Chapter 47 Nursing Management: Acute Kidney Injury and Chronic Kidney Disease (9th Edition) // CHAPTER 46 Acute Kidney & Chronic Kidney Disease (10th Edition)

Question 1

1. Which descriptions characterize acute kidney injury (select all that apply)?
   a. Primary cause of death is infection.
   b. It almost always affects older people.
   c. Disease course is potentially reversible.
   d. Most common cause is diabetic nephropathy.
   e. Cardiovascular disease is most common cause of death.

Answer 1

a. Primary cause of death is infection.
c. Disease course is potentially reversible.

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Question 2

2. RIFLE defines three stages of AKI based on changes in
   a. blood pressure and urine osmolality.
   b. fractional excretion of urinary sodium.
   c. estimation of GFR with the MDRD equation.
   d. serum creatinine or urine output from baseline.

Answer 2

d. serum creatinine or urine output from baseline.

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Question 3

3. During the oliguric phase of AKI, the nurse monitors the patient for (select all that apply)

a. hypotension.
b. ECG changes.
c. hypernatremia.
d. pulmonary edema.
e. urine with high specific gravity.

Answer 3

b. ECG changes.
d. pulmonary edema.

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Question 4

4. If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalances?
   a. Hyperkalemia and hyponatremia
   b. Hyperkalemia and hypernatremia
   c. Hypokalemia and hyponatremia
   d. Hypokalemia and hypernatremia

Answer 4

c. Hypokalemia and hyponatremia

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Question 5

*** 5. A patient is admitted to the hospital with chronic kidney disease. The nurse understands that this condition is characterized by

a. progressive irreversible destruction of the kidneys.
b. a rapid decrease in urine output with an elevated BUN.
c. an increasing creatinine clearance with a decrease in urine output.
d. prostration, somnolence, and confusion with coma and imminent death.

Answer 5

a. progressive irreversible destruction of the kidneys.

Chapter 47 Nursing Management: Acute Kidney Injury and Chronic Kidney Disease (9th Edition)
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Question 6

6. Nurses need to teach patients at risk for developing chronic kidney disease. Individuals considered to be at increased risk include (select all that apply)
   a. older African Americans.
   b. patients more than 60 years old.
   c. those with a history of pancreatitis.
   d. those with a history of hypertension.
   e. those with a history of type 2 diabetes.

Answer 6

a. older African Americans.
b. patients more than 60 years old.
d. those with a history of hypertension.
e. those with a history of type 2 diabetes.

Chapter 47 Nursing Management: Acute Kidney Injury and Chronic Kidney Disease (9th Edition)
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Question 7

7. Patients with chronic kidney disease experience an increased incidence of cardiovascular disease related to (select all that apply)
   a. hypertension.
   b. vascular calcifications.
   c. a genetic predisposition.
   d. hyperinsulinemia causing dyslipidemia.
   e. increased high-density lipoprotein levels.

Answer 7

a. hypertension.
b. vascular calcifications.
d. hyperinsulinemia causing dyslipidemia.

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Question 8

8. Nutritional support and management are essential across the entire continuum of chronic kidney disease. Which statements would be considered true related to nutritional therapy (select all that apply)?
   a. Fluid is not usually restricted for patients receiving peritoneal dialysis.
   b. Sodium and potassium may be restricted in someone with advanced CKD.
   c. Decreased fluid intake and a low potassium diet are hallmarks of the diet for a patient receiving hemodialysis.
   d. Decreased fluid intake and a low potassium diet are hallmarks of the diet for a patient receiving peritoneal dialysis.
   e. Increased fluid intake and a diet with potassium-rich foods are hallmarks of a diet for a patient receiving hemodialysis.

Answer 8

a. Fluid is not usually restricted for patients receiving peritoneal dialysis.
b. Sodium and potassium may be restricted in someone with advanced CKD.
c. Decreased fluid intake and a low potassium diet are hallmarks of the diet for a patient receiving hemodialysis.

