Ch 47 Acute Renal Failure and Chronic Renal Disease Flashcards
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
D.
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.
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.
D.
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.
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.”
A.
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.
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
B.
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.
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
C.
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.
Which assessment finding is a consequence of the oliguric phase of AKI?
a. Hypovolemia
b. Hyperkalemia
c. Hypernatremia
d. Thrombocytopenia
B.
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.
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
D.
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.
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.
A.
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.
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
A. and B.
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.
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)
D.
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.
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
A.
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.
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
B.
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.
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
B.
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.
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. Correct
d. Administer antiemetic medications.
C.
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.
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.
B.
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.
The nurse is caring for a 68-year-old man who had coronary artery bypass surgery 3 weeks ago. If the patient is now is in the oliguric phase of acute kidney disease, which action would be appropriate to include in the plan of care?
Provide foods high in potassium.
Restrict fluids based on urine output.
Monitor output from peritoneal dialysis.
Offer high protein snacks between meals.
A.
Fluid intake is monitored during the oliguric phase. Fluid intake is determined by adding all losses for the previous 24 hours plus 600 mL. Potassium and protein intake may be limited in the oliguric phase to avoid hyperkalemia and elevated urea nitrogen. Hemodialysis, not peritoneal dialysis, is indicated in acute kidney injury if dialysis is needed.
A 52-year-old man with stage 2 chronic kidney disease is scheduled for an outpatient diagnostic procedure using contrast media. Which action should the nurse take?
Assess skin turgor to determine hydration status.
Insert a urinary catheter for the expected diuresis.
Evaluate the patient’s lower extremities for edema.
Check the patient’s urine for the presence of ketones.
A.
Preexisting kidney disease is the most important risk factor for the development of contrast-associated nephropathy and nephrotoxic injury. If contrast media must be administered to a high-risk patient, the patient needs to have optimal hydration. The nurse should assess the hydration status of the patient before the procedure is performed. Indwelling catheter use should be avoided whenever possible to decrease the risk of infection.
A 56-year-old woman with type 2 diabetes mellitus and chronic kidney disease has a serum potassium level of 6.8 mEq/L. The nurse should assess the patient for fatigue. flank tenderness. cardiac dysrhythmias. elevated triglycerides.
C.
Hyperkalemia is the most serious electrolyte disorder associated with kidney disease. Fatal dysrhythmias can occur when the serum potassium level reaches 7 to 8 mEq/L. Fatigue and hypertriglyceridemia may be present but do not require urgent intervention. Tenderness or pain over the kidneys is not expected in CKD.
A frail 72-year-old woman with stage 3 chronic kidney disease is cared for at home by her family. The patient has a history of taking many over-the-counter medications. Which over-the-counter medications should the nurse teach the patient to avoid? Aspirin Acetaminophen (Tylenol) Diphenhydramine (Benadryl) Aluminum hydroxide (Amphogel)
D.
Antacids (that contain magnesium and aluminum) should be avoided because patients with kidney disease are unable to excrete these substances. Also, some antacids contain high levels of sodium that further increase blood pressure. Acetaminophen and aspirin (if taken for a short period of time) are usually safe for patients with kidney disease. Antihistamines may be used, but combination drugs that contain pseudoephedrine may increase blood pressure and should be avoided.
The home care nurse visits a 34-year-old woman receiving peritoneal dialysis. Which statement, if made by the patient, indicates a need for immediate follow-up by the nurse?
“Drain time is faster if I rub my abdomen.”
“The fluid draining from the catheter is cloudy.”
“The drainage is bloody when I have my period.”
“I wash around the catheter with soap and water.”
B.
The primary clinical manifestation of peritonitis is a cloudy peritoneal effluent. Blood may be present in the effluent of women who are menstruating, and no intervention is indicated. Daily catheter care may include washing around the catheter with soap and water. Drain time may be facilitated by gently massaging the abdomen.
A 25-year-old male patient has been admitted with a severe crushing injury after an industrial accident.
Which laboratory result will be most important to report to the health care provider?
a. Serum creatinine level 2.1 mg/dL
b. Serum potassium level 6.5 mEq/L
c. White blood cell count 11,500/μL
d. Blood urea nitrogen (BUN) 56 mg/dL
ANS: B
The hyperkalemia associated with crushing injuries may cause
cardiac arrest and should be treated immediately. The nurse
also will report the other laboratory values, but abnormalities
in these are not immediately life threatening
A 37-year-old female patient is hospitalized with acute kidney injury (AKI). Which
information will be most useful to the nurse in evaluating improvement in kidney function?
a. Urine volume
b. Creatinine level
c. Glomerular filtration rate (GFR)
d. Blood urea nitrogen (BUN) level
ANS: C
GFR is the preferred method for evaluating kidney function. BUN levels can
fluctuate based on factors such as fluid volume status and protein intake. Urine
output can be normal or high in patients with AKI and does not accurately
reflect kidney function. Creatinine alone is not an accurate reflection of renal
function
A 38-year-old patient who had a kidney transplant 8 years ago is receiving the immunosuppressants
tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone). Which assessment data will
be of most concern to the nurse?
a. The blood glucose is 144 mg/dL.
b. There is a nontender axillary lump.
c. The patient’s skin is thin and fragile.
d. The patient’s blood pressure is 150/92.
ANS: B
A nontender lump suggests a malignancy such as a lymphoma, which could
occur as a result of chronic immunosuppressive therapy. The elevated glucose,
skin change, and hypertension are possible side effects of the prednisone and
should be addressed, but they are not as great a concern as the possibility of a
malignancy
