Med Surg - Exam 2 - Ch 47 (AKI and CKD)

Question 1

What are intrarenal causes of acute kidney injury (AKI) (select all that apply)?

a. Anaphylaxis
b. Renal stones
c. Bladder cancer
d. Nephrotoxic drugs
e. Acute glomerulonephritis
f. Tubular obstruction by myoglobin

Answer 1

d. Nephrotoxic drugs
e. Acute glomerulonephritis
f. Tubular obstruction by myoglobin

Intrarenal causes of acute kidney injury (AKI) include conditions that cause direct damage to the kidney tissue, including nephrotoxic drugs, acute glomerulonephritis, and tubular obstruction by myoglobin, or prolonged ischemia. Anaphylaxis and other prerenal problems are frequently the initial cause of AKI. Renal stones and bladder cancer are among the postrenal causes of AKI.

Question 2

An 83-year-old patient was found lying on the bathroom floor. She said she fell 2 days ago and has not been able to take her heart medicine or eat or drink anything since then. What conditions could be causing prerenal AKI in this patient (select all that apply)?

a. Anaphylaxis
b. Renal calculi
c. Hypovolemia
d. Nephrotoxic drugs
e. Decreased cardiac output

Answer 2

c. Hypovolemia
e. Decreased cardiac output

Because the patient has had nothing to eat or drink for 2 days, she is probably dehydrated and hypovolemic. Decreased cardiac output (CO) is most likely because she is older and takes heart medicine, which is probably for heart failure or hypertension. Both hypovolemia and decreased CO cause prerenal AKI. Anaphylaxis is also a cause of prerenal AKI but is not likely in this situation. Nephrotoxic drugs would contribute to intrarenal causes of AKI and renal calculi would be a postrenal cause of AKI.

Question 3

Acute tubular necrosis (ATN) is the most common cause of intrarenal AKI. Which patient is most likely to develop ATN?

a. Patient with diabetes mellitus
b. Patient with hypertensive crisis
c. Patient who tried to overdose on acetominophen
d. Patient with major surgery who required a blood transfusion

Answer 3

d. Patient with major surgery who required a blood transfusion

Acute tubular necrosis (ATN) is primarily the result of ischemia, nephrotoxins, or sepsis. Major surgery is most likely to cause severe kidney ischemia in the patient requiring a blood transfusion. A blood transfusion hemolytic reaction produces nephrotoxic injury if it occurs. Diabetes mellitus, hypertension, and acetaminophen will not contribute to ATN.

Question 4

A dehydrated patient is in the Injury stage of the RIFLE staging of AKI. What would the nurse first anticipate in the treatment of this patient?

a. Assess daily weight
b. IV administration of fluid and furosemide (Lasix)
c. IV administration of insulin and sodium bicarbonate
d. Urinalysis to check for sediment, osmolality, sodium, and specific gravity

Answer 4

b. IV administration of fluid and furosemide (Lasix)

Injury is the stage of RIFLE classification when urine output is less than 0.5 mL/kg/hr for 12 hours, the serum creatinine is increased times two or the glomerular filtration rate (GFR) is decreased by 50%. This stage may be reversible by treating the cause or, in this patient, the dehydration by administering IV fluid and a low dose of a loop diuretic, furosemide (Lasix). Assessing the daily weight will be done to monitor fluid changes but it is not the first treatment the nurse should anticipate. IV administration of insulin and sodium bicarbonate would be used for hyperkalemia. Checking the urinalysis will help to determine if the AKI has a prerenal, intrarenal, or postrenal cause by what is seen in the urine but with this patient’s dehydration, it is thought to be prerenal to begin treatment.

Question 5

What indicates to a nurse that a patient with oliguria has prerenal oliguria?

a. Urine testing reveals a low specific gravity
b. Causative factor is malignant hypertension
c. Urine testing reveals a high sodium concentration
d. Reversal of oliguria occurs with fluid replacement

Answer 5

d. Reversal of oliguria occurs with fluid replacement

In prerenal oliguria, the oliguria is caused by a decrease in circulating blood volume and there is no damage yet to the renal tissue. It can be reversed by correcting the precipitating factor, such as fluid replacement for hypovolemia. Prerenal oliguria is characterized by urine with a high specific gravity and a low sodium concentration, whereas oliguria of intrarenal failure is characterized by urine with a low specific gravity and a high sodium concentration. Malignant hypertension causes damage to renal tissue and intrarenal oliguria.

Question 6

In a patient with AKI, which laboratory urinalysis result indicates tubular damage?

a. Hematuria
b. Specific gravity fixed at 1.010
c. Urine sodium of 12 mEq/L (12 mmol/L)
d. Osmolality of 1000 mOsm/kg (1000 mmol/kg)

Answer 6

b. Specific gravity fixed at 1.010

A urine specific gravity that is consistently 1.010 and a urine osmolality of about 300 mOsm/kg is the same specific gravity and osmolality as plasma. This indicates that tubules are damaged and unable to concentrate urine. Hematuria is more common with postrenal damage. Tubular damage is associated with a high sodium concentration (greater than 40 mEq/L).

Question 7

Metabolic acidosis occurs in the oliguric phase of AKI as a result of impairment of

a. ammonia synthesis.
b. excretion of sodium.
c. excretion of bicarbonate.
d. conservation of potassium.

Answer 7

a. ammonia synthesis.

Metabolic acidosis occurs in AKI because the kidneys cannot synthesize ammonia or excrete acid products of metabolism, resulting in an increased acid load. Sodium is lost in urine because the kidneys cannot conserve sodium. Impaired excretion of potassium results in hyperkalemia. Bicarbonate is normally generated and reabsorbed by the functioning kidney to maintain acid-base balance.

Question 8

What indicates to a nurse that a patient with AKI is in the recovery phase?

a. A return to normal weight
b. A urine output of 3700 mL/day
c. Decreasing sodium and potassium levels
d. Decreasing blood urea nitrogen (BUN) and creatinine levels

Answer 8

d. Decreasing blood urea nitrogen (BUN) and creatinine levels

The blood urea nitrogen (BUN) and creatinine levels remain high during the oliguric and diuretic phases of AKI. The recovery phase begins when the glomerular filtration returns to a rate at which BUN and creatinine stabilize and then decrease. Urinary output of 3 to 5 L/day, decreasing sodium and potassium levels, and fluid weight loss are characteristic of the diuretic phase of AKI.

Question 9

While caring for the patient in the oliguric phase of AKI, the nurse monitors the patient for associated collaborative problems. When should the nurse notify the health care provider?

a. Urine output is 300 mL/day.
b. Edema occurs in the feet, legs, and sacral area.
c. Cardiac monitor reveals a depressed T wave and elevated ST segment.
d. The patient experiences increasing muscle weakness and abdominal cramping.

Answer 9

d. The patient experiences increasing muscle weakness and abdominal cramping.

Hyperkalemia is a potentially life-threatening complication of AKI in the oliguric phase. Muscle weakness and abdominal cramping are signs of the neuromuscular impairment that occurs with hyperkalemia. In addition, hyperkalemia can cause the cardiac conduction abnormalities of peaked T wave, prolonged PR interval, prolonged QRS interval, and depressed ST segment. Urine output of 300 mL/day is expected during the oliguric phase, and is the development of peripheral edema.