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Question 9

9. An ESKD patient receiving hemodialysis is considering asking a relative to donate a kidney for transplantation. In assisting the patient to make a decision about treatment, the nurse informs the patient that
   a. successful transplantation usually provides better quality of life than that offered by dialysis.
   b. if rejection of the transplanted kidney occurs, no further treatment for the renal failure is available.
   c. hemodialysis replaces the normal functions of the kidneys, and patients do not have to live with the continual fear of rejection.
   d. the immunosuppressive therapy following transplantation makes the person ineligible to receive other forms of treatment if the kidney fails.

Answer 9

a. successful transplantation usually provides better quality of life than that offered by dialysis.

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Question 10

10. To assess the patency of a newly placed arteriovenous graft for dialysis, the nurse should (select all that apply)
    a. monitor the BP in the affected arm.
    b. irrigate the graft daily with low-dose heparin.
    c. palpate the area of the graft to feel a normal thrill.
    d. listen with a stethoscope over the graft to detect a bruit.
    e. frequently monitor the pulses and neurovascular status distal to the graft.

Answer 10

c. palpate the area of the graft to feel a normal thrill.
d. listen with a stethoscope over the graft to detect a bruit.
e. frequently monitor the pulses and neurovascular status distal to the graft.

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Question 11

11. A major advantage of peritoneal dialysis is
    a. the diet is less restricted and dialysis can be performed at home.
    b. the dialysate is biocompatible and causes no long-term consequences.
    c. high glucose concentrations of the dialysate cause a reduction in appetite, promoting weight loss.
    d. no medications are required because of the enhanced efficiency of the peritoneal membrane in removing toxins.

Answer 11

a. the diet is less restricted and dialysis can be performed at home.

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Question 12

12. A kidney transplant recipient complains of having fever, chills, and dysuria over the past 2 days. What is the first action that the nurse should take?
    a. Assess temperature and initiate workup to rule out infection.
    b. Reassure the patient that this is common after transplantation.
    c. Provide warm cover for the patient and give 1 g acetaminophen orally.
    d. Notify the nephrologist that the patient has developed symptoms of acute rejection.

Answer 12

a. Assess temperature and initiate workup to rule out infection.

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Question 13

*** 1. A 52-year-old man with stage 2 chronic kidney disease is scheduled for an outpatient diagnostic procedure using contrast media. Which action should the nurse take?

a. Assess skin turgor to determine hydration status.
b. Insert a urinary catheter for the expected diuresis.
c. Evaluate the patient’s lower extremities for edema.
d. Check the patient’s urine for the presence of ketones.

Answer 13

a. Assess skin turgor to determine hydration status.

Preexisting kidney disease is the most important risk factor for the development of contrast-associated nephropathy and nephrotoxic injury. If contrast media must be administered to a high-risk patient, the patient needs to have optimal hydration. The nurse should assess the hydration status of the patient before the procedure is performed. Indwelling catheter use should be avoided whenever possible to decrease the risk of infection.

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Question 14

2. A frail 72-year-old woman with stage 3 chronic kidney disease is cared for at home by her family. The patient has a history of taking many over-the-counter medications. Which over-the-counter medications should the nurse teach the patient to avoid?
   a. Aspirin
   b. Acetaminophen (Tylenol)
   c. Diphenhydramine (Benadryl)
   d. Aluminum hydroxide (Amphogel)

Answer 14

d. Aluminum hydroxide (Amphogel)

Antacids (that contain magnesium and aluminum) should be avoided because patients with kidney disease are unable to excrete these substances. Also, some antacids contain high levels of sodium that further increase blood pressure. Acetaminophen and aspirin (if taken for a short period of time) are usually safe for patients with kidney disease. Antihistamines may be used, but combination drugs that contain pseudoephedrine may increase blood pressure and should be avoided.

Chapter 47 Nursing Management: Acute Kidney Injury and Chronic Kidney Disease (9th Edition)
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Question 15

3. The nurse is caring for a 68-year-old man who had coronary artery bypass surgery 3 weeks ago. If the patient is now is in the oliguric phase of acute kidney disease, which action would be appropriate to include in the plan of care?
   a. Provide foods high in potassium.
   b. Restrict fluids based on urine output.
   c. Monitor output from peritoneal dialysis.
   d. Offer high protein snacks between meals.

Answer 15

b. Restrict fluids based on urine output.

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.

