Acute Renal Injury & CKD – NCLEX

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How do you determine that a patient’s oliguria is associated with acute renal failure (ARF)? A. Specific gravity of urine at 3 different times is 1.010. B. The serum creatinine level is normal. C. The blood urea nitrogen (BUN) level is normal or below. D. Hypokalemia is identified.
answer

A. Specific gravity of urine at 3 different times is 1.010. A urinalysis may show casts, red blood cells (RBCs), white blood cells (WBCs), a specific gravity fixed at about 1.010, and urine osmolality at about 300 mOsm/kg.
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When caring for a patient during the oliguric phase of acute kidney injury, what would be an appropriate nursing intervention? A. Weigh patient three times weekly B. Increase dietary sodium and potassium C. Provide a low-protein, high-carbohydrate diet D. Restrict fluids according to the previous day’s fluid loss
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D. Restrict fluids according to the previous day’s fluid loss Patients in the oliguric phase of acute kidney injury have fluid volume excess with potassium and sodium retention. They will need to have dietary sodium, potassium, and fluids restricted. Daily fluid intake is based on the previous 24-hour fluid loss (measured output plus 600 mL for insensible loss). The diet also needs to provide adequate, not low, protein intake to prevent catabolism. The patient should also be weighed daily, not just three times per week.
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Which assessment finding is commonly found in the oliguric phase of acute kidney injury (AKI)? A. Hypovolemia B. Hyperkalemia C. Hypernatremia D. Thrombocytopenia
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B. Hyperkalemia In AKI, the serum potassium levels increase because the normal ability of the kidneys to excrete potassium is impaired. Sodium levels are typically normal or diminished, whereas fluid volume is normally increased due to decreased urine output. Thrombocytopenia is not a consequence of AKI, although altered platelet function may occur in AKI.
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Which patient has the greatest risk for prerenal AKI? A. The patient is hypovolemic because of hemorrhage. B. The patient relates a history of chronic urinary tract obstruction. C. The patient has vascular changes related to coagulopathies. D. The patient is receiving antibiotics such as gentamicin.
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A. The patient is hypovolemic because of hemorrhage. Prerenal causes of AKI are factors external to the kidneys. These factors reduce systemic circulation, causing a reduction in renal blood flow, and they lead to decreased glomerular perfusion and filtration of the kidneys.
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The patient admitted to the intensive care unit after a motor vehicle accident has been diagnosed with AKI. Which finding indicates the onset of oliguria resulting from AKI? A. Urine output less than 1000 mL for the past 24 hours B. Urine output less than 800 mL for the past 24 hours C. Urine output less than 600 mL for the past 24 hours D. Urine output less than 400 mL for the past 24 hours
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D. Urine output less than 400 mL for the past 24 hours The most common initial manifestation of AKI is oliguria, a reduction to urine output to less than 400 mL/day.
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The patient in the oliguric phase of AKI excreted 300 mL of urine in addition to 100 mL of other losses during the past 24 hours. With appropriate calculations, you determine that for the next 24 hours the patient’s fluid allocation is A. 600 mL. B. 800 mL. C. 1000 mL. D. 1200 mL.
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C. 1000 mL. Fluid intake must be closely monitored during the oliguric phase. The rule for calculating the fluid restriction is to add all losses for the previous 24 hours to 600 mL for insensible losses.
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Your plan for care of a patient with AKI includes which goal of dietary management? A. Provide sufficient calories while preventing nitrogen excess. B. Deliver adequate calories while restricting fat and protein intake. C. Replace protein intake with enough fat intake to sustain metabolism. D. Restrict fluids, increase potassium intake, and regulate sodium intake.
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A. Provide sufficient calories while preventing nitrogen excess. The challenge of nutrition management in AKI is to provide adequate calories to prevent catabolism despite the restrictions required to prevent electrolyte and fluid disorders and azotemia (accumulation of nitrogen and wastes in blood).
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For the patient with AKI, which laboratory result would cause you the greatest concern? A. Potassium level of 5.9 mEq/L B. BUN level of 25 mg/dL C. Sodium level of 144 mEq/L D. pH of 7.5
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A. Potassium level of 5.9 mEq/L Hyperkalemia is one of the most serious complications in AKI because it can cause life-threatening cardiac dysrhythmias.
