Exemplar 6.B - Acute Kidney Injury

A client diagnosed with acute kidney injury (AKI) will be discharged to home in the next few days. When conducting dietary instruction, the nurse should teach the client to choose proteins that are high in biological value. Which client statement indicates that this teaching has been effective? A) "I will be sure to include eggs in my diet." B) "I should include vegetables at every meal." C) "Legumes should be included in my diet, because they are complete proteins." D) "I will eat nuts daily because they are high in protein."

A) "I will be sure to include eggs in my diet." Eggs are an excellent source of essential amino acids and are recommended as part of the diet for a client with acute kidney injury (AKI) who is on a protein-restricted diet. Legumes, nuts, and vegetables do contain protein, but they are incomplete proteins and thus not as good a protein source as eggs.

The nurse is caring for a client diagnosed with acute kidney injury (AKI). When reviewing the client's laboratory data, which findings should indicate to the nurse that the client has met the expected outcomes? Select all that apply. A) Decreasing serum creatinine B) Decreasing blood urea nitrogen (BUN) C) Decreasing neutrophil count D) Decreasing lymphocyte count E) Decreasing erythrocyte count

A) Decreasing serum creatinine B) Decreasing blood urea nitrogen (BUN) Creatinine is the metabolic end product of creatine phosphate and is excreted via the kidneys in relatively constant amounts. BUN, a measurement of the nitrogen portion of urea, is also excreted in urine and is a good indicator of renal function. Neutrophils, lymphocytes, and erythrocytes are not used to monitor the return of renal function.

A client diagnosed with frequent urinary tract infections is seen in the urology clinic. The nurse reviews the client's medical history and determines that the client is at risk for acute kidney injury. Which items in the client's history support this conclusion? Select all that apply. A) Dehydration B) Renal calculi C) Ineffective wound healing D) Low serum albumin E) Hypertension

A) Dehydration B) Renal calculi E) Hypertension Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury (AKI). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause AKI.

The nurse is concerned that an older adult client is at risk for developing acute kidney injury (AKI). Which data in the client's history supports the nurse's concern? Select all that apply. A) Diagnosed with hypotension B) Recent aortic valve replacement surgery C) Prescribed high doses of intravenous antibiotics D) Total hip replacement surgery 5 years ago E) Taking medication for type 2 diabetes mellitus

A) Diagnosed with hypotension B) Recent aortic valve replacement surgery C) Prescribed high doses of intravenous antibiotics Older adults develop acute kidney injury more frequently because of the higher incidence of serious illnesses, hypotension, major surgeries, diagnostic procedures, and treatment with nephrotoxic drugs. Decreased kidney function associated with aging also puts the older client at risk for acute kidney injury. Hypotension, aortic valve replacement surgery, and receipt of high doses of intravenous antibiotics increase this client's risk for developing acute kidney injury. A previous history of hip replacement surgery and current treatment for type 2 diabetes mellitus are not identified risk factors for the development of acute kidney injury.

The community nurse visits the home of a young child who is home from school because of sudden onset of nausea, vomiting, and lethargy. The nurse suspects acute kidney injury (AKI). Which clinical manifestations support the nurse's suspicions? Select all that apply. A) Elevated blood pressure B) Postural hypotension C) Wheezing D) Edema E) Hematuria

A) Elevated blood pressure D) Edema E) Hematuria Pediatric manifestations of acute kidney injury characteristically begin with a healthy child who suddenly becomes ill with nonspecific symptoms that indicate a significant illness or injury. These symptoms may include any combination of the following: nausea, vomiting, lethargy, edema, gross hematuria, oliguria, and hypertension. Postural hypotension is a manifestation of acute kidney injury in an older person. Wheezing is not a manifestation of acute kidney injury.

Which symptom suggests that a client is entering the maintenance phase of acute kidney injury (AKI)? A) Onset of metabolic acidosis B) Onset of diuresis C) Increase in glomerular filtration rate D) Decrease in serum potassium levels

A) Onset of metabolic acidosis The maintenance phase of AKI is characterized by a significant fall in glomerular filtration rate (GFR) and tubular necrosis. Oliguria, azotemia, fluid retention, electrolyte imbalances, and metabolic acidosis may all develop. Also during this phase, impaired potassium excretion leads to hyperkalemia, or increased serum potassium levels. Onset of diuresis and an increasing glomerular filtration rate are suggestive of the recovery phase, not the maintenance phase.

