Ch 19: Kidney Disorders and Therapeutic Management

The patient is a gravida 6, para 1. She is admitted after a cesarean section after an amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less than 80 mm Hg. Her temperature is 38°C, and her condition has caused her to develop prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter, which was placed into her right femoral access, and started on vasopressors with a fair response (BP, 80/50 mm Hg; HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis, the patient was begun on CVVH. Which of the statements best describes CVVH? · Complete renal replacement therapy requiring large volumes of ultrafiltrate and filter replacement · Complete renal replacement therapy that allows removal of solutes and modification of the volume and composition of extracellular fluid to occur evenly over time · Involves the introduction of sterile dialyzing fluid through an implanted catheter into the abdominal cavity, which relies on osmosis, diffusion, and active transport to help remove waste from the body · Complete renal replacement therapy that allows an exchange of fluid, solutes, and solvents across a semipermeable membrane at 100 to 300 mL/hr

Complete renal replacement therapy that allows removal of solutes and modification of the volume and composition of extracellular fluid to occur evenly over time

The nursing management plan for the patient with a urinary drainage catheter would include which interventions to prevent catheter-associated UTI (CAUTI)? (Select all that apply.) a.Insert urinary catheters using aseptic techniques. b.Change the urinary catheter daily. c.Review the need for the urinary catheter daily and remove promptly. d.Flush the urinary catheter q8 hours to maintain patency. e.Avoid unnecessary use of indwelling urinary catheters.

a.Insert urinary catheters using aseptic techniques. c.Review the need for the urinary catheter daily and remove promptly. e.Avoid unnecessary use of indwelling urinary catheters. The key components of CAUTI prevention are to avoid unnecessary use of urinary catheters, insert urinary catheters using aseptic technique, adopt evidence-based standards for maintenance of urinary catheters, review the need for the urinary catheter daily, and remove the catheter promptly.

The practitioner has ordered dialysis for a patient with acute heart failure who is unresponsive to diuretics. Which type of dialysis would the nurse anticipate being started on this patient? a.Intermittent ultrafiltration b.Continuous venovenous hemofiltration (CVVH) c.Continuous venovenous hemodialysis (CVVHD) d.Continuous venovenous hemodiafiltration (CVVHDF)

a.Intermittent ultrafiltration Intermittent ultrafiltration using a peripheral venous catheter is more likely to be used to remove excess volume from patients with acute decompensated heart failure when the kidneys are unresponsive to diuretics.

A patient is admitted with acute kidney injury (AKI). Which event from the patient's history was the most probable cause of the patient's AKI? a.Recent computed tomography of the brain with and without contrast b.A recent bout of acute heart failure after an acute myocardial infarction c.Twice-daily prescription of Lasix 40 mg by mouth d.A recent bout of benign prostatic hypertrophy and transurethral resection of the prostate

a.Recent computed tomography of the brain with and without contrast Intravenous contrast media can be nephrotoxic, especially with the patient's preexisting cardiac disease. The other choices, although possible causes, are less likely than the intravenous contrast media.

To remove fluid during hemodialysis, a positive hydrostatic pressure is applied to the blood and a negative hydrostatic pressure is applied to the dialysate bath. What is this process called? a.Ultrafiltration b.Hemodialysis c.Reverse osmosis d.Colloid extraction

a.Ultrafiltration To remove fluid, a positive hydrostatic pressure is applied to the blood, and a negative hydrostatic pressure is applied to the dialysate bath. The two forces together, called transmembrane pressure, pull and squeeze the excess fluid from the blood. The difference between the two values (expressed in millimeters of mercury [mm Hg]) represents the transmembrane pressure and results in fluid extraction, known as ultrafiltration, from the vascular space.

The practitioner has ordered continuous renal replacement therapy (CRRT) for a patient with acute kidney injury. The patient needs both the removal of fluids and a moderate amount of solutes. Which type of CRRT would the nurse anticipate being started on this patient? a.Slow continuous ultrafiltration (SCUF) b.Continuous venovenous hemofiltration (CVVH) c.Continuous venovenous hemodialysis (CVVHD) d.Continuous venovenous hemodiafiltration (CVVHDF)

b.Continuous venovenous hemofiltration (CVVH) CVVH is indicated when the patient's clinical condition warrants removal of significant volumes of fluid and solutes. Fluid is removed by ultrafiltration in volumes of 5 to 20 mL/min or up to 7 to 30 L/24 hr. Removal of solutes such as urea, creatinine, and other small non-protein-bound toxins is accomplished by convection.

