NCLEX Review: Acute Renal Failure/Kidney Transplants

A patient with renal insufficiency is scheduled for an intravenous pyelogram (IVP). Which of the following orders for the patient will the nurse question? a. Ibuprofen (Advil) 400 mg PO PRN for pain b. Dulcolax suppository 4 hours before IVP procedure c. Normal saline 500 ml IV before procedure d. NPO for 6 hours before IVP procedure

Answer: A Rationale: The contrast dye used in IVPs is nephrotoxic, and concurrent use of other nephrotoxic medications such as the NSAIDs should be avoided. The suppository and NPO status are necessary to ensure that adequate visualization during the IVP. IV fluids are used to ensure adequate hydration, which helps reduce the risk for contrast-induced renal failure.

A patient with acute renal failure (ARF) has an arterial blood pH of 7.30. The nurse will assess the patient for a. tachycardia. b. rapid respirations. c. poor skin turgor. d. vasodilation.

Answer: B Rationale: Patients with metabolic acidosis caused by ARF may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Tachycardia and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in ARF.Answer: B Rationale: Patients with metabolic acidosis caused by ARF may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Tachycardia and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in ARF.

After noting increasing QRS intervals in a patient with ARF, which action should the nurse take first? a. Notify the patient's health care provider. b. Check the chart for the most recent blood potassium level. c. Look at the patient's current BUN and creatinine levels. d. Document the QRS interval.

Answer: B Rationale: The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient's health care provider. The BUN and creatinine will be elevated in a patient with ARF, but these would not directly affect the ECG. Documentation of the QRS interval is also appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening bradycardia.

Which data obtained when assessing a patient who had a kidney transplant 8 years ago and who is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone) will be of most concern to the nurse? a. The blood glucose is 144 mg/dl. b. The patient has a round, moonlike face. c. There is a nontender lump in the axilla. d. The patient's blood pressure is 150/92.

Answer: C Rationale: A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result of chronic immunosuppressive therapy. The elevated glucose, moon face, and hypertension are possible side effects of the prednisone and should be addressed, but they are not as great a concern as the possibility of a malignancy.

To monitor for corticosteroid-related complications after a kidney transplant, the nurse teaches the patient to report a. pain at the donor kidney site. b. dizziness with position change. c. pain in the hips, knees, and other joints. d. changes in the character of the urine.

Answer: C Rationale: Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over a prolonged period. Pain at the site, orthostatic dizziness, and changes in the urine appearance are not associated with corticosteroid use.

The health care provider orders IV glucose and insulin to be given to a patient in ARF whose serum potassium level is 6.3 mEq/L. To best evaluate the effectiveness of the medications, the nurse will a. monitor the patient's electrocardiograph (ECG). b. check the blood glucose level. c. obtain serum potassium levels. d. assess BUN and creatinine levels.

Answer: C Rationale: Changes in potassium will impact on the ECG and muscle strength, but the nurse should expect to recheck the serum potassium level during the infusion of glucose and insulin to determine the effectiveness of the therapy. The blood glucose level should be monitored during the infusion to assess for hypoglycemia or hyperglycemia. The BUN and creatinine levels will not change with administration of glucose and insulin.

A patient in ARF has a gradual increase in urinary output to 3400 ml a day with a BUN of 92 mg/dl (33 mmol/L) and a serum creatinine of 4.2 mg (371 μmol/L). The nurse should plan to a. use a urine dipstick to monitor for proteinuria. b. auscultate the lungs to assess for pulmonary edema. c. take the blood pressure to check for hypotension. d. draw blood to monitor for hyperkalemia.

Answer: C Rationale: During the diuretic phase of ARF, fluid and electrolyte losses may cause hypovolemia, hypotension, hyponatremia, and hypokalemia. Proteinuria, pulmonary edema, and hyperkalemia occur during the oliguric phase.

Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess a. the BUN and creatinine. b. the blood glucose level. c. the patient's bowel sounds. d. the level of consciousness (LOC).

Answer: C Rationale: Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not impact on the nurse's decision to give the medication.

Two hours after a kidney transplant, the nurse obtains the following pieces of data when assessing the patient. 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 patient's central venous pressure (CVP) is decreased. d. The patient has level 8 (on a 10-point scale) incision pain when coughing.

Answer: C Rationale: 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.

A patient admitted with sepsis has had several episodes of severe hypotension. Laboratory results indicate a BUN 50 mg/dl (10.7 mmol/L), serum creatinine 2.0 mg/dl (177 µmol/L), urine sodium 70 mEq/L (70 mmol/L), urine specific gravity 1.010, and cellular casts and debris in the urine. The nurse knows these findings are consistent with a. chronic renal insufficiency. b. prerenal failure. c. postrenal failure. d. acute tubular necrosis.

Answer: D Rationale: The specific gravity and presence of casts and debris in the urinalysis suggest intrarenal failure and acute tubular necrosis. The sudden onset indicates that the renal failure is acute, not chronic. In prerenal failure, there would not be casts or debris in the urine. The patient does not have risk factors for postrenal failure.

