Chapter 51: CKD Flashcards

Question

A patient with CKD has a GFR of 55 mL/min/1.73 m². Which clinical intervention is most appropriate at this stage? A. Diagnosis and cardiovascular risk reduction B. Aggressive management of CKD-related complications C. Preparation for RRT, such as dialysis or kidney transplant D. Evaluation and treatment of CKD-related complications

Answer 1

D. Evaluation and treatment of CKD-related complications Rationale: A GFR of 55 mL/min/1.73 m² corresponds to Stage 3a CKD. The appropriate clinical action at this stage includes evaluating and treating complications. Cardiovascular risk reduction is emphasized in Stage 1, while aggressive complication management and RRT preparation occur in later stages.

Answer 2

B. Initiate dialysis immediately due to symptoms of uremia Rationale: A GFR of 18 mL/min/1.73 m² corresponds to Stage 4 CKD, but the presence of symptoms such as fatigue, nausea, and confusion indicates uremia, which requires immediate initiation of dialysis. Kidney transplantation and dietary changes are important but not the priority in this situation. Waiting 3 months to repeat testing could worsen the patient’s condition.

Answer 3

B. “Focus on cardiovascular risk reduction and monitoring kidney function.” Rationale: Stage 1 CKD is characterized by kidney damage with a normal or increased GFR (≥90 mL/min/1.73 m²). The focus at this stage is on cardiovascular risk reduction, early diagnosis, and routine monitoring. Dietary restrictions are unnecessary unless complications arise, and nephrotoxic drugs should be avoided.

Answer 4

D. 12 mL/min/1.73 m² Rationale: A GFR of <15 mL/min/1.73 m² indicates Stage 5 CKD. At this stage, dialysis or another form of RRT is initiated if uremia is present. GFR values of 70, 48, and 22 correspond to Stages 2, 3a, and 4, respectively, where RRT preparation or other interventions are the focus.

Answer 5

B. “We will focus on preparing you for dialysis or a kidney transplant.” Rationale: In Stage 4 CKD (GFR 15–29 mL/min/1.73 m²), preparation for RRT, such as dialysis or kidney transplant, is essential. While dietary changes are part of managing CKD, they cannot fully stop progression. Claiming that CKD progression cannot be managed is incorrect, as interventions can slow disease advancement.

Answer 6

B. Uremia Rationale: Uremia is a syndrome that occurs when kidney function declines to the point that toxins, such as urea and creatinine, accumulate in the body, typically when the GFR is 15 mL/min or less. Symptoms such as fatigue, pruritus, and confusion are characteristic of uremia. While hyperkalemia can also occur in CKD, the combination of these systemic symptoms is more indicative of uremia.

Answer 7

A. Retention of water and electrolytes Rationale: As kidney function deteriorates, the kidneys are unable to excrete water, urea, creatinine, and electrolytes, leading to fluid overload, generalized edema, and hypertension. Hormonal imbalances may contribute to other symptoms, but retention of water and electrolytes is the primary cause of these specific manifestations.

Answer 8

A. Peripheral neuropathy B. Pruritus D. Metallic taste in the mouth E. Confusion Rationale: Uremia can cause systemic symptoms due to the accumulation of toxins in the body. Peripheral neuropathy, pruritus, a metallic taste in the mouth, and confusion are common manifestations. Increased energy levels are not associated with uremia; patients often experience fatigue instead.

Answer 9

D. Prepare the patient for initiation of dialysis Rationale: Uremic symptoms develop when toxins accumulate due to severely decreased kidney function, typically at a GFR of 15 mL/min or less. Initiating dialysis is the priority to remove these toxins. While sodium bicarbonate and fluid restriction may be part of the management plan, they are not sufficient to address uremia. A high-protein diet is generally avoided in advanced CKD to reduce the production of nitrogenous waste.

Answer 10

A. Retention of urea and other waste products Rationale: Pruritus and a metallic taste in the mouth are caused by the accumulation of urea and other waste products in the body due to reduced kidney function. These symptoms are hallmark features of uremia. Hyperkalemia and hormonal imbalances can cause other systemic effects, but they do not directly result in these symptoms.

Answer 11

C. Discuss initiation of dialysis with the healthcare provider Rationale: A GFR of 13 mL/min indicates Stage 5 CKD with uremia. Symptoms such as nausea, muscle twitching, and lethargy are consistent with uremic toxicity. The priority intervention is initiating dialysis to remove accumulated toxins. Monitoring potassium levels and addressing dietary restrictions are important but secondary to managing uremia immediately.

Answer 12

A. Excess glucose levels associated with diabetes Rationale: In the early stages of CKD, patients typically do not experience significant changes in urine output due to kidney disease. However, since diabetes is the leading cause of CKD, polyuria is likely related to hyperglycemia causing osmotic diuresis. Fluid retention and anuria are more commonly seen in advanced CKD.

Answer 13

C. Anuria Rationale: Anuria, or the complete absence of urine output, is a hallmark of end-stage CKD and occurs after a prolonged period on dialysis. In earlier stages, patients may experience polyuria or nocturia, but anuria is a significant indicator of advanced disease progression.

Answer 14

A. Difficulty with fluid retention B. Anuria after dialysis D. Oliguria as GFR declines E. Proteinuria in early stages Rationale: As CKD progresses, patients often develop difficulty with fluid retention (leading to edema) and eventually anuria, particularly after prolonged dialysis. Oliguria (reduced urine output) is common as kidney function declines. Proteinuria often occurs in the early stages of CKD due to glomerular damage. Polyuria is more likely due to diabetes than CKD progression.

Answer 15

B. Administer diuretic therapy as prescribed Rationale: Reduced urine output and fluid retention (manifested as swelling) in CKD are managed initially with diuretic therapy to aid in fluid elimination. Dialysis may be needed in severe cases but is not the immediate response in this scenario. Increasing fluid intake would worsen fluid overload, and protein restriction is aimed at managing uremia, not fluid retention.

Answer 16

D. “My urine output will likely decrease over time, and I may stop making urine after starting dialysis.” Rationale: As CKD progresses, patients often experience decreasing urine output due to reduced kidney function, and anuria may develop after a period of dialysis. Diuretic therapy can help manage fluid retention but does not guarantee consistent urine output. Increased urine output is typically seen in conditions such as diabetes, not as CKD worsens.

Answer 17

C. Serum Creatinine Clearance Rationale: Serum creatinine clearance (calculated GFR) is the most accurate indicator of kidney function because it reflects the ability of the kidneys to filter waste products. BUN levels can be influenced by other factors such as protein intake and catabolism, and serum creatinine alone is less reliable without the GFR calculation.

