Chapter 26- Acute Kidney Injury and Chronic Kidney Disease- Patho

An 86-year-old female client has been admitted to the hospital for the treatment of dehydration and hyponatremia after she curtailed her fluid intake to minimize urinary incontinence. The client's admitting laboratory results are suggestive of prerenal failure. The nurse should be assessing this client for which of the following early signs of prerenal injury?

a) Intermittent periods of confusion
b) Excessive voiding of clear urine
c) Acute hypertensive crisis
d) Sharp decrease in urine output

Sharp decrease in urine output Dehydration and its consequent hypovolemia can result in acute renal failure that is prerenal in etiology. The kidney normally responds to a decrease in GFR with a decrease in urine output. Thus, an early sign of prerenal injury is a sharp decrease in urine output. Post-renal failure is obstructive in etiology, and intrinsic (or intrarenal) renal failure is reflective of deficits in the function of the kidneys themselves.

The primary care provider for a newly admitted hospital client has added the glomerular filtration rate (GFR) to the blood work scheduled for this morning. The client's GFR results return as 50 mL/minute/1.73 m2. The nurse explains to the client that this result represents:

a) Concentrated urine
b) A loss of over half the client's normal kidney function
c) A need to increase water intake
d) The kidneys are functioning normally

A loss of over half the client's normal kidney function In clinical practice, GFR is usually estimated using the serum creatinine concentration. A GFR below 60 mL/minute/1.73 m2 represents a loss of one half or more of the level of normal adult kidney function. -The GFR is not diagnostic for concentrated urine or the need to drink more water

Bruising of the skin is a manifestation of bleeding disorders in patients with CKD.

a) True
b) False

True Bleeding disorders manifested by persons with CKD include epistaxis, menorrhagia, gastrointestinal bleeding, and bruising of skin and subcutaneous tissues.

A patient has an obstructive urine outflow related to benign prostatic hyperplasia. Due to the inability to excrete adequate amounts of urine, which of the following types of renal failure should the nurse closely monitor for?

a) Postrenal failure
b) Intrarenal failure
c) Prerenal failure
d) Chronic renal failure

Postrenal failure Postrenal failure results from obstruction of urine outflow from the kidneys. The obstruction can occur in the ureter, bladder, or urethra. Due to the increased urine not being able to be excreted due to the obstruction, retrograde pressure occurs throughout the tubules and nephrons, which ultimately damages the nephrons. Prostatic hyperplasia is the most common underlying problem

A nurse is collecting a urine specimen prior to measuring the albumin level in a client's urine. A colleague questions the rationale for the test, stating, "I thought albumin was related to liver function, not kidney function." How can the nurse best respond to this statement?

a) "A urine test for albumin allows us to estimate the client's GFR quite accurately."
b) "Urine should normally be free of any proteins, and albumin is one of the more common proteins to be excreted in chronic renal failure."
c) "Urine albumin levels are useful for diagnosing diabetic kidney disease."
d) "A urine dipstick test will tell us exactly how much albumin is being spilled by the client's kidneys."

"Urine albumin levels are useful for diagnosing diabetic kidney disease." In clients with diabetes, albumin tests are useful adjunctive test of nephron injury and repair. -Urine is not normally completely free of proteins and a urine dipstick does not allow for the quantification of how much albumin is in a sample. -Albumin tests do not allow for an accurate indirect indication of GFR.

A patient has a marked decrease in the glomerular filtration rate (GFR) and has elevations in blood urea nitrogen, potassium, and creatinine levels. The patient's urine output has decreased to 10 mL/hr and has 3+ pitting edema in the lower extremities. In which of the following phases of acute tubular necrosis does the nurse determine the patient is in relating to this assessment data?

a) Maintenance phase
b) Onset phase
c) Initiating phase
d) Recovery phase

Maintenance phase The maintenance phase of acute tubular necrosis is characterized by a marked decrease in the GFR causing sudden retention of endogenous metabolites—such as urea, potassium, sulfate, and creatinine—that normally are cleared by the kidneys. Urine output usually is lowest at this point. Fluid retention gives rise to edema, water intoxication, and pulmonary congestion. If the period of oliguria is prolonged, hypertension frequently develops and with it signs of uremia.