Question 10

In caring for the patient with AKI, what should the nurse be aware of?

a. The most common cause of death in AKI is irreversible metabolic acidosis.
b. During the oliguric phase of AKI, daily fluid intake is limited to 1000 mL plus the prior day’s fluid loss.
c. Dietary sodium and potassium during oliguric phase of AKI are managed according to the patient’s urinary output.
d. One of the most important nursing measures in managing fluid balance in the patient with AKI is taking accurate daily weights.

Answer 10

d. One of the most important nursing measures in managing fluid balance in the patient with AKI is taking accurate daily weights.

Measuring daily weights with the same scale at the same time each day allows for the evaluation and detection of excessive body fluid gains or losses. Infection is the leading cause of death in AKI, so meticulous aseptic technique is critical. The fluid limitation in the oliguric phase is 600 mL plus the prior day’s measured fluid loss. Dietary sodium and potassium intake are managed according to the plasma levels.

Question 11

A 68-year-old man with a history of heart failure resulting from hypertension has AKI as a result of the effects of nephrotoxic diuretics. Currently his serum potassium is 6.2 mEq/L (6.2 mmol/L) with cardiac changes, his BUN is 108 mg/dL (38.6 mmol/L), his serum creatinine is 4.1 mg/dL (362 mmol/L), and his serum HCO3- is 14 mEq/L (14 mmol/L). He is somnolent and disoriented. Which treatment should the nurse expect to be used for him?

a. Loop diuretics
b. Renal replacement therapy
c. Insulin and sodium bicarbonate
d. Sodium polystyrene sulfonate (Kayexalate)

Answer 11

b. Renal replacement therapy

This patient has at least three of the six common indications for renal replacement therapy (RRT), including (1) high potassium level, (2) metabolic acidosis, and (3) changed mental status. The other indications are (4) volume overload, resulting in compromised cardiac status (this patient has a history of hypertension), (5) BUN greater than 120 mg/dL, and (6) pericarditis, pericardial effusion, or cardiac tamponade. Although the other treatments may be used, they will not be as effective as RRT for this older patient. Loop diuretics and increased fluid are used if the patient is dehydrated. Insulin and sodium bicarbonate can be used to temporarily drive the potassium into the cells. Sodium polystyrene sulfonate (Kayexalate) is used to actually decrease the amount of potassium in the body.

Question 12

Prevention of AKI is important because of the high mortality rate. Which patients are at an increased risk for AKI (select all that apply)?

a. An 86-year-old woman scheduled for cardiac catheterization
b. A 48-year-old man with multiple injuries from a motor vehicle incident
c. A 32-year-old woman following a C-section delivery for abruptio placentae
d. A 64-year-old woman with chronic heart failure admitted with bloody stools
e. A 58-year-old man with prostate cancer undergoing preoperative workup for prostatectomy

Answer 12

(all of the above)

a. An 86-year-old woman scheduled for cardiac catheterization
b. A 48-year-old man with multiple injuries from a motor vehicle incident
c. A 32-year-old woman following a C-section delivery for abruptio placentae
d. A 64-year-old woman with chronic heart failure admitted with bloody stools
e. A 58-year-old man with prostate cancer undergoing preoperative workup for prostatectomy

High-risk patients include those exposed to nephrotoxic agents and advanced age (a), massive trauma (b), prolonged hypovolemia or hypotension (possibly b and c), obstetric complications (c), cardiac failure (d), preexisting chronic kidney disease, extensive burns, or sepsis. Patients with prostate cancer may have obstruction of the outflow tract, which increases risk of postrenal AKI (e).

Question 13

A patient on a medical unit has a potassium level of 6.8 mEq/L. What is the priority action that the nurse should take?

a. Place the patient on a cardiac monitor.
b. Check the patient’s blood pressure (BP).
c. Instruct the patient to avoid high-potassium foods.
d. Call the lab and request a redraw of the lab to verify results.

Answer 13

a. Place the patient on a cardiac monitor.

Dysrhythmias may occur with an elevated potassium level and are potentially lethal. Monitor the rhythm while contacting the physician or calling the rapid response team. Vital signs should be checked. Depending on the patient’s history and cause of increased potassium, instruct the patient about dietary sources of potassium; however, this would not help at this point. The nurse may want to recheck the value but until then the heart rhythm needs to be monitored.

Question 14

A patient with AKI has a serum potassium level of 6.7 mEq/L (6.7 mmol/L) and the following arterial blood gas results: pH 7.28, PaCO2 30 mm Hg, PaO2 86 mm Hg, HCO3- 18 mEq/L (18 mmol/L). The nurse recognizes that treatment of the acid-base problem with sodium bicarbonate would cause a decrease in which value?

a. pH
b. Potassium level
c. Bicarbonate level
d. Carbon dioxide level

Answer 14

b. Potassium level

During acidosis, potassium moves out of the cell in exchange for H+ ions, increasing the serum potassium level. Correction of the acidosis with sodium bicarbonate will help to shift the potassium back into the cells. A decrease in pH and the bicarbonate and PaCO2 levels would indicate worsening acidosis.

Question 15

In replying to a patient’s questions about the seriousness of her chronic kidney disease (CKD), the nurse knows that the stage of CKD is based on what?

a. Total daily urine output
b. Glomerular filtration rate
c. Degree of altered mental status
d. Serum creatinine and urea levels

Answer 15

b. Glomerular filtration rate

Stages of chronic kidney disease are based on the GFR. No specific markers of urinary output, mental status, or azotemia classify the degree of chronic kidney disease (CKD).

Question 16

The patient with CKD is receiving dialysis, and the nurse observes excoriations on the patient’s skin. What pathophysiologic changes in CKD can contribute to this finding (select all that apply)?

a. Dry skin
b. Sensory neuropathy
c. Vascular calcifications
d. Calcium-phosphate skin deposits
e. Uremic crystallization from high BUN

Answer 16

a. Dry skin
b. Sensory neuropathy
d. Calcium-phosphate skin deposits

Pruritis is common in patients receiving dialysis. It causes scratching from dry skin, sensory neuropathy, and calcium-phosphate deposition in the skin. Vascular calcifications contribute to cardiovascular, not to itching skin. Uremic frost rarely occurs without BUN levles greawter than 200 mg/dL, which should not occur in a patient on dialysis; urea crystallizes on the skin and also causes pruritis.

Question 17

What causes the gastrointestinal (GI) manifestation of stomatitis in the patient with CKD?

a. High serum sodium levels
b. Irritation of the GI tract from creatinine
c. Increased ammonia from bacterial breakdown of urea
d. Iron salts, calcium-containing phosphate binders, and limited fluid intake

Answer 17

c. Increased ammonia from bacterial breakdown of urea

Uremic fetor, or the urine odor of the breath, is caused by high urea content in the blood. Increased ammonia from bacterial breakdown of urea leads to stomatitis and mucosal ulcerations. Irritation of the gastrointestinal (GI) tract from urea in CKD contributes to anorexia, nausea, and vomiting. Ingestion of iron salts and calcium-containing phosphate binders, limited fluid intake, and limited activity would cause constipation.

Question 18

The patient with CKD is brought to the emergency department with Kussmaul respirations. What does the nurse know about CKD that could cause the patient’s Kussmaul respirations?

a. Uremic pleuritis is occurring.
b. There is decreased pulmonary macrophage activity.
c. They are caused by respiratory compensation for metabolic acidosis.
d. Pulmonary edema from heart failure and fluid overload is occurring.

