What are intrarenal causes of acute kidney injury (AKI) (select all that apply)?
a. Anaphylaxis
b. Renal stones
c. Bladder cancer
d. Nephrotoxic drugs
e. Acute glomerulonephritis
f. Tubular obstruction by myoglobin
d, e, f. Intrarenal causes of acute kidney injury (AKI)
include conditions that cause direct damage to the
kidney tissue, including nephrotoxic drugs, acute
glomerulonephritis, and tubular obstruction by myoglobin,
or prolonged ischemia. Anaphylaxis and o
An 83-year-old female patient was found lying on the bathroom floor. She said she fell 2 days ago and has not been
able to take her heart medicine or eat or drink anything since then. What conditions could be causing prerenal AKI in
this patient (select a
c, e. Because the patient has had nothing to eat or drink
for 2 days, she is probably dehydrated and hypovolemic.
Decreased cardiac output (CO) is most likely because she is
older and takes heart medicine, which is probably for heart
failure or hypertensi
Acute tubular necrosis (ATN) is the most common cause of intrarenal AKI. Which patient is most likely to
develop ATN?
a. Patient with diabetes mellitus
b. Patient with hypertensive crisis
c. Patient who tried to overdose on acetaminophen
d. Patient with m
d. Acute tubular necrosis (ATN) is primarily the result
of ischemia, nephrotoxins, or sepsis. Major surgery
is most likely to cause severe kidney ischemia in the
patient requiring a blood transfusion. A blood transfusion
hemolytic reaction produces nephro
Priority Decision: A dehydrated patient is in the Injury stage of the RIFLE staging of AKI. What would the nurse
first anticipate in the treatment of this patient?
a. Assess daily weight
b. IV administration of fluid and furosemide (Lasix)
c. IV administr
b. Injury is the stage of RIFLE classification when urine
output is less than 0.5 mL/kg/hr for 12 hours, the serum
creatinine is increased times two or the glomerular
filtration rate (GFR) is decreased by 50%. This stage may
be reversible by treating the
What indicates to the nurse that a patient with oliguria has prerenal oliguria?
a. Urine testing reveals a low specific gravity.
b. Causative factor is malignant hypertension.
c. Urine testing reveals a high sodium concentration.
d. Reversal of oliguria o
d. In prerenal oliguria, the oliguria is caused by a decrease
in circulating blood volume and there is no damage
yet to the renal tissue. It can be reversed by correcting
the precipitating factor, such as fluid replacement
for
hypovolemia. Prerenal oligur
In a patient with AKI, which laboratory urinalysis result indicates tubular damage?
a. Hematuria
b. Specific gravity fixed at 1.010
c. Urine sodium of 12 mEq/L (12 mmol/L)
d. Osmolality of 1000 mOsm/kg (1000 mmol/kg)
b. A urine specific gravity that is consistently 1.010 and a
urine osmolality of about 300 mOsm/kg is the same specific
gravity and osmolality as plasma. This indicates that tubules
are damaged and unable to concentrate urine. Hematuria is
more common wit
Metabolic acidosis occurs in the oliguric phase of AKI as a result of impairment of
a. ammonia synthesis.
b. excretion of sodium.
c. excretion of bicarbonate.
d. conservation of potassium.
a. Metabolic acidosis occurs in AKI because the kidneys
cannot synthesize ammonia or excrete acid products of
metabolism, resulting in an increased acid load. Sodium
is lost in urine because the kidneys cannot conserve
sodium. Impaired excretion of potass
What indicates to the nurse that a patient with AKI is in the recovery phase?
a. A return to normal weight
b. A urine output of 3700 mL/day
c. Decreasing sodium and potassium levels
d. Decreasing blood urea nitrogen (BUN) and creatinine levels
d. The blood urea nitrogen (BUN) and creatinine levels
remain high during the oliguric and diuretic phases of
AKI. The recovery phase begins when the glomerular
filtration returns to a rate at which BUN and creatinine
stabilize and then decrease. Urinary
While caring for the patient in the oliguric phase of AKI, the nurse monitors the patient for associated collaborative
problems. When should the nurse notify the health care provider?
a. Urine output is 300 mL/day.
b. Edema occurs in the feet, legs, and s
d. Hyperkalemia is a potentially life-threatening
complication of AKI in the oliguric phase. Muscle
weakness and abdominal cramping are signs of the
neuromuscular impairment that occurs with hyperkalemia.
