Lippincott Q & A AKI and CKD

37. Which of the following is the most common initial manifestation of acute renal failure? ■ 1. Dysuria. ■ 2. Anuria. ■ 3. Hematuria. ■ 4. Oliguria

37. 4. Oliguria is the most common initial symptom of acute renal failure. Anuria is rarely the initial symptom. Dysuria and hematuria are not associated with acute renal failure.

38. A client developed shock after a severe myocardial infarction and has now developed acute renal failure. The client's family asks the nurse why the client has developed acute renal failure. The nurse should base the response on the knowledge that there was: ■ 1. A decrease in the blood flow through the kidneys. ■ 2. An obstruction of urine flow from the kidneys. ■ 3. A blood clot formed in the kidneys. ■ 4. Structural damage to the kidney resulting in acute tubular necrosis.

38. 1. There are three categories of acute renal failure: prerenal, intrarenal, and postrenal. Causes of prerenal failure occur outside the kidney and include poor perfusion and decreased circulating volume resulting from such factors as trauma, septic shock, impaired cardiac function, and dehydration. In this case of severe myocardial infarction, there was a decrease in perfusion of the kidneys caused by impaired cardiac function. An obstruction within the urinary tract, such as from kidney stones, tumors, or benign prostatic hypertrophy, is called postrenal failure. Structural damage to the kidney resulting from acute tubular necrosis is called intrarenal failure. It is caused by such conditions as hypersensitivity (allergic disorders), renal vessel obstruction, and nephrotoxic agents.

39. The client's blood urea nitrogen (BUN) concentration is elevated in acute renal failure. What is the likely cause of this finding? ■ 1. Fluid retention. ■ 2. Hemolysis of red blood cells. ■ 3. Below-normal metabolic rate. ■ 4. Reduced renal blood fl ow.

39. 4. Urea, an end product of protein metabolism, is excreted by the kidneys. Impairment in renal function caused by reduced renal blood flow results in an increase in the plasma urea level. Fluid retention, hemolysis of red blood cells, and lowered metabolic rate do not cause an elevated BUN value.

41. A client with acute renal failure has an increase in the serum potassium level. The nurse should monitor the client for: ■ 1. Cardiac arrest. ■ 2. Pulmonary edema. ■ 3. Circulatory collapse. ■ 4. Hemorrhage.

41. 1. Hyperkalemia places the client at risk for serious cardiac arrhythmias and cardiac arrest. Therefore, the nurse should carefully monitor the client for cardiac arrhythmias and be prepared to treat cardiac arrest when caring for a client with hyperkalemia. Increased potassium levels do not result in pulmonary edema, circulatory collapse, or hemorrhage

42. A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. The intended outcome of this diet is to: ■ 1. Act as a diuretic. ■ 2. Reduce demands on the liver. ■ 3. Help maintain urine acidity. ■ 4. Prevent the development of ketosis.

42. 4. High-carbohydrate foods meet the body's caloric needs during acute renal failure. Protein is limited because its breakdown may result in accumulation of toxic waste products. The main goal of nutritional therapy in acute renal failure is to decrease protein catabolism. Protein catabolism causes increased levels of urea, phosphate, and potassium. Carbohydrates provide energy and decrease the need for protein breakdown. They do not have a diuretic effect. Some specifi c carbohydrates infl uence urine pH, but this is not the reason for encouraging a high-carbohydrate, low-protein diet. There is no need to reduce demands on the liver through dietary manipulation in acute renal failure.

45. The client in acute renal failure has an external cannula inserted in the forearm for hemodialysis. Which of the following nursing measures is appropriate for the care of this client? ■ 1. Use the unaffected arm for blood pressure measurements. ■ 2. Draw blood from the cannula for routine laboratory work. ■ 3. Percuss the cannula for bruits each shift. ■ 4. Inject heparin into the cannula each shift.

45. 1. The unaffected arm should be used for blood pressure measurement. The external cannula must be handled carefully and protected from damage and disruption. In addition, a tourniquet or clamps should be kept at the bedside because dislodgment of the cannula would cause arterial hemorrhage. The arm with the cannula is not used for blood pressure measurement, I.V. therapy, or venipuncture. Patency is assessed by auscultating for bruits every shift. Heparin is not injected into the cannula to maintain patency. Because it is part of the general circulation, the cannula cannot be heparinized.