The nurse is planning care for a client diagnosed with acute kidney injury (AKI). The nurse plans the client's care based on the nursing diagnosis of Excess Fluid Volume. Which assessment data supports this nursing diagnosis? A) Pitting edema in the lower extremities B) Bowel sounds positive in four quadrants C) Wheezing in the lungs D) Generalized weakness

A) Pitting edema in the lower extremities The client in acute kidney injury (AKI) will likely be edematous, because the kidneys are not producing urine. Wheezing in the lungs is an assessment consistent with asthma, not AKI. Bowel sounds in four quadrants is a normal assessment finding. Generalized weakness may be due to whatever disease process precipitated the kidney failure.

A client with acute kidney failure is complaining of a metallic taste in the mouth and has no appetite. Based on this data, which intervention by the nurse is the most appropriate? A) Provide mouth care before meals. B) Administer an antiemetic as prescribed. C) Restrict fluids. D) Encourage the intake of protein, salt, and potassium.

A) Provide mouth care before meals. A metallic taste in the mouth is due to uremia. The nurse should provide mouth care before meals to reduce this taste sensation and improve the client's oral intake. An antiemetic would be prescribed for nausea. Restricting fluids would not reduce the metallic taste in the mouth. Encouraging intake of protein, salt, and potassium would exacerbate the uremia that is causing the metallic taste in the mouth.

The nurse is caring for a client admitted with a diagnosis of acute kidney injury (AKI). The client asks the nurse, "Are my kidneys failing? Will I need a kidney transplant?" Which response by the nurse is the most appropriate? A) "No, don't think that. You're going to be fine." B) "In most cases, your condition can be reversed with prompt treatment and usually will not destroy the kidneys." C) "Kidney transplantation is highly likely, so it would be a good idea to start talking to your family members about organ donation." D) "When the doctor comes to see you, we can talk about whether you will need a transplant."

B) "In most cases, your condition can be reversed with prompt treatment and usually will not destroy the kidneys." AKI is often resolved without the need for transplant if treatment is initiated quickly. There is no need to start lining up donors or wait for the provider to arrive to explore options. Telling the client that everything will be fine is condescending, provides no information, and is not within the nurse's ability to know.

A client diagnosed with acute kidney injury (AKI) has jugular vein distention, lower extremity edema, and elevated blood pressure. Based on this data, which nursing diagnosis is most appropriate? A) Ineffective Renal Tissue Perfusion B) Excess Fluid Volume C) Risk for Decreased Cardiac Tissue Perfusion D) Risk for Infection

B) Excess Fluid Volume Jugular vein distention, edema, and elevated blood pressure are all indications of excess fluid. Thus, the diagnosis Excess Fluid Volume should be selected to guide this client's care. Oliguria or reduced urine output would be a symptom associated with Ineffective Renal Tissue Perfusion. Alterations in heart rate and rhythm would be symptoms associated with Risk for Decreased Cardiac Tissue Perfusion. The client is not demonstrating any manifestations that indicate a Risk for Infection.

What is the most frequent complication during hemodialysis? A) Hemorrhage B) Hypotension C) Localized infection D) Hypertension

B) Hypotension Hypotension is the most frequent complication during hemodialysis. It may result from changes in serum osmolality, rapid removal of fluid from the vascular compartment, vasodilation, and other factors. Bleeding is another possible complication, although it does not occur as often as hypotension. Infection is also commonly associated with hemodialysis, although it occurs following treatment rather than during dialysis.

Which laboratory finding suggests that a client is experiencing acute kidney injury (AKI) as a result of glomerular damage? A) Hyperkalemia B) Proteinuria C) Urine specific gravity of 1.010 D) Moderate anemia

B) Proteinuria Proteinuria, or excess protein in the urine, is suggestive of glomerular damage as the cause of a client's AKI. Urine specific gravity of 1.010, moderate anemia, and hyperkalemia are common laboratory findings in clients with AKI, regardless of its cause.

A client diagnosed with acute kidney injury (AKI) is receiving peritoneal dialysis. The nurse is explaining the dialysis process to the client and family. Which statement should the nurse include in this discussion? A) "The peritoneum is more permeable because of the presence of excess metabolites." B) "The metabolites will diffuse from the interstitial space to the bloodstream mainly through diffusion and ultrafiltration." C) "The peritoneum acts as a semipermeable membrane through which wastes move by diffusion and osmosis." D) "The solutes in the dialysate will enter the bloodstream through the peritoneum."

