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Chapter 46: Acute Kidney Injury and Chronic Kidney Disease Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of

pain and coldness of the right fingers. Which action should the nurse take? Teach the patient about normal AVG function. Remind the patient to take a daily low-dose aspirin tablet. Report the patient’s symptoms to the health care provider. Elevate the patient’s arm on pillows to above the heart level.

a. b. c. d.

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. DIF: Cognitive Level: Apply (application) REF: 1088 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 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. hot, flushed face and neck. d. bounding peripheral pulses.

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. DIF: Cognitive Level: Apply (application) REF: 1072 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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 treatment goal in the plan will be a. augmenting fluid volume. c. diluting nephrotoxic substances. b. maintaining cardiac output. d. preventing systemic hypertension. 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. DIF: Cognitive Level: Apply (application) REF: 1073 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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 c. Cardiac rhythm b. Calcium level d. Neurologic status 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. DIF: Cognitive Level: Apply (application) REF: 1073 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 5. Which statement by a 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.” ANS: C

The patient with end-stage renal disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD. DIF: Cognitive Level: Apply (application) REF: 1082 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 6. 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)? c. Neurologic status d. Creatinine clearance

a. Blood pressure b. Phosphate level 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. DIF: Cognitive Level: Apply (application) REF: 1081 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 7. Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before

administering the medication, the nurse should assess the c. blood urea nitrogen (BUN). d. level of consciousness (LOC).

a. bowel sounds. b. blood glucose. 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. DIF: Cognitive Level: Apply (application) REF: 1080 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 8. Which menu choice by the patient who is receiving hemodialysis indicates that the nurse’s

teaching has been successful? Split-pea soup, English muffin, and nonfat milk Oatmeal with cream, half a banana, and herbal tea Poached eggs, whole-wheat toast, and apple juice Cheese sandwich, tomato soup, and cranberry juice

a. b. c. d.

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 is high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and cream is high in phosphate. DIF: Cognitive Level: Apply (application) REF: 1087 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 9. Before administration of calcium carbonate 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.

ANS: C

If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. 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. DIF: Cognitive Level: Apply (application) REF: 1081 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. A 37-yr-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? c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level

a. Urine volume b. Creatinine 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. DIF: Cognitive Level: Analyze (analysis) REF: 1079 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

11. A patient will need vascular access for hemodialysis. Which statement by the nurse accurately

describes an advantage of a fistula over a graft? A fistula is much less likely to clot. A fistula increases patient mobility. A fistula can accommodate larger needles. A fistula can be used sooner after surgery.

a. b. c. d.

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. DIF: Cognitive Level: Understand (comprehension) REF: 1088 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. 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? Auscultate for a bruit at the fistula site. Assess the quality of the left radial pulse. Compare blood pressures in the left and right arms. Irrigate the fistula site with saline every 8 to 12 hours.

a. b. c. d.

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. DIF: Cognitive Level: Understand (comprehension) REF: 1087 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 13. A 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. More protein is allowed because urea and creatinine are removed by dialysis. c. Dietary potassium is not restricted because the level is normalized by dialysis. d. Unlimited fluids are allowed because retained fluid is removed during dialysis. ANS: B

When 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. DIF: Cognitive Level: Apply (application) REF: 1087 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 14. Which action by a 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. 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. DIF: Cognitive Level: Apply (application) REF: 1086 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 15. Which information in a patient’s history indicates to the nurse that the patient is not an

appropriate candidate for kidney transplantation? The patient has type 1 diabetes. The patient has metastatic lung cancer. The patient has a history of chronic hepatitis C infection. The patient is infected with human immunodeficiency virus.

a. b. c. d.

ANS: B

Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant. DIF: Cognitive Level: Understand (comprehension) REF: 1092 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 16. Which assessment finding may indicate that a patient is experiencing adverse effects to a

corticosteroid prescribed after kidney transplantation? a. Postural hypotension c. Knee and hip joint pain b. Recurrent tachycardia d. Increased serum creatinine 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. DIF: Cognitive Level: Apply (application) REF: 1096 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 17. A 38-yr-old patient who had a kidney transplant 8 years ago is receiving the

immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone . Which assessment data will be of most concern to the nurse? a. Skin is thin and fragile. c. A nontender axillary lump. b. Blood pressure is 150/92. d. Blood glucose is 144 mg/dL. ANS: C

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. DIF: Cognitive Level: Analyze (analysis) REF: 1096 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity 18. 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. Acetaminophen c. Magnesium hydroxide b. Calcium phosphate d. Multivitamin with iron ANS: C

Magnesium is excreted by the kidneys, and patients with CKD should not use over-thecounter products containing magnesium. The other medications are appropriate for a patient with CKD. DIF: Cognitive Level: Apply (application) REF: 1081 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 19. Before administration of captopril 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.

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. DIF: Cognitive Level: Apply (application) REF: 1075 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 20. A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin 60

mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient’s a. blood glucose. c. serum creatinine. b. urine osmolality. d. serum potassium. 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. DIF: Cognitive Level: Apply (application) REF: 1083 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 21. A 55-yr-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 c. Hemoglobin level 13 g/dL b. Oxygen saturation 89% d. Blood pressure 98/56 mm Hg

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 greater than 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. DIF: Cognitive Level: Apply (application) REF: 1081 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 22. Which intervention will be included in the plan of care for a patient with acute kidney injury

(AKI) who has a temporary vascular access catheter in the left femoral vein? Start continuous pulse oximetry. Restrict physical activity to bed rest. Restrict the patient’s oral protein intake. Discontinue the urethral retention catheter.

a. b. c. d.

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. DIF: Cognitive Level: Apply (application) REF: 1088 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 23. A 25-yr-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? Serum creatinine level of 2.1 mg/dL Serum potassium level of 6.5 mEq/L White blood cell count of 11,500/µL Blood urea nitrogen (BUN) of 56 mg/dL

a. b. c. d.

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. DIF: Cognitive Level: Analyze (analysis) REF: 1072 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 24. A 72-yr-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. 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. DIF: Cognitive Level: Analyze (analysis) REF: 1071 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 25. A 62-yr-old female patient has been hospitalized for 4 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 less than 30 mL/min/1.73 m2. 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. DIF: Cognitive Level: Analyze (analysis) REF: 1072 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 26. 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. Review the chart for the patient’s current creatinine level. d. Check the medical record for the most re...