AKI (practice questions)
The newly graduated nurse is caring for a client diagnosed with acute kidney injury (AKI) experiencing hyperkalemia. The newly graduated nurse states to the nurse preceptor, "My client doesn't have diabetes but the doctor ordered intravenous insulin for my client. This must be a mistake." Which is the best response by the nurse preceptor? "Clients with AKI have elevated levels of creatinine which causes damage to the pancreas, leading to decreased insulin production." "The glucose mol
"The administration of intravenous insulin treats hyperkalemia by shifting extra potassium into the cells, decreasing extracellular potassium." Acute kidney injury (AKI) can be reversible when promptly treated, so the goal is to prevent further injury, manage the signs and symptoms, prevent complications, and promote recovery. The underlying cause should be addressed while carefully managing the body's fluids, electrolytes, and waste products of metabolism. This is achieved via a combination of intravenous (IV) fluids, diuretics, and correction of electrolyte disturbance, such as hyperkalemia. Intravenous insulin administration is a method of treating hyperkalemia by shifting potassium into the cells and out of the bloodstream. Clients who do not respond to treatment may require renal replacement therapy, such as dialysis, to control their volume overload, electrolyte imbalances, metabolic acidosis, and uremic symptoms.
BUN: Cr Ratio Normal?
10-20;1
Oliguric phase of AKI
< 400 mL/ 24hrs d/t -Ischemia (occurs w/ 24hrs) - nephrotoxins (within 1 week)
BUN: Cr Ratio - ATN
<10:1
BUN: Cr Ratio - PRERENAL
> 20:1
Non-oliguric AKI
> 400 mL/ 24hrs d/t - acute interstitial nephritis and ATN (Acute tubular necrosis)
The emergency department nurse is reviewing the laboratory results for several clients. Which client's results are consistent with the diagnosis of prerenal acute kidney injury (AKI)? Day 1 Day 2 Client 1 Urine specific gravity: 1.020 --> Urine specific gravity: 1.025 Client 2 Blood urea nitrogen (BUN): 25 mg/dL --> Blood urea nitrogen (BUN): 24 mg/dL Client 3 Creatinine: 1.8 mg/dL Creatinine 3.8 mg/dL Client 4 Potassium 5.2 mEq/L Potassiu
A progessive rise in creatinine over 24 to 48 hours is indicative of AKI. Normal creatinine is 0.6-1.2 mg/dL.
The nurse is assessing a client who has prerenal acute kidney injury (AKI). Which of the following items should the nurse include in the assessment? (Select all that apply.) A. Blood pressure B. Cardiac enzymes C. Urine output D. Serum creatinine E. Serum electrolytes
A, C, D, E
The public health nurse is educating a group of clients about the risk of developing acute kidney injury (AKI). Which non-modifiable factor(s) should the nurse include? Select all that apply. A. Advanced age B. Increased stress levels C. History of acute coronary syndrome (ACS) D. Uncontrolled hypertension E. Smoking tobacco F. History of autoimmune disease
A, C, F There are several factors that may put an individual at risk for acute kidney injury (AKI). Non-modifiable risk factors are ones that clients cannot change, whereas modifiable factors are ones that can be changed. There are some factors that can put an individual at risk for AKI. Unfortunately, many of the risk factors are non-modifiable and decrease kidney function over time, such as advanced age, diabetes mellitus, autoimmune diseases, certain cancers, uncontrolled hypertension, and heart, liver, or kidney disease.
The nurse is planning care for a client who has postrenal acute kidney injury cancer. The client has a serum creatinine of 5 mg/dL. Which of the followin, nurse complete? (Select all that apply.) A. Provide NSAIDS for pain. B. Assess the urine for blood. C. Monitor for intermittent anuria. D. Administer diuretic medication. E. Ensure protein is included in the diet.
B, C, E
A client suspected of having acute kidney injury (AKI) after experiencing a kidney stone is being seen by the nephrologist in the emergency department. Which diagnostic test(s) should the nurse anticipate? Select all that apply. A.Abdominal computed tomography (CT) scan with contrast B.Urine culture and sensitivity C.Comprehensive metabolic panel (CMP) D.Post-void urine residual E.Renal ultrasound
C, D, E The main diagnostic studies used for acute kidney injury (AKI) include standard laboratory tests, such as a comprehensive metabolic panel (CMP) which can show abnormal electrolyte levels like hyperkalemia, hyperphosphatemia, and hypocalcemia. Blood urea nitrogen (BUN) and creatinine will also be evaluated. A blood gas analysis can show metabolic acidosis. In addition, urinalysis can reveal proteinuria, hematuria, and casts. Computed tomography (CT) scan without contrast dye can assess renal blood flow and allow identification of an underlying cause. Renal ultrasound may be indicated to assess for urinary tract obstructions.