Answer 18

A. Nausea, lethargy, and headaches Rationale: Elevated BUN levels contribute to symptoms such as nausea, vomiting, lethargy, fatigue, impaired cognition, and headaches. These symptoms result from the accumulation of nitrogenous waste products in the bloodstream.

Answer 19

C. Cellular resistance to insulin Rationale: Impaired glucose metabolism due to cellular insensitivity to insulin leads to hyperinsulinemia in CKD. This occurs because the kidneys, which normally help excrete insulin, are unable to function properly, causing insulin to remain in circulation longer.

Answer 20

A. Hyperglycemia B. Dyslipidemia D. Hypertriglyceridemia E. Decreased HDL levels Rationale: CKD leads to hyperglycemia and hyperinsulinemia due to impaired glucose metabolism. Dyslipidemia occurs with increased VLDL and LDL levels and decreased HDL levels. Hypertriglyceridemia results from increased hepatic triglyceride production. Hypoinsulinemia is not associated with CKD.

Answer 21

C. Prescribe lipid-lowering agents as ordered Rationale: Lipid-lowering agents are used to manage dyslipidemia, which is common in CKD due to increased VLDL and LDL levels and decreased HDL levels. Corticosteroids and increased carbohydrate intake would exacerbate the condition, while dietary protein adjustments do not directly address lipid abnormalities.

Answer 22

B. Decreased insulin doses Rationale: In CKD, insulin remains in the circulation longer because it is excreted by the kidneys. When dialysis is initiated, patients often require less insulin as kidney function and glucose metabolism improve, though not to normal levels.

Answer 23

D. Accumulation of waste products Rationale: Elevated BUN and creatinine levels indicate waste product accumulation due to decreased kidney function. This contributes to symptoms such as fatigue, impaired cognition, and lethargy.

Answer 24

A. Increased protein intake B. Fever C. Corticosteroid use D. Dehydration Rationale: Elevated BUN levels can result from factors such as increased protein intake, fever (increased catabolism), corticosteroid use, and dehydration. Hypoglycemia does not directly affect BUN levels.

Answer 25

A. Increased LDL, decreased HDL, and increased triglycerides Rationale: Dyslipidemia in CKD typically involves increased LDL and VLDL levels, decreased HDL levels, and elevated triglycerides due to altered lipid metabolism.

Answer 26

A. Prepare the patient for dialysis Rationale: The patient’s GFR indicates severe kidney dysfunction (Stage 4 or 5 CKD), and the high BUN level suggests significant waste product accumulation. Dialysis is the priority intervention to manage uremia and prevent further complications. Antiemetics may provide symptom relief but do not address the underlying issue.

Answer 27

C. Prolonged insulin activity due to decreased renal clearance Rationale: In CKD, the kidneys cannot effectively excrete insulin, leading to prolonged insulin activity in the bloodstream. As a result, patients may require less insulin to manage blood glucose levels. This makes close monitoring essential.

Answer 28

A. Elevated LDL levels C. Elevated triglycerides D. Increased VLDL levels E. Decreased lipoprotein lipase activity Rationale: Dyslipidemia in CKD is characterized by elevated LDL, triglycerides, and VLDL levels, along with decreased HDL and reduced activity of lipoprotein lipase, which impairs the breakdown of lipoproteins.

Answer 29

A. Decrease protein intake to reduce nitrogenous waste Rationale: Reducing protein intake can help decrease nitrogenous waste production, thereby lowering BUN levels and alleviating symptoms like nausea and cognitive impairment. Fluid and sodium restriction are important but not directly related to BUN. Antiemetics address symptoms but do not resolve the underlying problem.

Answer 30

B. Enhanced hepatic triglyceride production Rationale: Hypertriglyceridemia in CKD results from increased hepatic triglyceride production due to hyperinsulinemia and decreased lipoprotein lipase activity, which impairs lipid breakdown.

Answer 31

D. Lower LDL and triglyceride levels to reduce CVD risk Rationale: The primary goal in managing dyslipidemia in CKD is to lower LDL and triglyceride levels to reduce the risk of cardiovascular disease (CVD), which is the leading cause of death in CKD patients. Dialysis may improve metabolism but is not the first step for lipid management.

Answer 32

D. Retention of nitrogenous waste products

Answer 33

B. Hyperkalemia Rationale: Hyperkalemia is the most critical electrolyte imbalance in CKD, as potassium levels of 7–8 mEq/L can lead to fatal dysrhythmias. This requires immediate intervention to prevent cardiac complications.

Answer 34

C. Impaired renal potassium excretion Rationale: In CKD, the kidneys’ ability to excrete potassium is diminished, leading to hyperkalemia. Although dietary intake may contribute, impaired excretion is the primary cause.

Answer 35

C. Sodium retention Rationale: Sodium retention is common in CKD due to impaired sodium excretion. This leads to fluid retention, contributing to edema and hypertension.

Answer 36

B. Dysrhythmias C. Hypotension D. Decreased mental status Rationale: Hypermagnesemia in CKD can lead to serious complications such as dysrhythmias, hypotension, and decreased mental status. Hypermagnesemia suppresses reflexes rather than increasing them. Seizures are not a common manifestation.

Answer 37

C. 2 g/day Rationale: Sodium intake in CKD is often restricted to 2 g/day to prevent sodium retention, which can contribute to fluid overload, edema, and hypertension.

Answer 38

C. Mild metabolic acidosis Rationale: In CKD, metabolic acidosis occurs due to the impaired excretion of acid and defective bicarbonate regeneration. A plasma bicarbonate level of 18 mEq/L indicates mild metabolic acidosis.

Answer 39

C. Bone demineralization Rationale: In CKD, bone demineralization serves as a compensatory mechanism by buffering metabolic acids. This prevents plasma bicarbonate levels from falling below 16–20 mEq/L.

Answer 40

B. Peripheral edema Rationale: Dilutional hyponatremia results from sodium retention with excess water, leading to peripheral edema. Muscle twitching and tachycardia are not common findings.

Answer 41

A. BUN levels are affected by protein intake and catabolism Rationale: BUN levels can be influenced by factors such as protein intake, fever, and corticosteroid use, making serum creatinine clearance (calculated GFR) a more reliable indicator of kidney function.

Answer 42

C. Limit the use of magnesium-containing medications Rationale: To prevent hypermagnesemia in CKD, it is important to avoid magnesium-containing medications such as antacids and laxatives, as the kidneys cannot effectively excrete magnesium.