A client with chronic kidney disease (CKD) is anemic. The nurse will attempt to alleviate the anemia in order to prevent which of the following? Select all that apply.

a) Decreased myocardial oxygen
b) Increased blood viscosity
c) Hypersomnia
d) Tachycardia
e) Fatigue

• Tachycardia • Fatigue • Decreased myocardial oxygen Uncorrected anemia provokes fatigue and insomnia, a decrease in blood viscosity, a decrease in myocardial oxygen supply, and tachycardia as the heart attempts to supply sufficient oxygen to the heart and brain

The health care provider has prescribed an aminoglycoside (gentamicin) for a client. The nurse is aware that the client is at risk for:

a) Ischemic acute tubular necrosis
b) Nephrotoxic acute tubular necrosis
c) Postrenal failure
d) Chronic kidney disease

Nephrotoxic acute tubular necrosis Pharmacologic agents that are directly toxic to the renal tubule include aminoglycosides (e.g., gentamicin), cancer chemotherapeutic agents such as cystplastin and ifosfamide, and radiocontrast agents. Nephrotoxic agents cause tubular injury by inducing varying combinations of renal vasoconstriction, direct tubular damage, or intratubular obstruction. -Postrenal failure results from obstruction of outflow of the kidneys. -CKD and its treatment can interfere with the absorption, distribution, and elimination of drugs. -Acute tubular necrosis (ATN) occurs most frequently in clients who have major trauma, severe hypovolemia, overwhelming sepsis, trauma, or burns.

The GFR is considered to be the best measure of renal function. What is used to estimate the GFR?

a) BUN
b) Serum creatinine
c) Serum protein
d) Albumin level

Serum creatinine In clinical practice, GFR is usually estimated using the serum creatinine concentration. The other answers are not used to estimate the GFR.

A client is diagnosed with chronic kidney disease (CKD). The nurse knows that which of the following statements regarding CKD are correct? Select all that apply

a) Onset is abrupt.
b) Symptoms appear with 50% of nephrons lost.
c) Renal damage is irreversible.
d) Hypertension is a major cause.
e) Less than 1% of population is affected.

• Renal damage is irreversible. • Hypertension is a major cause. CKD usually develops slowly, often over many years. Irreversible damage occurs, as symptoms do not appear until 80% of the nephrons cease to function. Approximately 10% of the United States population has CKD. Hypertension and diabetes are major causes of CKD.

Vitamin D metabolism is deranged in clients with chronic kidney disease (CKD). The nurse recognizes that which of the following statements regarding vitamin D is correct?

a) Calcitriol stimulates release of parathyroid hormone (PTH).
b) Calcitriol blocks gastrointestinal absorption of calcium.
c) Suppression of parathyroid hormone release is characteristic of CKD.
d) Kidneys convert inactive vitamin D to its active form, calcitriol.

Kidneys convert inactive vitamin D to its active form, calcitriol. Inactive vitamin D is converted to active calcitriol in the kidneys. Calcitriol enhances gastrointestinal absorption of calcium, and suppresses release of PTH. Elevated levels of PTH are characteristic of CKD as blood levels of phosphate rise and levels of calcium fall.

The nurse is caring for a patient who has had acute blood loss from ruptured esophageal varices. Which of the following does the nurse recognize is an early sign of prerenal failure?

a) Baseline blood pressure of 150/90 mm Hg that is now 130/80 mm Hg
b) Baseline heart rate of 100 bpm that has increased to 120 bpm
c) Foul smelling, cloudy urine
d) Baseline urine output of 50 mL/hr that is now 10 mL/hr

Baseline urine output of 50 mL/hr that is now 10 mL/hr The kidney normally responds to a decrease in the glomerular filtration rate with a decrease in urine output. Thus, an early sign of prerenal failure is a sharp decrease in urine output.

