chapter 49

Question 1

The nurse is caring for a client who has had an insertion of an arteriovenous graft (AVG)
in the right forearm and has symptoms of pain and coldness of the right fingers. Which of
the following actions should the nurse take?
a. Elevate the client’s arm above the level of the heart.
b. Report the client’s symptoms to the health care provider.
c. Remind the client about the need to take a daily low-dose Aspirin tablet.
d. Educate the client about the normal vascular response after AVG insertion.

Answer 1

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

Question 2

The nurse is caring for a client with acute kidney injury (AKI) who has an arterial blood
pH of 7.30. Which of the following assessment findings should the nurse anticipate?
a. Vasodilation
b. Poor skin turgor
c. Bounding pulses
d. Rapid respirations

Answer 2

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

Question 3

The nurse is caring for a client with severe heart failure who develops elevated blood urea
nitrogen (BUN) and creatinine levels. The nurse will plan care to meet which of the
following goals of treatment?
a. Replace fluid volume
b. Prevent hypertension
c. Maintain cardiac output
d. Dilute nephrotoxic substances

Answer 3

C

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

Question 4

The nurse is caring for a client with acute glomerulonephritis, acute kidney injury (AKI),
and hyperkalemia who is prescribed calcium gluconate IV. Which of the following
parameters should the nurse assess to evaluate the effectiveness of the medication?
a. Urine output
b. Calcium level
c. Cardiac rhythm
d. Neurological status

Answer 4

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

Question 5

The nurse is caring for a client with stage 2 chronic kidney disease (CKD) who is
scheduled for an intravenous pyelogram (IVP). Which of the following prescriptions for
the client should the nurse question?
a. NPO for 6 hours before IVP procedure
b. Normal saline 500 mL IV before procedure
c. Ibuprofen 400 mg PO PRN for pain
d. Dulcolax suppository 4 hours before IVP procedure

Answer 5

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

Question 6

The nurse is teaching a client with stage 5 chronic kidney disease (CKD) about
management of CKD. Which of the following client statements indicate that the teaching
was effective?
a. “I need to try to get more protein from dairy products.”
b. “I will try to increase my intake of fruits and vegetables.”
c. “I will measure my urinary output each day to help calculate the amount I can
drink.”
d. “I need to take the erythropoietin to boost my immune system and help prevent

infection.”

Answer 6

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

Question 7

The nurse is caring for a client with chronic kidney disease (CKD) who is prescribed
calcium carbonate. Which of the following parameters should the nurse assess in order to
determine the effectiveness of the treatment?
a. Blood pressure
b. Phosphate level
c. Neurological status
d. Creatinine clearance

Answer 7

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

Question 8

Which of the following assessments should the nurse complete before administering
sodium polystyrene sulphonate to a client with hyperkalemia?
a. Blood urea nitrogen (BUN) and creatinine
b. Blood glucose level
c. Client’s bowel sounds
d. Level of consciousness (LOC)

Answer 8

C
Sodium polystyrene sulphonate should not be given to a client who does not have normal
bowel function because bowel necrosis can occur. The BUN and creatinine, blood glucose,
and LOC would not affect the nurse’s decision to give the medication.

Question 9

The nurse is teaching a client who is receiving hemodialysis about appropriate dietary
choices. Which of the following menu choices by the client indicates that the teaching has
been effective?
a. Scrambled eggs, English muffin, and apple juice
b. Oatmeal with cream, half a banana, and herbal tea
c. Split-pea soup, whole-wheat toast, and nonfat milk
d. Cheese sandwich, tomato soup, and cranberry juice

Answer 9

A

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

Question 10

The nurse is preparing to administer calcium carbonate to a client with chronic kidney
disease (CKD). Which of the following laboratory results should the nurse check prior to
administration?
a. Creatinine
b. Potassium
c. Total cholesterol
d. Serum phosphate

Answer 10

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

Question 11

Which of the following information is most useful to the nurse in evaluating improvement
in kidney function for a client who is hospitalized with acute kidney injury (AKI)?
a. Blood urea nitrogen (BUN) level
b. Urine output
c. Creatinine level
d. Calculated glomerular filtration rate (GFR)

Answer 11

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

Question 12

The nurse is caring for a client who requires vascular access for hemodialysis and asks the
nurse what the differences are between an arteriovenous (AV) fistula and a graft. Which of
the following information should the nurse explain is an advantage of the fistula?
a. Is much less likely to clot
b. Increases client mobility
c. Accommodates larger needles.
d. Can be used sooner after surgery.

Answer 12

A

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

Question 13

The nurse is caring for a client with a left arm arteriovenous fistula. Which of the
following actions should the nurse include in the plan of care to maintain the patency of
the fistula?
a. Check the fistula site for a bruit and thrill.
b. Assess the rate and quality of the left radial pulse.
c. Compare blood pressures in the left and right arms.
d. Irrigate the fistula site with saline every 8–12 hours.