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Important nursing interventions for the patient with AKI are (select all that apply) A. careful monitoring of intake and output. B. daily patient weights. C. meticulous aseptic technique. D. increase intake of vitamin A and D. E. frequent mouth care.
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A. careful monitoring of intake and output. B. daily patient weights. C. meticulous aseptic technique. E. frequent mouth care. You have an important role in managing fluid and electrolyte balance during the oliguric and diuretic phases of AKI. Observing and recording accurate intake and output are essential. Measure daily weights with the same scale at the same time each day to assess excessive gains or losses of body fluids. Mouth care is important to prevent stomatitis, which develops when ammonia (produced by bacterial breakdown of urea) in saliva irritates the mucous membrane.
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What characterizes AKI (select all that apply)? A. Primary cause of death is infection. B. It usually affects older people. C. The disease course is potentially reversible. D. The most common cause is diabetic nephropathy. E. Cardiovascular disease is the most common cause of death.
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A. Primary cause of death is infection. C. The disease course is potentially reversible. AKI is potentially reversible. It has a high mortality rate, and the primary cause of death is infection; the primary cause of death for chronic kidney failure is cardiovascular disease. AKI commonly follows severe, prolonged hypotension or hypovolemia or exposure to a nephrotoxic agent. Although it can occur at any age, the older adult is more susceptible to AKI because the number of functioning nephrons decreases with age.
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During the oliguric phase of AKI, you monitor the patient for (select all that apply) A. hypertension. B. electrocardiographic (ECG) changes. C. hypernatremia. D. pulmonary edema. E. urine with high specific gravity.
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A. hypertension. B. electrocardiographic (ECG) changes. D. pulmonary edema. You monitor the patient in the oliguric phase of AKI for hypertension and pulmonary edema. When urinary output decreases, fluid retention occurs. The severity of the symptoms depends on the extent of the fluid overload. In the case of reduced urine output (anuria and oliguria), the neck veins may become distended and have a bounding pulse. Edema and hypertension may develop. Fluid overload can eventually lead to heart failure, pulmonary edema, and pericardial and pleural effusions. The patient is monitored for hyponatremia. Damaged tubules cannot conserve sodium, and the urinary excretion of sodium may increase, resulting in normal or below-normal levels of serum sodium. Monitoring may reveal ECG changes and hyperkalemia. Initially, clinical signs of hyperkalemia are apparent on electrocardiogram, which demonstrate peaked T waves, widening of the QRS complex, and ST-segment depression. Urinary specific gravity is fixed at about 1.010.
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If a patient is in the diuretic phase of AKI, you must monitor for which serum electrolyte imbalances? A. Hyperkalemia and hyponatremia B. Hyperkalemia and hypernatremia C. Hypokalemia and hyponatremia D. Hypokalemia and hypernatremia
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C. Hypokalemia and hyponatremia In the diuretic phase of AKI, the kidneys have recovered their ability to excrete wastes but not to concentrate the urine. Hypovolemia and hypotension can result from massive fluid losses. Because of the large losses of fluid and electrolytes, the patient must be monitored for hyponatremia, hypokalemia, and dehydration.
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You are preparing to administer a dose of PhosLo to a patient with chronic kidney disease (CKD). This medication should have a beneficial effect on which laboratory value? A. Sodium B. Potassium C. Magnesium D. Phosphorus
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D. Phosphorus Phosphorus and calcium have inverse or reciprocal relationships, meaning that when phosphorus levels are high, calcium levels tend to be low. Administration of calcium should help to reduce a patient’s abnormally high phosphorus level, as seen in CKD.
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A patient is admitted to the hospital with CKD. You understand that this condition is characterized by A. Progressive irreversible destruction of the kidneys B. A rapid decrease in urinary output with an elevated BUN level C. Increasing creatinine clearance with a decrease in urinary output D. Prostration, somnolence, and confusion with coma and imminent death
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A. Progressive irreversible destruction of the kidneys CKD involves progressive, irreversible loss of kidney function.
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Nurses need to educate patients at risk for CKD. Which individuals are considered to be at increased risk (select all that apply)? A. Older African Americans B. Individuals older than 60 years C. Those with a history of pancreatitis D. Those with a history of hypertension E. Those with a history of type 2 diabetes
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A. Older African Americans B. Individuals older than 60 years D. Those with a history of hypertension E. Those with a history of type 2 diabetes Risk factors for CKD include diabetes mellitus, hypertension, age older than 60 years, cardiovascular disease, family history of CKD, exposure to nephrotoxic drugs, and ethnic minorities (e.g., African American, Native American).
