, and dermatologic manifestations such as pruritus. Photophobia and thrombocytopenia are usually not associated with CKD.
The nurse knows that a patient with chronic kidney disease (CKD) may experience which of the following changes in skin integrity? Select all that apply. a) Pale skin b) Decreased perspiration c) Brittle fingernails d) Moist skin and mucous membranes e) Increased oil gland secretion
• Pale skin • Brittle fingernails • Decreased perspiration In CKD, anemia due to loss of erythropoietin activity causes pale skin. Perspiration and oil secretion are decreased, leading to dry skin. Fingernails become brittle.
Which of the following patients does the nurse need to monitor for the development of intense intrarenal vasoconstriction that may induce prerenal failure? Select all that apply. a) Patient taking cyclosporine to prevent rejection for a liver transplant b) Patient who is HIV positive c) Patient undergoing cardiac catheterization d) Patient with an elevated blood urea nitrogen who is taking ibuprofen every 6 hours for back pain e) Patient taking acetaminophen for fever
• Patient undergoing cardiac catheterization • Patient taking cyclosporine to prevent rejection for a liver transplant • Patient with an elevated blood urea nitrogen who is taking ibuprofen every 6 hours for back pain Some vasoactive mediators, drugs, and diagnostic agents stimulate intense intrarenal vasoconstriction and can induce glomerular hypoperfusion and prerenal failure. Examples include endotoxins, radiocontrast agents such as those used for cardiac catheterization, cyclosporine, and nonsteroidal anti-inflammatory drugs. -NSAIDs can reduce renal blood flow by inhibiting prostaglandin syntheses. In some persons with diminished renal perfusion, NSAIDs can precipitate prerenal failure. -Acetaminophen for short-term use does not predispose a patient to prerenal failure. -An HIV+ client is at no more risk than any other patient.
A client is diagnosed with chronic kidney disease (CKD). The nurse will monitor this client for which of the following Select all that apply. a) Hyponatremia b) Hypocalcemia c) Polyuria d) Hyperkalemia e) Metabolic alkalosis
• Polyuria • Hyperkalemia • Hypocalcemia • Hyponatremia The failing kidneys lose ability to concentrate urine and to reabsorb sodium. Hyperkalemia develops late in CKD, as nephrons can no longer regulate potassium excretion. Metabolic acidosis occurs when balance between sodium and bicarbonate is lost. Hypocalcemia develops as excretion of phosphate fails and blood levels of phosphate rise.
A patient has developed acute tubular necrosis (ATN). The nurse knows that which of the following groups of drugs can cause this type of renal injury? Select all that apply. a) Chemotherapy drugs b) Radiocontrast dyes c) Aminoglycoside anti-infectives d) Nonsteroidal antiinflammatory drugs (NSAID) e) Angiotensin converting enzyme inhibitors (ACEI)
• Radiocontrast dyes • Chemotherapy drugs • Aminoglycoside anti-infectives Aminoglycosides, radiocontrast agents and chemotherapy drugs such as cisplatin (Platinol) all are directly toxic to the nephron and ATN will occur. -NSAIDs inhibit the synthesis of prostaglandins needed to maintain renal blood flow, thus renal perfusion declines and prerenal failure can develop. -ACEI are generally not nephrotoxic and are often used to manage hypertension in persons with renal disease.
A client is diagnosed with chronic kidney disease (CKD). The nurse knows that which of the following statements regarding CKD are correct? Select all that apply a) Onset is abrupt. b) Symptoms appear with 50% of nephrons lost. c) Renal damage is irreversible. d) Hypertension is a major cause. e) Less than 1% of population is affected.
• Renal damage is irreversible. • Hypertension is a major cause. CKD usually develops slowly, often over many years. Irreversible damage occurs, as symptoms do not appear until 80% of the nephrons cease to function. Approximately 10% of the United States population has CKD. Hypertension and diabetes are major causes of CKD.
A nurse is assessing a client diagnosed with CKD for neuromuscular manifestation. Select the manifestations the nurse may expect to find. Select all that apply. a) Loss of recent memory b) Restless leg syndrome c) Perceptual errors d) Increased muscle strength e) Increased alertness f) Peripheral neuropathy
• Restless leg syndrome • Loss of recent memory • Peripheral neuropathy • Perceptual errors • Increased muscle strength Many persons with CKD have alterations in peripheral and central nervous system function. Restless leg syndrome is a manifestation of peripheral nerve involvement, and muscle weakness and atrophy are a manifestation of uremia. Reductions in alertness and awareness are the earliest and most significant indications of uremic encephalopathy. These often are followed by an inability to fix attention, loss of recent memory, and perceptual errors in identifying persons and objects.
Acute tubular necrosis (ATN) is the most common cause of intrinsic renal failure. One of the causes of ATN is ischemia. What are the most common causes of ischemic ATN? (Select all that apply.)
• Severe hypovolemia • Burns • Overwhelming sepsis Ischemic ATN occurs most frequently in persons who have major surgery, severe hypovolemia, overwhelming sepsis, trauma, and burns. Hypervolemia and hypertension are not considered contributing factors to ischemic ATN.
The nurse will monitor clients with which of the following disorders for development of chronic kidney disease (CKD)? Select all that apply. a) Diabetes b) Polycycstic kidney disease c) Systemic lupus erythematosus d) Hyperlipidemia e) Glomerulonephritis
• Systemic lupus erythematosus • Polycycstic kidney disease • Glomerulonephritis • Diabetes Permanent renal damage can result from systemic lupus erythematosus, polycycstic kidney disease, glomerulonephritis, or diabetes. Hypertension also is a frequent cause for CKD. Hyperlipidemia does not cause CKD but may develop in clients with CKD.