A patient was admitted with an infection that had to be treated with gentamicin, an aminoglycoside antibiotic. After 3 days of administration, the patient developed oliguria, and an elevated blood urea nitrogen and creatinine levels. The nurse suspects the patient has developed what type of kidney injury? a.Prerenal b.Intrarenal c.Anuric d.Postrenal

b.Intrarenal Any condition that produces an ischemic or toxic insult directly at parenchymal nephron tissue places the patient at risk for development of intrarenal. Ischemic damage may be caused by prolonged hypotension or low cardiac output. Toxic injury reaction may occur in response to substances that damage the kidney tubular endothelium, such as some antimicrobial medications and the contrast dye used in radiologic diagnostic studies.

A patient has developed acute kidney injury (AKI) secondary to cardiogenic shock. Which laboratory value would the nurse find helpful in evaluating patient's renal status? a.Serum sodium b.Serum creatinine c.Serum potassium d.Urine potassium

b.Serum creatinine In the acutely ill patient, small changes in the serum creatinine level and urine output may signal important declines in the glomerular filtration rate and kidney function.

What is the most common site for short-term vascular access for immediate hemodialysis? a.Subclavian artery b.Subclavian vein c.Femoral artery d.Radial vein

b.Subclavian vein Subclavian and femoral veins are catheterized when short-term access is required or when a graft or fistula vascular access is nonfunctional in a patient requiring immediate hemodialysis. Subclavian and femoral catheters are routinely inserted at the bedside. Most temporary catheters are venous lines only. Blood flows out toward the dialyzer and flows back to the patient through the same catheterized vein. A dual-lumen venous catheter is most commonly used.

A patient was admitted with liver failure and acute kidney injury (AKI). Which intravenous solution should the nurse question if it was ordered for this patient? a.D5W b.0.9% NaCl c.Lactated Ringer solution d.0.45% NaCl

c. Lactated Ringer solution Lactated Ringer solution is contraindicated for patients with kidney or liver diseases or in lactic acidosis.

A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodialysis (CVVHD). The nurse understands the patient should be closely monitored for what patient-related complications of the therapy? a.Air embolism, access failure, and blood leaks b.Decreased inflow pressure, air bubbles, and power surge c.Infection, hypotension, and electrolyte imbalances d.Catheter dislodgement, decreased outflow pressure, and acid-base imbalances

c.Infection, hypotension, and electrolyte imbalances Patient-related complications of continuous renal replacement therapy (CRRT) include dehydration, hypotension, electrolyte imbalances, acid-base imbalances, blood loss, hemorrhage, hypotension, and infection.

An elderly patient is in a motor vehicle accident and sustains a significant internal hemorrhage. The nurse knows the patient is at risk for developing what type of acute kidney injury (AKI)? a.Intrinsic b.Postrenal c.Prerenal d.Intrarenal

c.Prerenal Any condition that decreases blood flow, blood pressure, or kidney perfusion before arterial blood reaches the renal artery that supplies the kidney may be anatomically described as prerenal acute kidney injury (AKI). When arterial hypoperfusion caused by low cardiac output, hemorrhage, vasodilation, thrombosis, or other cause reduces the blood flow to the kidney, glomerular filtration decreases, and consequently urine output decreases.

A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodialysis (CVVHD). The nurse understands that this type of continuous renal replacement therapy (CRRT) is indicated for the patient who needs what type of treatment? a.Fluid removal only b.Fluid removal and moderate solute removal c.Fluid removal and maximum solute removal d.Maximum fluid and solute removal

d.Maximum fluid and solute removal (Study guide: c. fluid removal and maximum solute removal) Continuous venovenous hemodialysis (CVVHD) is indicated for patients who require large-volume removal of fluid and solutes.

A patient is admitted with sepsis and acute kidney injury (AKI). The patient is started on continuous renal replacement therapy (CRRT). The nurse knows that fluid is removed each hour is charted as what on the CRRT flow sheet? a.Convection b.Diffusion c.Replacement fluid d.Ultrafiltrate

d.Ultrafiltrate The fluid that is removed each hour is not called urine; it is known as ultrafiltrate. Typically, some of the ultrafiltrate is replaced through the continuous renal replacement therapy circuit by a sterile replacement fluid. Diffusion is the movement of solutes along a concentration gradient from a high concentration to a low concentration across a semipermeable membrane. Convection occurs when a pressure gradient is set up so that the water is pushed or pumped across the dialysis filter and carries the solutes from the bloodstream with it.

