Acute kidney injury 2

Prevention of AKI is important because of the high mortality rate. Which patients are at an increased risk for AKI (select all that apply)? a. An 86-year-old woman scheduled for cardiac catheterization b. A 48-year-old man with multiple injuries from a motor vehicle incident 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

(all of the above) a. An 86-year-old woman scheduled for cardiac catheterization b. A 48-year-old man with multiple injuries from a motor vehicle incident 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 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).

Nursing Implementation of AKI

* Prevention and early recognition most important ACUTE CARE -Accurate I&O -Daily weights -signs for hypervolemia (oliguria), hypovolemia(dieresis) -Assess for potassium/ sodium disturbances -meticulous aseptic technique to prevent infections -skin care to prevent pressure injuries -Mouth care to prevent stomatitis which develops when ammonia breakdown of urea in saliva irritates the mucus membranes -avoid or use of nephrotoxic drugs carefully AMBULATORY CARE Regulate protein and potassium Follow up care Teaching(s/s and preventative measures) Appropriate referrals

oliguric phase wrap uo

* sudden decrease in urine output < 400 ml/day *signs of excess fluid volume (hypervolemia): Htn, edema pleural and pericardial effusions, dysrhthmias, Hf and pulmonary edema *signs of uremia: Anorexia, n/v and pruritus * signs of metabolic acidosis (kussmaul respiration's) *signs of pericarditis: friction rub, chest pain with inspiration, and low grade fever -Elevated BUN and serum creatinine -Decreased specific gravity with pretense causes or normal with intrarenal causes - decreased GFR and creatinine clearance - normal to decreased serum sodium -Hyperkalemia -hypervolemia -hyperphospatemia yields hypocalcium

Diuretic phase wrap up

*Urine output rises to 1-3 L/day rising up to 5L *excessive urine output indicates that damaged nephrons are recovering their ability to excrete wastes * Dehydration, hypovolemia, hypotension and tachycardia can occur *loc improves - Gradual decline in BUN and serum creatinine levels but still elevated -continued low creatinine with improving GFR -Hypokalemia -Hyponatremia -Hypovolemia

Recovery phase wrap up

*slow process can take 1-2 years *Increased GFR * stabilization or continual decline in BUN and serum creatinine levels toward normal

Urine sediment

May show intrarenal problems

A client in the intensive care unit develops prerenal failure following surgery. Which of the following causes should the nurse suspect? A. Vascular disease B. Urethral obstruction C. Hypovolemia D. Glomerulonephritis

. Prerenal failure is caused by factors such as hypovolemia and decreased cardiac output that reduce renal bloodflow and perfusion, vascular disease may be a factor in the development of intrarenal failure. Urethral obstruction can cause post renal failure. Glomerulonephritis may be a factor in the development of

The client receiving dialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first? 1. Place the client in the Trendelenburg position. 2. Turn off the dialysis machine immediately. 3. Bolus the client with 500 mL of normal saline. 4. Notify the health care provider as soon as possible.

. Place the client in the Trendelenburg position. Rationale: The nurse should place the client's chair with the head lower than the body, which will shunt blood to the brain; this is the Trendelenburg position.

Serum Creatinine

0.6-1.2 mg/dL

urinalysis (UA)

urine screening test that includes physical observation, chemical tests, and microscopic evaluation of pee

The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should nurse implement first to prevent ARF? 1. Administer normal saline IV. 2. Take vital signs. 3. Place client on telemetry. 4. Assess abdominal dressing.

1. Administer normal saline IV. 1. Preventing and treating shock with blood and fluid replacement will prevent acute renal failure from hypoperfusion of the kidneys. Significant blood loss is expected in the client with a gunshot wound. 2. Taking and evaluating the client's VS is an appropriate action, but regardless of the results, this will not prevent ARF. 3. Placing the client on telemetry is an appropriate action, but telemetry is an assessment tool for the nurse and will not prevent ARF. 4. Assessment is often the first action, but assessing the abdominal dressing will not help prevent ARF.

The nurse is caring for a client diagnosed with ARF. Which laboratory values are most significant for diagnosing ARF? 1. BUN and creatinine. 2. WBC and hemoglobin. 3. Potassium and sodium. 4. Bilirubin and ammonia level.