46. The nurse initiates the client's first hemodialysis treatment. The client develops a headache, confusion, and nausea. The nurse should assess the client further for: ■ 1. Disequilibrium syndrome. ■ 2. Myocardial infarction. ■ 3. Air embolism. ■ 4. Peritonitis.

46. 1. Common symptoms of disequilibrium syndrome include headache, nausea and vomiting, confusion, and even seizures. Disequilibrium syndrome typically occurs near the end or after the completion of hemodialysis treatment. It is the result of rapid changes in solute composition and osmolality of the extracellular fluid. These symptoms are not related to cardiac function, air embolism, or peritonitis.

47. During dialysis, the client has disequilibrium syndrome. The nurse should first? ■ 1. Administer oxygen per nasal cannula. ■ 2. Slow the rate of dialysis. ■ 3. Reassure the client that the symptoms are normal. ■ 4. Place the client in Trendelenburg's position.

47. 2. If disequilibrium syndrome occurs during dialysis, the most appropriate intervention is to slow the rate of dialysis. The syndrome is believed to result from too-rapid removal of urea and excess electrolytes from the blood; this causes transient cerebral edema, which produces the symptoms. Administration of oxygen and position changes do not affect the symptoms. It would not be appropriate to reassure the client that the symptoms are normal.

48. The client receives heparin while receiving hemodialysis. The nurse explains the rationale supporting anticoagulation by making which of the following statements? ■ 1. "Regional anticoagulation is achieved by putting heparin in the dialysis machine and protamine sulfate, which reverses the anticoagulation, in the client." ■ 2. "You will receive warfarin sodium (Coumadin) to maintain anticoagulation between treatments." ■ 3. "Heparin does not enter the body, so there is no risk of bleeding." ■ 4. "Clotting time is seriously prolonged for several hours after each treatment."

48. 1. Regional anticoagulation can be achieved by infusing heparin in the dialyzer and protamine sulfate, its antagonist, in the client. Warfarin sodium (Coumadin) is not used in dialysis treatment. There is some risk of bleeding; however, clotting time is monitored carefully. The client's clotting time will not be seriously affected, although some rebound effect may occur.

49. Which of the following abnormal blood values would not be improved by dialysis treatment? ■ 1. Elevated serum creatinine level. ■ 2. Hyperkalemia. ■ 3. Decreased hemoglobin concentration. ■ 4. Hypernatremia.

49. 3. Dialysis has no effect on anemia. Because some red blood cells are injured during the procedure, dialysis aggravates a low hemoglobin concentration. Dialysis will clear metabolic waste products from the body and correct electrolyte imbalances.

50. The nurse teaches the client how to recognize signs and symptoms of infection in the shunt by telling the client to assess the shunt each day for: ■ 1. Absence of a bruit. ■ 2. Sluggish capillary refi ll time. ■ 3. Coolness of the involved extremity. ■ 4. Swelling at the shunt site.

50. 4. Signs and symptoms of an external access shunt infection include redness, tenderness, swelling, and drainage from around the shunt site. The absence of a bruit indicates closing of the shunt. Sluggish capillary refill time and coolness of the extremity indicate decreased blood flow to the extremity.

51. The client with acute renal failure is recovering and asks the nurse, "Will my kidneys ever function normally again?" The nurse's response is based on knowledge that the client's renal status will most likely: ■ 1. Continue to improve over a period of weeks. ■ 2. Result in the need for permanent hemodialysis. ■ 3. Improve only if the client receives a renal transplant. ■ 4. Result in end-stage renal failure.

51. 1. The kidneys have a remarkable ability to recover from serious insult. Recovery may take 3 to 12 months. The client should be taught how to recognize the signs and symptoms of decreasing renal function and to notify the physician if such problems occur. In a client who is recovering from acute renal failure, there is no need for renal transplantation or permanent hemodialysis. Chronic renal failure develops before end-stage renal failure.