Answer 13

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

Question 14

The nurse is caring for a client who has had progressive chronic kidney disease (CKD) for
several years and is starting hemodialysis. Which of the following information about diet
should the nurse include in client teaching?
a. Increased calories are needed because glucose is lost during hemodialysis.
b. Unlimited fluids are allowed since retained fluid is removed during dialysis.
c. More protein will be allowed because of the removal of urea and creatinine by
dialysis.
d. Dietary sodium and potassium are unrestricted because these levels are normalized
by dialysis.

Answer 14

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

Question 15

Which of the following actions by a client who is using peritoneal dialysis (PD) indicates
that the nurse should provide more teaching about PD?
a. The client slows the inflow rate when experiencing pain.
b. The client leaves the catheter exit site without a dressing.
c. The client plans 30–60 minutes for a dialysate exchange.
d. The client cleans the catheter while taking a bath every day.

Answer 15

D

Clients are taught to avoid insertion site infection and should be encouraged to take
showers rather than baths to avoid infections at the catheter insertion side. The other client
actions indicate good understanding of peritoneal dialysis.

Question 16

The nurse is taking a history for a client who is a possible candidate for a kidney transplant.
Which of the following information indicates that the client is not an appropriate candidate
for transplantation?
a. The client has metastatic lung cancer.
b. The client has poorly controlled type 1 diabetes.
c. The client has a history of chronic hepatitis C infection.
d. The client is infected with the human immunodeficiency virus.

Answer 16

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

Question 17

The nurse is caring for a client who had kidney transplantation several years ago. Which of
the following findings may indicate that the client is experiencing adverse effects to the
prescribed corticosteroid?
a. Joint pain
b. Tachycardia
c. Postural hypotension
d. Increase in creatinine level

Answer 17

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

Question 18

The nurse is assessing a client who had a kidney transplant 8 years ago and is receiving the
immunosuppressants tacrolimus, cyclosporin, and prednisone. Which of the following
findings is of most concern to the nurse?
a. The blood glucose is 7.9 mmol/L.
b. The client’s blood pressure is 150/92.
c. There is a nontender lump in the axilla.
d. The client has a round, moonlike face.

Answer 18

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

Question 19

The nurse is interviewing a client with chronic kidney disease (CKD) who brings all home
medications to the clinic to be reviewed by the nurse. Which of the following medications
being used by the client indicates that client teaching is required?
a. Multivitamin with iron
b. Milk of magnesia 30 mL
c. Calcium acetate
d. Acetaminophen 650 mg

Answer 19

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

Question 20

The nurse is caring for a client with hypertension and stage 2 chronic kidney disease
(CKD) who is prescribed ramapril. Which of the following laboratory tests should the
nurse assess before administration of the medication?
a. Glucose
b. Potassium
c. Creatinine
d. Phosphate

Answer 20

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

Question 21

The nurse is caring for a client with diabetes who has been admitted with pneumonia and
is prescribed gentamicin 60 mg IV. Which of the following parameters should the nurse
monitor to evaluate the client for adverse effects of the medication?
a. Urine osmolality
b. Serum potassium
c. Blood glucose level
d. Blood urea nitrogen (BUN) and creatinine

Answer 21

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

Question 22

The nurse is caring for a client with end-stage renal disease (ESRD). Which of the
following findings indicate that the nurse should consult with the health care provider
before giving the prescribed erythropoiesis-stimulating agent (ESA)?
a. Creatinine 99 mcmol/L
b. Oxygen saturation 89%
c. Hemoglobin level 130 g/L
d. Blood pressure 98/56 mm Hg

Answer 22

C
High hemoglobin levels are associated with a higher rate of thromboembolic events and
increased risk of death from serious cardiovascular events (heart attack, heart failure,
stroke) when ESA is administered to a target hemoglobin of 110 g/L with a range of
100–120 g/L). Hemoglobin levels higher than 120 g/L indicate a need for a decrease in
erythropoiesis-stimulating agent dose. The other information will also be reported to the
health care provider but will not affect whether the medication is administered.

Question 23

The nurse is caring for a client with acute kidney injury (AKI) who requires hemodialysis
and a temporary vascular access is obtained by placing a catheter in the left femoral vein.
Which of the following interventions should be included in the plan of care?
a. Place the client on bed rest.
b. Start continuous pulse oximetry.
c. Discontinue the retention catheter.
d. Restrict the client’s oral protein intake.

Answer 23

A
The client 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 client 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 client needs continuous pulse oximetry.