1. BUN and creatinine. 1. Blood urea nitrogen (BUN) levels reflect the balance between the production and excretion of urea from the kidneys. Creatinine is a by-product of the metabolism of the muscles and is excreted by the kidneys. Creatinine is the ideal substance for determining renal clearance because it is relatively constant in the body and is the laboratory value most significant in diagnosing renal failure. 2. WBCs are monitored for infection, and hemoglobin is monitored for blood loss. 3. Potassium (intracellular) and sodium (interstitial) are electrolytes and are monitored for a variety of diseases or conditions not specific to renal function. Potassium levels will increase with renal failure, but the level is not a diagnostic indicator for renal failure. 4. Bilirubin and ammonia levels are laboratory values determining the function of the liver, not the kidneys.

The nurse and unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task is most appropriate for the nurse to delegate? 1. Collect a clean voided midstream urine specimen. 2. Evaluate the client's 8-hour intake and output. 3. Assist in checking a unit of blood prior to hanging. 4. Administer a cation-exchange resin enema.

1. Collect a clean voided midstream urine specimen. 1. The UAP can collect specimens. Collecting a midstream urine specimen requires the client to clean the perineal area, to urinate a little, and then collect the rest of the urine output in a sterile container. 2. The UAP can obtain the client's intake and output, but the nurse must evaluate the data to determine if interventions are needed or if interventions are effective. 3. 2 registered nurses must check the unit of blood at the bedside prior to administering it. 4. This is a medication enema and UAPs cannot administer medications. Also, for this to be ordered, the client must be unstable with an excessivey high serum potassium level.

The client is diagnosed with ARF. Which signs/symptoms indicate to the nurse the client is in the recovery period? Select all that apply. 1. Increased alertness and no seizure activity. 2. Increase in hemoglobin and hematocrit. 3. Denial of nausea and vomiting. 4. Decreased urine-specific gravity. 5. Increased serum creatinine level.

1. Increased alertness and no seizure activity. 2. Increase in hemoglobin and hematocrit. 3. Denial of nausea and vomiting. 1. Renal failure affects almost every system in the body. Neurologically, the client may have drowsiness, headache, muscle twitching, and seizures. In the recovery period, the client is alert and has no seizure activity. 2. In renal failure, levels of erythropoietin are decreased, leading to anemia. An increase in hemoglobin and hematocrit indicates the client is in the recovery period. 3. Nausea, vomiting, and diarrhea are common in the client with ARF; therefore, an absence of these indicates the client is in the recovery period. 4. The client in the recovery period has an increased urine-specific gravity. 5. The client in the recovery period has a decreased serum creatinine level.

The client diagnosed with CKD has a new arteriovenous fistula in the left forearm. Which intervention should the nurse implement? 1. Teach the client to carry heavy objects with the right arm. 2. Perform all laboratory blood tests on the left arm. 3. Instruct the client to lie on the left arm during the night. 4. Discuss the importance of not performing any hand exercises.

1. Teach the client to carry heavy objects with the right arm. Rationale: Carry heavy objects in the left arm could cause the fistula to clot by putting undue stress on the site, so the client should carry objects with the right arm.

Specific gravity of urine

1.010-1.030

How long does the oliguric phase last?

10-14 days

BUN

10-20

BUN

10-20 mg/dL

The nurse is discussing kidney transplants with clients at a dialysis center. Which population is less likely to participate in organ donation? 1. Caucasian. 2. African American. 3. Asian. 4. Hispanic.

2. African American Rationale: Many in the African American culture believe the body must be kept intact after death, and organ donation is rare among African Americans. This is also why a client of African American descent will be on a transplant waiting list longer than people of other races. This is because of tissue-typing compatibility. Remember, this does not apply to all African-Americans; every client is an individual

The client diagnosed with ARF is placed on bedrest. The client asks the nurse, "Why do I have to stay in bed? I don't feel bad." Which scientific rationale supports the nurse's response? 1. Bedrest helps increase the blood return to the renal circulation. 2. Bedrest reduces the metabolic rate during the acute stage. 3. Bedrest decreases the workload of the left side of the heart. 4. Bedrest aids in reduction or peripheral and sacral edema.