The nurse knows that a patient with which glomerular filtration rate (GFR) would be classified as "decreased GFR"?

a) 120 mL/min
b) 70 mL/min
c) 100 mL/min
d) 40 mL/min

70 mL/min Normal GFR is 120-130 mL/min. Persons with a GFR of 60-89 mL/min who have no discernible renal damage are classified as "decreased GFR." Causes for this condition include removal of one kidney, fluid volume depletion, and advanced age. GFR below 60 mL/min for greater than three months is defined as chronic kidney disease

A patient in renal failure has marked decrease in renal blood flow caused by hypovolemia, caused by gastrointestinal bleeding. The nurse is aware that this form of renal failure can be reversed if the bleeding is under control. Which of the following forms of acute renal injury does this patient have?

a) Postrenal failure
b) Chronic renal failure
c) Prerenal failure
d) Intrarenal failure

Prerenal failure Prerenal failure, the most common form of acute renal failure, is characterized by a marked decrease in renal blood flow. It is reversible if the cause of the decreased renal blood flow can be identified and corrected before kidney damage occurs.

The nurse is reviewing the diagnosis of four male clients. Select the diagnosis that places the clients at risk for developing postrenal kidney failure.

a) Severe hypovolemia
b) Acute pyelonephritis
c) Intratubular obstruction
d) Prostatic hyperplasia

Prostatic hyperplasia The most common cause of postrenal kidney failure is prostatic hyperplasia. Postrenal failure results from conditions that obstruct urine outflow. The obstruction can occur in the ureter, bladder, or urethra. -Intratubular obstruction and acute pyelonephritis are intrarenal causes of kidney failure, and severe hypovolemia is a prerenal cause.

The nurse is instructing a patient with advanced kidney disease (AKD) about a dietary regimen. Which of the following restrictions should the nurse be sure to include in the treatment plan to decrease the progress of renal impairment in people with AKD?

a) Dietary protein
b) Fats
c) Foods high in calcium
d) Carbohydrates

Dietary protein Restriction of dietary proteins may decrease the progress of renal impairment in people with advanced renal disease. Proteins are broken down to form nitrogenous wastes, and reducing the amount of protein in the diet lowers the blood urea nitrogen and reduces symptoms.

A 35-year-old client is diagnosed with acute kidney injury (AKI) and is started on hemodialysis. The client is concerned with the diagnosis and wants to know what to expect in the progression of this disorder. Which statement best addresses the client's concern?

a) "You will need to have a renal transplant to live a productive, healthy life."
b) "Once your condition improves you can be placed on peritoneal dialysis for the rest of your life."
c) "The occurrence of acute kidney injury will always eventually result in chronic renal failure."
d) "Acute kidney injury is abrupt in onset and often reversible if recognized early and treated appropriately."

"Acute kidney injury is abrupt in onset and often reversible if recognized early and treated appropriately." AKI is the result of a rapid decline in kidney function that increases blood levels of nitrogenous wastes. Once the underlying cause is treated, AKI is potentially reversible if the precipitating factors can be corrected or removed before permanent damage occurs.

A client is diagnosed with acute renal injury. The nurse will evaluate the client for which of the following possible causes for this disorder? Select all that apply.

a) Hormonal imbalance
b) Ischemic injury
c) Obstruction of urinary outflow
d) Nephrotoxic substances
e) Nonischemic reduced renal blood flow

• Ischemic injury • Nonischemic reduced renal blood flow • Obstruction of urinary outflow • Nephrotoxic substances Acute renal injury can result from ischemia, reduced renal blood without ischemia, nephrotoxic substances including some drugs, and obstruction of urinary outflow. Hormonal imbalance usually does not cause renal injury.