Answer 43

B. Promotes bone demineralization Rationale: In CKD, metabolic acidosis promotes bone demineralization as a compensatory mechanism to buffer excess acids. This can contribute to weakened bones over time.

Answer 44

A. Breakdown of cellular protein C. Metabolic acidosis D. Bleeding Rationale: Hyperkalemia in CKD results from impaired potassium excretion, breakdown of cellular protein, bleeding, and metabolic acidosis. Decreased potassium intake and increased excretion would not lead to hyperkalemia.

Answer 45

B. Serum bicarbonate level of 16–20 mEq/L Rationale: In CKD, plasma bicarbonate levels typically stabilize at 16–20 mEq/L as bone demineralization compensates for excess acid, reflecting the body’s buffering capacity.

Answer 46

C. Decreased erythropoietin production Rationale: Anemia in CKD primarily results from decreased erythropoietin production. Erythropoietin stimulates the bone marrow to produce RBCs, and its deficiency is a hallmark of CKD-related anemia.

Answer 47

B. Parathyroid hormone (PTH) Rationale: Increased PTH levels in CKD can inhibit erythropoiesis, shorten RBC survival, and cause bone marrow fibrosis, contributing to anemia.

Answer 48

C. Normocytic, normochromic Rationale: Anemia in CKD is normocytic and normochromic, indicating that the RBCs are normal in size and color but fewer in number due to decreased erythropoietin production.

Answer 49

A. Impaired platelet function Rationale: Impaired platelet function due to decreased aggregation and release of platelet factor III is the most common cause of bleeding in CKD patients with uremia.

Answer 50

A. Increased RBC hemolysis B. GI bleeding C. Frequent blood samplings E. Bone marrow fibrosis Rationale: Anemia in CKD is multifactorial, with contributing factors including increased RBC hemolysis, GI bleeding, frequent blood samplings, and bone marrow fibrosis due to increased PTH levels. RBC lifespan is decreased, not increased.

Answer 51

C. Folic acid Rationale: Folic acid, which is water-soluble and dialyzable, is essential for RBC maturation. CKD patients often require daily folic acid supplementation (1 mg/day).

Answer 52

D. Intravenous (IV) iron therapy Rationale: IV iron therapy is the most effective method for restoring iron levels in dialysis patients, as oral iron supplements may not be well absorbed and can cause GI side effects.

Answer 53

D. Improves platelet aggregation Rationale: Regular dialysis corrects bleeding tendencies in CKD by improving platelet aggregation and normalizing the release of platelet factor III, addressing the underlying platelet dysfunction.

Answer 54

B. Suppressed cellular and humoral immunity Rationale: CKD suppresses both cellular and humoral immune responses, leading to an increased risk of infection. These changes impair the body’s ability to fight infections effectively.

Answer 55

C. Vascular access catheter insertions Rationale: Vascular access for hemodialysis, such as catheters and needle insertions, increases the risk of infection by providing entry points for pathogens.

Answer 56

B. Macrocytic RBCs Rationale: Macrocytic RBCs can indicate a folic acid deficiency. Folic acid is dialyzable and needs to be supplemented in CKD patients to prevent anemia related to RBC maturation defects.

Answer 57

A. Hyperglycemia B. Impaired WBC function C. Overproduction of erythropoietin D. External trauma from vascular access Rationale: CKD patients are at higher risk of infection due to hyperglycemia, impaired WBC function, and external trauma from vascular access. Overproduction of erythropoietin and excessive platelet aggregation are not contributing factors.

Answer 58

A. Petechiae Rationale: Petechiae, small red or purple spots caused by bleeding into the skin, are a common sign of impaired platelet function, which is a hallmark of bleeding tendencies in CKD.

Answer 59

B. Cardiovascular disease (CVD) Rationale: Cardiovascular disease is the leading cause of death in CKD patients due to complications like myocardial infarction, heart failure, and stroke.

Answer 60

B. Calcium deposits in the vascular medial layer Rationale: Vascular calcification, specifically calcium deposits in the medial layer of arteries, leads to arterial stiffness in CKD patients.

Answer 61

A. Hypertension Rationale: Hypertension is both a cause and a consequence of CKD. It results from sodium retention, ECF volume expansion, and increased renin production.

Answer 62

A. Abnormal bone metabolism C. Drug therapies like calcium-phosphate binders D. Vascular smooth muscle cells changing into chondrocytes or osteoblast-like cells Rationale: Vascular calcification in CKD results from abnormal bone metabolism, drug therapies like calcium-phosphate binders, and vascular smooth muscle cells transforming into chondrocyte- or osteoblast-like cells.

Answer 63

D. Long-standing hypertension Rationale: Long-standing hypertension, extracellular fluid (ECF) volume overload, and anemia are key contributors to the development of LVH in CKD patients.

Answer 64

D. Friction rub on auscultation Rationale: Uremic pericarditis commonly presents with a pericardial friction rub, chest pain, and a low-grade fever.

Answer 65

A. Dysrhythmias Rationale: Hyperkalemia increases the risk of potentially fatal dysrhythmias due to its effect on cardiac electrical conduction.

Answer 66

A. Retinopathy B. Nephropathy C. Cardiomyopathy E. Encephalopathy Rationale: Uncontrolled hypertension in CKD patients can lead to retinopathy, nephropathy, cardiomyopathy, and encephalopathy. Hyperlipidemia, while common, is not a direct consequence of hypertension.

Answer 67

C. Managing blood pressure Rationale: Managing blood pressure is crucial in CKD management to prevent complications such as left ventricular hypertrophy, heart failure, and retinopathy.

Answer 68

B. Uremic pericarditis Rationale: Uremic pericarditis can lead to pericardial effusion and, if untreated, progress to cardiac tamponade, a life-threatening condition.

Answer 69

B. Increasing total body calcium and phosphate levels Rationale: Calcium-phosphate binders can contribute to vascular calcification by increasing total body calcium and phosphate levels, which deposit in the vasculature.

Answer 70

C. Hypertension Rationale: Sodium retention and ECF volume overload in CKD commonly lead to hypertension, which is a significant cardiovascular manifestation and a risk factor for further complications.

Answer 71

D. Kussmaul breathing Rationale: Kussmaul breathing is a deep, labored breathing pattern that helps increase CO2 removal to compensate for severe acidosis.

