Lewis Ch 46: Acute Kidney Injury and Chronic Kidney Disease

Question 1

After the insertion of an arteriovenous graft in the right forearm, a patient reports pain and coldness of the right fingers. Which action should the nurse take?

a. Remind the patient to take a daily low-dose aspirin tablet.
b. Report the patient’s symptoms to the health care provider.
c. Elevate the patient’s arm on pillows above the heart level.
d. Teach the patient about normal arteriovenous graft function

Answer 1

b. Report the patient’s symptoms to the health care provider.

The patient’s problems suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevating the arm above the heart will further decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.

Question 2

Which assessment finding should the nurse expect when a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30?

a. Persistent skin tenting
b. Rapid, deep respirations
c. Hot, flushed face and neck
d. Bounding peripheral pulses

Answer 2

b. Rapid, deep respirations

Patients with metabolic acidosis caused by AKI may have Kussmaul respirations to eliminate carbon dioxide. Bounding pulses 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 AKI.

Question 3

The nurse is planning care for a patient with severe heart failure who has developed increased blood urea nitrogen (BUN) and creatinine levels. What will be the primary treatment goal in the plan?

a. Augmenting fluid volume
b. Maintaining cardiac output
c. Diluting nephrotoxic substances
d. Preventing systemic hypertension

Answer 3

b. Maintaining cardiac output

The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient’s heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses could be correct.

Question 4

A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV?

a. Urine volume
b. Calcium level
c. Cardiac rhythm
d. Neurologic status

Answer 4

c. Cardiac rhythm

The calcium gluconate helps prevent dysrhythmias that might be caused by the hyperkalemia. The nurse will monitor the other data as well, but these will not be helpful in determining the effectiveness of the calcium gluconate.

Question 5

Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse’s teaching about management of CKD has been effective?

a. “I need to get most of my protein from low-fat dairy products.”
b. “I will increase my intake of fruits and vegetables to 5 per day.”
c. “I will measure my output each day to help calculate the amount I can drink.”
d. “I need erythropoietin injections to boost my immunity and prevent infection.”

Answer 5

c. “I will measure my output each day to help calculate the amount I can drink.”

The patient with end-stage renal disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. 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.

Question 6

Which information will the nurse monitor to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)?

a. Blood pressure
b. Phosphate level
c. Neurologic status
d. Creatinine clearance

Answer 6

b. Phosphate level

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.

Question 7

Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. What should the nurse assess before administering the medication?

a. Bowel sounds
b. Blood glucose
c. Blood urea nitrogen (BUN)
d. Level of consciousness (LOC)

Answer 7

a. Bowel sounds

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 affect the nurse’s decision to give the medication.

Question 8

Which menu choice by the patient who is receiving hemodialysis indicates that the nurse’s teaching has been successful?

a. Split-pea soup, English muffin, and nonfat milk
b. Poached eggs, whole-wheat toast, and apple juice
c. Oatmeal with cream, half a banana, and herbal tea
d. Cheese sandwich, tomato soup, and cranberry juice

Answer 8

b. Poached eggs, whole-wheat toast, and apple juice

Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup is high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and cream is high in phosphate.

Question 9

Which laboratory result should the nurse check before administering calcium carbonate to a patient with chronic kidney disease?

a. Serum potassium
b. Serum phosphate
c. Serum creatinine
d. Serum cholesterol

Answer 9

b. Serum phosphate

If serum phosphate is increased, the calcium and phosphate can cause soft tissue calcification. Calcium carbonate should not be given until the phosphate level is lowered. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered.

Question 10

A patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function?

a. Urine volume
b. Creatinine level
c. Glomerular filtration rate (GFR)
d. Blood urea nitrogen (BUN) level

Answer 10

c. Glomerular filtration rate (GFR)

GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.

Question 11

A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft?

a. A fistula is much less likely to clot.
b. A fistula increases patient mobility.
c. A fistula can be used sooner after surgery.
d. A fistula can accommodate larger needles.

Answer 11

a. A fistula is much less likely to clot.

Arteriovenous (AV) fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impact on needle size or patient mobility.

Question 12

Which action will the nurse include in the plan of care to maintain the patency of a patient’s eft arm arteriovenous fistula?

a. Auscultate for a bruit at the fistula site.
b. Assess the quality of the left radial pulse.
c. Compare blood pressures in the left and right arms.
d. Irrigate the fistula site with saline every 8 to 12 hours.

Answer 12

a. Auscultate for a bruit at the fistula site.

The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula.

Question 13

A patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching?

a. Increased calories are needed because glucose is lost during hemodialysis.
b. More protein is allowed because urea and creatinine are removed by dialysis.
c. Dietary potassium is not restricted because the level is normalized by dialysis.
d. Unlimited fluids are allowed because retained fluid is removed during dialysis.

Answer 13

b. More protein is allowed because urea and creatinine are removed by dialysis.

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.