A drug abuser was found unconscious after shooting up heroin 2 days prior. Because of the pressure placed on the hip and arm, the client has developed rhabdomyolysis. The nurse knows this can:

a) Be cured by administering an anticoagulant immediately
b) Cause the kidney to develop renal stones due to stasis
c) Cause compartment syndrome in the lower extremities
d) Obstruct the renal tubules with myoglobin and damage tubular cells

Obstruct the renal tubules with myoglobin and damage tubular cells Myoglobin normally is not found in the serum or urine. It has a low molecular weight; if it escapes into the circulation, it is rapidly filtered in the glomerulus. A life-threatening condition known as rhabdomyolysis occurs when increasing myoglobinuria levels cause myoglobin to precipitate in the renal tubules, leading to obstruction and damage to surrounding tubular cells. Myoglobinuria most commonly results from muscle trauma but may result from exertion, hyperthermia, sepsis, prolonged seizures, and alcoholism or drug abuse. -Rhabdomyolysis is not cured with anticoagulation administration nor does it cause kidney stones. -Compartment syndrome occurs when there is insufficient blood supply to muscles and nerves due to increased pressure within one of the body's compartments.

A child is diagnosed with chronic kidney disease (CKD). The nurse knows that which of the following statements regarding supportive renal therapy in children are true? Select all that apply.

• Early transplantation is the preferred treatment when considering long-term effects. • Children older than 12 years will benefit from hemodialysis. • Peritoneal dialysis is generally most appropriate for children younger than 6. Children between birth and 5 years of age often are managed with peritoneal dialysis. -For those older than 12 years of age hemodialysis is usually preferred. -Early transplantation in young children is the best choice to promote physical growth, improve cognitive function, and foster psychosocial development. -Immunosuppressive therapy in children is similar to that required in adults. -Corticosteroids such as prednisone have risk for growth retardation.

Which of the following patients does the nurse need to monitor for the development of intense intrarenal vasoconstriction that may induce prerenal failure? Select all that apply.

a) Patient taking cyclosporine to prevent rejection for a liver transplant

b) Patient who is HIV positive

c) Patient undergoing cardiac catheterization

d) Patient with an elevated blood urea nitrogen who is taking ibuprofen every 6 hours for back pain

e) Patient taking acetaminophen for fever

• Patient undergoing cardiac catheterization • Patient taking cyclosporine to prevent rejection for a liver transplant • Patient with an elevated blood urea nitrogen who is taking ibuprofen every 6 hours for back pain Some vasoactive mediators, drugs, and diagnostic agents stimulate intense intrarenal vasoconstriction and can induce glomerular hypoperfusion and prerenal failure. Examples include endotoxins, radiocontrast agents such as those used for cardiac catheterization, cyclosporine, and nonsteroidal anti-inflammatory drugs. -NSAIDs can reduce renal blood flow by inhibiting prostaglandin syntheses. In some persons with diminished renal perfusion, NSAIDs can precipitate prerenal failure. -Acetaminophen for short-term use does not predispose a patient to prerenal failure. -An HIV+ client is at no more risk than any other patient.

A family physician is providing care for a 61 year-old obese male who has a history of diabetes and hypertension. Blood work has indicated that the man has a GFR of 51 mL/min with elevated serum creatinine levels. Which of the following statements will the physician most likely provide to the client in light of these results?

a) "You're in kidney failure and I'll be starting dialysis treatment immediately."

b) "Your chronic kidney disease has likely been caused by your diabetes and high blood pressure."

c) "You likely have chronic kidney disease and there may be urine in your blood until it is controlled."

d) "We will regularly monitor your kidney function, but most likely your kidneys will be able to compensate on their own and intervention is not required."

"Your chronic kidney disease has likely been caused by your diabetes and high blood pressure." Diabetes and hypertension are conditions that can cause chronic kidney disease (CKD). While the kidneys do have a remarkable ability to compensate for impaired function, this fact does not mean that treatment would not be undertaken. -Hematuria is not a common manifestation of CKD and the clients GFR of 51 mL/min does not indicate kidney failure or the need for dialysis.