2. Bedrest reduces the metabolic rate during the acute stage. 1. Kidney function is improved about 40% when recumbent, but this is not the scientific rationale for bedrest in ARF. 2. Bedrest reduces exertion and the metabolic rate, thereby reducing catabolism and subsequent release of potassium and accumulation of endogenous waste products (urea and creatinine). 3. This is a scientific rationale for prescribing bedrest in clients with heart failure. 4. This is not the scientific rationale for prescribing bedrest. The foot of the bed may be elevated to help decrease peripheral edema, and bedrest causes an increase in sacra edema

The nurse is caring for a client diagnosed with rule-out ARF. Which condition predisposes the client to developing prerenal failure? 1. Diabetes mellitus. 2. Hypotension. 3. Aminoglycosides. 4. Benign prostatic hypertrophy

2. Hypotension. 1.DM is a disease that may lead to chronic renal failure. 2. Hypotension, which causes a decreased blood supply to the kidney, is one of the most common causes of prerenal failure (before the kidney). 3. Nephrotoxic medications are a cause of intrarenal failure (directly to kidney). 4. Benign prostatic hypertrophy (BPH) is a cause of post renal failure (after the kidney).

The UAP tells the nurse the client with ARF has a white crystal-like layer on top of the skin. Which intervention should the nurse implement? 1. Have the assistant apply a moisture barrier cream to the skin. 2. Instruct the UAP to bathe the client in cool water. 3. Tell the UAP not to turn the client in this condition. 4. Explain this is normal and do not do anything for the client.

2. Instruct the UAP to bathe the client in cool water. 1. Moisture barrier cream will keep the crystals on the skin. 2. These crystals are uremic frost resulting from irritating toxins deposited in the client's tissues. Bathing in cool water will remove the crystals, promote client comfort, and decrease the itching resulting from uremic frost. 3. The client should be turned every 2 hours or more frequently to prevent skin breakdown. 4. This may occur with ARF, and it does require a nursing intervention.

The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first? 1. The client who has a hemoglobin of 9.8 g/dL and hematocrit of 30%. 2. The client who does not have a palpable thrill or auscultated bruit. 3. The client who is complaining of being exhausted and is sleeping. 4. The client who did not take antihypertensive medication this morning.

2. The client who does not have a palpable thrill or auscultated bruit. Rationale: This client's dialysis access is compromised and he or she should be assessed first.

The male client diagnosed with CKD secondary to diabetes has been receiving dialysis for 12 years. The client is notified he will not be placed on the kidney transplant list. The client tells the nurse he will not be back for any more dialysis treatments. Which response by the nurse is most therapeutic? 1. "You cannot just quit your dialysis. This is not an option." 2. "You're angry at not being on the list, and you want to quit dialysis?" 3. "I will call your nephrologist right now so you can talk to the HCP." 4. "Make your funeral arrangements because you are going to die."

2. Your angry at not being on the list, and you want to quit dialysis? Rationale: Reflecting the client's feelings and restating them are therapeutic responses the nurse should use when addressing the client's issues.

HCO3 normal range

22-26 mEq/L

The client diagnosed with ARF is admitted to the intensive care unit and placed on a therapeutic diet. Which diet is most appropriate for the client? 1. A high-potassium and low-calcium diet. 2. A low-fat and low-cholesterol diet. 3. A high-carbohydrate and restricted-protein diet. 4. A regular diet with six (6) small feedings a day.

3. A high-carbohydrate and restricted-protein diet. 1. The diet is low potassium, and calcium is not restricted in ARF. 2. This is a diet recommended for clients with cardiac disease and atherosclerosis. 3. Carbohydrates are increased to provide for the client's caloric intake and protein is restricted to minimize protein breakdown and to prevent accumulation of toxic waste products. 4. This client must be on a therapeutic diet, and small feedings are not required.

The nurse is developing a plan of care for a client diagnosed with ARF. Which statement is appropriate outcome for the client? 1. Monitor intake and output every shift. 2. Decrease of pain by 3 levels on a 1-10 scale. 3. Electrolytes are within normal limits. 4. Administer enemas to decrease hyperkalemia.

3. Electrolytes are within normal limits. 1. This is a nursing intervention, not a client outcome. 2. This is a measurable client outcome, but acute renal failure does not cause pain. 3. Renal failure causes an imbalance of electrolytes (potassium, sodium, calcium, phosphorus). Therefore, the desired client outcome is electrolytes within normal limits. 4. A Kayexalate resin enema may be administered to help decrease the potassium level, but this is an intervention, not a client outcome.