Question 14

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?

a. The patient leaves the catheter exit site without a dressing.
b. The patient plans 30 to 60 minutes for a dialysate exchange.
c. The patient cleans the catheter while in the bathtub each day.
d. The patient slows the inflow rate when experiencing abdominal pain.

Answer 14

c. The patient cleans the catheter while in the bathtub each day.

Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis.

Question 15

Which information in a patient’s history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation?

a. The patient has type 1 diabetes.
b. The patient has metastatic lung cancer.
c. The patient has a history of chronic hepatitis C infection
d. The patient is infected with human immunodeficiency virus.

Answer 15

b. The patient has metastatic lung cancer.

Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant.

Question 16

Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid taken for four years after kidney transplantation?

a. Postural hypotension
b. Recurrent tachycardia
c. Knee and hip joint pain
d. Increased serum creatinine

Answer 16

c. Knee and hip joint pain

Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over a prolonged period. Increased creatinine level, orthostatic dizziness, and tachycardia are not associated with corticosteroid use.

Question 17

A patient who had a kidney transplant eight years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone. Which assessment data will be of most concern to the nurse?

a. Skin is thin and fragile.
b. Blood pressure is 150/92.
c. A nontender axillary lump.
d. Blood glucose is 144 mg/dL.

Answer 17

c. A nontender axillary lump.

A nontender lump suggests a secondary cancer, such as a lymphoma, which could occur as a result of chronic immunosuppressive therapy. The increased glucose, skin change, 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 cancer

Question 18

The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required?

a. Acetaminophen
b. Calcium phosphate
c. Magnesium hydroxide
d. Multivitamin with iron

Answer 18

c. Magnesium hydroxide

Since magnesium is excreted by the kidneys, patients with CKD should not use over-the-counter products containing magnesium. The other medications are appropriate for a patient with CKD.

Question 19

What laboratory value should the nurse check before administering captopril to a patient with stage 2 chronic kidney disease?

a. Glucose
b. Potassium
c. Creatinine
d. Phosphate

Answer 19

b. Potassium

Angiotensin-converting enzyme (ACE) inhibitors are frequently 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 whether the captopril was given or not.

Question 20

A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin. What should the nurse monitor for adverse effects of the medication?

a. Blood glucose
b. Urine osmolality
c. Serum creatinine
d. Serum potassium

Answer 20

c. Serum creatinine

When a patient with diabetes, which increases risk for chronic kidney disease (CKD), receives a potentially nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels. The other laboratory values would not be useful in assessing for the adverse effects of the gentamicin.

Question 21

A 55-yr-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication?

a. Creatinine 1.6 mg/dL
b. Oxygen saturation 89%
c. Hemoglobin level 13 g/dL
d. Blood pressure 98/56 mm Hg

Answer 21

c. Hemoglobin level 13 g/dL

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)
when erythropoietin (EPO) is administered to a target hemoglobin of greater than 12 g/dL 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.

Question 22

Which intervention will be included in the plan of care for a patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein?

a. Start continuous pulse oximetry.
b. Restrict the patient’s protein intake.
c. Restrict physical activity to bed rest.
d. Discontinue the urethral retention catheter.

Answer 22

c. Restrict physical activity to bed rest.

The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to remain in place because accurate measurement of output will be needed. There is no indication that the patient needs continuous pulse oximetry.

Question 23

A 25-yr-old patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider?

a. Serum creatinine level of 2.1 mg/dL
b. Serum potassium level of 6.5 mEq/L
c. White blood cell count of 11,500/μL
d. Blood urea nitrogen (BUN) of 56 mg/dL

Answer 23

b. Serum potassium level of 6.5 mEq/L

The hyperkalemia associated with crushing injuries may cause cardiac arrest and should be treated immediately. The nurse will report the other laboratory values, but abnormalities in these are not immediately life threatening.

Question 24

A 72-yr-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first?

a. Insert urethral catheter.
b. Obtain renal ultrasound.
c. Draw a complete blood count.
d. Infuse normal saline at 50 mL/hr.

Answer 24

a. Insert urethral catheter.

The patient’s elevation in BUN is most likely associated with hydronephrosis caused by the
acute urinary retention, so the insertion of an indwelling catheter is the first action to prevent
ongoing postrenal failure for this patient. The other actions are appropriate but should be implemented after the catheter

Question 25

A 62-yr-old female patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider?

a. The creatinine level is 3.0 mg/dL.
b. Urine output over an 8-hour period is 2500 mL.
c. The blood urea nitrogen (BUN) level is 67 mg/dL.
d. The glomerular filtration rate is less than 30 mL/min/1.73 m .

Answer 25

b. Urine output over an 8-hour period is 2500 mL.

The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy

Question 26

A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first?

a. Notify the patient’s health care provider.
b. Document the QRS interval measurement.
c. Check the patient’s most recent potassium level.
d. Review the chart for the patient’s current creatinine level.

Answer 26

c. Check the patient’s most recent potassium level.

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 increased in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval is also appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening dysrhythmias.