Answer 72

C. Pulmonary edema Rationale: Pulmonary edema occurs in CKD patients due to fluid overload, which can lead to difficulty breathing and decreased oxygenation.

Answer 73

B. Uremic pleuritis Rationale: Uremic pleuritis (or pleurisy) is an inflammation of the pleura that occurs in CKD patients, often contributing to respiratory discomfort and pain.

Answer 74

D. Fluid overload Rationale: Fluid overload, which can cause pulmonary edema and pleural effusions, is a common cause of dyspnea in CKD patients.

Answer 75

C. Provide high-protein, high-calorie foods to prevent malnutrition. Rationale: The patient’s symptoms suggest impaired oral intake and potential malnutrition. Providing high-protein, high-calorie foods helps prevent further nutritional decline and supports the healing process. While other options address symptoms, they do not directly address the nutritional risk.

Answer 76

C. Administer antiemetic medication as prescribed. Rationale: Antiemetic medication is the most appropriate intervention for managing nausea in a patient with CKD and uremic fetor. This helps reduce nausea and improve comfort. While other interventions may be helpful for overall management, antiemetic therapy directly addresses the patient’s symptom.

Answer 77

B. Administer an antiemetic before meals to prevent vomiting. Rationale: Diabetic gastroparesis causes delayed gastric emptying, contributing to nausea and vomiting. Administering antiemetic medication before meals can help prevent these symptoms and improve the patient’s ability to eat. Other interventions are less relevant for managing the gastroparesis.

Answer 78

D. Encourage the patient to engage in light exercise daily. Rationale: Light exercise is an effective intervention for promoting bowel motility and alleviating constipation. While other options may also be useful, encouraging physical activity addresses the root cause of the constipation in this patient.

Answer 79

C. Assess the patient’s platelet count and coagulation status. Rationale: GI bleeding in CKD patients is commonly related to mucosal irritation and platelet dysfunction. Assessing the patient’s platelet count and coagulation status is crucial to identify any bleeding risks and prevent further complications. While other actions are also important, monitoring coagulation parameters is the priority in this case.

Answer 80

A. Assess the patient for potential electrolyte imbalances. Rationale: Lethargy, irritability, and difficulty concentrating in CKD patients are often related to electrolyte imbalances and the buildup of nitrogenous waste products. Assessing for these imbalances is a critical first step before initiating further interventions.

Answer 81

D. Monitor the patient’s neurological status closely and prepare for dialysis. Rationale: Peripheral neuropathy in CKD is a result of nerve damage caused by the buildup of toxins, and dialysis is the primary treatment option to address the underlying cause. Monitoring the patient’s neurological status is essential, as it will guide the appropriate interventions, including dialysis.

Answer 82

A. Loss of deep tendon reflexes Rationale: Loss of deep tendon reflexes is a sign of motor neuropathy, which may accompany peripheral neuropathy in CKD. This symptom indicates a progression of nerve involvement beyond sensory changes, and further management is needed.

Answer 83

C. Initiate dialysis to manage the underlying causes. Rationale: Asterixis is a sign of uremic encephalopathy, which is a result of the accumulation of nitrogenous waste products in the body. Dialysis is the most appropriate intervention to address the underlying cause and reduce neurological symptoms.

Answer 84

D. Consider dialysis to address the underlying causes of neuropathy. Rationale: Uremic neuropathy is a common complication of CKD, and dialysis is the most effective treatment to address the underlying causes, such as the accumulation of waste products. Other interventions may support symptom management, but dialysis is the priority for disease management.

Answer 85

A. Recommend stretching exercises before bed to reduce muscle cramps. Rationale: Stretching exercises before bed can help alleviate muscle cramps, a common symptom of CKD-related neuropathy. While other options may address some aspects of CKD, they are not directly helpful for managing leg cramps.

Answer 86

A. Increased nitrogenous waste products in the blood Rationale: Altered mental status in stage 5 CKD is often caused by the accumulation of nitrogenous waste products (uremia) when renal function is severely impaired, and renal replacement therapy is not initiated.

Answer 87

C. Monitor the patient’s renal function and prepare for dialysis. Rationale: The progression of peripheral neuropathy in CKD is largely due to the buildup of toxins that affect nerve function. Monitoring renal function and preparing the patient for dialysis is critical to slowing or halting the progression of neurological deterioration.

Answer 88

A. The patient is at risk for falls due to difficulty walking. Rationale: Bilateral foot drop is a serious complication that can impair the patient’s ability to walk and maintain balance, placing them at high risk for falls and injury. Fall precautions and mobility support should be prioritized.

Answer 89

C. Begin dialysis to reduce the buildup of waste products. Rationale: Restless legs syndrome in CKD is often related to the accumulation of waste products and is typically managed through dialysis, which helps to reduce these toxins. Other interventions may offer symptomatic relief but do not address the root cause of the condition.

Answer 90

C. Prepare for dialysis to manage the increased BUN level. Rationale: A rapidly increasing BUN level can lead to uremic encephalopathy, which may cause seizures and coma. Dialysis is the most effective intervention to address this issue by removing nitrogenous waste products.

Answer 91

D. Increased nitrogenous waste products affecting the CNS Rationale: Increased nitrogenous waste products, such as urea, can accumulate in the blood as kidney function declines, leading to CNS depression, including irritability, difficulty concentrating, and altered mental status.

Answer 92

D. Increased risk for fractures due to weakened bones Rationale: Low serum calcium and high phosphate levels in CKD-MBD lead to bone demineralization and weakened bone structure, increasing the risk of fractures. These imbalances trigger parathyroid hormone (PTH) secretion, leading to further bone remodeling and weakening.

Answer 93

A. Hypocalcemia caused by CKD-MBD Rationale: Low ionized calcium levels, which are common in CKD-MBD, can lead to symptoms such as muscle cramps and tingling in the hands. These symptoms are typically associated with hypocalcemia, which occurs as a result of impaired kidney function and reduced activation of vitamin D.

Answer 94

A. To increase serum calcium levels and decrease phosphate levels Rationale: The primary role of calcium and phosphate binders in CKD-MBD is to decrease serum phosphate levels and prevent the further decline in serum calcium levels, helping to restore balance between calcium and phosphate.

Answer 95

C. Increased parathyroid hormone (PTH) levels causing bone remodeling Rationale: Osteitis fibrosa occurs when increased PTH levels cause excessive bone remodeling, leading to bone decalcification and replacement of bone tissue with fibrous tissue. This is a direct result of CKD-MBD and is a common complication of CKD.