In addition, hyperkalemia can cause the cardiac co
In caring for the patient with AKI, what should the nurse be aware of?
a. The most common cause of death in AKI is irreversible metabolic acidosis.
b. During the oliguric phase of AKI, daily fluid intake is limited to 1000 mL plus the prior day's measured
d. Measuring daily weights with the same scale at the
same time each day allows for the evaluation and detection
of excessive body fluid gains or losses. Infection is the
leading cause of death in AKI, so meticulous aseptic
technique is critical. The flui
A 68-year-old man with a history of heart failure resulting from hypertension has AKI as a result of the effects of
nephrotoxic diuretics. Currently his serum potassium is 6.2 mEq/L (6.2 mmol/L) with cardiac changes, his BUN
is 108 mg/dL (38.6 mmol/L), hi
b. This patient has at least three of the six common
indications for renal replacement therapy (RRT), including
(1) high potassium level, (2) metabolic acidosis, and (3)
changed mental status. The other indications are (4) volume
overload, resulting in co
Prevention of AKI is important because of the high mortality rate. Which patients are at increased risk for AKI
(select all that apply)?
a. An 86-year-old woman scheduled for a cardiac catheterization
b. A 48-year-old man with multiple injuries from a mot
a, b, c, d, e. High-risk patients include those exposed
to nephrotoxic agents and advanced age (a), massive
trauma (b), prolonged hypovolemia or hypotension
(possibly b and c), obstetric complications (c), cardiac
failure (d), preexisting chronic kidney d
Priority Decision: A patient on a medical unit has a potassium level of 6.8 mEq/L. What is the priority action that
the nurse should take?
a. Place the patient on a cardiac monitor.
b. Check the patient's blood pressure (BP).
c. Instruct the patient to av
a. Dysrhythmias may occur with an elevated potassium
level and are potentially lethal. Monitor the rhythm while
contacting the physician or calling the rapid response
team. Vital signs should be checked. Depending on the
patient's history and cause of inc
A patient with AKI has a serum potassium level of 6.7 mEq/L (6.7 mmol/L) and the following arterial blood gas
results: pH 7.28, PaCO2 30 mm Hg, PaO2 86 mm Hg, HCO3
? 18 mEq/L (18 mmol/L). The nurse recognizes that
treatment of the acid-base problem with s
b. During acidosis, potassium moves out of the cell in
exchange for H+ ions, increasing the serum potassium level.
Correction of the acidosis with sodium bicarbonate will
help to shift the potassium back into the cells. A decrease
in pH and the bicarbonat
In replying to a patient's questions about the seriousness of her chronic kidney disease (CKD), the nurse knows that
the stage of CKD is based on what?
a. Total daily urine output
b. Glomerular filtration rate
c. Degree of altered mental status
d. Serum c
b. Stages of chronic kidney disease are based on the
GFR. No specific markers of urinary output, mental
status, or azotemia classify the degree of chronic kidney
disease (CKD).
The patient with CKD is receiving dialysis, and the nurse observes excoriations on the patient's skin. What
pathophysiologic changes in CKD can contribute to this finding (select all that apply)?
a. Dry skin
b. Sensory neuropathy
c. Vascular calcification
a, b, d. Pruritus is common in patients receiving dialysis.
It causes scratching from dry skin, sensory neuropathy,
and calcium-phosphate deposition in the skin. Vascular
calcifications contribute to cardiovascular disease, not to
itching skin. Uremic fro
What causes the gastrointestinal (GI) manifestation of stomatitis in the patient with CKD?
a. High serum sodium levels
b. Irritation of the GI tract from creatinine
c. Increased ammonia from bacterial breakdown of urea
d. Iron salts, calcium-containing ph
c. Uremic fetor, or the urine odor of the breath, is caused
by high urea content in the blood. Increased ammonia from
bacterial breakdown of urea leads to stomatitis and mucosal
ulcerations. Irritation of the gastrointestinal (GI) tract from
urea in CKD c
The patient with CKD is brought to the emergency department with Kussmaul respirations. What does the nurse
know about CKD that could cause this patient's Kussmaul respirations?
a. Uremic pleuritis is occurring.
b. There is decreased pulmonary macrophage
c. Kussmaul respirations occur with severe metabolic
acidosis when the respiratory system is attempting to
compensate by removing carbon dioxide with exhalations.
Uremic pleuritis would cause a pleural friction rub.
