Chapter 46 Acute Kidney and Chronic Kidney Disease

Question 1

1. After the insertion of an arteriovenous graft (AVG) in the right forearm, a 54-year-old patient complains of pain and coldness of the right fingers. Which action should the nurse take?
   a. Teach the patient about normal AVG function.
   b. Remind the patient to take a daily low-dose aspirin tablet.
   c. Report the patient’s symptoms to the health care provider.
   d. Elevate the patient’s arm on pillows to above the heart level.

Answer 1

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

Question 2

2. When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of
   a. persistent skin tenting
   b. rapid, deep respirations.
   c. bounding peripheral pulses.
   d. hot, flushed face and neck.

Answer 2

ANS: B
Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.

Question 3

3. The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary collaborative treatment goal in the plan will be
   a. augmenting fluid volume.
   b. maintaining cardiac output.
   c. diluting nephrotoxic substances.
   d. preventing systemic hypertension.

Answer 3

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

Question 4

4. A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV?
   a. Urine volume
   b. Calcium level
   c. Cardiac rhythm
   d. Neurologic status

Answer 4

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

Question 5

5. A 48-year-old patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which order for the patient will the nurse question?
   a. NPO for 6 hours before procedure
   b. Ibuprofen (Advil) 400 mg PO PRN for pain
   c. Dulcolax suppository 4 hours before procedure
   d. Normal saline 500 mL IV infused before procedure

Answer 5

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

Question 6

6. Which statement by a 62-year-old patient with stage 5 chronic kidney disease (CKD) indicates that the nurse’s teaching about management of CKD has been effective?
   a. “I need to get most of my protein from low-fat dairy products.”
   b. “I will increase my intake of fruits and vegetables to 5 per day.”
   c. “I will measure my urinary output each day to help calculate the amount I can drink.”
   d. “I need to take erythropoietin to boost my immune system and help prevent infection.”

Answer 6

ANS: C
The patient with end-stage kidney disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD.

Question 7

7. Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)?
   a. Blood pressure
   b. Phosphate level
   c. Neurologic status
   d. Creatinine clearance

Answer 7

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

Question 8

8. Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the
   a. bowel sounds.
   b. blood glucose.
   c. blood urea nitrogen (BUN).
   d. level of consciousness (LOC).

Answer 8

ANS: A
Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not affect the nurse’s decision to give the medication

Question 9

9. Which menu choice by the patient who is receiving hemodialysis indicates that the nurse’s teaching has been successful?
   a. Split-pea soup, English muffin, and nonfat milk
   b. Oatmeal with cream, half a banana, and herbal tea
   c. Poached eggs, whole-wheat toast, and apple juice
   d. Cheese sandwich, tomato soup, and cranberry juice

Answer 9

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

Question 10

10. Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check laboratory results for
    a. potassium level.
    b. total cholesterol.
    c. serum phosphate.
    d. serum creatinine.

Answer 10

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

Question 11

11. 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

Answer 11

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.

Question 12

12. A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft?
    a. A fistula is much less likely to clot.
    b. A fistula increases patient mobility.
    c. A fistula can accommodate larger needles.
    d. A fistula can be used sooner after surgery.

Answer 12

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

Question 13

13. When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula?
    a. Auscultate for a bruit at the fistula site.
    b. Assess the quality of the left radial pulse.
    c. Compare blood pressures in the left and right arms.
    d. Irrigate the fistula site with saline every 8 to 12 hours.

Answer 13

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

Question 14

14. A 64-year-old male patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching?
    a. Increased calories are needed because glucose is lost during hemodialysis.
    b. Unlimited fluids are allowed because retained fluid is removed during dialysis.
    c. More protein is allowed because urea and creatinine are removed by dialysis.
    d. Dietary potassium is not restricted because the level is normalized by dialysis.

Answer 14

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

Question 15

15. Which action by a 70-year-old patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?
    a. The patient leaves the catheter exit site without a dressing.
    b. The patient plans 30 to 60 minutes for a dialysate exchange.
    c. The patient cleans the catheter while taking a bath each day.
    d. The patient slows the inflow rate when experiencing abdominal pain.

Answer 15

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

Question 16

16. Which information in a patient’s history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation?
    a. The patient has type 1 diabetes.
    b. The patient has metastatic lung cancer.
    c. The patient has a history of chronic hepatitis C infection.
    d. The patient is infected with the human immunodeficiency virus.

Answer 16

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

Question 17

17. Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation?
    a. Postural hypotension
    b. Recurrent tachycardia
    c. Knee and hip joint pain
    d. Increased serum creatinine

Answer 17

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

Question 18

18. 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.

Answer 18

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.

Question 19

19. . The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required?
    a. Multivitamin with iron
    b. Magnesium hydroxide
    c. Acetaminophen (Tylenol)
    d. Calcium phosphate (PhosLo)

Answer 19

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

Question 20

20. Before administration of captopril (Capoten) to a patient with stage 2 chronic kidney disease (CKD), the nurse will check the patient’s
    a. glucose.
    b. potassium.
    c. creatinine.
    d. phosphate.

Answer 20

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

Question 21

21. A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient’s
    a. blood glucose.
    b. urine osmolality.
    c. serum creatinine.
    d. serum potassium.

Answer 21

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

Question 22

22. A 55-year-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication?
    a. Creatinine 1.6 mg/dL
    b. Oxygen saturation 89%
    c. Hemoglobin level 13 g/dL
    d. Blood pressure 98/56 mm Hg

Answer 22

ANS: C
High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when erythropoietin (EPO) is administered to a target hemoglobin of >12 g/dL. Hemoglobin levels higher than 12 g/dL indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider but will not affect whether the medication is administered.