The patient has pre-renal AKI and just had a AAA surg The Pt: weight is 100kg Urine output is 80cc in 4 hrs BP is 92/58 What is the priority nursing intervention? a. kidney-punch the patient to stimulate adequate perfusion b . Trendelenburg positioning c. Start fluid challenge protocol d. assess pedal pulses bilaterally e. Call the provider
C.FLUID CHALLENGE " sometimes giving the pt. 500mls of NaCl BOLUS" is enough to jump-start the kidneys" Think pre, intra, post? Pt. is behind on output 0.5mls x 100kg = 50mls per hour desired output. Currently the patient is at 80cc/4hrs= 20mls per hour.. 25% of baseline output decrease = 12.5% (bp don't trip, hes still mostly prefusing)
A nurse is caring for a client who is in the oliguric-anuric stage of acute kidney injury. The client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness. Which of the following actions should the nurse take first? A. Administer an analgesic to the client B. Check the client's electrolyte values C. Measure the client's weight D. Restrict the clients protein intake
Check the client's electrolyte values The nurse should apply the urgent versus nonurgent priority-setting framework when caring for the client. Using this framework, the nurse should consider urgent needs to be the priority because they pose a greater threat to the client. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. The nurse should check the client's most recent potassium value because these findings are manifestations of hyperkalemia, which can lead to cardiac dysrhythmias. Incorrect Answers: A. Administering an analgesic for a dull headache is important to manage the client's pain; however, there is another action that the nurse should take first. C. Measuring the client's weight is important to monitor the client's fluid balance; however, there is another action the nurse should take first. D. Restricting the client's protein intake is important to man
oliguria
Decreased urine output
Which assessment findings would alert the nurse that the patient has entered the diuretic phase of acute kidney injury (AKI)? (Select all that apply.) Dehydration Hypokalemia Hypernatremia BUN increases Urine output increases Serum creatinine increases
Dehydration Hypokalemia Urine output increases Rationale: The hallmark of entering the diuretic phase is the production of copious amounts of urine. Dehydration, hypokalemia, and hyponatremia occur in the diuretic phase of AKI because the nephrons can excrete wastes but not concentrate urine. Serum BUN and serum creatinine levels begin to decrease.
Which patient diagnosis or treatment is most consistent with prerenal acute kidney injury (AKI)? IV tobramycin Incompatible blood transfusion Poststreptococcal glomerulonephritis Dissecting abdominal aortic aneurysm
Dissecting abdominal aortic aneurysm Rationale: A dissecting abdominal aortic aneurysm is a prerenal cause of AKI because it can decrease renal artery perfusion and therefore the glomerular filtrate rate. Aminoglycoside antibiotic administration, a hemolytic blood transfusion reaction, and poststreptococcal glomerulonephritis are intrarenal causes of AKI.
urine qualities in Oliguric/Anuric Phase
Increase -> Na+ Sediment of RBCs, Casts, Proteins (bloody, with necrotic cell sediment, protein should NEVER be in urine)
Phase of AKI: Recovery
Increase of GFR • BUN & Cr plateau then decline • Major improvement 1st 1-2wks of recovery • Stable kidney fx may take up to 12 mos.
A nurse is preparing an in-service program about the stages of acute kidney injury (AKI). Which of the following pieces of information should the nurse include about prerenal azotemia? A. Prerenal azotemia begins prior to the onset of symptoms. B. Interference with renal perfusion causes prerenal azotemia. C. Preenal azotemia is irreversible, even in the early stages. D. Infections and tumors cause prerenal azotemia.
Interference with renal perfusion causes prerenal azotemia. Prerenal azotemia results from interference with renal perfusion, such as from heart failure or hypovolemic shock. Incorrect Answers: A. Clients who have prerenal azotemia typically have tachycardia, lethargy, reduced urine output, and other manifestations. C. In early stages, reversal of prerenal azotemia is possible with correction of hypovolemia and improvement in blood pressure and cardiac output. D. Infections and ingested toxins cause intrarenal AKI, not prerenal azotemia.