An alert and oriented patient presents with a pulmonary artery wedge pressure of 4 mm Hg and a cardiac index of 0.8. The BUN is 44 mg/dL, creatinine is 3.2 mg/dL, and BP is 88/36 mm Hg. Urine output is 15 mL/hr. Lungs are clear to auscultation with no peripheral edema noted. Which of the following treatments would the physician most likely order? · Lasix 40 mg intravenous push · 0.9% normal saline at 125 mL/hr · Dopamine 15 μg/kg/min · Transfuse 1 U of packed red blood cells

· 0.9% normal saline at 125 mL/hr

The patient is a gravida 6, para 1. She is admitted after a cesarean section after an amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less than 80 mm Hg. Her temperature is 38°C, and her condition has caused her to develop prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter, which was placed into her right femoral access, and started on vasopressors with a fair response (BP, 80/50 mm Hg; HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis, the patient was begun on CVVH. Identify three complications of CVVH therapy. · Fat emboli, increased ultrafiltration, and hypertension · Hyperthermia, overhydration, and power surge · Air embolism, decreased inflow pressure, and electrolyte imbalance · Blood loss, decreased outflow resistance, and acid-base imbalance

· Air embolism, decreased inflow pressure, and electrolyte imbalance

A patient has been hospitalized for a subtotal gastrectomy. After the procedure, an infection developed that eventually had to be treated with gentamicin, an aminoglycoside antibiotic. After 3 days of administration, oliguria occurred, and subsequent laboratory values indicated elevated BUN and creatinine levels. The patient is transferred to the critical care unit with acute kidney injury (previously known as acute tubular necrosis). The patient's vital signs are stable. Which dialysis method would be most appropriate for the patient's condition? · Peritoneal dialysis · Hemodialysis · Continuous renal replacement therapy · Continuous venovenous hemodialysis (CVVH)

· Hemodialysis

. The patient is a gravida 6, para 1. She is admitted after a cesarean section after an amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less than 80 mm Hg. Her temperature is 38°C, and her condition has caused her to develop prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter, which was placed into her right femoral access, and started on vasopressors with a fair response (BP, 80/50 mm Hg; HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis, the patient was begun on CVVH. Why would this therapy be chosen for this patient? · Hyperdynamic patients can better tolerate abrupt fluid and solute changes. · It is the treatment of choice for patients with diminished renal perfusion who are unresponsive to diuretics. · It is indicated for patients who require large-volume removal for severe uremia or critical acid-base imbalances. · It is indicated for hemodynamically unstable patients, who are often intolerant of the abrupt fluid and solute changes that can occur with hemodialysis.

· It is indicated for hemodynamically unstable patients, who are often intolerant of the abrupt fluid and solute changes that can occur with hemodialysis.

A patient has been hospitalized for a subtotal gastrectomy. After the procedure, an infection developed that eventually had to be treated with gentamicin, an aminoglycoside antibiotic. After 3 days of administration, oliguria occurred, and subsequent laboratory values indicated elevated BUN and creatinine levels. The patient is transferred to the critical care unit with acute kidney injury (previously known as acute tubular necrosis). The fluid that is removed each hour is not called urine; it is known as · convection. · diffusion. · replacement fluid. · ultrafiltrate.

· ultrafiltrate.

A patient with chronic renal failure receives hemodialysis treatments 3 days a week. Every 2 weeks, the patient requires a transfusion of 1 or 2 U of packed red blood cells. What is the probable reason for this patient's frequent transfusion needs? · Too much blood phlebotomized for tests · Increased destruction of red blood cells because of the increased toxin levels · Lack of production of erythropoietin to stimulate red blood cell formation · Fluid retention causing hemodilution

Lack of production of erythropoietin to stimulate red blood cell formation

Which of the following IV solutions is recommended for treatment of prerenal failure? · Dextrose in water · Normal saline · Albumin · Lactated Ringer solution

Normal saline

A patient is admitted with respiratory failure and is being mechanically ventilated. The nurse understands there is a significant association between acute kidney injury and respiratory failure. How does mechanical ventilation alter kidney function? (Select all that apply.) a.Decreases blood flow to the kidney. b.Decreases glomerular filtration rate (GFR). c.Damages the kidney tubular endothelium. d.Decreases urine output. e.Hinders flow of urine from the kidneys.

a.Decreases blood flow to the kidney. b.Decreases glomerular filtration rate (GFR). d.Decreases urine output. Mechanical ventilation can alter kidney function. Positive-pressure ventilation reduces blood flow to the kidney, lowers the GFR, and decreases urine output. These effects are intensified with the addition of positive end-expiratory pressure (PEEP).

What is the recommended nutritional intake of protein to control azotemia in the patient with acute kidney injury? a.0.5 to 1.0 g/kg/day b.1.2 to 1.5 g/kg/day c.1.7 to 2.5 g/kg/day d.2.5 to 3.5 g/kg/day

b.1.2 to 1.5 g/kg/day The recommended energy intake is between 20 and 30 kcal/kg/day, with 1.2 to 1.5 g/kg of protein per day to control azotemia (increased blood urea nitrogen level).