Question 23

23. Which intervention will be included in the plan of care for a male patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein?
    a. Start continuous pulse oximetry.
    b. Restrict physical activity to bed rest.
    c. Restrict the patient’s oral protein intake.
    d. Discontinue the urethral retention catheter.

Answer 23

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

Question 24

24. 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

Answer 24

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.

Question 25

25. A 72-year-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first?
    a. Insert urethral catheter.
    b. Obtain renal ultrasound.
    c. Draw a complete blood count.
    d. Infuse normal saline at 50 mL/hour.

Answer 25

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

Question 26

27. A 62-year-old female patient has been hospitalized for 8 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider?
    a. The creatinine level is 3.0 mg/dL.
    b. Urine output over an 8-hour period is 2500 mL.
    c. The blood urea nitrogen (BUN) level is 67 mg/dL.
    d. The glomerular filtration rate is

Answer 26

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

Question 27

28. A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first?
    a. Notify the patient’s health care provider.
    b. Document the QRS interval measurement.
    c. Check the medical record for most recent potassium level.
    d. Check the chart for the patient’s current creatinine level.

Answer 27

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

Question 28

29. A 42-year-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first?
    a. Insert a urinary retention catheter.
    b. Place the patient on a cardiac monitor.
    c. Administer epoetin alfa (Epogen, Procrit).
    d. Give sodium polystyrene sulfonate (Kayexalate).

Answer 28

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

Question 29

29. A patient has arrived for a scheduled hemodialysis session. Which nursing action is most appropriate for the registered nurse (RN) to delegate to a dialysis technician?
    a. Teach the patient about fluid restrictions.
    b. Check blood pressure before starting dialysis.
    c. Assess for causes of an increase in predialysis weight.
    d. Determine the ultrafiltration rate for the hemodialysis.

Answer 29

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

Question 30

30. A licensed practical/vocational nurse (LPN/LVN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention?
    a. The LPN/LVN administers the erythropoietin subcutaneously.
    b. The LPN/LVN assists the patient to ambulate out in the hallway.
    c. The LPN/LVN administers the iron supplement and phosphate binder with lunch.
    d. The LPN/LVN carries a tray containing low-protein foods into the patient’s room.

Answer 30

ANS: C
Oral phosphate binders should not be given at the same time as iron because they prevent the iron from being absorbed. The phosphate binder should be given with a meal and the iron given at a different time. The other actions by the LPN/LVN are appropriate for a patient with renal insufficiency.

Question 31

31. A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2 L inflows. Which information should the nurse report immediately to the health care provider?
    a. The patient has an outflow volume of 1800 mL.
    b. The patient’s peritoneal effluent appears cloudy.
    c. The patient has abdominal pain during the inflow phase.
    d. The patient’s abdomen appears bloated after the inflow.

Answer 31

ANS: B
Cloudy appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient.

Question 32

32. The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider?
    a. The urine output is 900 to 1100 mL/hr.
    b. The patient’s central venous pressure (CVP) is decreased.
    c. The patient has a level 7 (0 to 10 point scale) incisional pain.
    d. The blood urea nitrogen (BUN) and creatinine levels are elevated.

Answer 32

ANS: B
The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant.

Question 33

33. During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness. Which action should the nurse take first?
    a. Slow down the rate of dialysis.
    b. Check patient’s blood pressure (BP).
    c. Review the hematocrit (Hct) level.
    d. Give prescribed PRN antiemetic drugs.

Answer 33

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

Question 34

34. The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider?
    a. Heart rate
    b. Urine output
    c. Creatinine clearance
    d. Blood urea nitrogen (BUN) level

Answer 34

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

Question 35

35. A patient complains of leg cramps during hemodialysis. The nurse should first
    a. massage the patient’s legs.
    b. reposition the patient supine.
    c. give acetaminophen (Tylenol).
    d. infuse a bolus of normal saline.

Answer 35

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

Question 36

36. A 74-year-old who is progressing to stage 5 chronic kidney disease asks the nurse, “Do you think I should go on dialysis? Which initial response by the nurse is best?
    a. “It depends on which type of dialysis you are considering.”
    b. “Tell me more about what you are thinking regarding dialysis.”
    c. “You are the only one who can make the decision about dialysis.”
    d. “Many people your age use dialysis and have a good quality of life.”

Answer 36

ANS: B
The nurse should initially clarify the patient’s concerns and questions about dialysis. The patient is the one responsible for the decision and many people using dialysis do have good quality of life, but these responses block further assessment of the patient’s concerns. Referring to which type of dialysis the patient might use only indirectly responds to the patient’s question.

Question 37

37. After receiving change-of-shift report, which patient should the nurse assess first?
    a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange
    b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level
    c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L
    d. Patient who has just returned from having hemodialysis and has a heart rate of 124/min

Answer 37

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

Question 38

38. Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis (select all that apply)?
    a. Avoid commercial salt substitutes.
    b. Drink 1500 to 2000 mL of fluids daily.
    c. Take phosphate-binders with each meal.
    d. Choose high-protein foods for most meals.
    e. Have several servings of dairy products daily.

Answer 38

ANS: A, C, D
Patients who are receiving peritoneal dialysis should have a high-protein diet. Phosphate binders are taken with meals to help control serum phosphate and calcium levels. Commercial salt substitutes are high in potassium and should be avoided. Fluid intake is limited in patients requiring dialysis. Dairy products are high in phosphate and usually are limited.