Answer 18

c. They are caused by respiratory compensation for metabolic acidosis.

Kussmaul respirations occur with severe metabolic acidosis when the respiratory system is attempting to compensate by removing carbon dioxide with exhalations. Uremic pleuritis would cause a pleural friction rub. Decreased pulmonary macrophage activity increases the risk of pulmonary infection. Dyspnea would occur with pulmonary edema.

Question 19

Which serum laboratory value indicates to the nurse that the patient’s CKD is getting worse?

a. Decreased BUN
b. Decreased sodium
c. Decreased creatinine
d. Decreased calculated glomerular filtration rate (GFR)

Answer 19

d. Decreased calculated glomerular filtration rate (GFR)

As GFR decreases, BUN and serum creatinine levels increase. Although elevated BUN and creatinine indicate that waste products are accumulating, the calculated GFR is considered a more accurate indicator of kidney function than BUN or serum creatinine.

Question 20

What is the most serious electrolyte disorder associated with kidney disease?

a. Hypocalcemia
b. Hyperkalemia
c. Hyponatremia
d. Hypermagnesemia

Answer 20

b. Hyperkalemia

Hyperkalemia can lead to life-threatening dysrhythmias. Hypocalcemia leads to an accelerated rate of bone remodeling and potentially to tetany. Hyponatremia may lead to confusion. Elevated sodium levels lead to edema, hypertension, and heart failure. Hypermagnesemia may decrease reflexes, mental status, and blood pressure.

Question 21

For a patient with CKD the nurse identifies a nursing diagnosis for risk of injury: fracture related to alteration in calcium and phosphorus metabolism. What is the pathologic process directly related to the increased risk for fractures?

a. Loss of aluminum through the impaired kidneys
b. Deposition of calcium phosphate in soft tissues of the body
c. Impaired vitamin D activation resulting in decreased GI absorption of calcium
d. Increased release of parathyroid hormone in response to decreased calcium levels

Answer 21

c. Impaired vitamin D activation resulting in decreased GI absorption of calcium

The calcium-phosphorus imbalances that occur in CKD result in hypocalcemia, from a deficiency of active vitamin D and increased phosphorus levels. This leads to an increased rate of bone remodeling with a weakened bone matrix. Aluminum accumulation is also believed to contribute to the osteomalacia. Osteitis fibrosa involves replacement of calcium in the bone with fibrous tissue and is primarily a result of elevated levels of parathyroid hormone resulting from hypocalcemia.

Question 22

What is the most appropriate snack for the nurse to offer a patient with stage 4 CKD?

a. Raisins
b. Ice cream
c. Dill pickles
d. Hard candy

Answer 22

d. Hard candy

A patient with CKD may have unlimited intake of sugars and starches (unless the patient is diabetic) and hard candy is an appropriate snack and may help to relieve the metallic and urine taste that is common in the mouth. Raisins are a high-potassium food. Ice cream contains protein and phosphate and counts as fluid. Pickled foods have high sodium content.

Question 23

Which complication of chronic kidney disease is treated with erythropoietin (EPO)?

a. Anemia
b. Hypertension
c. Hyperkalemia
d. Mineral and bone disorder

Answer 23

a. Anemia

Erythropoietin is used to treat anemia, as it stimulates the bone marrow to produce red blood cells.

Question 24

The patient with CKD asks why she is receiving nifedipine (Procardia) and furosemide (Lasix). The nurse understands that these drugs are being used to treat the patient’s

a. anemia.
b. hypertension.
c. hyperkalemia.
d. mineral and bone disorder.

Answer 24

b. hypertension.

Nifedipine (Procardia) is a calcium channel blocker and furosemide (Lasix) is a loop diuretic. Both are used to treat hypertension.

Question 25

Which drugs will be used to treat the patient with CKD for mineral and bone disorder (select all that apply)? a. Cinacalcet (Sensipar) b. Sevelamer (Renagel) c. IV glucose and insulin d. Calcium acetate (PhosLo) e. IV 10% calcium gluconate

Answer 25

a. Cinacalcet (Sensipar) b. Sevelamer (Renagel) d. Calcium acetate (PhosLo) Cinacalcet (Sensipar), a calcimimetic agent to control secondary hyperparathyroidism; sevelamer (Renagel), a noncalcium phosphate binder; and calcium acetate (PhosLo), a calcium-based phosphate binder are used to treat mineral and bone disorder in CKD. IV glucose and insulin and IV 10% calcium gluconate along with sodium polystyrene sulfonate (Kayexalate) are used to treat the hyperkalemia of CKD.

Question 26

What accurately describes the care of the patient with CKD? a. A nutrient that is commonly supplemented for the patient on dialysis because it is dialyzable is iron. b. The syndrome that includes all of the signs and symptoms seen in the various body systems in CKD is azotemia. c. The use of morphine is contraindicated in the patient with CKD because accumulation of its metabolites may cause seizures. d. The use of calcium-based phosphate binders in the patient with CKD is contraindicated when serum calcium levels are increased.

Answer 26

d. The use of calcium-based phosphate binders in the patient with CKD is contraindicated when serum calcium levels are increased. In the patient with CKD, when serum calcium levels are increased, calcium-based phosphate binders are not used. The nutrient supplemented for patients on dialysis is folic acid. The various body system manifestations occur with uremia, which includes azotemia. Meperidine is contraindicated in patients with CKD related to possible seizures.

Question 27

During the nursing assessment of the patient with renal insuffiency, the nurse asks the patient specifically about a history of a. angina. b. asthma. c. hypertension. d. rheumatoid arthritis.

Answer 27

c. hypertension. The most common causes of CKD in the United States are diabetes mellitus and hypertension. The nurse should obtain information on long-term health problems that are related to kidney disease. The other disorders are not closely associated with renal disease.

Question 28

The patient with chronic kidney disease is considering whether to use peritoneal dialysis (PD) or hemodialysis (HD). What are advantages of PD when compared to HD (select all that apply)? a. Less protein loss b. Rapid fluid removal c. Less cardiovascular stress d. Decreased hyperlipidemia e. Requires fewer dietary restrictions

Answer 28

c. Less cardiovascular stress e. Requires fewer dietary restrictions Peritoneal dialysis is less stressful for the cardiovascular system and requires fewer dietary restrictions. Peritoneal dialysis actually contributes to more protein loss and increased hyperlipidemia. The fluid and creatinine removal are slower with peritoneal dialysis than hemodialysis.

Question 29

What does the dialysate for PD routinely contain? a. Calcium in a lower concentration than in the blood b. Sodium in a higher concentration than in the blood c. Dextrose in a higher concentration than in the blood d. Electrolytes in an equal concentration to that of the blood

Answer 29

c. Dextrose in a higher concentration than in the blood Dextrose or icodextrin or amino acid is added to dialysate fluid to create an osmotic gradient across the membrane to remove excess fluid from the blood. The dialysate fluid has no potassium so that potassium will diffuse into the dialysate from the blood. Dialysate also usually contains higher calcium to promote its movement into the blood. Dialysate sodium is usually less than or equal to that of blood to prevent sodium and fluid retention.