The client receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the client? 1. Notify the HCP if the oral temperature is 102F or greater. 2. Apply ice to the access site if it starts bleeding at home. 3. Keep fingernails short and try not to scratch the skin. 4. Encourage significant other to make decisions for client. 3. Keep fingernails short and try not to scratch the skin. Uremic frost, which results when the skin attempts to take over the function of the kidneys, causes itching, which can lead to scratching possibly resulting in a break in the skin. 95

3. Keep fingernails short and try not to scratch the skin. Rationale: Uremic frost, which results when the skin attempts to take over the function of the kidneys, causes itching, which can lead to scratching possibly resulting in a break in the skin

The client diagnosed with ARF is experiencing hyperkalemia. Which medication should the nurse prepare to administer to help decrease the potassium level? 1. Erythropoietin. 2. Calcium gluconate. 3. Regular insulin. 4. Osmotic diuretic.

3. Regular insulin. \ 1. Erythropoietin is a chemical catalyst produced by the kidneys to stimulate RBC production; it does not affect potassium level. 2. Calcium gluconate helps protect the heart from the effect of high potassium levels. 3. Regular insulin, along with glucose, will drive potassium into the cells, thereby lowering serum potassium levels temporarily. 4. A loop diuretic, not an osmotic diurectic, may be ordered to help decrease the potassium level.

The male patient diagnosed with CKD has received the initial dose of erythropoietin, a biologic response modifier, 1 week ago. Which complaint by the client indicates the need to notify the health-care provider? 1. The client complains of flu-like symptoms. 2. The client complains of being tired all the time. 3. The client reports an elevation in his blood pressure. 4. The client reports discomfort in his legs and back.

3. The client reports an elevation in his blood pressure. Rationale: After initial administration of erythropoietin, a client's antihypertensive medications may need to be adjusted. Therefore, this complaint requires notification of the HCP. Erythropoietin therapy is contraindicated in clients with uncontrolled hypertension.

The nurse is caring for the client diagnosed with chronic kidney disease (CKD) who is experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in this client? 1. There is an increased excretion of phosphates and organic acids, which leads to an increase in arterial blood pH. 2. A shortened life span of red blood cells because of damage secondary to dialysis treatments in turn leads to metabolic acidosis. 3. The kidney cannot excrete increased levels of acid because they cannot excrete ammonia or cannot reabsorb sodium bicarbonate. 4. An increase in nausea and vomiting causes a loss of hydrochloric acid and the respiratory system cannot compensate adequately.

3. The kidney cannot excrete increased levels of acid because they cannot excrete ammonia or cannot reabsorb sodium bicarbonate. Rationale: This is the correct scientific rationale for metabolic acidosis occurring in the client with CKD.

phosphorus

3.0-4.5 mg/dL

PaCO2 normal range

35-45 mm Hg

The nurse caring for a client diagnosed with CKD writes a client problem of "noncompliance with dietary restrictions." Which intervention should be included in the plan of care? 1. Teach the client the proper diet to eat while undergoing dialysis. 2. Refer the client and significant other to the dietitian. 3. Explain the importance of eating the proper foods. 4. Determine the reason for the client not adhering to the diet.

4. Determine the reason for the client not adhering to the diet. Rationale: Noncompliance is a choice the client has a right to make, but the nurse should determine the reason for the noncompliance and then take appropriate actions based on the client's rationale. For example, if the client has financial difficulties, the nurse may suggest how the client can afford the proper foods along with medications, or the nurse may be able to refer the client to a social worker.

The nurse is developing a nursing care plan for the client diagnosed with CKD. Which nursing problem is priority for the client? 1. Low self-esteem. 2. Knowledge deficit. 3. Activity intolerance. 4. Excess fluid volume.

4. Excess fluid volume Rationale: Excess fluid volume is priority because of the stress placed on the heart and vessels, which could lead to heart failure, pulmonary edema, and death.

The nurse is admitting a client diagnosed with acute renal failure (ARF). Which question is most important for the nurse to ask during the admission interview? 1. "Have you recently traveled outside the United States?" 2. "Did you recently begin a vigorous exercise program?" 3. "Is there a chance you have been exposed to a virus?" 4. "Which over-the-counter medications do you take regularly?"