Chronic kidney disease (CKD) can cause derangement of calcium and phosphate metabolism. The nurse will monitor a client with CKD for which of the following? Select all that apply.

a) Decreased blood levels of phosphate

b) Decreased blood levels of calcium

c) Excess calcium deposits in bone

d) Decreased release of parathyroid hormone (PTH)

e) Impaired phosphate excretion

• Impaired phosphate excretion • Decreased blood levels of calcium In CKD, renal ability to excrete phosphate declines. As blood levels of phosphate increase, levels of calcium inversely related to phosphate, fall. This provokes an increase in PTH, which stimulates mobilization of calcium from bone.

A patient has prerenal failure. The nurse knows that this type of failure is characterized by which relationship of blood urea nitrogen (BUN) to serum creatinine levels?

a) An elevated BUN level and decreased creatinine level

b) A BUN to creatinine level ratio of 20:1

c) A BUN to creatinine level ratio of 10:1

d) An elevated creatinine level and decreased BUN level

A BUN to creatinine level ratio of 20:1 In prerenal failure, glomerular filtration rate (GFR) decreases, allowing more filtered urea to be reabsorbed into the circulatory system. Creatinine is filtered but remains in the forming urine. Thus the BUN to creatinine ratio rises to 20:1. A ratio of 10:1 is normal.

A client is diagnosed with renal failure. The nurse must monitor for failure of which of the following functions? Select all that apply.

a) Electrolyte balance

b) Removal of metabolic waste from blood

c) Adrenal secretion

d) Acid-base balance

e) Maintenance of body water

• Maintenance of body water • Electrolyte balance • Acid-base balance • Removal of metabolic waste from blood Functions of the kidney include removal of metabolic end products and regulation of body water, electrolyte balance and acid-base balance. -Although the adrenal glands are located above the kidneys, the kidneys are not directly involved in their regulation.

The nurse is preparing to assess a client who has just been admitted to the hospital with a diagnosis of prerenal failure. Which would the nurse expect the client to manifest? Select all that apply.

a) BUN-to-serum creatinine ratio of greater than 20:1

b) Increased urinary output

c) Decreased urinary output

d) Increased BUN

e) Decreased BUN

f) BUN to serum creatinine ratio of 10:1

• Decreased urinary output • Increased BUN • BUN-to-serum creatinine ratio of greater than 20:1 Prerenal injury is manifested by a sharp decrease in urine output and a disproportionate elevation of blood urea nitrogen (BUN) in relation to serum creatinine levels. Consequently, there also is a disproportionate elevation in the ratio of BUN to serum creatinine, from a normal value of 10:1 to a ratio greater than 20:1.

The nurse will monitor clients with which of the following disorders for development of chronic kidney disease (CKD)? Select all that apply.

a) Diabetes

b) Polycycstic kidney disease

c) Systemic lupus erythematosus

d) Hyperlipidemia

e) Glomerulonephritis

• Systemic lupus erythematosus • Polycycstic kidney disease • Glomerulonephritis • Diabetes Permanent renal damage can result from systemic lupus erythematosus, polycycstic kidney disease, glomerulonephritis, or diabetes. Hypertension also is a frequent cause for CKD. Hyperlipidemia does not cause CKD but may develop in clients with CKD.

A nurse is assessing a client diagnosed with CKD for neuromuscular manifestation. Select the manifestations the nurse may expect to find. Select all that apply.

a) Loss of recent memory

b) Restless leg syndrome

c) Perceptual errors

d) Increased muscle strength

e) Increased alertness

f) Peripheral neuropathy

• Restless leg syndrome • Loss of recent memory • Peripheral neuropathy • Perceptual errors • Increased muscle strength Many persons with CKD have alterations in peripheral and central nervous system function. Restless leg syndrome is a manifestation of peripheral nerve involvement, and muscle weakness and atrophy are a manifestation of uremia. Reductions in alertness and awareness are the earliest and most significant indications of uremic encephalopathy. These often are followed by an inability to fix attention, loss of recent memory, and perceptual errors in identifying persons and objects.