A male client develops acute renal failure (ARF) after receiving I.V. therapy with a nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 ml, nurse Andy suspects that the client is at risk for: a. cardiac arrhythmia. b. paresthesia. c. dehydration. d. pruritus.

Answer: a. Think about the labs. This patient would be high potassium, high phosphorus, low calcium, and low sodium r/t dilution

A adult client has had laboratory work done as part of a routine physical examination. The nurse interprets that the client may have a mild degree of renal insufficiency if which of the following serum creatinine levels is noted? a) 0.2 mg/dlL b) 0.5 mg/dL c) 1.9 mg/dL d) 3.5 mg/dL

c) 1.9 mg/dL the normal serum creatinine level foadults is 0.6 to 1.3 mg/dL. The client with a mild degree of renal insufficiency would have a slight elevated level. A creatinie level of 0.2 mg/dL is low, and a level of 0.5 mg/dL is just below normal. A creeatinie level of 3.5 mg/dL may be associated with acute or chronic renal failure.

The client in end-stage of renal failure had undergone kidney transplant. Which of the following assessment findings indicate kidney transplant rejection? a) increased urinary output, BUN = 15 mg/dL b) HCT = 50%, Hgb = 17 g/dl c) decreased urinary output, sudden weight gain d) decreased urinary output, sudden weight loss

c) decreased urinary output, sudden weight gain

The home care nurse is making follow-up visits to a client following renal transplant. The nurse assesses the client for which signs of acute graft rejection? a) hypotension, graft tenderness, and anemia b) hypertension, oliguria, thirst, and hypothermia c) fever, hypertension, graft tenderness, and malaise d) fever, vomiting, hypotension, and copious amounts of dilute urine

c) fever, hypertension, graft tenderness, and malaise

Which of the following anti-hypertensive medications is contraindicated for clients with renal insufficiency? a) beta-adrenergic blockers b) calcium-channel blockers c) direct-acting vasodilators d) angiotensin-converting enzyme inhibitors

d) angiotensin-converting enzyme inhibitors

In the oliguric phase of renal failure, what is the most appropriate nursing diagnosis? a) fluid volume deficit b) activity intolerance c) ineffective breathing pattern d) fluid volume excess

d) fluid volume excess

The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported IMMEDIATELY? a. Blood urea nitrogen 50 mg/dl b. Hemoglobin of 10.3 mg/dl c. Venous blood pH 7.30 d. Serum potassium 6 mEq/L

d.

A patient who received a kidney transplant returns for a follow-up visit to the outpatient clinic and reports a lump in her breast. Transplant recipients are: 1) At increased risk for cancer due to immunosuppression caused by cyclosporine (Neoral) 2) Consumed with fear after the life-threatening experience of having a transplant 3) At increased risk for tumors because of the kidney transplant 4) At decreased risk for cancer, so the lump is most likely benign

1) Cyclosporine suppresses the immune response to prevent rejection of the transplanted kidney. The use of cyclosporine places the patient at risk for tumors.

The most common early sign of kidney disease is: 1. Sodium retention 2. Elevated BUN level 3. Development of metabolic acidosis 4. Inability to dilute or concentrate urine

2.

You expect a patient in the oliguric phase of renal failure to have a 24 hour urine output less than: 1) 200ml 2) 400ml 3) 800ml 4) 1000ml

2)

A client received a kidney transplant 2 months ago. He's admitted to the hospital with the diagnosis of acute rejection. Which of the following assessment findings would be expected? 1) Hypotension 2) Normal body temperature 3) Decreased WBC count 4) Elevated BUN and creatinine levels

4)

Adverse reactions of prednisone therapy include which of the following conditions? 1) Acne and bleeding gums 2) Sodium retention and constipation 3) Mood swings and increased temperature 4) Increased blood glucose levels and decreased wound healing.

4)

A patient in the oliguric phase of acute renal failure has a 24-hour fluid output of 150 ml emesis and 250 ml urine. The nurse plans a fluid replacement for the following day of ___ ml. a. 400 b. 800 c. 1000 d. 1400

Answer: C Rationale: Usually fluid replacement should be based on the patient's measured output plus 600 ml/day for insensible losses.

A client with acute renal failure moves into the diuretic phase after 1 week of therapy. During this phase, the client must be assessed for signs of developing: a. Renal failure b. Hypovolemia c. Hyperkalemia d. Metabolic acidosis

b.

The nurse is caring for a client following a kidney transplant. The client develops oliguria. Which of the following would the nurse anticipate to be prescribed as the treatment of oliguria? 1) Encourage fluid intake 2) Administration of diuretics 3) Irrigation of foley catheter 4) Restricting fluids

2)

You suspect kidney transplant rejection when the patient shows which symptoms? 1) Pain in the incision, general malaise, and hypotension 2) Pain in the incision, general malaise, and depression 3) Fever, weight gain, and diminished urine output 4) Diminished urine output and hypotension

3) Symptoms of rejection include fever, rapid weight gain, hypertension, pain over the graft site, peripheral edema, and diminished urine output.