Question 30

Number the following in the order of the phases of exchange in PD. Begin with 1 and end with 3. ____ a. Drain ____ b. Dwell ____ c. Inflow

Answer 30

1 - c. Inflow 2 - b. Dwell 3 - a. Drain

Question 31

In which type of dialysis does the patient dialyze during sleep and leave the fluid in the abdomen during the day? a. Long nocturnal hemodialysis b. Automated peritoneal dialysis (APD) c. Continuous venovenous hemofiltration (CVVH) d. Continuous ambulatory peritoneal dialysis (CAPD)

Answer 31

b. Automated peritoneal dialysis (APD) Automated peritoneal dialysis (APD) is the type of dialysis in which the patient dialyzes during sleep and leaves the fluid in the abdomen during the day. Long nocturnal hemodialysis occurs while the patient is sleeping and is done up to six times per week. Continuous venovenous hemofiltration (CVVH) is a type of continuous renal replacement therapy used to treat AKI. Continuous ambulatory peritoneal dialysis (CAPD) is a dialysis that is done with exchanges of 1.5 to 3 L of dialysate at least four times daily.

Question 32

To prevent the most common serious complication of PD, what is important for the nurse to do? a. Infuse the dialysate slowly. b. Use strict aseptic technique in the dialysis procedures. c. Have the patient empty the bowel before the inflow phase. d. Reposition the patient frequently and promote deep breathing.

Answer 32

b. Use strict aseptic technique in the dialysis procedures. Peritonitis is a common complication of peritoneal dialysis (PD) and may require catheter removal and termination of dialysis. Infection occurs from contamination of the dialysate or tubing or from progression of exit-site or tunnel infections and strict sterile technique must be used by health professionals as well as the patient to prevent contamination. Too-rapid infusion may cause shoulder pain and pain may be caused if the catheter tip touches the bowel. Difficulty breathing, atelectasis, and pneumonia may occur from pressure of the fluid on the diaphragm, which may be prevented by elevating the head of the bed and promoting repositioning and deep breathing.

Question 33

A patient on hemodialysis develops a thrombus of a subcutaneous arteriovenous (AV) graft, requiring its removal. While waiting for a replacement graft or fistula, the patient is more likely to have what done for treatment? a. Peritoneal dialysis b. Peripheral vascular access using radial artery c. Silastic catheter tunneled subcutaneously to the jugular vein d. Peripherally inserted central catheter (PICC) line inserted into subclavian vein.

Answer 33

c. Silastic catheter tunneled subcutaneously to the jugular vein A more permanent, soft, flexible Silastic double-lumen catheter is used for long-term access when other forms of vascular access have failed. These catheters are tunneled subcutaneously and have Dacron cuffs that prevent infection from tracking along the catheter.

Question 34

A man with end-stage kidney disease is scheduled for hemodialysis following healing of an arteriovenous fistula (AVF). What should the nurse explain to him that will occur during dialysis? a. He will be able to visit, read, sleep, or watch TV while reclining in a chair. b. He will be placed on a cardiac monitor to detect any adverse effects that might occur. c. The dialyzer will remove and hold part of his blood for 20 to 30 minutes to remove the waste products. d. A large catheter with two lumens will be inserted into the fistula to send blood to and return it from the dialyzer.

Answer 34

a. He will be able to visit, read, sleep, or watch TV while reclining in a chair. While patients are undergoing hemodialysis, they can perform quiet activities that do not require the limb that has the vascular access. Blood pressure is monitored frequently and the dialyzer monitors dialysis function but cardiac monitoring is not usually indicated. The hemodialysis machine continuously circulates both the blood and dialysate past the semipermeable membrane in the machine. Graft and fistula access involve the insertion of two needles into the site: one to remove blood from and the other to return blood to the dialyzer.

Question 35

What is the primary way that a nurse will evaluate the patency of an AVF? a. Palpate for pulses distal to the graft site. b. Auscultate for the presence of a bruit at the site. c. Evaluate the color and temperature of the extremity. d. Assess for the presence of numbness and tingling distal to the site.

Answer 35

b. Auscultate for the presence of a bruit at the site. A patent arteriovenous fistula (AVF) creates turbulent blood flow that can be assessed by listening for a bruit or palpated for a thrill as the blood passes through the graft. Assessment of neurovascular status in the extremity distal to the graft site is important to determine that the graft does not impair circulation to the extremity but the neurovascular status does not indicate whether the graft is open.

Question 36

A patient with AKI is a candidate for continuous renal replacement therapy (CRRT). What is the most common indication for use of CRRT? a. Azotemia b. Pericarditis c. Fluid overload d. Hyperkalemia

Answer 36

c. Fluid overload Continuous renal replacement therapy (CRRT) is indicated for the patient with AKI as an alternative or adjunct to hemodialysis to slowly remove solutes and fluid in the hemodynamically unstable patient. It is especially useful for treatment of hyperkalemia, pericarditis, or other serious effects of uremia.

Question 37

A patient rapidly progressing toward end-stage kidney disease asks about the possibility of a kidney transplant. In responding to the patient, the nurse knows that what is a contraindication to kidney transplantation? a. Hepatitis C infection b. Coronary artery disease c. Refractory hypertension d. Extensive vascular disease

Answer 37

d. Extensive vascular disease Extensive vascular disease is a contraindication for renal transplantation, primarily because adequate blood supply is essential for the health of the new kidney. Other contraindications include disseminated malignancies, refractory or untreated cardiac disease, chronic respiratory failure, chronic infection, or unresolved psychosocial disorders. Coronary artery disease (CAD) may be treated with bypass surgery before transplantation and transplantation can relieve hypertension. Hepatitis B or C infection is not a contraindication.

Question 38

During immediate postoperative care of a recipient of a kidney transplant, what should the nurse expect to do? a. Regulate fluid intake hourly based on urine output. b. Monitor urine-tinged drainage on abdominal dressing. c. Medicate the patient frequently for incisional flank pain. d. Remove the urinary catheter to evaluate the ureteral implant.

Answer 38

a. Regulate fluid intake hourly based on urine output. Fluid and electrolyte imbalance is critical in the transplant recipient patient, especially because diuresis often begins soon after surgery. Fluid replacement is adjusted hourly based on kidney function and urine output. Urine-tinged drainage on the abdominal dressing may indicate leakage from the ureter implanted into the bladder and the health care provider should be notified. The donor patient may have a flank or laparoscopic incision(s) where the kidney was removed. The recipient has an abdominal incision where the kidney was placed in the iliac fossa. The urinary catheter is usually used for 2 to 3 days to monitor urine output and kidney function.

Question 39

A patient received a kidney transplant last month. Because of the effects of immunosuppressive drugs and CKD, what complication of transplantation should the nurse be assessing the patient for to decrease the risk of mortality? a. Infection b. Rejection c. Malignancy d. Cardiovascular disease

Answer 39

a. Infection Infection is a significant cause of morbidity and mortality after transplantation because the surgery, the immunosuppressive drugs, and the effects of CKD all suppress the body's normal defense mechanisms, thus increasing the risk of infection. The nurse must assess the patient as well as use aseptic technique to prevent infections. Rejection may occur but for other reasons. Malignancy occurrence increases later due to immunosuppressive therapy. Cardiovascular disease is the leading cause of death after renal transplantation but this would not be expected to cause death within the first month after transplantation.

