Lewis Chapter 49 TEST BANK

Question 1

The nurse is caring for a patient who has had an insertion of an arteriovenous graft (AVG) in the right forearm and has symptoms of pain and coldness of the right fingers. Which of the
following actions should the nurse take?

a. Elevate the patient’s arm above the level of the heart.
b. Report the patient’s symptoms to the health care provider.
c. Remind the patient about the need to take a daily low-dose Aspirin tablet.
d. Educate the patient about the normal vascular response after AVG insertion.

Answer 1

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

Question 2

The nurse is caring for a patient with acute kidney injury (AKI) who has an arterial blood pH of 7.30. Which of the following assessment findings should the nurse anticipate?

a. Vasodilation
b. Poor skin turgor
c. Bounding pulses
d. Rapid respirations

Answer 2

ANS: D
Patients with metabolic acidosis caused by AKI may have Kussmaul’s respirations as the lungs try to regulate 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 caring for a patient with severe heart failure who develops elevated blood urea nitrogen (BUN) and creatinine levels. The nurse will plan care to meet which of the following
goals of treatment?

a. Replace fluid volume.
b. Prevent hypertension.
c. Maintain cardiac output.
d. Dilute nephrotoxic substances.

Answer 3

ANS: C
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 would be correct

Question 4

The nurse is caring for a patient with acute glomerulonephritis, acute kidney injury (AKI), and hyperkalemia who is prescribed calcium gluconate IV. Which of the following parameters
should the nurse assess to evaluate the effectiveness of the medication?

a. Urine output
b. Calcium level
c. Cardiac rhythm
d. Neurological status

Answer 4

ANS: C
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

The nurse is caring for a patient with stage 2 chronic kidney disease (CKD) who is scheduled for an intravenous pyelogram (IVP). Which of the following prescriptions for the patient
should the nurse question?

a. NPO for 6 hours before IVP procedure
b. Normal saline 500 mL IV before procedure
c. Ibuprofen 400 mg PO PRN for pain
d. Dulcolax suppository 4 hours before IVP procedure

Answer 5

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

Question 6

The nurse is teaching a patient with stage 5 chronic kidney disease (CKD) about management of CKD. Which of the following patient statements indicate that the teaching was effective?

a. “I need to try to get more protein from dairy products.”
b. “I will try to increase my intake of fruits and vegetables.”
c. “I will measure my urinary output each day to help calculate the amount I can drink.”
d. “I need to take the erythropoietin to boost my immune system and help prevent infection.”

Answer 6

ANS: C
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 7

The nurse is caring for a patient with chronic kidney disease (CKD) who is prescribed calcium carbonate. Which of the following parameters should the nurse assess in order to determine the effectiveness of the treatment?

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

Answer 7

ANS: B
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 8

Which of the following assessments should the nurse complete before administering sodium polystyrene sulphonate to a patient with hyperkalemia?

a. Blood urea nitrogen (BUN) and creatinine
b. Blood glucose level
c. Patient’s bowel sounds
d. Level of consciousness (LOC)

Answer 8

ANS: C
Sodium polystyrene sulphonate should not be given to a patient who does not have normal bowel function 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 9

The nurse is teaching a patient who is receiving hemodialysis about appropriate dietary choices. Which of the following menu choices by the patient indicates that the teaching has
been effective?

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

Answer 9

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

Question 10

The nurse is preparing to administer calcium carbonate to a patient with chronic kidney disease (CKD). Which of the following laboratory results should the nurse check prior to administration?

a. Creatinine
b. Potassium
c. Total cholesterol
d. Serum phosphate

Answer 10

ANS: D
If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. The 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 11

Which of the following information is most useful to the nurse in evaluating improvement in kidney function for a patient who is hospitalized with acute kidney injury (AKI)?

a. Blood urea nitrogen (BUN) level
b. Urine output
c. Creatinine level
d. Calculated glomerular filtration rate (GFR)

Answer 11

ANS: D
GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status. 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 12

The nurse is caring for a patient who requires vascular access for hemodialysis and asks the nurse what the differences are between an arteriovenous (AV) fistula and a graft. Which of the
following information should the nurse explain is an advantage of the fistula?

a. Is much less likely to clot.
b. Increases patient mobility.
c. Accommodates larger needles.
d. Can be used sooner after surgery.

Answer 12

ANS: A
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 13

The nurse is caring for a patient with a left arm arteriovenous fistula. Which of the following
actions should the nurse include in the plan of care to maintain the patency of the fistula?

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

Answer 13

ANS: A
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 14

The nurse is caring for a patient who has had progressive chronic kidney disease (CKD) for
several years and is starting hemodialysis. Which of the following information about diet
should the nurse include in patient teaching?

a. Increased calories are needed because glucose is lost during hemodialysis.
b. Unlimited fluids are allowed since retained fluid is removed during dialysis.
c. More protein will be allowed because of the removal of urea and creatinine by
dialysis.
d. Dietary sodium and potassium are unrestricted because these levels are normalized by dialysis.