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Patients with CKD have an increased incidence of cardiovascular disease related to (select all that apply) A. hypertension. B. vascular calcifications. C. a genetic predisposition. D. hyperinsulinemia causing dyslipidemia. E. increased high-density lipoproteins levels.
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A. hypertension. B. vascular calcifications. D. hyperinsulinemia causing dyslipidemia. Traditional cardiovascular risk factors, such as hypertension and elevated lipid levels, are common in CKD patients. Hyperinsulinemia stimulates hepatic production of triglycerides. Most patients with uremia develop dyslipidemia. Much of the cardiovascular disease may be related to nontraditional risk factors such as vascular calcification and arterial stiffness. Vascular calcification and arterial stiffness are major contributors to cardiovascular disease in CKD. Calcium deposits in the vascular medial layer are associated with stiffening of the blood vessels. The mechanisms involved are multifactorial and incompletely understood, but they include (1) vascular smooth muscle cells that change into a chondrocyte or osteoblast-like cell, (2) high total body calcium and phosphate levels due to abnormal bone metabolism, (3) impaired renal excretion, and (4) drug therapies to treat the bone disease (e.g., calcium phosphate binders).
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Measures indicated in the conservative therapy of CKD include A. decreased fluid intake, carbohydrate intake, and protein intake. B. increased fluid intake; decreased carbohydrate intake and protein intake. C. decreased fluid intake and protein intake; increased carbohydrate intake. D. decreased fluid intake and carbohydrate intake; increased protein intake.
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C. decreased fluid intake and protein intake; increased carbohydrate intake. Water and any other fluids are not routinely restricted in the pre-end-stage renal disease (ESRD) stages. Patients on hemodialysis have a more restricted diet than patients receiving peritoneal dialysis. For those receiving hemodialysis, as their urinary output diminishes, fluid restrictions are enhanced. Intake depends on the daily urine output. Generally, 600 mL (from insensible loss) plus an amount equal to the previous day’s urine output is allowed for a patient receiving hemodialysis. Patients are advised to limit fluid intake so that weight gains are no more than 1 to 3 kg between dialyses (interdialytic weight gain). For the patient who is undergoing dialysis, protein is not routinely restricted. The beneficial role of protein restriction in CKD stages 1 through 4 as a means to reduce the decline in kidney function is being studied. Historically, dietary counseling often encouraged restriction of protein for CKD patients. Although there is some evidence that protein restriction has benefits, many patients find these diets difficult to adhere to. For CKD stages 1 through 4, many clinicians encourage a diet with normal protein intake. However, you should teach patients to avoid high-protein diets and supplements because they may overstress the diseased kidneys.
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The advantage of continuous replacement therapy over hemodialysis is its ability to A. remove fluid without the use of a dialysate. B. remove fluid in less than 24 hours. C. allow the patient to receive the therapy at the work site. D. be administered through a peripheral line.
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A. remove fluid without the use of a dialysate. Several features of continuous replacement therapy are different from those of hemodialysis. Solute removal can occur by convection (no dialysate required) in addition to osmosis and diffusion. The process can take days or weeks. The patient cannot receive the therapy at work and a vascular access device is required.
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You are caring for a patient receiving continuous replacement therapy and notice that the filtrate is blood tinged. What is your priority action? A. Place the patient in Trendelenburg position. B. Initiate a peripheral intravenous line. C. Suspend treatment immediately. D. Administer vitamin K (Aquamephyton) per order.
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C. Suspend treatment immediately. The ultrafiltrate should be clear yellow, and specimens may be obtained for evaluation of serum chemistries. If the ultrafiltrate becomes bloody or blood tinged, a possible rupture in the filter membrane should be suspected, and treatment is suspended immediately to prevent blood loss and infection.