Question 40

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

Answer 40

a. Primary cause of death is infection. c. Disease course is potentially reversible. Acute kidney injury (AKI) is potentially reversible. AKI has a high mortality rate, and the primary cause of death in patients with AKI is infection; the primary cause of death in patients with chronic kidney failure is cardiovascular disease. Most commonly, AKI follows severe, prolonged hypotension or hypovolemia or exposure to a nephrotoxic agent. Older adults are more susceptible to AKI as because the number of functioning nephrons decreases with age, but AKI can occur at any age.

Question 41

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

Answer 41

d. serum creatinine or urine output from baseline. The RIFLE classification is used to describe the stages of AKI. RIFLE standardizes the diagnosis of AKI. Risk (R) is the first stage of AKI, followed by injury (I), which is the second stage, and then increasing in severity to the final or third stage of failure (F). The two outcome variables are loss (L) and end-stage kidney disease (E). The first three stages are characterized by the serum creatinine level and urine output.

Question 42

During the oliguric phase of AKI, the nurse monitors the patient for (select all that apply) a. hypotension. b. ECG changes. c. hypernatremia. d. pulmonary edema. e. urine with high specific gravity.

Answer 42

b. ECG changes. d. pulmonary edema. The nurse monitors the patient in the oliguric phase of acute renal failure for the following: • Hypertension and pulmonary edema: When urinary output decreases, fluid retention occurs. The severity of the symptoms depends on the extent of the fluid overload. In the case of reduced urine output (i.e., anuria and oliguria), the neck veins may become distended with a bounding pulse. Edema and hypertension may develop. Fluid overload can eventually lead to heart failure (HF), pulmonary edema, and pericardial and pleural effusions. • Hyponatremia: Damaged tubules cannot conserve sodium. Consequently, the urinary excretion of sodium may increase, which results in normal or below-normal serum levels of sodium. • Electrocardiographic changes and hyperkalemia: Initially, clinical signs of hyperkalemia are apparent on electrocardiogram (ECG) demonstrating peaked T waves, widening of the QRS complex, and ST-segment depression. • Urinary specific gravity: Urinary specific gravity is fixed at about 1.010.

Question 43

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

Answer 43

c. Hypokalemia and hyponatremia In the diuretic phase of AKI, the kidneys have recovered the ability to excrete wastes but not the ability to concentrate urine. Hypovolemia and hypotension can result from massive fluid losses. Because of the large losses of fluid and electrolytes, the patient must be monitored for hyponatremia, hypokalemia, and dehydration.

Question 44

A patient is admitted to the hospital with chronic kidney disease. The nurse understands that this condition is characterized by a. progressive irreversible destruction of the kidneys. b. a rapid decrease in urine output with an elevated BUN. c. an increasing creatinine clearance with a decrease in urine output. d. prostration, somnolence, and confusion with coma and imminent death.

Answer 44

a. progressive irreversible destruction of the kidneys. Chronic kidney disease (CKD) involves progressive, irreversible loss of kidney function.

Question 45

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

Answer 45

a. older African Americans. b. patients more than 60 years old. d. those with a history of hypertension. e. those with a history of type 2 diabetes. Risk factors for CKD include diabetes mellitus, hypertension, age older than 60 years, cardiovascular disease, family history of CKD, exposure to nephrotoxic drugs, and ethnic minority (e.g., African American, Native American).

Question 46

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

Answer 46

a. hypertension. b. vascular calcifications. d. hyperinsulinemia causing dyslipidemia. CKD patients have traditional cardiovascular (CV) risk factors, such as hypertension and elevated lipids. Hyperinsulinemia stimulates hepatic production of triglycerides. Most patients with uremia develop dyslipidemia. Much CV disease may be related to nontraditional CV risk factors, such as vascular calcification and arterial stiffness, which are major contributors to CV disease in CKD. Calcium deposits in the vascular medial layer are associated with stiffening of the blood vessels. The mechanisms involved are multifactorial and incompletely understood, but they include (1) change of vascular smooth muscle cells into chondrocytes or osteoblast-like cells, (2) high total-body amounts of calcium and phosphate as a result of abnormal bone metabolism, (3) impaired renal excretion, and (4) drug therapies to treat the bone disease (e.g., calcium phosphate binders).

Question 47

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

Answer 47

a. Fluid is not usually restricted for patients receiving peritoneal dialysis. b. Sodium and potassium may be restricted in someone with advanced CKD. c. Decreased fluid intake and a low potassium diet are hallmarks of the diet for a patient receiving hemodialysis. Water and any other fluids are not routinely restricted before end-stage kidney disease (ESKD). Patients receiving hemodialysis have a more restricted diet than do patients receiving peritoneal dialysis. Patients receiving hemodialysis are frequently educated about the need for a dietary restriction of potassium-rich foods. However, patients receiving peritoneal dialysis may actually require replacement of potassium because of the higher losses of potassium with peritoneal dialysis. Sodium and salt restriction is common for all patients with CKD. For those receiving hemodialysis, as their urinary output diminishes, fluid restrictions are enhanced. Intake depends on the daily urine output. In general, 600 mL (from insensible loss) plus an amount equal to the previous day’s urine output is allowed for a patient receiving hemodialysis. Patients are advised to limit fluid intake so that weight gains between dialysis sessions (i.e., interdialytic weight gain) are no more than 1 to 2 kg. For the patient who is undergoing dialysis, protein is not routinely restricted. The beneficial role of protein restriction in CKD stages 1 through 4 as a means to reduce the decline in kidney function is controversial. Historically, dietary counseling often encouraged restriction of protein for individuals with CKD. Although there is some evidence that protein restriction has benefits, many patients find these diets difficult to adhere to. For CKD stages 1 through 4, many clinicians encourage a diet with normal protein intake. However, patients must be taught to avoid high-protein diets and supplements because they may overstress the diseased kidneys.

Question 48

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

Answer 48

a. successful transplantation usually provides better quality of life than that offered by dialysis. Kidney transplantation is extremely successful, with 1-year graft survival rates of about 90% for deceased donor organs and 95% for live donor organs. An advantage of kidney transplantation over dialysis is that it reverses many of the pathophysiologic changes associated with renal failure when normal kidney function is restored. It also eliminates the dependence on dialysis and the need for the accompanying dietary and lifestyle restrictions. Transplantation is less expensive than dialysis after the first year.

Question 49

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

Answer 49

c. palpate the area of the graft to feel a normal thrill. d. listen with a stethoscope over the graft to detect a bruit. e. frequently monitor the pulses and neurovascular status distal to the graft. A thrill can be felt on palpation of the area of anastomosis of the arteriovenous graft, and a bruit can be heard with a stethoscope. The bruit and thrill are created by arterial blood rushing into the vein. The blood pressure should not be taken in the arm with the AV graft.

Question 50

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

Answer 50

a. the diet is less restricted and dialysis can be performed at home. Advantages of peritoneal dialysis include fewer dietary restrictions and the possibility of home dialysis.

Question 51

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

Answer 51

a. Assess temperature and initiate workup to rule out infection. The nurse needs to be astute in the observation and assessment of kidney transplant recipients because prompt diagnosis and treatment of infections can improve patient outcomes. Fever, chills, and dysuria indicate an infection. The temperature should be assessed, and the patient should undergo diagnostic testing to rule out an infection.