Decreased pulmonary macrophage activity
Which serum laboratory value indicates to the nurse that the patient's CKD is getting worse?
a. Decreased BUN
b. Decreased sodium
c. Decreased creatinine
d. Decreased calculated glomerular filtration rate (GFR)
d. As GFR decreases, BUN and serum creatinine levels
increase. Although elevated BUN and creatinine indicate
that waste products are accumulating, the calculated GFR
is considered a more accurate indicator of kidney function
than BUN or serum creatinine.
What is the most serious electrolyte disorder associated with kidney disease?
a. Hypocalcemia
b. Hyperkalemia
c. Hyponatremia
d. Hypermagnesemia
b. Hyperkalemia can lead to life-threatening dysrhythmias.
Hypocalcemia leads to an accelerated rate of bone
remodeling and potentially to tetany. Hyponatremia may
lead to confusion. Elevated sodium levels lead to edema,
hypertension, and heart failure. H
For a patient with CKD the nurse identifies a nursing diagnosis of risk for injury: fracture related to alterations
in calcium and phosphorus metabolism. What is the pathologic process directly related to the increased risk for
fractures?
a. Loss of alumi
c. The calcium-phosphorus imbalances that occur in
CKD result in hypocalcemia, from a deficiency of active
vitamin D and increased phosphorus levels. This leads to
an increased rate of bone remodeling with a weakened
bone matrix. Aluminum accumulation is
Priority Decision: What is the most appropriate snack for the nurse to offer a patient with stage 4 CKD?
a. Raisins
b. Ice cream
c. Dill pickles
d. Hard candy
d. A patient with CKD may have unlimited intake of sugars
and starches (unless the patient is diabetic) and hard candy
is an appropriate snack and may help to relieve the metallic
and urine taste that is common in the mouth. Raisins are
a high-potassium f
Which complication of chronic kidney disease is treated with erythropoietin (EPO)?
a. Anemia
b. Hypertension
c. Hyperkalemia
d. Mineral and bone disorder
a. Erythropoietin is used to treat anemia, as it stimulates the
bone marrow to produce red blood cells.
The patient with CKD asks why she is receiving nifedipine (Procardia) and furosemide (Lasix). The nurse
understands that these drugs are being used to treat the patient's
a. anemia.
b. hypertension.
c. hyperkalemia.
d. mineral and bone disorder.
b. Nifedipine (Procardia) is a calcium channel blocker and
furosemide (Lasix) is a loop diuretic. Both are used to treat
hypertension.
Which drugs will be used to treat the patient with CKD for mineral and bone disorder (select all that apply)?
a. Cinacalcet (Sensipar)
b. Sevelamer (Renagel)
c. IV glucose and insulin
d. Calcium acetate (PhosLo)
e. IV 10% calcium gluconate
a, b, d. Cinacalcet (Sensipar), a calcimimetic agent
to control secondary hyperparathyroidism; sevelamer
(Renagel), a noncalcium phosphate binder; and calcium
acetate (PhosLo), a calcium-based phosphate binder are
used to treat mineral and bone disorder i
What accurately describes the care of the patient with CKD?
a. A nutrient that is commonly supplemented for the patient on dialysis because it is dialyzable is iron.
b. The syndrome that includes all of the signs and symptoms seen in the various body syst
d. In the patient with CKD, when serum calcium levels
are increased, calcium-based phosphate binders are not
used. The nutrient supplemented for patients on dialysis is
folic acid. The various body system manifestations occur
with uremia, which includes a
During the nursing assessment of the patient with renal insufficiency, the nurse asks the patient specifically about a
history of
a. angina.
b. asthma.
c. hypertension.
d. rheumatoid arthritis.
c. The most common causes of CKD in the United States
are diabetes mellitus and hypertension. The nurse should
obtain information on long-term health problems that
are related to kidney disease. The other disorders are not
closely associated with renal di
The patient with chronic kidney disease is considering whether to use peritoneal dialysis (PD) or hemodialysis (HD).
What are advantages of PD when compared to HD (select all that apply)?
a. Less protein loss
b. Rapid fluid removal
c. Less cardiovascular
c, e. Peritoneal dialysis is less stressful for the
cardiovascular system and requires fewer dietary
restrictions. Peritoneal dialysis actually contributes to more
protein loss and increased hyperlipidemia. The fluid and
creatinine removal are slower with
What does the dialysate for PD routinely contain?
a. Calcium in a lower concentration than in the blood
b. Sodium in a higher concentration than in the blood
c. Dextrose in a higher concentration than in the blood
d. Electrolytes in an equal concentration
c. Dextrose or icodextrin or amino acid is added to dialysate
fluid to create an osmotic gradient across the membrane
to remove excess fluid from the blood. The dialysate fluid
has no potassium so that potassium will diffuse into the
dialysate from the bl
Number the following in the order of the phases of exchange in PD. Begin with 1 and end with 3.