C) "The peritoneum acts as a semipermeable membrane through which wastes move by diffusion and osmosis." The peritoneum acts as a semipermeable membrane, allowing substances to move from an area of high concentration (the blood) to an area of lower concentration (the dialysate). Metabolic waste products and excess water can be eliminated through osmosis and diffusion using the peritoneum as the semipermeable membrane.

A client diagnosed with recurrent urinary tract calculi would be at elevated risk for which of the following types of acute kidney injury (AKI)? A) Prerenal AKI B) Intrinsic AKI C) Postrenal AKI D) Intrarenal AKI

C) Postrenal AKI Obstructive causes of AKI are classified as postrenal. Any condition that prevents urine excretion—including urinary tract calculi—can lead to postrenal AKI. In comparison, prerenal AKI results from conditions that affect renal blood flow and perfusion, and intrinsic AKI (also called intrarenal AKI) is characterized by acute damage to the renal parenchyma and nephrons

A young school-age client is in the hospital with an acute kidney injury diagnosis following a streptococcus infection. The client's parents primarily speak Spanish but have a limited ability to understand English. Through an interpreter, the parents ask the nurse what mistake they made that caused their child to be so sick. Which response by the nurse is the most appropriate? A) "Your child does not eat enough dietary protein." B) "Your child has a congenital defect that led to renal failure." C) "Your child's renal failure has been caused by a low calcium level." D) "Your child's recent infection may have caused the renal failure."

D) "Your child's recent infection may have caused the renal failure." Clients with streptococcus are at risk for kidney and cardiac sequelae. In this case, the child has no evidence of a congenital defect leading to acute kidney injury (AKI). A low-protein or low-calcium diet will not lead to AKI.

Which medication is used to increase renal blood flow in clients with acute kidney injury? A) Furosemide (Lasix) B) Mannitol (Osmitrol) C) Bumetanide (Bumex) D) Dopamine (Intropin)

D) Dopamine (Intropin) In clients with acute kidney injury, dopamine (Intropin) is administered in low doses by intravenous infusion to increase renal blood flow. If restoration of renal blood flow does not improve urinary output, a potent loop diuretic, such as furosemide (Lasix) or bumetanide (Bumex), or an osmotic diuretic, such as mannitol (Osmitrol), may be given with intravenous fluids. These medications help "wash" nephrotoxins out of the kidneys and reestablish urine output.

A client agrees to receive long-term hemodialysis to treat acute kidney injury (AKI). Based on this information, the nurse should prepare the client for which surgical procedure? A) Insertion of a double-lumen catheter into the subclavian artery B) Placement of a peritoneal catheter C) Insertion of a subarachnoid-peritoneal shunt D) Placement of an arteriovenous fistula

D) Placement of an arteriovenous fistula For long-term vascular access needed for hemodialysis, an arteriovenous (AV) fistula is created. The fistula is created by surgical anastomosis of an artery and vein, usually the radial artery and cephalic vein. It takes about a month for the fistula to mature so that it can be used for taking and replacing blood during dialysis. A double-lumen catheter inserted into a major artery is used as temporary vascular access for continuous renal replacement therapy. A peritoneal catheter is used for peritoneal dialysis, not hemodialysis. A subarachnoid-peritoneal shunt is used to remove excess cerebrospinal fluid and not for hemodialysis.

The nurse is planning care for a client admitted with a diagnosis of heart failure. Based on this diagnosis, which type of kidney failure is the client at an increased risk for experiencing? A) Prerenal hypovolemia B) Intrarenal glomerular injury C) Intrarenal acute tubular necrosis D) Prerenal low cardiac output

D) Prerenal low cardiac output Heart failure is one possible cause of prerenal kidney failure due to low cardiac output. In comparison, causes of prerenal kidney failure due to hypovolemia include hemorrhage, dehydration, burns, wounds, and excess fluid loss from the gastrointestinal tract. Causes of intrarenal kidney failure due to glomerular injury include glomerulonephritis, disseminated intravascular coagulation, vasculitis, hypertension, toxemia of pregnancy, and hemolytic uremic syndrome. Finally, causes of intrarenal kidney failure due to acute tubular necrosis include ischemia resulting from conditions associated with prerenal failure, toxins, hemolysis, and rhabdomyolysis.