Question 52

Prerenal AKI

Answer 52

Prerenal: factors external to the kidneys - Reduce systemic circulation --> reduction in blood flow --> decreased glomerular perfusion and filtration of kidneys - Kidney tubular and glomerular function is preserved - glomerular filtration is reduced as a result of decreased perfusion - Oliguria in PRERENAL - there is no damage to kidney tissue (parenchyma) -- it's caused by decrease in circulating blood volume, readily reversible with treatment - Can lead to intrarenal disease if renal ischemia is prolonged, decreased perfusion for extended time --> damage to kidney parenchyma HYPOVOLEMIA - Dehydration - Hemorrhage - GI losses (diarrhea, vomiting) - Excessive diuresis - Hypoalbuminemia - Burns DECREASED CARDIAC OUTPUT - Dardiac dysrhythmias - Cardiogenic shock - Heart failure - Myocardial infarction DECREASED PERIPHERAL VASCULAR RESISTANCE - Anaphylaxis - Neurologic injury - Septic shock DECREASED RENOVASCULAR BLOOD FLOW - Bilateral renal vein thrombosis - Embolism - Hepatorenal syndrome - Renal artery thrombosis

Question 53

Intrarenal AKI

Answer 53

- Conditions that cause direct damage to the kidney tissue, resulting in impaired nephron function - Most common cause of AKI for hospitalized patients - Usually results from: o Prolonged ischemia o Nephrotoxins -- can cause obstruction of intrarenal structures by crystallizing or causing damage to epithelial cells of tubules o Hemoglobin released from RBCS or myoglobin released from necrotic muscle cells -- can block tubules and cause renal vasoconstriction o MAY also be caused by diseases of the kidney such as acute glomerulonephritis and SLE - Acute tubular necrosis (ATN) - most common intrarenal cause of AKI o Primarily the result of ischemia, nephrotoxins or sepsis o Ischemic or nephrotoxic ATN 90% of cases o Severe ischemia - disruption in basement membrane and patchy destruction of tubular epithelium o Nephrotoxic agents - cause necrosis of tubular epithelial cells --> slough off and plug tubules - Potentially reversible if basement membrane not destroyed and tubular epithelium regenerates NEPHROTOXIC INJURY - Drugs: aminoglycosides (gentamicin, amikacin), amphotericin B - Contrast media - Hemolytic blood transfusion reaction - Severe crush injury - Chemical exposure: ethylene glycol, lead, arsenic, carbon tetrachloride INTERSTITIAL NEPHRITIS - Allergies: antibiotics (sulfonamides, rifampin), NSAIDS, ACE inhibitors - Infections: bacterial (acute pyelonephritis), viral (CMV), fungal (candidiasis) OTHER CAUSES - Prolonged prerenal ischemia - Acute glomerulonephritis - Thrombotic disorders - Toxemia of pregnancy - Malignant hypertension - Systemic lupus erythematosus

Question 54

Postrenal AKI

Answer 54

- Mechanical obstruction in outflow of urine --> urine refluxes into renal pelvis --> impaired kidney function - Common causes are BPH, prostate cancer, calculi, trauma, and extrarenal tumors - Bilateral ureteral obstruction --> hydronephrosis (kidney dilation), increase in hydrostatic pressure, tubular blockage - Account for less than 10% of AKI cases - If bilateral obstruction is relieved within 48 hours of onset, complete recovery is likely - After 12 weeks, recovery is unlikely -- prolonged obstruction can lead to tubular atrophy and irreversible kidney fibrosis - Benign prostatic hyperplasia - Bladder cancer - Calculi formation - Neuromuscular disorders - Prostate cancer - Spinal cord disease - Strictures - Trauma (back, pelvis, perineum)

Question 55

RIFLE Classification for staging AKI

Answer 55

Risk: - Serum creatinine increased x 1.5 OR GFR decreased by 25% - Urine output 4 mg/dL with acute rise = or > 0.5 mg/dL - Urine output 4 wk End-stage kidney disease: - Complete loss of kidney function >3 mo

Question 56

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

Answer 56

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

Question 57

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

Answer 57

d. Restrict fluids according to previous daily loss. Patients in the oliguric phase of acute kidney injury will have fluid volume excess with potassium and sodium retention. Therefore they will need to have dietary sodium, potassium, and fluids restricted. Daily fluid intake is based on the previous 24-hour fluid loss (measured output plus 600 ml for insensible loss). The diet also needs to provide adequate, not low, protein intake to prevent catabolism. The patient should also be weighed daily, not just three times each week.

Question 58

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

Answer 58

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

Question 59

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

Answer 59

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

Question 60

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

Answer 60

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

Question 61

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

Answer 61

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

Question 62

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

Answer 62

d. Dissecting abdominal aortic aneurysm A dissecting abdominal aortic aneurysm is a prerenal cause of AKI because it can decrease renal artery perfusion and therefore the glomerular filtrate rate. Aminoglycoside antibiotic administration, a hemolytic blood transfusion reaction, and poststretpcoccal glomerulonephritis are intrarenal causes of AKI.

Question 63

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

Answer 63

a. Monitor the patient's cardiac status. The nurse's priority is to monitor the patient's cardiac status. With the rapidly progressing glomerulonephritis, renal function begins to fail and fluid, potassium, and hydrogen retention lead to hypervolemia, hyperkalemia, and metabolic acidosis. Excess fluid increases the workload of the heart, and hyperkalemia can lead to life-threatening dysrhythmias. Teaching about hand washing and observation of the patient are important nursing interventions but are not the priority. Electrolyte measurement is a collaborative intervention that will be done as ordered by the health care provider.

Question 64

The nurse knows the patient with AKI has entered the diuretic phase when what assessments occur (select all that apply)? a. Dehydration b. Hypokalemia c. Hypernatremia d. BUN increases e. Serum creatinine increases

Answer 64

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

Question 65

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

Answer 65

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

Question 66

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

Answer 66

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

Question 67

Which patient should be taught preventive measures for CKD by the nurse because this patient is most likely to develop CKD? a. A 50-year-old white female with hypertension b. A 61-year-old Native American male with diabetes c. A 40-year-old Hispanic female with cardiovascular disease d. A 28-year-old African American female with a urinary tract infection

Answer 67

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

Question 68

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

Answer 68

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

Question 69

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

Answer 69

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

Question 70

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

Answer 70

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

Question 71

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

Answer 71

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

Question 72

The nurse is admitting a client diagnosed with acute renal failure (ARF). Which question is most important for the nurse to ask during the admission interview? 1. "Have you recently traveled outside the United States?" 2. "Did you recently begin a vigorous exercise program?" 3. "Is there a chance you have been exposed to a virus?" 4. "Which over-the-counter medications do you take regularly?"

Answer 72

4. "Which over-the-counter medications do you take regularly?" Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and some herbal remedies are neprotoxic; therefore, asking about medication is appropriate.

Question 73

The nurse is caring for a client diagnosed with ARF. Which laboratory values are most significant for diagnosing ARF? 1. BUN and creatinine. 2. WBC and hemoglobin. 3. Potassium and sodium. 4. Bilirubin and ammonia level.

Answer 73

1. BUN and creatinine. Blood urea nitrogen (BUN) levels reflect the balance between the production and excretion of urea from the kidneys. Creatinine is a by-product of the metabolism of the muscles and is excreted by the kidneys. Creatinine is the ideal substance for determining renal clearance because it is relatively constant in the body and is the laboratory value most significant in diagnosing renal failure.