A patient with severe heart failure develops elevated BUN and creatinine levels. The nurse plans care for the patient based on the knowledge that collaborative care of the patient will be directed toward the goal of a. preventing hypertension. b. replacing fluid volume. c. diluting nephrotoxic substances. d. maintaining cardiac output.

Answer: D Rationale: The primary goal of treatment for ARF is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing ARF, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct.

A hospitalized patient is in the oliguric phase of acute renal failure. The nurse should implement which of the following interventions? A. Administer laxatives to prevent fluid overload B. Limit fluid intake C. Closely monitor hemoglobin level D. Administer dopamine to increase renal perfusion

B.

A client has just received a renal transplant and has started cyclosporine therapy to prevent graft rejection. Which of the following conditions is a major complication of this drug therapy? 1) Depression 2) Hemorrhage 3) Infection 4) Peptic ulcer disease

3) Immunosuppresive drug.

Which statement correctly distinguishes renal failure from prerenal failure? 1) With prerenal failure, vasoactive substances such as dopamine (Intropin) increase blood pressure 2) With prerenal failure, there is less response to such diuretics as furosemide (Lasix) 3) With prerenal failure, an IV isotonic saline infusion increases urine output 4) With prerenal failure, hemodialysis reduces the BUN level

3) Prerenal failure is caused by such conditions as hypovolemia that impairs kidney perfusion; giving isotonic fluids improves urine output. Vasoactive substances can increase blood pressure in both conditions.

A hospitalized patient is in the oliguric phase of acute renal failure. The nurse should implement which of the following? Select all that apply. A. Keep strict intake and output records. B. Closely monitor potassium levels. C. Administer dopamine to increase renal perfusion. D. Limit fluid intake. E. Administer laxatives to prevent fluid overload.

A, B, D

Which sign indicated the second phase of acute renal failure? 1. Daily doubling of urine output (4 to 5 L/day) 2. Urine output less than 400 ml/day 3. Urine output less than 100 ml/day 4. Stabilization of renal function

1. Daily doubling of the urine output indicates that the nephrons are healing. This means the patient is passing into the second phase (dieresis) of acute renal failur

You're developing a care plan with the nursing diagnosis risk for infection for your patient that received a kidney transplant. A goal for this patient is to: 1) Remain afebrile and have negative cultures 2) Resume normal fluid intake within 2 to 3 days 3) Resume the patient's normal job within 2 to 3 weeks 4) Try to discontinue cyclosporine (Neoral) as quickly as possible

1) The immunosuppressive activity of cyclosporine places the patient at risk for infection, and steroids can mask the signs of infection. The patient may not be able to resume normal fluid intake or return to work for an extended period of time and the patient may need cyclosporine therapy for life.

Which cause of hypertension is the most common in acute renal failure? 1) Pulmonary edema 2) Hypervolemia 3) Hypovolemia 4) Anemia

2) Acute renal failure causes hypervolemia as a result of overexpansion of extracellular fluid and plasma volume with the hypersecretion of rennin. Therefore, hypervolemia causes hypertension.

A patient has developed acute renal failure (ARF) with a 24-hour urine output of 350 mL. The nurse should assess the patient for: Pruritus Polyphagia Cardiac arrhythmias Tetany

3)

Which of the following symptoms indicate acute rejection of a transplanted kidney? 1) Edema, nausea 2) Fever, anorexia 3) Weight gain, pain at graft site 4) Increased WBC count, pain with voiding

3)

The client is to undergo kidney transplantation with a living donor. Which of the following preoperative assessments is important? 1) Urine output 2) Signs of graft rejection 3) Signs and symptoms of rejection 4) Client's support system and understanding of lifestyle changes.

4)

In the immediate postoperative period, the nurse caring for a patient who is a recipient of a kidney transplant would expect that fluid therapy would involve administration of IV fluids a. to be determined hourly, based on every milliliter of urine output. b. at a minimum rate of 100 ml/hr to perfuse the kidney. c. titrated to keep blood pressure within a normal range. d. at a rate to keep urine clear and without blood clots.

Answer: A Rationale: Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. Fluid infusion rate is titrated rather than being at a set rate. Blood pressure and urine appearance are not the major parameters considered when titrating fluid infusion.

For a male client in the oliguric phase of acute renal failure (ARF), which nursing intervention is most important? A. Encouraging coughing and deep breathing B. Promoting carbohydrate intake C. Limiting fluid intake D. Providing pain-relief measures

C.

The client with acute renal failure has a serum potassium of 6.0 mEq/L. The nurse would plan which of the following as a priority action? a) check the sodium level b) place the client on a cardiac monitor c) encourage increased vegetables in the diet d) allow an extra 500 ml of fluid intake to dilute the electrolyte concentration

b) place the client on a cardiac monitor