4. Medications such as NSAIDs and some herbal remedies are nephrotoxic; therefore, asking about medications is appropriate. 1. Usually there are no diseases or conditions warranting this question when discussing ARF. 2. Vigorous exercise will not impede blood flow to the kidneys, leading to ARF. 3. Usually viruses do not cause ARF. 4. Medications such as NSAIDs and some herbal remedies are nephrotoxic; therefore, asking about medications is appropriate.

The client diagnosed with ARF has a serum potassium level of 6.8 mEq/L. Which collaborative treatment should the nurse anticipate for the client? 1. Administer a phosphate binder. 2. Type and crossmatch for whole blood. 3. Assess the client for leg cramps. 4. Prepare the client for dialysis.

4. Prepare the client for dialysis. 1. Phosphate binders are used to treat elevated phosphorus levels, not elevated potassium levels. 2. Anemia is not the result of an elevated potassium level. 3. Assessment is an independent nursing action, which is appropriate for the elevated potassium level, but the question asks for a collaborative treatment. 4. Normal potassium level is 3.5 to 5.5 mEq/L. A level of 6.8 mEq/L is life threatening and could lead to cardiac dysrhythmias. Therefore, the client may be dialyzed to decrease the potassium level quickly. This requires a health-care provider order, so it is a collaborative intervention.

The client diagnosed with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse? 1. Inability to auscultate a bruit over the fistula. 2. The client's abdomen is soft, is nontender, and has bowel sounds. 3. The dialysate being removed from the client's abdomen is clear. 4. The dialysate instilled was 1,500 mL and removed was 1,500 mL.

4. The dialysate instilled was 1500 mL and removed was 1500 mL. Rationale: Because the client is in ESRD, fluid must be removed from the body, so the output should be more than the amount instilled. These assessment data require intervention by the nurse.

Creatinine clearance (24hr urine)

60-135

ph

7.35-7.45

glucose

70-100 mg/dL

calcium

8.5-10.0 mg/dL

GFR (glomerular filtration rate)

90-120 mL/min Renal function

What nursing measures are included in the plan of care for a client with acute renal failure? A. Observe for signs of a secondary infection. B. Provide a high-protein, low-carbohydrate diet. C. In and out catheterization for residual urine. D. Force fluids to 2000 ml in 24 hours.

:A. Observe for signs of a secondary infection. Secondary infections are the cause of death in 50-90% of clients with acute renal failure. A low protein diet is most often offered. Catheterizations are avoided. Fluids may be limited if the client is in ARF.

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. "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.

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. Apple, green beans, and a roast beef sandwich When the patient selects an apple, green beans, and a roast beef sandwich, the patient demonstrates understanding of the low potassium diet. Granola, dried fruits, nuts and seeds, milk products, chocolate sauce, bran cereal, banana, and orange juice all have elevated levels of potassium, at or above 200 mg per 1/2 cup.

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. Hypernatremia d. BUN increases e. Serum creatinine increases

A. Dehydration B. 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 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.

A. 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 client with chronic kidney disease has a nursing diagnosis of disturbed sensory perception related to central nervous system changes induced by uremic toxins. An appropriate nursing intervention for this problem is to A. Convey a caring attitude and foster the nurse-patient relationship B. Keep the client on strict bed-rest to avoid possible falls or other injuries. C. Reinforce restricted protein intake to prevent nitrogenous product accumulation. D. Provide an opportunity for the client to discuss concerns about the condition

Answer: C Rationale: Uremia is caused by the products of protein breakdown, and protein restriction is used to decrease uremia. Because the primary cause of the patient's disturbed sensory perception is the uremia, conveying a caring attitude and providing opportunities for the patient to discuss concerns will not be as helpful as protein restriction. Although safety is a concern for the patient, bed rest is likely to promote weakness. The patient should be supervised when out of bed. Cognitive Level: Application Text Reference: p. 1211 Nursing Process: Implementation NCLEX: Physiological Integrity

Two hours after a kidney transplant, the nurse obtains all these data when assessing the client. Which information is most important to communicate to the health care provider? A. The BUN and creatinine levels are elevated. B. The urine output is 900 to 1100 ml/hr. C. The blood pressure is 88/50 mmHg. D. The pain level is 8/10 at incision when client coughs.