Question 74

The nurse is caring for a client diagnosed with rule-out ARF. Which condition predisposes the client to developing prerenal failure? 1. Diabetes mellitus. 2. Hypotension. 3. Aminoglycosides. 4. Benign prostatic hypertrophy

Answer 74

2. Hypotension. Hypotension, which causes a decreased blood supply to the kidney, is one of the most common causes of prerenal failure (before the kidney).

Question 75

The client is diagnosed with ARF. Which signs/symptoms indicate to the nurse the client is in the recovery period? Select all that apply. 1. Increased alertness and no seizure activity. 2. Increase in hemoglobin and hematocrit. 3. Denial of nausea and vomiting. 4. Decreased urine-specific gravity. 5. Increased serum creatinine level.

Answer 75

1. Increased alertness and no seizure activity. 2. Increase in hemoglobin and hematocrit. 3. Denial of nausea and vomiting. 1. Renal failure affects almost every system in the body. Neurologically, the client may have drowsiness, headache, muscle twitching, and seizures. In the recovery period, the client is alert and has no seizure activity. 2. In renal failure, levels of erythropoietin are decreased, leading to anemia. An increase in hemoglobin and hematocrit indicates the client is in the recovery period. 3. Nausea, vomiting, and diarrhea are common in the client with ARF; therefore, an absence of these indicates the client is in the recovery period.

Question 76

The client diagnosed with ARF has a serum potassium level of 6.8 mEq/L. Which collaborative treatment should the nurse anticipate for the client? 1. Administer a phosphate binder. 2. Type and crossmatch for whole blood. 3. Assess the client for leg cramps. 4. Prepare the client for dialysis.

Answer 76

4. Prepare the client for dialysis. Normal potassium level is 3.5 to 5.5 mEq/L. A level of 6.8 mEq/L is life threatening and could lead to cardiac dysrhythmias. Therefore, the client may be dialyzed to decrease the potassium level quickly. This requires a health-care provider order, so it is a collaborative intervention.

Question 77

The nurse is developing a plan of care for a client diagnosed with ARF. Which statement is appropriate outcome for the client? 1. Monitor intake and output every shift. 2. Decrease of pain by 3 levels on a 1-10 scale. 3. Electrolytes are within normal limits. 4. Administer enemas to decrease hyperkalemia.

Answer 77

3. Electrolytes are within normal limits. Renal failure causes an imbalance of electrolytes (potassium, sodium, calcium, phosphorus). Therefore, the desired client outcome is electrolytes within normal limits.

Question 78

The client diagnosed with ARF is admitted to the intensive care unit and placed on a therapeutic diet. Which diet is most appropriate for the client? 1. A high-potassium and low-calcium diet. 2. A low-fat and low-cholesterol diet. 3. A high-carbohydrate and restricted-protein diet. 4. A regular diet with six (6) small feedings a day.

Answer 78

3. A high-carbohydrate and restricted-protein diet. Carbohydrates are increased to provide for the client's caloric intake and protein is restricted to minimize protein breakdown and to prevent accumulation of toxic waste products.

Question 79

The client diagnosed with ARF is placed on bedrest. The client asks the nurse, "Why do I have to stay in bed? I don't feel bad." Which scientific rationale supports the nurse's response? 1. Bedrest helps increase the blood return to the renal circulation. 2. Bedrest reduces the metabolic rate during the acute stage. 3. Bedrest decreases the workload of the left side of the heart. 4. Bedrest aids in reduction or peripheral and sacral edema.

Answer 79

2. Bedrest reduces the metabolic rate during the acute stage. Bedrest reduces exertion and the metabolic rate, thereby reducing catabolism and subsequent release of potassium and accumulation of endogenous waste products (urea and creatinine).

Question 80

The nurse and unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task is most appropriate for the nurse to delegate? 1. Collect a clean voided midstream urine specimen. 2. Evaluate the client's 8-hour intake and output. 3. Assist in checking a unit of blood prior to hanging. 4. Administer a cation-exchange resin enema.

Answer 80

1. Collect a clean voided midstream urine specimen. The UAP can collect specimens. Collecting a midstream urine specimen requires the client to clean the perineal area, to urinate a little, and then collect the rest of the urine output in a sterile container.

Question 81

The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should nurse implement first to prevent ARF? 1. Administer normal saline IV. 2. Take vital signs. 3. Place client on telemetry. 4. Assess abdominal dressing.

Answer 81

1. Administer normal saline IV. Preventing and treating shock with blood and fluid replacement will prevent acute renal failure from hypoperfusion of the kidneys. Significant blood loss is expected in the client with a gunshot wound.

Question 82

The UAP tells the nurse the client with ARF has a white crystal-like layer on top of the skin. Which intervention should the nurse implement? 1. Have the assistant apply a moisture barrier cream to the skin. 2. Instruct the UAP to bathe the client in cool water. 3. Tell the UAP not to turn the client in this condition. 4. Explain this is normal and do not do anything for the client.

Answer 82

2. Instruct the UAP to bathe the client in cool water. These crystals are uremic frost resulting from irritating toxins deposited in the client's tissues. Bathing in cool water will remove the crystals, promote comfort, and decrease the itching resulting from uremic frost.

Question 83

The client diagnosed with ARF is experiencing hyperkalemia. Which medication should the nurse prepare to administer to help decrease the potassium level? 1. Erythropoietin. 2. Calcium gluconate. 3. Regular insulin. 4. Osmotic diuretic.

Answer 83

3. Regular insulin. Regular insulin, along with glucose, will drive potassium into the cells, thereby lowering serum potassium levels temporarily.

Question 84

The nurse is caring for the client diagnosed with chronic kidney disease (CKD) who is experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in this client? 1. There is an increased excretion of phosphates and organic acids, which leads to an increase in arterial blood pH. 2. A shortened life span of red blood cells because of damage secondary to dialysis treatments in turn leads to metabolic acidosis. 3. The kidney cannot excrete increased levels of acid because they cannot excrete ammonia or cannot reabsorb sodium bicarbonate. 4. An increase in nausea and vomiting causes a loss of hydrochloric acid and the respiratory system cannot compensate adequately.

Answer 84

2. A shortened life span of red blood cells because of damage secondary to dialysis treatments in turn leads to metabolic acidosis. This is the correct scientific rationale for metabolic acidosis occurring in the client with CKD.

Question 85

The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first? 1. The client who has a hemoglobin of 9.8 g/dL and hematocrit of 30%. 2. The client who does not have a palpable thrill or auscultated bruit. 3. The client who is complaining of being exhausted and is sleeping. 4. The client who did not take antihypertensive medication this morning.

Answer 85

2. The client who does not have a palpable thrill or auscultated bruit. The client's dialysis is compromised and he or she should be assessed first.

Question 86

The male patient diagnosed with CKD has received the initial dose of erythropoietin, a biologic response modifier, 1 week ago. Which complaint by the client indicates the need to notify the health-care provider? 1. The client complains of flu-like symptoms. 2. The client complains of being tired all the time. 3. The client reports an elevation in his blood pressure. 4. The client reports discomfort in his legs and back.

Answer 86

3. The client reports an elevation in his blood pressure. After the initial administration of erythropoietin, a client's antihypertensive medications may need to be adjusted. Therefore, this complaint requires notification of the HCP. Erythropoietin therapy is contraindicated in clients with uncontrolled hypertension.