a. Drain
b. Dwell
c. Inflow
a. 3; b. 2; c. 1
In which type of dialysis does the patient dialyze during sleep and leave the fluid in the abdomen during the day?
a. Long nocturnal hemodialysis
b. Automated peritoneal dialysis (APD)
c. Continuous venovenous hemofiltration (CVVH)
d. Continuous ambulator
b. Automated peritoneal dialysis (APD) is the type of
dialysis in which the patient dialyzes during sleep and
leaves the fluid in the abdomen during the day. Long
nocturnal hemodialysis occurs while the patient is
sleeping and is done up to six times per
To prevent the most common serious complication of PD, what is important for the nurse to do?
a. Infuse the dialysate slowly.
b. Use strict aseptic technique in the dialysis procedures.
c. Have the patient empty the bowel before the inflow phase.
d. Repos
b. Peritonitis is a common complication of peritoneal
dialysis (PD) and may require catheter removal
and termination of dialysis. Infection occurs from
contamination of the dialysate or tubing or from
progression of exit-site or tunnel infections and stri
A patient on hemodialysis develops a thrombus of a subcutaneous arteriovenous (AV) graft, requiring its removal.
While waiting for a replacement graft or fistula, the patient is most likely to have what done for treatment?
a. Peritoneal dialysis
b. Periph
c. A more permanent, soft, flexible Silastic double-lumen
catheter is used for long-term access when other forms of
vascular access have failed. These catheters are tunneled
subcutaneously and have Dacron cuffs that prevent infection
from tracking along t
A man with end-stage kidney disease is scheduled for hemodialysis following healing of an arteriovenous fistula
(AVF). What should the nurse explain to him that will occur during dialysis?
a. He will be able to visit, read, sleep, or watch TV while reclin
a. While patients are undergoing hemodialysis, they can
perform quiet activities that do not require the limb that has
the vascular access. Blood pressure is monitored frequently
and the dialyzer monitors dialysis function but cardiac
monitoring is not us
What is the primary way that a nurse will evaluate the patency of an AVF?
a. Palpate for pulses distal to the graft site.
b. Auscultate for the presence of a bruit at the site.
c. Evaluate the color and temperature of the extremity.
d. Assess for the pres
b. A patent arteriovenous fistula (AVF) creates turbulent
blood flow that can be assessed by listening for a bruit
or palpated for a thrill as the blood passes through the
graft. Assessment of neurovascular status in the extremity
distal to the graft site
A patient with AKI is a candidate for continuous renal replacement therapy (CRRT). What is the most common
indication for use of CRRT?
a. Azotemia
b. Pericarditis
c. Fluid overload
d. Hyperkalemia
c. Continuous renal replacement therapy (CRRT) is
indicated for the patient with AKI as an alternative or
adjunct to hemodialysis to slowly remove solutes and fluid
in the hemodynamically unstable patient. It is especially
useful for treatment of fluid ov
A patient rapidly progressing toward end-stage kidney disease asks about the possibility of a kidney transplant. In
responding to the patient, the nurse knows that what is a contraindication to kidney transplantation?
a. Hepatitis C infection
b. Coronary
d. Extensive vascular disease is a contraindication for
renal transplantation, primarily because adequate blood
supply is essential for the health of the new kidney. Other
contraindications include disseminated malignancies,
refractory or untreated cardia
Priority Decision: During the immediate postoperative care of a recipient of a kidney transplant, what should the
nurse expect to do?
a. Regulate fluid intake hourly based on urine output.
b. Monitor urine-tinged drainage on abdominal dressing.
c. Medicat
a. Fluid and electrolyte balance is critical in the transplant
recipient patient, especially because diuresis often begins
soon after surgery. Fluid replacement is adjusted hourly
based on kidney function and urine output. Urine-tinged
drainage on the abd
A patient received a kidney transplant last month. Because of the effects of immunosuppressive drugs and CKD,
what complication of transplantation should the nurse be assessing the patient for to decrease the risk of mortality?
a. Infection
b. Rejection
c
a. Infection is a significant cause of morbidity and
mortality after transplantation because the surgery,
the immunosuppressive drugs, and the effects of CKD
all suppress the body's normal defense mechanisms,
thus increasing the risk of infection. The nur