Question 27

A patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first?

a. Insert a urinary retention catheter.
b. Administer epoetin alfa (Epogen).
c. Place the patient on a cardiac monitor.
d. Give sodium polystyrene sulfonate (Kayexalate).

Answer 27

c. Place the patient on a cardiac monitor.

Because hyperkalemia can cause fatal dysrhythmias, the initial action should be to monitor the
cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and
anemia. The catheter allows monitoring of the urine output but does not correct the cause of the renal failure

Question 28

A patient has arrived for a scheduled hemodialysis session. Which nursing action is appropriate for the registered nurse (RN) to delegate to a dialysis technician?

a. Teach the patient about fluid restrictions.
b. Check blood pressure before starting dialysis.
c. Assess for causes of an increase in predialysis weight.
d. Determine the ultrafiltration rate for the hemodialysis.

Answer 28

b. Check blood pressure before starting dialysis.

Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of the appropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN.

Question 29

A licensed practical/vocational nurse (LPN/VN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention?

a. The LPN/VN assists the patient to ambulate in the hallway.
b. The LPN/VN administers the erythropoietin subcutaneously.
c. The LPN/VN administers the iron supplement and phosphate binder with lunch.
d. The LPN/VN carries a tray containing low-protein foods into the patient’s room.

Answer 29

c. The LPN/VN administers the iron supplement and phosphate binder with lunch.

Oral phosphate binders should not be given at the same time as iron because they prevent the iron from being absorbed. The phosphate binder should 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.

Question 30

A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2-L inflows. Which information should the nurse report promptly to the health care provider?

a. The patient has an outflow volume of 1800 mL.
b. The patient’s peritoneal effluent appears cloudy.
c. The patient’s abdomen appears bloated after the inflow.
d. The patient has abdominal pain during the inflow phase.

Answer 30

b. The patient’s peritoneal effluent appears cloudy.

Cloudy-appearing peritoneal effluent is a sign of peritonitis and should 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.

Question 31

The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider?

a. The urine output is 900 to 1100 mL/hr.
b. The patient’s central venous pressure (CVP) is decreased.
c. The patient reports level 7 (0- to 10-point scale) incisional pain.
d. The blood urea nitrogen (BUN) and creatinine levels are elevated.

Answer 31

b. The patient’s central venous pressure (CVP) is decreased.

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.

Question 32

During routine hemodialysis, a patient reports nausea and dizziness. Which action should the nurse take first?

a. Slow down the rate of dialysis.
b. Check the blood pressure (BP).
c. Review the hematocrit (Hct) level.
d. Give prescribed PRN antiemetic drugs.

Answer 32

b. Check the blood pressure (BP).

The patient’s reports of nausea and dizziness suggest hypotension, so the first action should be to check the BP. The other actions may also be appropriate based on the blood pressure obtained.

Question 33

The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider?

a. Heart rate
b. Urine output
c. Creatinine clearance
d. Blood urea nitrogen (BUN) level

Answer 33

b. Urine output

Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. The other data will be monitored but are not the most important determinants of fluid infusion rate.

Question 34

A patient reports leg cramps during hemodialysis. What action should the nurse take?

a. Massage the patient’s legs.
b. Reposition the patient supine.
c. Give acetaminophen (Tylenol).
d. Infuse a bolus of normal saline.

Answer 34

d. Infuse a bolus of normal saline.

Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.

Question 35

A 74-yr-old patient who is progressing to stage 5 chronic kidney disease asks the nurse, “Do you think I should go on dialysis?” Which initial response by the nurse is best?

a. “It depends on which type of dialysis you are considering.”
b. “Tell me more about what you are thinking regarding dialysis.”
c. “You are the only one who can make the decision about dialysis.”
d. “Many people your age use dialysis and have a good quality of life.”

Answer 35

b. “Tell me more about what you are thinking regarding dialysis.”

The nurse should 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.

Question 36

After receiving change-of-shift report, which patient should the nurse assess first?

a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange.
b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level.
c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L.
d. Patient who has just returned from having hemodialysis with a heart rate of 110/min.

Answer 36

d. Patient who has just returned from having hemodialysis with a heart rate of 110/min.

The patient who has tachycardia after hemodialysis may be bleeding or excessively hypovolemic and should be assessed immediately for these complications. The other patients also need assessments or interventions but are not at risk for life-threatening complications.

Question 37

Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis? (Select all that apply.)

a. Avoid commercial salt substitutes.
b. Restrict fluid intake to 1000 mL daily.
c. Take phosphate binders with each meal.
d. Choose high-protein foods for most meals.
e. Have several servings of dairy products daily.

Answer 37

a. Avoid commercial salt substitutes.
c. Take phosphate binders with each meal.
d. Choose high-protein foods for most meals.

Patients who are receiving peritoneal dialysis should have a high-protein diet. Phosphate binders are taken with meals to help control serum phosphate and calcium levels. Commercial salt substitutes are high in potassium and should be avoided. Fluid intake is not limited unless weight and blood pressure are not controlled. Dairy products are high in phosphate and usually are limited.