Answer 14

ANS: C
Once the patient is started on dialysis and nitrogenous wastes are removed, there is less
protein lost; therefore more protein in the diet is encouraged. Fluids are still restricted to avoid
excessive weight gain and complications such as shortness of breath. Glucose is not lost
during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the
complications associated with high levels of these electrolytes.

Question 15

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

a. The patient slows the inflow rate when experiencing pain.
b. The patient leaves the catheter exit site without a dressing.
c. The patient plans 30–60 minutes for a dialysate exchange.
d. The patient cleans the catheter while taking a bath every day.

Answer 15

ANS: D
Patients are taught to avoid insertion site infection and should be 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 16

The nurse is taking a history for a patient who is a possible candidate for a kidney transplant.
Which of the following information indicates that the patient is not an appropriate candidate
for transplantation?

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

Answer 16

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

Question 17

The nurse is caring for a patient who had kidney transplantation several years ago. Which of the following findings may indicate that the patient is experiencing adverse effects to the
prescribed corticosteroid?

a. Joint pain
b. Tachycardia
c. Postural hypotension
d. Increase in creatinine level

Answer 17

ANS: A
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
caused by corticosteroid use

Question 18

The nurse is assessing a patient who had a kidney transplant 8 years ago and is receiving the immunosuppressants tacrolimus, cyclosporin, and prednisone. Which of the following findings is of most concern to the nurse?

a. The blood glucose is 7.9 mmol/L.
b. The patient’s blood pressure is 150/92.
c. There is a nontender lump in the axilla.
d. The patient has a round, moonlike face.

Answer 18

ANS: C
A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result
of persistent immuno-suppressive therapy. The elevated glucose, moon face, and hypertension
are possible adverse effects of the prednisone and should be addressed, but they are not as
great a concern as the possibility of a malignancy.

Question 19

The nurse is interviewing a patient with chronic kidney disease (CKD) who brings all home
medications to the clinic to be reviewed by the nurse. Which of the following medications
being used by the patient indicates that patient teaching is required?

a. Multivitamin with iron
b. Milk of magnesia 30 mL
c. Calcium acetate
d. Acetaminophen 650 mg

Answer 19

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

Question 20

The nurse is caring for a patient with hypertension and stage 2 chronic kidney disease (CKD) who is prescribed ramipril. Which of the following laboratory tests should the nurse assess before administration of the medication?

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

Answer 20

ANS: B
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 ramipril was given or not.

Question 21

The nurse is caring for a patient with diabetes who has been admitted with pneumonia and is
prescribed gentamicin 60 mg IV. Which of the following parameters should the nurse monitor
to evaluate the patient for adverse effects of the medication?

a. Urine osmolality
b. Serum potassium and sodium
c. Blood glucose level
d. Blood urea nitrogen (BUN) and creatinine

Answer 21

ANS: D
When a patient at risk for chronic kidney disease (CKD) receives a nephrotoxic medication, it
is important to monitor renal function with BUN and creatinine levels. The other laboratory
values would not be useful in determining the effect of the gentamicin

Question 22

The nurse is caring for a patient with end-stage renal disease (ESRD). Which of the following
findings indicate that the nurse should consult with the health care provider before giving the
prescribed erythropoiesis-stimulating agent (ESA)?

a. Creatinine 99 mcmol/L
b. Oxygen saturation 89%
c. Hemoglobin level 130 g/L
d. Blood pressure 98/56 mm Hg

Answer 22

ANS: C
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 ESA is administered to a target hemoglobin of 110 g/L with a range of 100–120 g/L). Hemoglobin levels higher than 120 g/L indicate a need for a decrease in erythropoiesis-stimulating agent dose. The other information will also be reported to the health care provider but will not affect whether the medication is administered.

Question 23

The nurse is caring for a patient with acute kidney injury (AKI) who requires hemodialysis
and a temporary vascular access is obtained by placing a catheter in the left femoral vein.
Which of the following interventions should be included in the plan of care?

a. Place the patient on bed rest.
b. Start continuous pulse oximetry.
c. Discontinue the urinary catheter.
d. Restrict the patient’s oral protein intake.

Answer 23

ANS: A
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 urinary
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 24

The nurse is caring for a patient who has been admitted with a severe crush injury after an
industrial accident. Which of the following laboratory results is most important to report to the health care provider?

a. Serum creatinine level 190 mcmol/L
b. Serum potassium level 6.5 mmol/L
c. White blood cell count 11.5  109/L
d. Blood urea nitrogen (BUN) 18 mmol/L

Answer 24

ANS: B
The hyperkalemia associated with crush injuries may cause life-threatening cardiac
arrhythmias leading to cardiac arrest and should be treated immediately. The nurse will also
report the other laboratory values, but abnormalities in these are not immediately life-threatening.