Answer 96

B. Delayed bone turnover and defective mineralization of newly formed bone Rationale: Osteomalacia is caused by slow bone turnover and defective mineralization of newly formed bone, which occurs due to low vitamin D levels and impaired calcium absorption in CKD. This leads to weakened bones and an increased risk of fractures.

Answer 97

B. Disruption of cardiac conduction and potential cardiac arrest Rationale: Vascular calcifications in CKD can disrupt cardiac conduction, increasing the risk of arrhythmias and potentially causing cardiac arrest. This is a significant complication of CKD-MBD and is a major contributor to cardiovascular disease.

Answer 98

B. Uremic red eye due to calcium deposits in the eye Rationale: Uremic red eye is caused by irritation from calcium deposits in the eye, a complication of CKD-MBD. This occurs due to the imbalance of calcium and phosphate in the body, which leads to vascular calcifications.

Answer 99

C. Bone biopsy Rationale: The gold standard for diagnosing CKD-MBD is a bone biopsy, which allows for direct examination of bone tissue to confirm the presence of osteomalacia or osteitis fibrosa. Other diagnostic methods, such as blood tests and imaging, can provide supportive information but are not definitive.

Answer 100

A. Increased calcium absorption from the GI tract Rationale: Vitamin D supplementation helps increase calcium absorption from the GI tract. In CKD, where active vitamin D production is impaired, supplementation is necessary to optimize calcium levels and improve overall mineral metabolism.

Answer 101

D. To reduce phosphate levels and prevent further calcium depletion Rationale: Phosphate binders are used to reduce phosphate levels in the blood, which helps prevent further depletion of calcium and mitigates the development of complications such as vascular calcifications and bone mineralization disorders.

Answer 102

A. Dry skin and sensory neuropathy Rationale: Itching in CKD patients, especially those undergoing dialysis, is often due to dry skin, calcium-phosphate deposition in the skin, and sensory neuropathy. These factors contribute to the discomfort, which can lead to skin damage from excessive scratching.

Answer 103

A. Uremic frost Rationale: Uremic frost occurs when urea crystallizes on the skin, typically seen in patients with very high BUN levels (over 200 mg/dL). This condition is rare and is a sign of severe uremia.

Answer 104

C. Apply moisturizing lotions and use antihistamines as prescribed Rationale: Itching in dialysis patients can be alleviated by moisturizing the skin and using antihistamines to control the pruritus. This addresses the common causes of itching in CKD, including dry skin and sensory neuropathy.

Answer 105

A. Skin infections Rationale: Intense itching, especially when scratched to the point of breaking the skin, can lead to skin infections. This is a common complication in CKD patients with refractory pruritus.

Answer 106

B. Apply topical antibiotics to scratched areas Rationale: The nurse should prioritize preventing and managing infection in areas where the patient has scratched. Applying topical antibiotics can help prevent further complications. Managing the itching is also essential but secondary to addressing the infection risk.

Answer 107

D. Decreased estrogen, progesterone, and luteinizing hormone levels Rationale: In women with CKD, low levels of estrogen, progesterone, and luteinizing hormone cause anovulation and menstrual changes, including amenorrhea. This disruption in hormonal balance is a common cause of infertility in these patients.

Answer 108

A. Peripheral neuropathy causing impotence Rationale: Peripheral neuropathy is a common cause of impotence in men with CKD. Nerve damage can affect sexual function, leading to erectile dysfunction. Anemia, while contributing to fatigue and decreased libido, is not directly linked to impotence.

Answer 109

C. Restoration of ovulation due to dialysis Rationale: In women with CKD, dialysis can help restore normal menstrual cycles and ovulation by improving overall kidney function, which in turn helps normalize hormone levels. This is a common observation in patients starting dialysis.

Answer 110

B. Pregnancy carries significant risk for both the mother and fetus Rationale: Pregnancy in patients with a kidney transplant carries significant risks for both the mother and fetus, including complications related to kidney function, immunosuppressive therapy, and overall maternal health. Although some patients can carry a fetus to term, careful monitoring and management are essential.

Answer 111

A. Emotional lability and depression caused by the physical changes of CKD Rationale: Personality and behavioral changes, emotional lability, and depression are common in patients with CKD, often due to the physical changes caused by the disease, such as edema, skin changes, and the presence of access devices. These factors can lead to anxiety and depressive symptoms.

Answer 112

B. Providing information on available psychological support or counseling Rationale: Providing psychological support or counseling can help address emotional distress and body image issues. It allows the patient to express their feelings and develop coping strategies. Simply reassuring the patient or discouraging discussions may not address the underlying emotional needs.

Answer 113

D. Decreased kidney function leading to slowed mental activity Rationale: Decreased kidney function can lead to slowed mental activity, which can make the patient appear disengaged and have difficulty concentrating. This is a common psychologic change seen in CKD patients due to the buildup of uremic toxins and the physical effects of the disease.

Answer 114

C. Evaluate for albuminuria with a urine test, as it may not be detected on routine urinalysis. Rationale: Albuminuria, which is not detected on routine urinalysis, should be evaluated in patients with diabetes who have persistent proteinuria. This test is essential for assessing kidney function and identifying early kidney damage.

Answer 115

A. GFR (Glomerular Filtration Rate) Rationale: GFR is the preferred method for assessing kidney function, as serum creatinine alone is an inaccurate reflection of kidney function. GFR calculations, such as those using the MDRD equation, provide a more reliable measure of kidney function.

Answer 116

A. Detect any obstructions and assess kidney size Rationale: A renal ultrasound is used to detect obstructions in the kidneys and determine their size. It is not a diagnostic tool for measuring kidney function or assessing the results of a kidney biopsy.

Answer 117

B. Obtain tissue samples to help determine the underlying cause of CKD Rationale: A kidney biopsy is performed to obtain tissue samples, which help establish the diagnosis and cause of CKD. It is not used to measure kidney function or detect infections.

Answer 118

A. It is often the first sign of kidney damage in CKD. Rationale: Persistent proteinuria is typically the first sign of kidney damage in CKD. Further testing is required to evaluate the cause of the proteinuria and assess kidney function.

Answer 119

C. Albuminuria may be present even if no protein is detected on standard urinalysis. Rationale: In patients with diabetes, albuminuria may be present even when protein is not detected on routine urinalysis, making albuminuria testing essential for early detection of kidney damage.

Answer 120

D. MDRD Study equation Rationale: The MDRD Study equation is the preferred method for calculating GFR, as it provides a more accurate estimate of kidney function than other methods, such as the Cockcroft-Gault formula.