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Question 16

4. A 56-year-old woman with type 2 diabetes mellitus and chronic kidney disease has a serum potassium level of 6.8 mEq/L. The nurse should assess the patient for
   a. fatigue.
   b. flank tenderness.
   c. cardiac dysrhythmias.
   d. elevated triglycerides.

Answer 16

c. cardiac dysrhythmias.

Hyperkalemia is the most serious electrolyte disorder associated with kidney disease. Fatal dysrhythmias can occur when the serum potassium level reaches 7 to 8 mEq/L. Fatigue and hypertriglyceridemia may be present but do not require urgent intervention. Tenderness or pain over the kidneys is not expected in CKD.

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Question 17

5. The home care nurse visits a 34-year-old woman receiving peritoneal dialysis. Which statement, if made by the patient, indicates a need for immediate follow-up by the nurse?
   a. “Drain time is faster if I rub my abdomen.”
   b. “The fluid draining from the catheter is cloudy.”
   c. “The drainage is bloody when I have my period.”
   d. “I wash around the catheter with soap and water.”

Answer 17

b. “The fluid draining from the catheter is cloudy.”

The primary clinical manifestation of peritonitis is a cloudy peritoneal effluent. Blood may be present in the effluent of women who are menstruating, and no intervention is indicated. Daily catheter care may include washing around the catheter with soap and water. Drain time may be facilitated by gently massaging the abdomen.

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Question 18

1. The patient has had type 1 diabetes mellitus for 25 years and is now reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse finds that the patient has newly developed hypertension and difficulty with blood glucose control. The nurse should know that which diagnostic study will be most indicative of chronic kidney disease (CKD) in this patient?
   a. Serum creatinine
   b. Serum potassium
   c. Microalbuminuria
   d. Calculated glomerular filtration rate (GFR)

Answer 18

d. Calculated glomerular filtration rate (GFR)

The best study to determine kidney function or chronic kidney disease (CKD) that would be expected in the patient with diabetes is the calculated GFR that is obtained from the patient’s age, gender, race, and serum creatinine. It would need to be abnormal for 3 months to establish a diagnosis of CKD. A creatinine clearance test done with a blood sample and a 24-hour urine collection is also important. Serum creatinine is not the best test for CKD because the level varies with different patients. Serum potassium levels could explain why the patient has an irregular heartbeat. The finding of microalbuminuria can alert the patient with diabetes about potential renal involvement and potentially failing kidneys. However, urine albumin levels are not used for diagnosis of CKD.

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Question 19

2. Which statement by the nurse regarding continuous ambulatory peritoneal dialysis (CAPD) would be of highest priority when teaching a patient new to this procedure?
   a. “It is essential that you maintain aseptic technique to prevent peritonitis.”
   b. “You will be allowed a more liberal protein diet once you complete CAPD.”
   c. “It is important for you to maintain a daily written record of blood pressure and weight.”
   d. “You will need to continue regular medical and nursing follow-up visits while performing CAPD.”

Answer 19

a. “It is essential that you maintain aseptic technique to prevent peritonitis.”

Peritonitis is a potentially fatal complication of peritoneal dialysis, and thus it is imperative to teach the patient methods of preventing this from occurring. Although the other teaching statements are accurate, they do not have the potential for morbidity and mortality as does peritonitis, thus making that statement of highest priority.

Chapter 47 Nursing Management: Acute Kidney Injury and Chronic Kidney Disease (9th Edition)
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Question 20

3. Which assessment finding is a consequence of the oliguric phase of AKI?
   a. Hypovolemia
   b. Hyperkalemia
   c. Hypernatremia
   d. Thrombocytopenia

Answer 20

b. Hyperkalemia

In AKI the serum potassium levels increase because the normal ability of the kidneys to excrete potassium is impaired. Sodium levels are typically normal or diminished, whereas fluid volume is normally increased because of decreased urine output. Thrombocytopenia is not a consequence of AKI, although altered platelet function may occur in AKI.

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Question 21

4. The patient has a form of glomerular inflammation that is progressing rapidly. She is gaining weight, and the urine output is steadily declining. What is the priority nursing intervention?
   a. Monitor the patient’s cardiac status.
   b. Teach the patient about hand washing.
   c. Obtain a serum specimen for electrolytes.
   d. Increase direct observation of the patient.