A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodiafiltration (CVVHDF). The nurse understands the patient should be closely monitored for what circuit-related complications of the therapy? a.Hypervolemia, hypothermia, and hyperkalemia b.Access dislodgment, decreased outflow pressures, and bleeding c.Filter clotting, access failure, and air embolism d.Increased overflow pressure, dehydration, and calcium loss

c.Filter clotting, access failure, and air embolism Circuit-related complications of continuous renal replacement therapy include air embolism, clotted hemofilter, poor ultrafiltration, blood leaks, broken filter, disconnection, access failure, and catheter dislodgement.

To assess whether or not an arteriovenous fistula is functioning, what must the nurse do and why? a.Palpate the quality of the pulse distal to the site to determine whether a thrill is present; auscultate with a stethoscope to appreciate a bruit to assess the quality of the blood flow. b.Palpate the quality of the pulse proximal to the site to determine whether a thrill is present; auscultate with a stethoscope to appreciate a bruit to assess the quality of the blood flow. c.Palpate gently over the site of the fistula to determine whether a thrill is present; listen with a stethoscope over this site to appreciate a bruit to assess the quality of the blood flow. d.Palpate over the site of the fistula to determine whether a thrill is present; check whether the extremity is pink and warm.

c.Palpate gently over the site of the fistula to determine whether a thrill is present; listen with a stethoscope over this site to appreciate a bruit to assess the quality of the blood flow. The nurse frequently assesses the quality of blood flow through the fistula. A patent fistula has a thrill when palpated gently with the fingers and a bruit when auscultated with a stethoscope. The extremity should be pink and warm to the touch. No blood pressure measurements, intravenous infusions, or laboratory phlebotomy is performed on the arm with the fistula.

What is a continuous venovenous hemodialysis filter permeable to? · Electrolytes · Red blood cells · Protein · Lipids

· Electrolytes

One therapeutic measure for treating hyperkalemia is the administration of dextrose and regular insulin. Which description regarding how this treatment works is accurate? a.Forces potassium out of the serum into the lymphatic space. b.Promotes higher excretion of potassium in the urine. c.Binds with potassium lowering available amounts. d.Forces potassium out of the serum into the cells.

d.Forces potassium out of the serum into the cells. Acute hyperkalemia can be treated temporarily by intravenous administration of insulin and glucose. An infusion of 50 mL of 50% dextrose accompanied by 10 units of regular insulin forces potassium out of the serum and into the cells.

What is the dose for low-dose dopamine? · 1 to 2 mcg/kg/min · 1 to 2 mg/kg/min · 2 to 3 mcg/kg/min · 2 to 3 mg/kg/min

· 2 to 3 mcg/kg/min

Which of the following diuretics maybe combined to work on different parts of the nephron? · Loop and thiazide diuretics · Loop and osmotic diuretics · Osmotic and carbonic anhydrase inhibitor diuretics · Thiazide and osmotic diuretics

· Loop and thiazide diuretics

.Which of the following conditions is associated between kidney failure and respiratory failure? (Select all that apply.) · ARDS · Lower GFR · Increased urine output · Decreased urine output · Decreased blood flow to the kidneys

· ARDS · Lower GFR · Decreased urine output · Decreased blood flow to the kidneys

Which of the following medications is considered a loop diuretic? · Acetazolamide (Diamox) · Furosemide (Lasix) · Mannitol · Metolazone (Zaroxolyn)

· Furosemide (Lasix)

A patient has acute kidney injury (previously known as acute tubular necrosis). The following blood work was noted: complete blood count shows a white blood cell count of 11,000 mm3, a hemoglobin of 8 g/dL, and a hematocrit of 30%. His chemistry panel shows serum potassium, 4.5 mg/dL; serum sodium, 135 mg/dL; serum calcium, 8.5 mg/dL; BUN, 20 mg/dL; and creatinine, 1.5 mg/dL. What laboratory value(s) need(s) to be treated most immediately and why? · Administration of 5% dextrose in water and insulin because the patient is hyperkalemic and needs this level reduced · Administration of Epogen to treat anemia · Administration of a broad-spectrum antibiotic to treat the elevated blood cell count · Administration of a calcium supplement for low calcium

Administration of Epogen to treat anemia

A patient has sepsis and is placed on broad-spectrum antibiotics. Her temperature is 37.8°C. Her BUN level is elevated. She continues on vasopressor therapy. What other steps should be taken to protect the patient from inadequate organ perfusion? · Increase net ultrafiltrate of fluid. · Discontinue vasopressor support. · Assess the patient for blood loss and hypotension. · Notify the physician of access pressures.

Assess the patient for blood loss and hypotension.

Which electrolytes pose the most potential hazard if not within normal limits for a person with renal failure? · Phosphorous and calcium · Potassium and calcium · Magnesium and sodium · Phosphorous and magnesium

· Potassium and calcium