74. The nurse assesses the client who has chronic renal failure and notes the following: crackles in the lung bases, elevated blood pressure, and weight gain of 2 lb in 1 day. Based on these data, which of the following nursing diagnoses is appropriate? ■ 1. Excess fluid volume related to the kidney's inability to maintain fluid balance. ■ 2. Ineffective breathing pattern related to fluid in the lungs. ■ 3. Ineffective tissue perfusion related to interrupted arterial blood flow. ■ 4. Ineffective therapeutic regimen management related to lack of knowledge about therapy.

74. 1. Crackles in the lungs, weight gain, and elevated blood pressure are indicators of excess fl uid volume, a common complication in chronic renal failure. The client's fl uid status should be monitored carefully for imbalances on an ongoing basis. Although the client has ineffective breathing, the primary cause is related to the renal failure. There are no data to suggest ineffective tissue perfusion or lack of knowledge.

75. What is the primary disadvantage of using peritoneal dialysis for long-term management of chronic renal failure? ■ 1. The danger of hemorrhage is high. ■ 2. It cannot correct severe imbalances. ■ 3. It is a time-consuming method of treatment. ■ 4. The risk of contracting hepatitis is high.

75. 3. A disadvantage of peritoneal dialysis in long-term management of chronic renal failure is that it requires large blocks of time. The risk of hemorrhage or hepatitis is not high with peritoneal dialysis. Peritoneal dialysis is effective in maintaining a client's fluid and electrolyte balance.

76. A client with chronic renal failure who receives hemodialysis three times a week is experiencing severe nausea. What should the nurse advise the client to do to manage the nausea? Select all that apply. ■ 1. Drink fluids before eating solid foods. ■ 2. Have limited amounts of fluids only when thirsty. ■ 3. Limit activity. ■ 4. Keep all dialysis appointments. ■ 5. Eat smaller, more frequent meals.

76. 2, 4, 5. To manage nausea, the nurse can advise the client to drink limited amounts of fluid only when thirsty, eat food before drinking fluids to alleviate dry mouth, encourage strict follow-up for blood work, dialysis, and health care provider visits. Smaller, more frequent meals may help to reduce nausea and facilitate medication taking. The client should be as active as possible to avoid immobilization because it increases bone demineralization. The client should also maintain the dialysis schedule because the dialysis will remove wastes that can contribute to nausea.

77. The dialysis solution is warmed before use in peritoneal dialysis primarily to: ■ 1. Encourage the removal of serum urea. ■ 2. Force potassium back into the cells. ■ 3. Add extra warmth to the body. ■ 4. Promote abdominal muscle relaxation

77. 1. The main reason for warming the peritoneal dialysis solution is that the warm solution helps dilate peritoneal vessels, which increases urea clearance. Warmed dialyzing solution also contributes to client comfort by preventing chilly sensations, but this is a secondary reason for warming the solution. The warmed solution does not force potassium into the cells or promote abdominal muscle relaxation.

78. Which of the following assessments would be most appropriate for the nurse to make while the dialysis solution is dwelling within the client's abdomen? ■ 1. Assess for urticaria. ■ 2. Observe respiratory status. ■ 3. Check capillary refill time. ■ 4. Monitor electrolyte status.

78. 2. During dwell time, the dialysis solution is allowed to remain in the peritoneal cavity for the time ordered by the physician (usually 20 to 45 minutes). During this time, the nurse should monitor the client's respiratory status because the pressure of the dialysis solution on the diaphragm can create respiratory distress. The dialysis solution would not cause urticaria or affect circulation to the fingers. The client's laboratory values are obtained before beginning treatment and are monitored every 4 to 8 hours during the treatment, not just during the dwell time.

79. During the client's dialysis, the nurse observes that the solution draining from the abdomen is consistently blood-tinged. The client has a permanent peritoneal catheter in place. Which interpretation of this observation would be correct? ■ 1. Bleeding is expected with a permanent peritoneal catheter. ■ 2. Bleeding indicates abdominal blood vessel damage. ■ 3. Bleeding can indicate kidney damage. ■ 4. Bleeding is caused by too-rapid infusion of the dialysate.

79. 2. Because the client has a permanent catheter in place, blood-tinged drainage should not occur. Persistent blood-tinged drainage could indicate damage to the abdominal vessels, and the physician should be notified. The bleeding is originating in the peritoneal cavity, not the kidneys. Too-rapid infusion of the dialysate can cause pain, not blood tinged drainage.