Answer 121

B. GFR using MDRD formula Rationale: The GFR using the MDRD formula is the most accurate method for assessing kidney function in CKD patients. It helps determine the extent of kidney damage more effectively than serum creatinine levels alone.

Answer 122

A. Renal ultrasound Rationale: A renal ultrasound is used to detect kidney obstructions and assess kidney size, providing valuable information for diagnosing CKD. Other tests, such as a kidney biopsy or BUN, serve different diagnostic purposes.

Answer 123

C. Routine urinalysis detects other forms of protein, but not albumin. Rationale: Routine urinalysis detects some forms of protein, but not albumin, which requires a separate test for accurate identification, especially in patients with CKD or diabetes.

Answer 124

B. Preserving existing kidney function and preventing disease progression. Rationale: The primary goal in CKD therapy is to preserve existing kidney function and prevent disease progression. Although addressing CVD is important, the focus is on slowing kidney disease progression through early recognition and treatment of potential causes.

Answer 125

A. Referral to a nephrologist as soon as CKD is diagnosed. Rationale: Early referral to a nephrologist allows for proper monitoring and management of CKD, which is crucial for slowing the progression of the disease and preventing complications.

Answer 126

D. Treating both cardiovascular disease and slowing kidney disease progression. Rationale: The treatment plan for CKD patients with HF should focus on managing both cardiovascular disease and slowing the progression of kidney disease, as these conditions often exacerbate one another.

Answer 127

A. Hyperparathyroidism, CKD-MBD, anemia, and dyslipidemia. Rationale: In stages 1 through 4, the focus is on managing complications such as hyperparathyroidism, CKD-MBD, anemia, and dyslipidemia, which can slow the progression of kidney disease and improve overall health.

Answer 128

C. Detecting and treating reversible causes of kidney failure such as infections or dehydration. Rationale: Early detection and treatment of potentially reversible causes of kidney failure, such as infections, dehydration, or nephrotoxins, can help prevent the progression of CKD and preserve kidney function.

Answer 129

C. Diarrhea Rationale: Sodium polystyrene sulfonate has an osmotic laxative effect, which can cause diarrhea. The nurse should educate the patient about this potential side effect and monitor for any signs of excessive diarrhea.

Answer 130

A. To promote potassium evacuation through the bowel. Rationale: Sodium polystyrene sulfonate is a cation-exchange resin that helps lower potassium levels by promoting potassium evacuation from the bowel. It has an osmotic laxative effect, which is why diarrhea is a common side effect.

Answer 131

A. Monitor the patient for signs of water retention and sodium overload. Rationale: Sodium polystyrene sulfonate exchanges sodium for potassium, which may cause sodium and water retention. The nurse should closely monitor for signs of fluid overload and hypernatremia.

Answer 132

A. “Take this medication at least 2 hours apart from other medications.” Rationale: Sodium zirconium cyclosilicate (SZC) should be administered at least 2 hours apart from other medications to prevent interference with their absorption. It is used for long-term management of hyperkalemia, not for emergencies.

Answer 133

A. ACE inhibitors can increase serum potassium levels and decrease GFR. Rationale: ACE inhibitors and ARBs can increase serum potassium levels and decrease GFR. These medications must be used with caution, especially in patients with CKD, as they may exacerbate kidney function decline.

Answer 134

B. Encourage weight loss if the patient is overweight or obese. Rationale: Weight loss is an important component of managing hypertension, especially in patients with CKD. Reducing weight can help lower blood pressure and improve overall kidney health.

Answer 135

A. Decreasing proteinuria and potentially delaying the progression of CKD. Rationale: ACE inhibitors decrease proteinuria and may help slow the progression of CKD. They are particularly beneficial for patients with diabetes or nondiabetic proteinuria.

Answer 136

C. “Measure your blood pressure in the supine, sitting, and standing positions.” Rationale: Blood pressure should be measured in multiple positions (supine, sitting, and standing) to assess the effect of antihypertensive drugs and identify orthostatic hypotension or other changes in BP.

Answer 137

C. Combining two or more medications from different classes. Rationale: Most patients with CKD and hypertension require two or more antihypertensive medications to achieve target blood pressure. Combining medications from different classes enhances effectiveness and reduces the risk of side effects.

Answer 138

A. Discontinue the ACE inhibitor and notify the healthcare provider. Rationale: ACE inhibitors can increase serum potassium levels, and a significant rise in potassium is a concern. The nurse should notify the healthcare provider and consider discontinuing the medication or adjusting the dosage to prevent life-threatening hyperkalemia.

Answer 139

B. Administer calcium and vitamin D supplements if necessary. Rationale: In the later stages of CKD, hypocalcemia can be treated with calcium and vitamin D supplements if serum phosphate levels are normal but hypocalcemia persists.

Answer 140

A. To avoid the risk of vascular calcifications associated with calcium-based binders. Rationale: Sevelamer carbonate is a non-calcium-based phosphate binder, which is used to avoid increasing the calcium load and reduce the risk of vascular calcifications, especially in patients with elevated calcium levels.

Answer 141

B. Phosphate and calcium levels to avoid hypercalcemia and hypocalcemia. Rationale: Patients on phosphate binders should have their phosphate and calcium levels monitored to prevent complications such as hypercalcemia or hypocalcemia, which can affect bone and vascular health.

Answer 142

B. To reduce parathyroid hormone (PTH) levels by increasing the sensitivity of calcium receptors in the parathyroid glands. Rationale: Cinacalcet (Sensipar) is a calcimimetic agent that increases the sensitivity of calcium receptors in the parathyroid glands, leading to decreased PTH secretion, which helps control secondary hyperparathyroidism in CKD.

Answer 143

D. Constipation. Rationale: Constipation is a common side effect of phosphate binders like calcium acetate and calcium carbonate, and patients may require stool softeners to manage this side effect.

Answer 144

D. They depend on the kidneys for excretion, which can lead to toxicity in patients with impaired renal function. Rationale: Magnesium-containing antacids depend on the kidneys for excretion, and in patients with CKD, impaired renal function can lead to magnesium toxicity, which can cause serious complications.

Answer 145

C. To activate vitamin D and reduce high parathyroid hormone (PTH) levels. Rationale: Calcitriol (Rocaltrol) is the active form of vitamin D, which is used to treat secondary hyperparathyroidism in CKD patients by activating vitamin D and reducing PTH levels.