Question 25

The nurse is caring for a patient with a history of benign prostatic hyperplasia (BPH) with
acute urinary retention and an elevated blood urea nitrogen (BUN) and creatinine. Which of
the following prescribed therapies should the nurse implement first?

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

Answer 25

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

Question 26

The nurse is caring for a patient who was admitted 10 days previously with acute kidney
injury (AKI) caused by dehydration. Which of the following findings is most important for the
nurse to report to the health care provider?
a. The blood urea nitrogen (BUN) level is 23.1 mmol/L.
b. The creatinine level is 186 mcmol/L.
c. Urine output over an 8-hour period is 2500 mL.
d. The glomerular filtration rate is <30 mL/minute/1.73 m2
.

Answer 26

ANS: C
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 27

After noting lengthening QRS intervals in a patient with acute kidney injury (AKI), which of
the following actions should the nurse take first?

a. Document the QRS interval.
b. Notify the patient’s health care provider.
c. Look at the patient’s current blood urea nitrogen (BUN) and creatinine levels.
d. Check the patient’s most recent blood potassium level.

Answer 27

ANS: D
The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the
most recent potassium and then notify the patient’s health care provider. The BUN and
creatinine will be elevated in a patient with AKI, but they would not directly affect the
electrocardiogram (ECG). Documentation of the QRS interval also is appropriate, but
interventions to decrease the potassium level are needed to prevent life-threatening
bradycardia.

Question 28

The nurse is caring for a patient with acute kidney injury who is dehydrated with symptoms of oliguria, anemia, and hyperkalemia. Which of the following prescribed actions should the
nurse take first?

a. Insert a urinary retention catheter.
b. Place the patient on a cardiac monitor.
c. Administer an erythropoiesis-stimulating agent (ESA).
d. Give sodium polystyrene sulfonate.

Answer 28

ANS: B
Since hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to
monitor the cardiac rhythm. ESA’s 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 29

The nurse is caring for a patient who is receiving hemodialysis and has symptoms of nausea,
vomiting, and sudden onset of confusion. Which of the following actions is priority?

a. Infuse a hypotonic solution.
b. Increase the rate of the dialysis.
c. Administer an antiemetic medication.
d. Stop the dialysis solution.

Answer 29

ANS: D
The patient’s symptoms suggest disequilibrium syndrome, which is a rare complication of
modern HD and develops as a result of very rapid changes in the composition of the
extracellular fluid. Urea, sodium, and other solutes are removed more rapidly from the blood than from the cerebrospinal fluid and the brain. This creates a high osmotic gradient in the
brain resulting in the shift of fluid into the brain, causing cerebral edema. Manifestations
include nausea, vomiting, confusion, restlessness, headaches, twitching and jerking, and seizures. Treatment consists of slowing or stopping dialysis and infusing hypertonic saline
solution, albumin, or mannitol to draw fluid from the brain cells back into the systemic
circulation

Question 30

The RN observes a nursing student carrying out all of these actions while caring for a patient
with stage 2 chronic kidney disease. Which of the following actions require the RN to
intervene?

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

Answer 30

ANS: C
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 RN student are appropriate for a patient
with renal insufficiency

Question 31

The nurse is assessing a patient who is receiving peritoneal dialysis with 2 L inflows. Which
of the following information should be reported immediately 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 has abdominal pain during the inflow phase.
d. The patient complains of feeling bloated after the inflow

Answer 31

ANS: B
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 32

Two hours after a kidney transplant, the nurse obtains all of the following data when assessing
the patient. Which information is most important to communicate to the health care provider?

a. The urine output is 900–1100 mL/hour.
b. The blood urea nitrogen (BUN) and creatinine levels are elevated.
c. The patient’s central venous pressure (CVP) is decreased.
d. The patient has level 8 (on a 10-point scale) incisional pain

Answer 32

ANS: C
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 33

The nurse is caring for a patient in the oliguric phase of acute renal failure who has a 24-hour
fluid output of 150 mL emesis and 250 mL urine. Which of the following amounts in mL
should the nurse plan a fluid replacement for the following day?

a. 400
b. 800
c. 1000
d. 1400

Answer 33

ANS: C
Usually fluid replacement should be based on the patient’s measured output plus 600 mL/day
for insensible losses.

Question 34

The nurse is caring for a patient receiving hemodialysis who has symptoms of nausea and
dizziness. Which of the following actions should the nurse take first?

a. Slow down the rate of dialysis.
b. Obtain blood to check the blood urea nitrogen (BUN) level.
c. Check the patient’s blood pressure.
d. Give prescribed PRN antiemetic drugs.

Answer 34

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

Question 35

Which of the following parameters is most important for the nurse to consider when titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation?

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

Answer 35

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

Question 36

The nurse is caring for a patient who has leg cramps during hemodialysis. Which of the
following actions should the nurse implement first?

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

Answer 36

ANS: D
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.