80. During dialysis, the nurse observes that the flow of dialysate stops before all the solution has drained out. The nurse should: ■ 1. Have the client sit in a chair. ■ 2. Turn the client from side to side. ■ 3. Reposition the peritoneal catheter. ■ 4. Have the client walk.

80. 2. Fluid return with peritoneal dialysis is accomplished by gravity flow. Actions that enhance gravity flow include turning the client from side to side, raising the head of the bed, and gently massaging the abdomen. The client is usually confined to a recumbent position during the dialysis. The nurse should not attempt to reposition the catheter.

81. Which of the following nursing interventions should be included in the client's plan of care during dialysis therapy? ■ 1. Limit the client's visitors. ■ 2. Monitor the client's blood pressure. ■ 3. Pad the side rails of the bed. ■ 4. Keep the client on nothing-by-mouth (NPO) status.

81. 2. Because hypotension is a complication associated with peritoneal dialysis, the nurse records intake and output, monitors vital signs, and observes the client's behavior. The nurse also encourages visiting and other diversional activities. A client on peritoneal dialysis does not need to be placed in a bed with padded side rails or kept on NPO status.

82. The client performs his own peritoneal dialysis. What should the nurse teach the client about preventing peritonitis? Select all that apply. ■ 1. Broad-spectrum antibiotics may be administered to prevent infection. ■ 2. Antibiotics may be added to the dialysate to treat peritonitis. ■ 3. Clean technique is permissible for prevention of peritonitis. ■ 4. Peritonitis is characterized by cloudy dialysate drainage and abdominal discomfort. ■ 5. Peritonitis is the most common and serious complication of peritoneal dialysis.

82. 1, 2, 4, 5. Broad-spectrum antibiotics may be administered to prevent infection when a peritoneal catheter is inserted for peritoneal dialysis. If peritonitis is present, antibiotics may be added to the dialysate. Aseptic technique is imperative. Peritonitis, the most common and serious complication of peritoneal dialysis, is characterized by cloudy dialysate drainage, diffuse abdominal pain, and rebound tenderness.

83. After completion of peritoneal dialysis, the nurse should expect the client to exhibit which of the following characteristics? ■ 1. Hematuria. ■ 2. Weight loss. ■ 3. Hypertension. ■ 4. Increased urine output.

83. 2. Weight loss is expected because of the removal of fluid. The client's weight before and after dialysis is one measure of the effectiveness of treatment. Blood pressure usually decreases because of the removal of fluid. Hematuria would not occur after completion of peritoneal dialysis. Dialysis only minimally affects the damaged kidneys' ability to manufacture urine.

84. Aluminum hydroxide gel (Amphojel) is prescribed for the client with chronic renal failure to take at home. What is the expected outcome of giving this drug? ■ 1. Relieving the pain of gastric hyperacidity. ■ 2. Preventimg Curling's stress ulcers. ■ 3. Binding phosphate in the intestine. ■ 4. Reversing metabolic acidosis.

84. 3. A client in renal failure develops hyperphosphatemia that causes a corresponding excretion of the body's calcium stores, leading to renal osteodystrophy. To decrease this loss, aluminum hydroxide gel is prescribed to bind phosphates in the intestine and facilitate their excretion. Gastric hyperacidity is not necessarily a problem associated with chronic renal failure. Antacids will not prevent Curling's stress ulcers and do not affect metabolic acidosis.

85. The nurse teaches the client with chronic renal failure when to take aluminum hydroxide gel (Amphojel). Which of the following statements would indicate that the client understands the teaching? ■ 1. "I'll take it every 4 hours around the clock." ■ 2. "I'll take it between meals and at bedtime." ■ 3. "I'll take it when I have a sour stomach." ■ 4. "I'll take it with meals and bedtime snacks."

85. 4. Aluminum hydroxide gel (Amphojel) is administered to bind the phosphates in ingested foods and must be given with or immediately after meals and snacks. There is no need for the client to take it on a 24-hour schedule. It is not administered to treat hyperacidity in clients with chronic renal failure and therefore is not prescribed between meals.