Answer 21

a. Monitor the patient’s cardiac status.

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.

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Question 22

5. A 78-year-old patient has Stage 3 CKD and is being taught about a low potassium diet. The nurse knows the patient understands the diet when the patient selects which foods to eat?
   a. Apple, green beans, and a roast beef sandwich
   b. Granola made with dried fruits, nuts, and seeds
   c. Watermelon and ice cream with chocolate sauce
   d. Bran cereal with ½ banana and milk and orange juice

Answer 22

a. Apple, green beans, and a roast beef sandwich

When the patient selects an apple, green beans, and a roast beef sandwich, the patient demonstrates understanding of the low potassium diet. Granola, dried fruits, nuts and seeds, milk products, chocolate sauce, bran cereal, banana, and orange juice all have elevated levels of potassium, at or above 200 mg per 1/2 cup.

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Question 23

6. The patient was diagnosed with prerenal AKI. The nurse should know that what is most likely the cause of the patient’s diagnosis?
   a. IV tobramycin (Nebcin)
   b. Incompatible blood transfusion
   c. Poststreptococcal glomerulonephritis
   d. Dissecting abdominal aortic aneurysm

Answer 23

d. Dissecting abdominal aortic aneurysm

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 poststretpcoccal glomerulonephritis are intrarenal causes of AKI.

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Question 24

*** 7. Which patient should be taught preventive measures for CKD by the nurse because this patient is most likely to develop CKD?

a. A 50-year-old white female with hypertension
b. A 61-year-old Native American male with diabetes
c. A 40-year-old Hispanic female with cardiovascular disease
d. A 28-year-old African American female with a urinary tract infection

Answer 24

b. A 61-year-old Native American male with diabetes

It is especially important for the nurse to teach CKD prevention to the 61-year-old Native American with diabetes. This patient is at highest risk because diabetes causes about 50% of CKD. This patient is the oldest, and Native Americans with diabetes develop CKD 6 times more frequently than other ethnic groups. Hypertension causes about 25% of CKD. Hispanics have CKD about 1.5 times more than non-Hispanics. African Americans have the highest rate of CKD because hypertension is significantly increased in African Americans. A UTI will not cause CKD unless it is not treated or UTIs occur recurrently.

Chapter 47 Nursing Management: Acute Kidney Injury and Chronic Kidney Disease (9th Edition)
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Question 25

8. When caring for a patient during the oliguric phase of acute kidney injury (AKI), what is an appropriate nursing intervention?
   a. Weigh patient three times weekly.
   b. Increase dietary sodium and potassium.
   c. Provide a low-protein, high-carbohydrate diet.
   d. Restrict fluids according to previous daily loss.

Answer 25

d. Restrict fluids according to previous daily loss.

Patients in the oliguric phase of acute kidney injury 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.

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Question 26

9. A 24-year-old female donated a kidney via a laparoscopic donor nephrectomy to a non-related recipient. The patient is experiencing a lot of pain and refuses to get up to walk. How should the nurse handle this situation?
   a. Have the transplant psychologist convince her to walk.
   b. Encourage even a short walk to avoid complications of surgery.
   c. Tell the patient that no other patients have ever refused to walk.
   d. Tell the patient she is lucky she did not have an open nephrectomy.

Answer 26

b. Encourage even a short walk to avoid complications of surgery.

Because ambulating will improve bowel, lung, and kidney function with improved circulation, even a short walk with assistance should be encouraged after pain medication. The transplant psychologist or social worker’s role is to determine if the patient is emotionally stable enough to handle donating a kidney, while postoperative care is the nurse’s role. Trying to shame the patient into walking by telling her that other patients have not refused and telling the patient she is lucky she did not have an open nephrectomy (implying how much more pain she would be having if it had been open) will not be beneficial to the patient or her postoperative recovery.

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Question 27

10. A patient is recovering in the intensive care unit (ICU) after receiving a kidney transplant approximately 24 hours ago. What is an expected assessment finding for this patient during this early stage of recovery?
    a. Hypokalemia
    b. Hyponatremia
    c. Large urine output
    d. Leukocytosis with cloudy urine output

Answer 27

c. Large urine output

Patients frequently experience diuresis in the hours and days immediately following a kidney transplant. Electrolyte imbalances and signs of infection are unexpected findings that warrant prompt intervention.