Answer 146

B. Withhold vitamin D and replace calcium-based phosphate binders with non-calcium-based binders. Rationale: If a patient develops hypercalcemia after calcium and vitamin D supplementation, the nurse should withhold vitamin D and replace calcium-based phosphate binders with non-calcium-based binders to prevent further complications.

Answer 147

A. Aluminum toxicity, which is associated with osteomalacia and other bone diseases. Rationale: Aluminum-containing preparations should be used with caution in CKD patients due to the risk of aluminum toxicity, which can cause osteomalacia and other bone disorders.

Answer 148

C. “This surgery will completely stop my body from producing parathyroid hormone.” Rationale: Total parathyroidectomy does not completely stop parathyroid hormone (PTH) production. The transplanted tissue in the forearm will continue to produce PTH as needed. If excessive PTH production occurs, some cells can be removed from the forearm.

Answer 149

B. Hypocalcemia. Rationale: Cinacalcet (Sensipar) can lower calcium levels, leading to hypocalcemia as a side effect. This occurs because the drug increases the sensitivity of the calcium receptors on the parathyroid glands, which reduces PTH secretion and calcium levels.

Answer 150

A. To reduce calcium retention and the risk of vascular calcification. Rationale: Phosphate is restricted to about 1 g/day when patients require RRT to help manage calcium balance and reduce the risk of vascular calcification associated with high phosphate levels.

Answer 151

B. It should be taken with meals to maximize its effectiveness in binding phosphate. Rationale: Lanthanum carbonate (Fosrenol) is most effective when taken with meals because it binds phosphate in the bowel during digestion, helping to lower phosphate levels in the body.

Answer 152

A. Vitamin D deficiency, leading to decreased calcium absorption. Rationale: Vitamin D deficiency contributes to the progression of CKD-MBD because it leads to decreased calcium absorption from the GI tract, further exacerbating hypocalcemia and promoting secondary hyperparathyroidism.

Answer 153

C. IV iron is preferred for patients on dialysis due to the greater need for iron and difficulty absorbing oral iron. Rationale: IV iron is preferred for dialysis patients because they have an increased need for iron, and oral iron supplements are less effective due to gastrointestinal side effects and poor absorption.

Answer 154

D. To treat iron deficiency due to increased erythropoiesis. Rationale: IV iron sucrose (Venofer) is used in dialysis patients to treat iron deficiency, which often occurs due to the increased demand for iron to support erythropoiesis during EPO therapy.

Answer 155

B. Constipation. Rationale: Constipation is a common side effect of oral iron supplements, which can reduce patient adherence to treatment. Stool softeners may be necessary to manage this side effect.

Answer 156

C. Blood transfusions increase the risk of developing antibodies, complicating future kidney transplants. Rationale: Blood transfusions are avoided in CKD patients unless absolutely necessary because they increase the risk of developing antibodies, which can make it harder to find a compatible donor for kidney transplantation.

Answer 157

B. Calcium in phosphate binders binds with iron, preventing its absorption. Rationale: Calcium in phosphate binders can bind with iron, preventing its absorption in the gastrointestinal tract. Therefore, iron supplements should not be taken at the same time as phosphate binders.

Answer 158

A. Hemoglobin and hematocrit levels. Rationale: Hemoglobin and hematocrit levels should be monitored regularly in patients receiving EPO therapy to assess the effectiveness of treatment and ensure that hemoglobin levels do not increase too rapidly.

Answer 159

B. Uncontrolled hypertension. Rationale: Erythropoietin (EPO) therapy is contraindicated in patients with uncontrolled hypertension due to the risk of increasing blood pressure and exacerbating cardiovascular problems.

Answer 160

C. To stimulate erythropoiesis and increase red blood cell production. Rationale: Erythropoietin (EPO) is given to stimulate erythropoiesis and increase red blood cell production in CKD patients, addressing the anemia caused by reduced EPO production by the kidneys.

Answer 161

D. The patient’s response to the drug and healthcare provider’s recommendation. Rationale: The choice of dyslipidemia medication, such as statins or fibrates, should be based on the patient’s response to the drug and the healthcare provider’s recommendation, taking into consideration individual treatment goals and comorbidities.

Answer 162

C. Statins are particularly recommended in CKD patients with diabetes who are not yet on dialysis. Rationale: Statins are especially recommended in CKD patients with diabetes, particularly before dialysis is initiated, as they help lower LDL cholesterol and reduce the risk of cardiovascular disease (CVD).

Answer 163

B. Lower LDL cholesterol levels. Rationale: Statins, such as atorvastatin (Lipitor), are primarily used to lower LDL cholesterol levels, which helps reduce the risk of cardiovascular disease (CVD) in patients with chronic kidney disease (CKD).

Answer 164

D. To prevent drug toxicity due to decreased elimination of drugs. Rationale: In CKD, the kidneys’ ability to eliminate drugs is impaired, leading to drug accumulation and increased risk of toxicity. Therefore, drug doses and frequency must be adjusted based on the severity of kidney disease to prevent adverse effects.

Answer 165

C. Metformin. Rationale: Diabetic agents such as metformin are of particular concern in CKD patients because decreased renal function may lead to drug accumulation, increasing the risk of toxicity, such as lactic acidosis.

Answer 166

B. Increased risk of drug toxicity due to impaired renal elimination. Rationale: In CKD patients, the kidneys’ decreased ability to eliminate drugs, including opioids, can lead to drug accumulation and increased risk of toxicity, requiring careful dose adjustments.

Answer 167

C. Preventing calorie-protein malnutrition while maintaining good nutrition. Rationale: Nutrition therapy in CKD aims to prevent calorie-protein malnutrition, which can result from altered metabolism, dietary restrictions, and other complications, while maintaining overall good nutrition.

Answer 168

B. Depression and anorexia caused by the disease process. Rationale: Depression, anorexia, altered metabolism, and other factors such as nausea and dietary restrictions contribute to calorie-protein malnutrition in CKD patients.

Answer 169

D. They can overburden the already diseased kidneys. Rationale: High-protein diets and supplements can place an additional burden on the already diseased kidneys, potentially worsening kidney function.

Answer 170

B. To reduce fluid retention without restricting fluid intake. Rationale: Diuretics are used in CKD stages 1 to 5 not on HD to help reduce fluid retention, as routine fluid restriction is not typically necessary for these patients.

Answer 171

A. To prevent thirst and manage fluid retention effectively. Rationale: Spacing fluid intake throughout the day helps prevent excessive thirst and supports effective management of fluid retention in CKD patients.