Question 24

The nurse is caring for a client who has been admitted with a severe crushing injury after
an industrial accident. Which of the following laboratory results is most important to
report to the health care provider?
a. Serum creatinine level 190 mcmol/L
b. Serum potassium level 6.5 mmol/L
c. White blood cell count 11.5 ́ 109/L
d. Blood urea nitrogen (BUN) 18 mmol/L

Answer 24

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

Question 25

The nurse is caring for a client with a history of benign prostatic hyperplasia (BPH) with
acute urinary retention and an elevated blood urea nitrogen (BUN) and creatinine. Which
of the following prescribed therapies should the nurse implement first?
a. Obtain renal ultrasound.
b. Insert retention catheter.
c. Infuse normal saline at 50 mL/hour.
d. Draw blood for complete blood count.

Answer 25

B
The client’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 client. The other actions also are appropriate but should
be implemented after the retention catheter.

Question 26

The nurse is caring for a client who was admitted 10 days previously with acute kidney
injury (AKI) caused by dehydration. Which of the following findings is most important for
the nurse to report to the health care provider?
a. The blood urea nitrogen (BUN) level is 23.1 mmol/L.
b. The creatinine level is 186 mcmol/L.
c. Urine output over an 8-hour period is 2 500 mL.
d. The glomerular filtration rate is <30 mL/minute/1.73m2.

Answer 26

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

Question 27

After noting lengthening QRS intervals in a client with acute kidney injury (AKI), which
of the following actions should the nurse take first?
a. Document the QRS interval.
b. Notify the client’s health care provider.
c. Look at the client’s current blood urea nitrogen (BUN) and creatinine levels.
d. Check the client’s most recent blood potassium level.

Answer 27

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

Question 28

The nurse is caring for a client with acute kidney injury who is dehydrated with symptoms
of oliguria, anemia, and hyperkalemia. Which of the following prescribed actions should
the nurse take first?
a. Insert a urinary retention catheter.
b. Place the client on a cardiac monitor.
c. Administer an erythropoiesis-stimulating agent (ESA).
d. Give sodium polystyrene sulfonate.

Answer 28

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

Question 29

The nurse is caring for a client who is receiving hemodialysis and has symptoms of nausea,
vomiting, and a headache. Which of the following actions is priority?
a. Infuse a hypotonic solution
b. Increase the rate of the dialysis
c. Administer an antiemetic medication
d. Stop the dialysis solution

Answer 29

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

Question 30

The RN observes a nursing student carrying out all of these actions while caring for a
client with stage 2 chronic kidney disease. Which of the following actions require the RN
to intervene?
a. The student administers erythropoietin subcutaneously.
b. The student assists the client to ambulate in the hallway.
c. The student gives the iron supplement and phosphate binder with lunch.
d. The student carries a tray containing low-protein foods into the client’s room.

Answer 30

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

Question 31

The nurse is assessing a client who is receiving peritoneal dialysis with 2 L inflows.
Which of the following information should be reported immediately to the health care
provider?
a. The client has an outflow volume of 1 800 mL.
b. The client’s peritoneal effluent appears cloudy.
c. The client has abdominal pain during the inflow phase.
d. The client complains of feeling bloated after the inflow.

Answer 31

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
client.

Question 32

Two hours after a kidney transplant, the nurse obtains all of the following data when
assessing the client. Which information is most important to communicate to the health
care provider?
a. The urine output is 900–1 100 mL/hour.
b. The blood urea nitrogen (BUN) and creatinine levels are elevated.
c. The client’s central venous pressure (CVP) is decreased.
d. The client has level 8 (on a 10-point scale) incisional pain.

Answer 32

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

Question 33

The nurse is caring for a client in the oliguric phase of acute renal failure who has a
24-hour fluid output of 150 mL emesis and 250 mL urine. Which of the following amounts
in mL should the nurse plan a fluid replacement for the following day?
a. 400
b. 800
c. 1 000
d. 1 400

Answer 33

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

Question 34

The nurse is caring for a client receiving hemodialysis who has symptoms of nausea and
dizziness. Which of the following actions should the nurse take first?
a. Slow down the rate of dialysis.
b. Obtain blood to check the blood urea nitrogen (BUN) level.
c. Check the client’s blood pressure.
d. Give prescribed PRN antiemetic drugs.

Answer 34

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

Question 35

Which of the following parameters is most important for the nurse to consider when
titrating the IV fluid infusion rate immediately after a client has had kidney
transplantation?
a. Heart rate
b. Blood urea nitrogen (BUN) level
c. Urine output
d. Creatinine clearance

Answer 35

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

Question 36

The nurse is caring for a client who has leg cramps during hemodialysis. Which of the
following actions should the nurse implement first?
a. Reposition the client
b. Massage the client’s legs
c. Give acetaminophen
d. Infuse a bolus of normal saline

Answer 36

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.