Sexual dysfunction in people with CKD is thought to be multifactorial. What are thought to be causes of sexual dysfunction in people with CKD? (Select all that apply.)

a) Uremic toxins

b) Antihypertensive drugs

c) Psychological factors

d) Inability to vasodilate veins

e) High incidence of sexually transmitted diseases

• Antihypertensive drugs • Psychological factors • Uremic toxins The cause of sexual dysfunction in men and women with CKD is unclear. The cause probably is multifactorial and may result from high levels of uremic toxins, neuropathy, altered endocrine function, psychological factors, and medications (e.g., antihypertensive drugs). The other answers do not apply in this situation.

A client is diagnosed with chronic kidney disease (CKD). The nurse will monitor this client for which of the following Select all that apply.

a) Hyponatremia

b) Hypocalcemia

c) Polyuria

d) Hyperkalemia

e) Metabolic alkalosis

• Polyuria • Hyperkalemia • Hypocalcemia • Hyponatremia The failing kidneys lose ability to concentrate urine and to reabsorb sodium. Hyperkalemia develops late in CKD, as nephrons can no longer regulate potassium excretion. Metabolic acidosis occurs when balance between sodium and bicarbonate is lost. Hypocalcemia develops as excretion of phosphate fails and blood levels of phosphate rise.

A client has experienced severe hemorrhage and is in prerenal failure. The nurse anticipates the laboratory results of the client's BUN and serum creatinine to identify:

a) BUN elevates and creatinine decreases.

b) Creatinine level rises and BUN decreases.

c) The BUN-to-creatinine ratio is 20:1.

d) The BUN-to-creatinine ratio is 10:1.

The BUN-to-creatinine ratio is 20:1. Prerenal injury is manifested by a sharp decrease in urine output and a disproportionate elevation of blood urea nitrogen (BUN) in relation to serum creatinine levels. The kidney normally responds to a decrease in the GFR with a decrease in urine output. An early sign of prerenal injury is a sharp decrease in urine output. A low GFR allows more time for small particles such as urea to be reabsorbed into the blood. Creatinine, which is larger and nondiffusible, remains in the tubular fluid, and the total amount of creatinine that is filtered, although small, is excreted in the urine. Consequently, there also is a disproportionate elevation in the ratio of BUN to serum creatinine, from a normal value of 10:1 to a ratio greater than 20:1.

Which of the following have the potential to cause chronic kidney disease? (Select all that apply.)

• Hypertension • Diabetes • Glomerulonephritis CKD can result from a number of conditions including diabetes, hypertension, glomerulonephritis as well as systemic lupus erythematosus, and polycystic kidney disease. These conditions slowly but steadily destroy renal tissue resulting in irreversible loss of function. Cardiomyopathies do not cause renal failure; they cause heart failure.

The nurse knows that uremia or "urine in the blood" is often used to describe the clinical manifestations of chronic kidney disease (CKD). Which of the following are early signs and symptoms of uremia? Select all that apply.

a) Elevated blood glucose

b) Nausea

c) Apathy

d) Fatigue

e) Weakness

• Fatigue • Nausea • Apathy • Weakness As nitrogenous wastes accumulate in the circulatory system, symptoms of fatigue, nausea, apathy, and weakness will appear. CKD does not immediately affect blood glucose.

A client is diagnosed with chronic kidney disease (CKD). The nurse recognizes that which of the following statements regarding CKD are correct? Select all that apply.

a) Functioning nephrons compensate for those that are damaged.

b) The rate of nephron destruction is the same in all clients.

c) Signs and symptoms develop gradually.

d) There is a reduction in glomerular filtration rate (GFR) as nephrons are destroyed.

e) Nephron destruction takes place over many months.

• Nephron destruction takes place over many months. • Signs and symptoms develop gradually. • Functioning nephrons compensate for those that are damaged. • There is a reduction in glomerular filtration rate (GFR) as nephrons are destroyed. In CKD, the rate of nephron destruction occurs over many months and is different among clients. Signs and symptoms develop gradually as nephrons are destroyed and functioning nephrons gradually lose the ability to compensate for this. As nephrons are destroyed, GFR declines. (

The clinical nurse educator on a nephrology unit of a large, urban hospital is orientating recent nursing graduates to the unit. Which of the following teaching points about acute tubular necrosis (ATN) should the educator include in the orientation session?

a) "Trauma, burns and major surgery are common precursors to ATN."

b) "The cardinal signs of ATN are oliguria and retention of potassium, creatinine and sulfates."

c) "Ureteral and bladder outlet obstructions are often contributors to ATN."

d) "Tubular epithelial cells are sensitive to ischemia and toxins, and damage is irreversible."