86. The client with chronic renal failure tells the nurse he takes magnesium hydroxide (milk of magnesia) at home for constipation. The nurse suggests that the client switch to psyllium hydrophilic mucilloid (Metamucil) because: ■ 1. Milk of magnesia can cause magnesium intoxication. ■ 2. Milk of magnesia is too harsh on the bowel. ■ 3. Metamucil is more palatable. ■ 4. Milk of magnesia is high in sodium.

86. 1. Magnesium is normally excreted by the kidneys. When the kidneys fail, magnesium can accumulate and cause severe neurologic problems. Milk of magnesia is harsher than Metamucil, but magnesium toxicity is a more serious problem. A client may find both milk of magnesia and Metamucil unpalatable. Milk of magnesia is not high in sodium.

87. The nurse is determining which teaching approaches for the client with chronic renal failure and uremia would be most appropriate. The nurse should: ■ 1. Provide all needed teaching in one extended session. ■ 2. Validate the client's understanding of the material frequently. ■ 3. Conduct a one-on-one session with the client. ■ 4. Use videotapes to reinforce the material as needed

87. 2. Uremia can cause decreased alertness, so the nurse needs to validate the client's comprehension frequently. Because the client's ability to concentrate is limited, short lessons are most effective. If family members are present at the sessions, they can reinforce the material. Written materials that the client can review are superior to videotapes because clients may not be able to maintain alertness during the viewing of the videotape.

88. The nurse is instructing the client with chronic renal failure to maintain adequate nutritional intake. Which of the following diets would be most appropriate? ■ 1. High-carbohydrate, high-protein. ■ 2. High-calcium, high-potassium, high-protein. ■ 3. Low-protein, low-sodium, low-potassium. ■ 4. Low-protein, high-potassium.

88. 3. Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. The degree of dietary restriction depends on the degree of renal impairment. The client should also receive a high-carbohydrate diet along with appropriate vitamin and mineral supplements. Calcium requirements remain 1,000 to 2,000 mg/day.

89. The nurse is discussing concerns about sexual activity with a client with chronic renal failure. Which one of the following strategies would be most useful? ■ 1. Help the client to accept that sexual activity will be decreased. ■ 2. Suggest using alternative forms of sexual expression and intimacy. ■ 3. Tell the client to plan rest periods after sexual activity. ■ 4. Suggest that the client avoid sexual activity to prevent embarrassment.

89. 2. Altered sexual functioning commonly occurs in chronic renal failure and can stress marriages and relationships. Altered sexual functioning can be caused by decreased hormone levels, anemia, peripheral neuropathy, or medication. The client should not decrease or avoid sexual activity but instead should modify it. The client should rest before sexual activity.

90. A client with chronic renal failure has asked to be evaluated for a home continuous ambulatory peritoneal dialysis (CAPD) program. The nurse should explain that the major advantage of this approach is that it: ■ 1. Is relatively low in cost. ■ 2. Allows the client to be more independent. ■ 3. Is faster and more effi cient than standard peritoneal dialysis. ■ 4. Has fewer potential complications than standard peritoneal dialysis.

90. 2. The major benefit of CAPD is that it frees the client from daily dependence on dialysis centers, health care personnel, and machines for life-sustaining treatment. This independence is a valuable outcome for some people. CAPD is costly and must be done daily. Adverse effects and complications are similar to those of standard peritoneal dialysis. Peritoneal dialysis usually takes less time but cannot be done at home.

91. The client asks about diet changes when using continuous ambulatory peritoneal dialysis (CAPD). Which of the following would be the nurse's best response? ■ 1. "Diet restrictions are more rigid with CAPD because standard peritoneal dialysis is a more effective technique." ■ 2. "Diet restrictions are the same for both CAPD and standard peritoneal dialysis." ■ 3. "Diet restrictions with CAPD are fewer than with standard peritoneal dialysis because dialysis is constant." ■ 4. "Diet restrictions with CAPD are fewer than with standard peritoneal dialysis because CAPD works more quickly."

91. 3. Dietary restrictions with CAPD are fewer than those with standard peritoneal dialysis because dialysis is constant, not intermittent. The constant slow diffusion of CAPD helps prevent accumulation of toxins and allows for a more liberal diet. CAPD does not work more quickly, but more consistently. Both types of peritoneal dialysis are effective. CN: Basic care and comfort; CL: Synthesize

43. The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which of the following snacks is most appropriate? ■ 1. A gelatin dessert. ■ 2. Yogurt. ■ 3. An orange. ■ 4. Peanuts.