Answer 172

C. For patients on HD as their urine output decreases. Rationale: Fluid restriction is typically recommended for patients on hemodialysis (HD) as their urine output decreases. For CKD stages 1 to 5 not receiving dialysis, fluids are not routinely restricted.

Answer 173

C. Bananas and oranges Rationale: Patients on HD should avoid foods high in potassium, such as bananas, oranges, tomatoes, and potatoes, to prevent hyperkalemia.

Answer 174

B. Patients using PD Rationale: Patients using peritoneal dialysis (PD) may lose potassium during dialysis exchanges and often require oral potassium supplementation rather than restriction.

Answer 175

A. They often contain potassium chloride. Rationale: Salt substitutes should be avoided in potassium-restricted diets because they often contain potassium chloride, which can contribute to hyperkalemia in CKD patients.

Answer 176

B. 2 to 4 g/day Rationale: Patients with CKD are typically advised to restrict sodium intake to 2 to 4 g/day to help manage fluid retention and hypertension.

Answer 177

C. The kidneys lose the ability to excrete phosphate efficiently. Rationale: As kidney function declines, the kidneys lose the ability to efficiently excrete phosphate, leading to an accumulation in the blood.

Answer 178

B. 1 g/day Rationale: By the time a patient reaches ESRD, phosphate intake is typically limited to about 1 g/day to prevent hyperphosphatemia and associated complications.

Answer 179

C. Meat and dairy products Rationale: Foods high in phosphate, such as meat and dairy products (e.g., milk, cheese, yogurt, and ice cream), should be limited in patients with ESRD to manage phosphate levels.

Answer 180

C. They bind phosphate from the diet and reduce serum phosphate levels. Rationale: Phosphate binders bind dietary phosphate in the gastrointestinal tract, preventing its absorption and helping to control serum phosphate levels in patients with CKD.

Answer 181

C. Hypermagnesemia Rationale: Magnesium from antacids can accumulate in patients with CKD due to reduced excretion by the kidneys, leading to hypermagnesemia.

Answer 182

B. BUN and creatinine Rationale: BUN and serum creatinine levels are essential indicators of kidney function and should be closely monitored when nephrotoxic drugs are prescribed.

Answer 183

A. “I can take ibuprofen when I have a headache.” Rationale: NSAIDs like ibuprofen can contribute to kidney damage and should be avoided in patients with CKD.

Answer 184

C. “A transplant is the best treatment for ESRD, but donor organ availability is limited.” Rationale: While a kidney transplant is the best treatment for ESRD, the critical shortage of donor organs limits this option. Dialysis is often used until a transplant becomes available.

Answer 185

C. A 60-year-old with poorly controlled diabetes Rationale: Poorly controlled diabetes is a leading cause of CKD, making this patient the highest risk.

Answer 186

C. Routine urinalysis and GFR monitoring Rationale: Early detection of CKD through routine urinalysis and GFR calculation is essential for prevention and timely management.

Answer 187

B. “Check your blood pressure daily and report high readings.” Rationale: Monitoring and reporting blood pressure changes are critical for managing CKD and preventing complications.

Answer 188

C. Increased serum creatinine Rationale: An increase in serum creatinine indicates worsening kidney function, a hallmark of CKD progression.

Answer 189

A. Risk for electrolyte imbalance Rationale: Fluid retention can lead to electrolyte imbalances, requiring immediate attention to prevent complications.

Answer 190

B. “A kidney transplant may eliminate the need for dialysis.” Rationale: A kidney transplant may eliminate the need for dialysis, offering a better outcome for many ESRD patients.

Answer 191

D. “NSAIDs can worsen kidney damage and increase disease progression.” Rationale: NSAIDs can impair kidney function and accelerate CKD progression, especially when used inappropriately.

Answer 192

D. Monitor the patient for cardiac arrhythmias. Rationale: Hyperkalemia can cause life-threatening cardiac arrhythmias, making cardiac monitoring a priority.

Answer 193

C. Elevate the head of the bed and assess lung sounds. Rationale: Elevating the head of the bed and assessing lung sounds are immediate actions to improve breathing and evaluate the severity of fluid overload.

Answer 194

a. progressive irreversible destruction of the kidneys.

Answer 195

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

Answer 196

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

Answer 197

c. “I will measure my output each day to help calculate the amount I can drink.” Rationale: The patient with end-stage renal disease is taught to measure urine output as a means of determining an appropriate oral fluid intake; the total urine output plus 600-1000 ml is the daily fluid allowance. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD.

Answer 198

b. Phosphate level Rationale: Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate.

Answer 199

b. Serum phosphate Rationale: If serum phosphate is increased, the calcium and phosphate can cause soft tissue calcification. When calcium levels are increased or there is evidence of existing vascular or soft tissue calcifications, non–calcium-based phosphate binders are used. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered.

Answer 200

b. More protein is allowed because urea and creatinine are removed by dialysis. Rationale: When the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Glucose is not lost during hemodialysis. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.

Answer 201

c. Magnesium hydroxide Rationale: Magnesium is excreted by the kidneys, so patients with CKD should not use over-the-counter products containing magnesium. The other medications are appropriate for a patient with CKD.

Answer 202

b. Potassium Rationale: Angiotensin-converting enzyme (ACE) inhibitors are often used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention. Therefore, careful monitoring of potassium levels is needed in patients who are at risk for hyperkalemia. The other laboratory values would also be monitored in patients with CKD but would not affect administration of captopril.

Answer 203

c. Hemoglobin level 13 g/dL Rationale: High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) so the recommendation is to use the lowest possible dose of erythropoietin. Hemoglobin levels well in the normal range indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider but will not affect whether the medication is administered.

Answer 204

c. The LPN/VN administers the iron supplement and phosphate binder with lunch. Rationale: Oral phosphate binders would not be given at the same time as iron because they prevent the iron from being absorbed. The phosphate binder would be given with a meal and the iron given at a different time. The other actions by the LPN/VN are appropriate for a patient with renal insufficiency.

Answer 205

b. The patient‘s peritoneal effluent appears cloudy. Rationale: Cloudy-appearing peritoneal effluent is a sign of possible peritonitis and would be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient.

Answer 206

b. “Tell me more about what you are thinking regarding dialysis.” Rationale: The nurse would initially clarify the patient‘s concerns and questions about dialysis. The patient is the one responsible for the decision, and many people using dialysis do have good quality of life, but these responses block further assessment of the patient‘s concerns. Referring to which type of dialysis the patient might use only indirectly responds to the patient‘s question.