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A patient with a history of end-stage renal disease (ESRD) resulting from diabetes mellitus has presented to the outpatient dialysis unit for his scheduled hemodialysis. Which assessment should you prioritize before, during, and after his treatment? A. Level of consciousness B. Blood pressure and fluid balance C. Temperature, heart rate, and blood pressure D. Assessment for signs and symptoms of infection
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B. Blood pressure and fluid balance Although all of the assessments are relevant to the care of a patient receiving hemodialysis, the nature of the procedure indicates a particular need to monitor blood pressure and fluid balance.
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Which statement regarding continuous ambulatory peritoneal dialysis (CAPD) is of highest priority when teaching a patient new to this procedure? A. “It is essential that you maintain aseptic technique to prevent peritonitis.” B. “You will be allowed a more liberal protein diet after you complete CAPD.” C. “It is important for you to maintain a daily written record of blood pressure and weight.” D. “You must continue regular medical and nursing follow-up visits while performing CAPD.”
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A. “It is essential that you maintain aseptic technique to prevent peritonitis.” Peritonitis is a potentially fatal complication of peritoneal dialysis, and it is imperative to teach the patient methods to prevent it from occurring. Although the other teaching statements are accurate, they do not address the potential for mortality by peritonitis, making that nursing action the highest priority.
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How should you assess the patency of a newly placed arteriovenous graft for dialysis? A. Irrigate the graft daily with low-dose heparin. B. Monitor for any increase in blood pressure in the affected arm. C. Listen with a stethoscope over the graft for presence of a bruit. D. Frequently monitor the pulses and neurovascular status distal to the graft.
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C. Listen with a stethoscope over the graft for presence of a bruit. A thrill can be felt by palpating the area of anastomosis of the arteriovenous graft, and a bruit can be heard with a stethoscope. The bruit and thrill are created by arterial blood rushing into the vein.
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What are the main advantages of peritoneal dialysis compared to hemodialysis? A. No medications are required because of the enhanced efficiency of the peritoneal membrane in removing toxins. B. The diet is less restricted and dialysis can be performed at home. C. The dialysate is biocompatible and causes no long-term consequences. D. High glucose concentrations of the dialysate cause a reduction in appetite, promoting weight loss.
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B. The diet is less restricted and dialysis can be performed at home. Advantages of peritoneal dialysis include fewer dietary restrictions and home dialysis is possible.
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A patient is recovering in the intensive care unit (ICU) after receiving a kidney transplant approximately 24 hours earlier. What is an expected assessment finding for this patient during the early stage of recovery? A. Hypokalemia B. Hyponatremia C. Large urine output D. Leukocytosis with cloudy urine output
answer

C. Large urine output Patients frequently experience diuresis in the hours and days immediately after kidney transplantation. Electrolyte imbalances and signs of infection are unexpected findings that warrant prompt intervention.
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An ESRD patient receiving hemodialysis is considering asking a relative to donate a kidney for transplantation. In assisting the patient to make a decision about treatment, what do you tell the patient? A. Successful transplantation usually provides better quality of life than that offered by dialysis. B. If rejection of the transplanted kidney occurs, no further treatment for the renal failure is available. C. The immunosuppressive therapy that is required after transplantation causes fatal malignancies in many patients. D. Hemodialysis replaces the normal functions of the kidneys, and patients do not have to live with the continual fear of rejection.
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A. Successful transplantation usually provides better quality of life than that offered by dialysis. Kidney transplantation is extremely successful, with 1-year graft survival rates of about 90% for deceased donor transplants and 95% for live donor transplants. An advantage of kidney transplantation compared with dialysis is that it reverses many of the pathophysiologic changes associated with renal failure when normal kidney function is restored. It also eliminates the dependence on dialysis and the accompanying dietary and lifestyle restrictions. Transplantation is also less expensive than dialysis after the first year.
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A kidney transplant recipient complains of fever, chills, and dysuria over the past 2 days. What is the first action that you should take? A. Assess temperature and initiate a workup to rule out infection. B. Provide warm covers for the patient and give 1 gram of acetaminophen orally. C. Reassure the patient and let him know this is common after transplantation. D. Notify the nephrologist that the patient has developed symptoms of acute rejection.
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A. Assess temperature and initiate a workup to rule out infection. You must be astute in the observation and assessment of kidney transplant recipients, because prompt diagnosis and treatment of infections can improve patient outcomes. Fever, chills, and dysuria indicate a possible infection. The temperature should be assessed, and the patient should have diagnostic tests to identify or rule out an infection.

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