Answer: b. The patient's central venous pressure (CVP) is decreased. 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.

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. 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.

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. Blood pressure and fluid balanceAlthough 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 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.

B. 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.

Which assessment finding is a consequence of the oliguric phase of AKI? a. Hypovolemia b. Hyperkalemia c. Hypernatremia d. Thrombocytopenia

B. 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.

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. 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.

Rena biopsy

Best for confirmation of intrarenal causes

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. 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.

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. 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.

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

C. Large urine output Patients frequently experience diuresis in the hours and days immediately following a kidney transplant. Electrolyte imbalances and signs of infection are unexpected findings that warrant prompt intervention.

The longer the oliguria phase last, the poor the prognosis for

Complete kidney functioning recovery

Intrarenal causes of AKI

Conditions That caused direct damage to kidneys Infections: pyelonephritis, Ep-Stein Barr, fungal Allergies: nsaids, antibiotics, ace inhibitors Nephrototoxic injuries: Chemical exposure, contrast media, blood transfusion reaction, severe crush injury, hypertension, lupus, glomerulonephritis note: Neprhotoxic agents cause acute tubular necrosis, accounts for 90% of intrarenal AKI patients

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. 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 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

D. 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 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 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.

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

D. Restrict fluids according to previous daily loss. Patients in the oliguric phase of acute kidney injury will have fluid volume excess with potassium and sodium retention. Therefore they will need to have dietary sodium, potassium, and fluids restricted. Daily fluid intake is based on the previous 24-hour fluid loss (measured output plus 600 ml for insensible loss). The diet also needs to provide adequate, not low, protein intake to prevent catabolism. The patient should also be weighed daily, not just three times each week

Nursing Assessment for AKI

Daily weights I&O monitoring Vitals Examine urine for color, specific gravity, glucose, protein, blood and sediment Assess access site for dialysis( inflammation) Mental status, LOC Assess oral mucosa for dryness and inflammation Auscultation lungs for crackles, wheezes Monitor heart for S gallop, murmurs, dysthymia

Nursing diagnosis of AKI

Electrolyte imbalance Fluid imbalance Risk for infection Fatigue

Having an MRI or MRA with the contrast media _______ is not advised as it could be fatal

Gadolinium

_______ and _______ would be a cause of intrarenal causes because they block the tubules and cause vasoconstriction

Hemoglobin and myoglobin

In the event that contrast media has to be used what should you do

Hydrate, hydrate, hydrate

Post-renal causes of AKI

Involves mechanical obstruction in the outflow of urine Most common postrenal causes are benign prosthetic hyperplasia, prostate cancer, stones, trauma extrarenal tumors

AKI

Rapid loss of kidney functioning potentially reversible

Oliguria

Reduction in urine < 400 mL/day Occurs within 1-7 days of AKI If ischemia is the cause oliguria occurs within 24 hours

The rifle classification describes the stages of acute kidney injury

Risk: Serum creatinine up by 1.5 GFR decreased by 25% Injury: Serum creatinine up by 2 GFR decreased by 50% Failure: Serum creatinine up by 3 GFR decreased by 75% Loss: Persistent acute failure Complete loss of kidney function >4 wks ESRD: Complete kidney function loss > 3 mos

Management of AKI

Treat precipitating causes Fluid restriction (600 mL plus previous 24hr fluid loss is what should be allocated the following day Follow Diuretic therapy (usually loops, furosemide, bumetanide{bumex }, or an osmotic diuretic {mannitol} Adequate protein intake (0.6-2g/kg/day) Enteral nutrition Dietary restrictions (potassium, phosphate, sodium) Calcium supplements or phosphate binding agents Dialysis if necessary Continuous RRT

kidney ultrasound

Usually the first test done of AKI provides imaging without exposure to nephrotoxic contrast agents

An EKSD 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.

Which complication of chronic kidney disease is treated with erythropoietin (EPO)? a. Anemia b. Hypertension c. Hyperkalemia d. Mineral and bone disorder a. AnemiaErythropoietin is used to treat anemia, as it stimulates the bone marrow to produce red blood cells.

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

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.

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. Cinacalcet (Sensipar) b. Sevelamer (Renagel) d. Calcium acetate (PhosLo) 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. Dry skin b. Sensory neuropathy d. Calcium-phosphate skin deposits Pruritis 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, not to itching skin. Uremic frost rarely occurs without BUN levles greawter than 200 mg/dL, which should not occur in a patient on dialysis; urea crystallizes on the skin and also causes pruritis.