43. 1. Gelatin desserts contain little or no potassium and can be served to a client on a potassium restricted diet. Foods high in potassium include bran and whole grains; most dried, raw, and frozen fruits and vegetables; most milk and milk products; chocolate, nuts, raisins, coconut, and strong brewed coffee.

35. A client is to receive peritoneal dialysis. To prepare for the procedure, the nurse should? ■ 1. Assess the dialysis access for a bruit and thrill. ■ 2. Insert an indwelling urinary catheter and drain all urine from the bladder. ■ 3. Ask the client to turn toward the left side. ■ 4. Warm the solution in the warmer.

35. 4. Solution for peritoneal dialysis should be warmed to body temperature in a warmer or with a heating pad; do not use the microwave. Cold dialysate increases discomfort. Assessment for a bruit and thrill is necessary with hemodialysis when the client has a fi stula, graft, or shunt. An indwelling urinary catheter is not required for this procedure. The nurse should position the client in a supine or low Fowler's position.

36. A client has been admitted with acute renal failure. What should the nurse do? Select all that apply. ■ 1. Elevate the head of the bed 30 to 45 degrees. ■ 2. Take vital signs. ■ 3. Establish an I.V. access site. ■ 4. Call the admitting physician for orders. ■ 5. Contact the hemodialysis unit.

36. 1, 2, 3, 4. Elevation of the head of the bed will promote ease of breathing. Respiratory manifestations of acute renal failure include shortness of breath, orthopnea, crackles, and the potential for pulmonary edema. Therefore, priority is placed on facilitation of respiration. The nurse should assess the vital signs because the pulse and respirations will be elevated. Establishing a site for I.V. therapy will become important because fl uids will be administered I.V. in addition to orally. The physician will need to be contacted for further orders; there is no need to contact the hemodialysis unit.

40. The client's serum potassium level is elevated in acute renal failure, and the nurse administers sodium polystyrene sulfonate (Kayexalate). This drug acts to: ■ 1. Increase potassium excretion from the colon. ■ 2. Release hydrogen ions for sodium ions. ■ 3. Increase calcium absorption in the colon. ■ 4. Exchange sodium for potassium ions in the colon.

40. 4. Polystyrene sulfonate, a cation-exchange resin, causes the body to excrete potassium through the gastrointestinal tract. In the intestines, particularly the colon, the sodium of the resin is partially replaced by potassium. The potassium is then eliminated when the resin is eliminated with feces. Although the result is to increase potassium excretion, the specific method of action is the exchange of sodium ions for potassium ions. Polystyrenesulfonate does not release hydrogen ions or increase calcium absorption.

44. In the oliguric phase of acute renal failure, the nurse should assess the client for: ■ 1. Pulmonary edema. ■ 2. Metabolic alkalosis. ■ 3. Hypotension. ■ 4. Hypokalemia.

44. 1. Pulmonary edema can develop during the oliguric phase of acute renal failure because of decreased urine output and fl uid retention. Metabolic acidosis develops because the kidneys cannot excrete hydrogen ions, and bicarbonate is used to buffer the hydrogen. Hypertension may develop as a result of fl uid retention. Hyperkalemia develops as the kidneys lose the ability to excrete potassium.

92. A client is receiving continous ambulatory peritoneal dialysis (CAPD). The nurse should assess the client for which of the following signs of peritoneal infection? ■ 1. Cloudy dialysate fluid. ■ 2. Swelling in the legs. ■ 3. Poor drainage of the dialysate fluid. ■ 4. Redness at the catheter insertion site.

92. 1. Cloudy drainage indicates bacterial activity in the peritoneum. Other signs and symptoms of infection are fever, hyperactive bowel sounds, and abdominal pain. Swollen legs may indicate heart failure. Poor drainage of dialysate fl uid is probably the result of a kinked catheter. Redness at the insertion site indicates local infection, not peritonitis. However, a local infection that is left untreated can progress to the peritoneum. CN: Reduction of risk potential; CL: Analyze