A patient is recovering in the intensive care unit (ICU) 24 hours after receiving a kidney transplant. What is an expected assessment finding during the earliest stage of recovery? Hypokalemia Hyponatremia Large urine output Leukocytosis with cloudy urine output
Large urine output Rationale: Patients often have diuresis in the hours and days immediately after a kidney transplant. Electrolyte imbalances and signs of infection are unexpected findings that warrant prompt intervention.
The patient has rapidly progressing glomerular inflammation. Weight has increased and urine output is steadily declining. What is the priority nursing intervention? Monitor the patient's cardiac status. Teach the patient about hand washing. Obtain a serum specimen for electrolytes. Increase direct observation of the patient.
Monitor the patient's cardiac status. Rationale: The nurse's priority is to monitor the patient's cardiac status. With the rapidly progressing glomerulonephritis, renal function begins to fail and fluid, potassium, and hydrogen retention lead to hypervolemia, hyperkalemia, and metabolic acidosis. Excess fluid increases the workload of the heart, and hyperkalemia can lead to life-threatening dysrhythmias. Teaching about hand washing and observation of the patient are important nursing interventions but are not the priority. Electrolyte measurement is a collaborative intervention that will be done as ordered by the health care provider.
Anuria AKI
No urine output d/t - obstruction
Informatics in Practice:
Pts on ABX therapy = RISK FOR AKI • Computer alerts you about elevated creatinine lvl (text msg) • Notify provider early; meds can be stopped or decreased
When caring for a patient during the oliguric phase of acute kidney injury (AKI), which nursing action is appropriate? Weigh patient three times weekly. Increase dietary sodium and potassium. Provide a low-protein, high-carbohydrate diet. Restrict fluids according to previous daily loss.
Restrict fluids according to previous daily loss. Rationale: Patients in the oliguric phase of AKI will have fluid volume excess with potassium and sodium retention. Therefore, they will need to have dietary sodium, potassium, and fluids restricted. Daily fluid intake is based on the previous 24-hour fluid loss (measured output plus 600 mL for insensible loss). The diet also needs to provide adequate, not low, protein intake to prevent catabolism. The patient should also be weighed daily, not just three times each week.
The nurse is caring for a patient who is in the oliguric phase of acute kidney disease. Which action would be appropriate to include in the plan of care? Provide foods high in potassium. Restrict fluids based on urine output. Monitor output from peritoneal dialysis. Offer high-protein snacks between meals.
Restrict fluids based on urine output. Rationale: Fluid intake is monitored during the oliguric phase. Fluid intake is determined by adding all losses for the previous 24 hours plus 600 mL. Potassium and protein intake may be limited in the oliguric phase to avoid hyperkalemia and elevated urea nitrogen. Hemodialysis, not peritoneal dialysis, is indicated in acute kidney injury if dialysis is needed.
RN MGMT: AKI
Serum Tests for AKI • Creatinine (more stable) • BUN (less stable) • Affected by catabolism, bleeding, and dehydration • BUN:creatinine ratio (normal 10-20;1) >20:1, suspect prerenal causes <10:1, suspect ATN Serum osmolality (solutes dissolved in blood)
The nurse is caring for a client diagnosed with Acute Kidney Injury (AKI) with the following laboratory results: Laboratory value Result Potassium 4.3 mEq/L Phosphate 7 mg/dL Sodium 155 mEq/L Based upon the laboratory results, which prescription order should the nurse question? 5% dextrose (D5W) intravenously Sodium polystyrene Sevelamer carbonate Furosemide
Sodium polystyrene The nurse should question this medication since sodium polystyrene is a potassium binder used to treat hyperkalemia. Normal potassium levels are 3.5-5.1 mEq/L, so this medication is not indicated.
azotemia
accumulation of nitrogenous waste products (urea nitrogen, creatinine) in the blood.
Acute Kidney Injury (AKI)
aka renal failure partial or complete impairment of kidney function. has a rapid onset.
Phase of AKI: Diuretic
infection prevention #1 d/t SEPSIS risk Caution - hypovolemia & hypotension Caution: Electrolyte loss (serum hyponatremia, hypokalemia, dehydration) - d/t urine excretion Automaticity → ARRHYTHMIA Osmotic diuresis r/t high urea in glomerular filtrate Tubules unable to concentrate urine GRADUAL Increase in output 1-3L per day
Serum changes during Oliguric/Anuric Phase
↑↑ K+ > 5.5 mEqL ↑↑ BUN > 20 mg/dl ↑↑ Cr > 1.2 mg/dl Na+ ≤135 mEqL