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. Increased fluid intake and a diet with a potassium-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.

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

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. 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 as because the number of functioning nephrons decreases with age, but AKI can occur at any age.

During 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. Regulate fluid intake hourly based on urine output. Fluid and electrolyte imbalance 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.

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. ammonia synthesis. 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 acid-base balance.

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. e. increased high-density lipoprotein levels.

Nurses need to 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.

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.

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

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. Renal replacement therapy 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.

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

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.

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

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

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

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

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. 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.

n 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. Specific gravity fixed at 1.010 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).

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

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. hypertension. Nifedipine (Procardia) is a calcium channel blocker and furosemide (Lasix) is a loop diuretic. Both are used to treat hypertension.

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

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. Fluid overload 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 hyperkalemia, pericarditis, or other serious effects of uremia.

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

An 83-year-old 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. Hypovolemia e. Decreased cardiac output 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.

For a patient with CKD the nurse identifies a nursing diagnosis for risk of injury: fracture related to alteration 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. Impaired vitamin D activation resulting in decreased GI absorption of calcium 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.

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. Increased ammonia from bacterial breakdown of urea 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 would cause constipation.

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. Less cardiovascular stress e. Requires fewer dietary restrictions 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 CKD is brought to the emergency department with Kussmaul respirations. What does the nurse know about CKD that could cause the 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. They are caused by respiratory compensation for metabolic acidosis. Kussmaul respirations occur with severe metabolic acidosis when the respiratory system is attempting to compensate by removing carbon dioxide with exhalations. Uremic pleuritis would cause a pleural friction rub. Decreased pulmonary macrophage activity increases the risk of pulmonary infection. Dyspnea would occur with pulmonary edema.

During the nursing assessment of the patient with renal insuffiency, the nurse asks the patient specifically about a history of a. angina. b. asthma. c. hypertension. d. rheumatoid arthritis.

c. hypertension. 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.

The assess the patency of a newly placed arteriovenous graft for dialysis, the nurse should (select all that apply) a. monitor the BP in the affected arm. b. irrigate the graft daily with low-dose heparin. c. palpate the area of the graft to feel a normal thrill. d. listen with a stethoscope over the graft to detect a bruit. e. frequently monitor the pulses and neurovascular status distal to the graft.

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.

Renal scan

can assess abnormalities in kidney blood flow, tubular function, and the collecting system.

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

What indicates to a 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. Decreasing blood urea nitrogen (BUN) and creatinine levels 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.

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 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.

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

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. Nephrotoxic drugs e. Acute glomerulonephritis f. Tubular obstruction by myoglobin 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.

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 fluid loss. c. Dietary sodium and potassium during 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. One of the most important nursing measures in managing fluid balance in the patient with AKI is taking accurate daily weights. 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.

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 acetominophen d. Patient with major surgery who required a blood transfusion d. Patient with major surgery who required a blood transfusionAcute 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 will not contribute to ATN.

d. Patient with major surgery who required a blood transfusion 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 will not contribute to ATN.

What indicates to a 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. Reversal of oliguria occurs with fluid replacement 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.

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. The patient experiences increasing muscle weakness and abdominal cramping. 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, and is the development of peripheral edema.

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. The use of calcium-based phosphate binders in the patient with CKD is contraindicated when serum calcium levels are increased. 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.

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. 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 kidney disease (E). The first three stages are characterized by the serum creatinine level and urine output.

ataxia

lack of muscle coordination

metabolic acidosis

low pH, low HCO3

Pre-renal causes of AKI

hypovolemia (hemorrhage, dehydration, diarrhea, vomiting), decreased cardiac output (dysrhythmias, HF, MI), decreased peripheral vascular resistance (anaphylaxis, septic shock), decreased renovascular blood flow (embolism, renal artery thrombosis)

pyelonephritis

inflammation of the renal pelvis and the kidney

oliguria phase of acute kidney injury

significant decrease in GFR; rise in BUN, creatinine, fluid overload, urine formation is decreased, nephrons filled with WBCs and inflammation occurs

Hyperplasia

the enlargement of an organ or tissue because of an abnormal increase in the number of cells in the tissues