"Trauma, burns and major surgery are common precursors to ATN." ATN is often preceded by major surgery, burns or trauma. Many cases of ATN are nonoliguric, and obstructions that are postrenal in nature are not common causes of ATN. Damage to tubular epithelial cells is not necessarily irreversible.

Glomerular filtration rate (GFR) is the best indicator of renal function. The nurse knows that GFR can vary with which of the following factors? Select all that apply.

a) Age

b) Body size

c) Diet

d) Ethnicity

e) Gender

• Gender • Age • Body size • Ethnicity GFR, the best indicator of overall renal function, varies with age, gender, body size, and ethnicity. Equations are available for calculating GFR based on serum creatinine and these variables. Diet, if it includes sufficient fluid intake to maintain hydration, should not affect GFR.

Following the diagnosis of acute renal failure, the nurse knows that one of the earliest manifestations of residual tubular damage is which of the following lab/diagnostic results?

a) Elevated blood urea nitrogen (BUN).

b) Serum creatinine elevation.

c) Inability to concentrate urine.

d) Reduced glomerular filtration rate.

Elevated blood urea nitrogen (BUN). Urine tests that measure urine osmolality, urinary sodium concentration, and fractional excretion of sodium help differentiate prerenal azotemia, in which the reabsorptive capacity of the tubular cells is maintained, from tubular necrosis, in which these functions are lost. One of the earliest manifestations of tubular damage is the inability to concentrate urine. Conventional markers of serum creatinine and urea nitrogen, fractional secretion of sodium to assess glomerular filtration rate (GFR), and urine output do not manifest for 1-2 days after the acute renal failure has begun.

A nurse educator is performing client education with a 51 year-old man who has been recently diagnosed with chronic kidney disease. Which of the following statements by the client would the nurse most likely want to correct or clarify?

a) "My heart rate might go up because of my kidney disease and my blood might be a lot thinner than it should be."

b) "My kidney problems increase my chance of developing high blood pressure or diabetes."

c) "I'll be prone to anemia, since I'm not producing as much of the hormone that causes my bones to produce red blood cells."

d) "I'll have a risk of either bleeding too easily or possibly clotting too quickly, though dialysis can help minimize these effects."

"My kidney problems increase my chance of developing high blood pressure or diabetes." While high blood pressure can be causative of- or consequent to- renal failure, diabetes is not normally a result of existing CKD. Persons with renal failure are indeed prone to anemia, increased heart rate, decreased blood viscosity, and coagulopathies. The risk of bleeding and thrombotic disorders can be partially mitigated by dialysis

A 45-year-old client with chronic kidney disease (CKD) voices concern about her dialysis treatment. The client would like to work and spend time with her family. Which type of dialysis will best fit this client's lifestyle?

a) Hemodialysis

b) Continuous ambulatory peritoneal dialysis

c) Nocturnal intermittent peritoneal dialysis (NIPD)

d) Continuous cyclic peritoneal dialysis

Nocturnal intermittent peritoneal dialysis (NIPD) In NIPD, the client is given 10 hours of automatic cycling each night, with the abdomen left dry during the day. This is the most beneficial for this client. Individual preference, manual ability, lifestyle, knowledge of the procedure, and physiologic response to treatment are used to determine the type of dialysis that is used. Hemodialysis is generally three times a week for 3 to 4 hours a day. CAPD involves exchanging the dialysate four to six times per day. In CCPD, the last exchange remains in the abdomen during the day

Neuromuscular disorders can be triggered by CKD. For those clients on dialysis, approximately two thirds suffer from what peripheral neuropathy?

a) Raynaud syndrome

b) Tingling and loss of sensation in lower limbs

c) Burning hands and feet

d) Restless legs syndrome

Restless legs syndrome Restless legs syndrome is a manifestation of peripheral nerve involvement and can be seen in as many as two thirds of clients on dialysis. The other answers are not correct.