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Question 28

11. The nurse preparing to administer a dose of calcium acetate (PhosLo) to a patient with chronic kidney disease (CKD) should know that this medication should have a beneficial effect on which laboratory value?
    a. Sodium
    b. Potassium
    c. Magnesium
    d. Phosphorus

Answer 28

d. Phosphorus

Phosphorus and calcium have inverse or reciprocal relationships, meaning that when phosphorus levels are high, calcium levels tend to be low. Therefore administration of calcium should help to reduce a patient’s abnormally high phosphorus level, as seen with CKD. PhosLo will not have an effect on sodium, potassium, or magnesium levels.

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Question 29

12. Diffusion, osmosis, and ultrafiltration occur in both hemodialysis and peritoneal dialysis. The nurse should know that ultrafiltration in peritoneal dialysis is achieved by which method?
    a. Increasing the pressure gradient
    b. Increasing osmolality of the dialysate
    c. Decreasing the glucose in the dialysate
    d. Decreasing the concentration of the dialysate

Answer 29

b. Increasing osmolality of the dialysate

Ultrafiltration in peritoneal dialysis is achieved by increasing the osmolality of the dialysate with additional glucose. In hemodialysis the increased pressure gradient from increased pressure in the blood compartment or decreased pressure in the dialysate compartment causes ultrafiltration. Decreasing the concentration of the dialysate in either peritoneal or hemodialysis will decrease the amount of fluid removed from the blood stream.

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Question 30

13. During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do for the patient?
    a. Administer hypertonic saline.
    b. Administer a blood transfusion.
    c. Decrease the rate of fluid removal.
    d. Administer antiemetic medications.

Answer 30

c. Decrease the rate of fluid removal.

The patient is experiencing hypotension from a rapid removal of vascular volume. The rate and volume of fluid removal will be decreased, and 0.9% saline solution may be infused. Hypertonic saline is not used because of the high sodium load. A blood transfusion is not indicated. Antiemetic medications may help the nausea but would not help the hypovolemia.

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Question 31

14. The nurse knows the patient with AKI has entered the diuretic phase when what assessments occur (select all that apply)?

a. Dehydration
b. Hypokalemia
c. Hypernatremia
d. BUN increases
e. Serum creatinine increases

Answer 31

a. Dehydration
b. Hypokalemia

Dehydration, hypokalemia, and hyponatremia occur in the diuretic phase of AKI because the nephrons can excrete wastes but not concentrate urine. Therefore the serum BUN and serum creatinine levels also begin to decrease.

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Question 32

15. A patient with a history of end-stage kidney disease secondary to diabetes mellitus has presented to the outpatient dialysis unit for his scheduled hemodialysis. Which assessments should the nurse prioritize before, during, and after his treatment?
    a. Level of consciousness
    b. Blood pressure and fluid balance
    c. Temperature, heart rate, and blood pressure
    d. Assessment for signs and symptoms of infection

Answer 32

b. Blood pressure and fluid balance

Although all of the assessments are relevant to the care of a patient receiving hemodialysis, the nature of the procedure indicates a particular need to monitor the patient’s blood pressure and fluid balance.

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Question 33

16. The physician has decided to use renal replacement therapy to remove large volumes of fluid from a patient who is hemodynamically unstable in the intensive care unit. The nurse should expect which treatment to be used for this patient?
    a. Hemodialysis (HD) 3 times per week
    b. Automated peritoneal dialysis (APD)
    c. Continuous venovenous hemofiltration (CVVH)
    d. Continuous ambulatory peritoneal dialysis (CAPD)

Answer 33

c. Continuous venovenous hemofiltration (CVVH)

CVVH removes large volumes of water and solutes from the patient over a longer period of time by using ultrafiltration and convection. HD 3 times per week would not be used for this patient because fluid and solutes build up and then are rapidly removed. With APD (used at night instead of during the day) fluid and solutes build up during the day and would not benefit this patient as much. CAPD will not as rapidly remove large amounts of fluid as CVVH can do.

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