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Chapter 46: Acute Kidney Injury & Chronic Kidney Disease

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28 terms jawgaman00Preview Chapte 17 terms witc 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?

• Insert urethral catheter
• Obtain renal ultrasound
• Draw CBC and BMP
• Infuse normal saline at 50 ml/hr

ANS: A

The patients 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 post renal failure for this patient. the other actions also are appropriate but should be implemented after the retention catheter.Which assessment would indicate to the nurse that a patient has oliguria related to an infrarenal acute kidney injury?

• Urinary sodium levels are low
• The serum creatinine level is normal
• Oliguria is relieved after fluid replacement
• Urine testing shows a specific gravity of 1.010

ANS: D

The urine specific gravity in oliguria of intrarenal acute kidney injury will be fixed at 1.010. This value reflects tubular damage with loss of concentrating ability by the kidneys. the serum creatinine level is above normal in oliguria of infrarenal acute kidney injury. Urinary secretion of sodium increases with oliguria of infrarenal acute kidney injury. Prerenal oliguria related to hypovolemia will usually respond to fluid replacement.A 42-yr-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia.Which prescribed action should the nurse take first?

• Insert a urinary retention catheter
• Place the patient on a cardiac monitor
• Administer epoetin alfa (Epogen, Procrit)
• Give sodium polystyrene sulfonate (Kayexalate)

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.

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?

• The patient leaves the catheter exit site without a

dressing.

• The patient plans 30 to 60 minutes for a dialysate

exchange.

• the patient cleans the catheter while taking a bath each

day.

• 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.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 symptoms to the health care

provider.

• elevate the patients arm on pillows to above the heart

level.

ANS: C

the patients 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.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 potency 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.

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 latency. 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.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.

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.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?

• teach the patient about fluid restrictions.
• check blood pressure before starting dialysis.
• assess for causes of an increase in predialysis weight.
• determine the ultrafiltration rate for the hemodialysis.

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.

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?

• Skin is thin and fragile.
• A nontender axillary lump.
• Blood pressure is 150/92.
• Blood glucose is 144 mg/dL.

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.When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of

• persistent skin tenting
• hot, flushed face and neck.
• rapid, deep respirations.
• bounding peripheral pulses.

ANS: C

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.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

• augmenting fluid volume.
• diluting nephrotoxic substances.
• maintaining cardiac output.
• preventing systemic hypertension.

ANS: 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 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.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?

• Urine volume
• Cardiac rhythm
• Calcium level
• Neurologic status

ANS: B

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.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

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.

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?

• Increased calories are needed because glucose is lost

during hemodialysis.

• More protein is allowed because urea and creatinine

are removed by dialysis.

• Dietary potassium is not restricted because the level is

normalized by dialysis.

• 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.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.

ANS: B

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

• Notify the patient's health care provider.
• Document the QRS interval measurement.
• Review the chart for the patient's current creatinine

level.

• Check the medical record for the most recent

potassium level.

ANS: D

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.A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2-L inflows. Which information should the nurse report promptly to the health care provider?

• The patient has an outflow volume of 1800 mL.
• The patient's peritoneal effluent appears cloudy.
• The patient's abdomen appears bloated after the

inflow.

• The patient has abdominal pain during the inflow

phase.

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.During routine hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first?

• Slow down the rate of dialysis.
• Check the blood pressure (BP).
• Review the hematocrit (Hct) level.
• Give prescribed PRN antiemetic drugs.

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.