Question 87

The nurse is developing a nursing care plan for the client diagnosed with CKD. Which nursing problem is priority for the client? 1. Low self-esteem. 2. Knowledge deficit. 3. Activity intolerance. 4. Excess fluid volume.

Answer 87

4. Excess fluid volume. Excess fluid volume is priority because of the stress placed on the heart and vessels, which could lead to heart failure, pulmonary edema, and death.

Question 88

The client diagnosed with CKD has a new arteriovenous fistula in the left forearm. Which intervention should the nurse implement? 1. Teach the client to carry heavy objects with the right arm. 2. Perform all laboratory blood tests on the left arm. 3. Instruct the client to lie on the left arm during the night. 4. Discuss the importance of not performing any hand exercises.

Answer 88

1. Teach the client to carry heavy objects with the right arm. Carry heavy objects in the left arm could cause the fistula to clot by putting undue stress on the site, so the client should carry objects with the right arm.

Question 89

The male client diagnosed with CKD secondary to diabetes has been receiving dialysis for 12 years. The client is notified he will not be placed on the kidney transplant list. The client tells the nurse he will not be back for any more dialysis treatments. Which response by the nurse is most therapeutic? 1. "You cannot just quit your dialysis. This is not an option." 2. "You're angry at not being on the list, and you want to quit dialysis?" 3. "I will call your nephrologist right now so you can talk to the HCP." 4. "Make your funeral arrangements because you are going to die."

Answer 89

2. "You're angry at not being on the list, and you want to quit dialysis?" Reflecting the client's feelings and restating them are therapeutic responses the nurse should use when addressing the client's issues.

Question 90

The nurse is discussing kidney transplants with clients at a dialysis center. Which population is less likely to participate in organ donation? 1. Caucasian. 2. African American. 3. Asian. 4. Hispanic.

Answer 90

2. African American. Many in the African American culture believe the body must be kept intact after death, and organ donation is rare among African Americans. This is also why a client of African American descent will be on a transplant waiting list longer than people of other races. This is because of tissue-typing compatibility. Remember, this does not apply to all African-Americans; every client is an individual.

Question 91

The client receiving dialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first? 1. Place the client in the Trendelenburg position. 2. Turn off the dialysis machine immediately. 3. Bolus the client with 500 mL of normal saline. 4. Notify the health care provider as soon as possible.

Answer 91

1. Place the client in the Trendelenburg position. The nurse should place the client's chair with the head lower than the body, which will shunt blood to the brain; this is the Trendelenburg position.

Question 92

The nurse caring for a client diagnosed with CKD writes a client problem of "noncompliance with dietary restrictions." Which intervention should be included in the plan of care? 1. Teach the client the proper diet to eat while undergoing dialysis. 2. Refer the client and significant other to the dietitian. 3. Explain the importance of eating the proper foods. 4. Determine the reason for the client not adhering to the diet.

Answer 92

4. Determine the reason for the client not adhering to the diet. Noncompliance is a choice the client has a right to make, but the nurse should determine the reason for the noncompliance and then take appropriate actions based on the client's rationale. For example, if the client has financial difficulties, the nurse may suggest how the client can afford the proper foods along with medications, or the nurse may be able to refer the client to a social worker.

Question 93

The client diagnosed with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse? 1. Inability to auscultate a bruit over the fistula. 2. The client's abdomen is soft, is nontender, and has bowel sounds. 3. The dialysate being removed from the client's abdomen is clear. 4. The dialysate instilled was 1,500 mL and removed was 1,500 mL.

Answer 93

4. The dialysate instilled was 1,500 mL and removed was 1,500 mL. Because the client is in ESRD, fluid must be removed from the body, so the output should be more than the amount instilled. These assessment data require intervention by the nurse.

Question 94

The client receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the client? 1. Notify the HCP if the oral temperature is 102F or greater. 2. Apply ice to the access site if it starts bleeding at home. 3. Keep fingernails short and try not to scratch the skin. 4. Encourage significant other to make decisions for client.

Answer 94

3. Keep fingernails short and try not to scratch the skin. Uremic frost, which results when the skin attempts to take over the function of the kidneys, causes itching, which can lead to scratching possibly resulting in a break in the skin.

Question 95

``` A client in the intensive care unit develops prerenal failure following surgery. Which of the following causes should the nurse suspect? A. Vascular disease B. Urethral obstruction C. Hypovolemia D. Glomerulonephritis ```

Answer 95

C. Hypovolemia

Question 96

What nursing measures are included in the plan of care for a client with acute renal failure? A. Observe for signs of a secondary infection. B. Provide a high-protein, low-carbohydrate diet. C. In and out catheterization for residual urine. D. Force fluids to 2000 ml in 24 hours.

Answer 96

A. Observe for signs of a secondary infection.

Question 97

A client with chronic kidney disease has a nursing diagnosis of disturbed sensory perception related to central nervous system changes induced by uremic toxins. An appropriate nursing intervention for this problem is to A. Convey a caring attitude and foster the nurse-patient relationship B. Keep the client on strict bed-rest to avoid possible falls or other injuries. C. Reinforce restricted protein intake to prevent nitrogenous product accumulation. D. Provide an opportunity for the client to discuss concerns about the condition

Answer 97

C. Reinforce restricted protein intake to prevent nitrogenous product accumulation.

Question 98

Two hours after a kidney transplant, the nurse obtains all these data when assessing the client. Which information is most important to communicate to the health care provider? A. The BUN and creatinine levels are elevated. B. The urine output is 900 to 1100 ml/hr. C. The blood pressure is 88/50 mmHg. D. The pain level is 8/10 at incision when client coughs.

Answer 98

C. The blood pressure is 88/50 mmHg.

Question 99

The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should the nurse implement to prevent the client from developing acute renal failure? 1. Maintain the client's BP greater than 90/60. 2. Insert an indwelling catheter with a urimeter. 3. Prepare for a peritoneal gastric lavage. 4. Assess the client's abdominal dressing.

Answer 99

1. Maintain the client's BP greater than 90/60. Maintaining a blood pressure (BP), which prevents hypoperfusion of the kidneys, which help prevent ARF. This can be accomplished with intravenous fluids and blood transfusions.

Question 100

Which priority intervention should the nurse implement for the client diagnosed with acute renal failure who has a serum potassium level of 6.8 mEq/L? 1. Administer Kayexalate, a cation, rectally 2. Restrict the client from any potassium intake 3. Place the client on cardiac telemetry 4. Prepare the client for dialysis

Answer 100

3. Place the client on cardiac telemetry A level of 6.8 mEq/L is life threatening and could lead to cardiac dysrhythmias. Placing the client on cardiac telemetry is the priority intervention.

Question 101

The nurse is caring for the client diagnosed with chronic kidney disease (CKD) who is on hemodialysis. Which data would warrant the nurse questioning dialyzing the client? 1. The client has a hemoglobin of 9.8 mg/dL and a hematocrit of 30% 2. The client has a palpable thrill and ausculatated bruit 3. The client was complaining of being exhausted and is sleeping 4. The client has a weight loss of 2 kg from the previous treatment

Answer 101

4. The client has a weight loss of 2 kg from the previous treatment The client with CKD usually has weight gain between treatments which is called the wet weight. After dialysis, the client should lose weight, so a weight loss would warrant the nurse questioning administering the dialysis treatment because the client is below the previous dry weight.