A client has acute pyelonephritis. The nurse will monitor the client for development of which of the following?

a) Prerenal failure

b) Post renal failure

c) Intrarenal failure

d) Chronic kidney disease

Intrarenal failure Acute pyelonephritis, an active bacterial infection, can cause tubular cell necrosis and intrarenal failure. Acute pyelonephritis does not cause prerenal or postrenal failure or chronic kidney disease unless it is not treated

A client is diagnosed with decreased gomerular filtration rate but has no renal damage. The nurse recognizes that this can occur with which of the following? Select all that apply.

a) Carbohydrate diet

b) Heart failure

c) Dehydration

d) Cirrhosis

e) Removal of one kidney

• Cirrhosis • Heart failure • Removal of one kidney • Dehydration Chronic reduction in glomerular filtration rate with no renal damage can be the result of depleted body fluid, removal of one kidney, and conditions such as heart failure and cirrhosis which decrease renal perfusion. A carbohydrate diet should not affect GFR.

A nurse is collecting a urine specimen prior to measuring the albumin level in a client's urine. A colleague questions the rationale for the test, stating, "I thought albumin was related to liver function, not kidney function." How can the nurse best respond to this statement?

"Urine albumin levels are useful for diagnosing diabetic kidney disease." Explanation: In clients with diabetes, albumin tests are useful adjunctive test of nephron injury and repair. Urine is not normally completely free of proteins and a urine dipstick does not allow for the quantification of how much albumin is in a sample. Albumin tests do not allow for an accurate indirect indication of GFR.

The nurse knows that one of the earliest manifestations of acute renal failure (ARF) is which of the following?

a) Elevated plasma uric acid
b) Polyuria
c) Elevated urinary glucose
d) Hypokalemia

Polyuria One of the earliest signs of ARF is loss of ability to concentrate urine. The other answer selections are not notable markers of early renal failure; however, they may develop as renal failure progresses.

While assessing a peritoneal dialysis client in his or her home, the nurse notes that the fluid draining from the abdomen is cloudy, is white in color, and contains a strong odor. The nurse suspects this client has developed a serious complication known as:

a) Bladder erosion
b) Bowel perforation
c) Peritonitis
d) Too much sugar in the dialysis solution

Peritonitis Potential problems with peritoneal dialysis include infection, catheter malfunction, dehydration, hyperglycemia, and hernia. -Bowel perforation can occur, but the fluid would be stool colored. -The client may develop hyperglycemia; however, this will not cause the fluid to be cloudy. -If bladder erosion had occurred, the fluid would look like urine and not be cloudy and white.

The nurse recognizes that renal failure has many underlying causes, including which of the following? Select all that apply

a) Renal disease
b) Malnutrition
c) Systemic disease
d) Hepatic disease
e) Nonrenal urological abnormalities

• Systemic disease • Renal disease • Nonrenal urological abnormalities Underlying causes of renal failure include renal or systemic disease and nonrenal urologic abnormalities. -Hepatic disease and malnutrition might gradually influence renal function as they can influence many body functions, but are not considered direct causes of renal failure.

As chronic kidney disease progresses, the second stage (renal insufficiency) is identified by:

a) Decrease in GFR to 30 to 59 mL/minute/1.73 m2
b) Diminished GFR to less than 15 mL/minute/1.73 m2
c) Decrease in GFR of 60 to 89 mL/minute/1.73 m2
d) GFR decrease to 15 to 29 mL/minute/1.73 m2

Decrease in GFR of 60 to 89 mL/minute/1.73 m2 Diminished renal reserve is characteristic of renal insufficiency, when labs remain normal but there is renal insufficiency. Only the second stage, formerly known as renal insufficiency, is characterized by a decrease in GFR of 60 to 89 mL/minute/1.73 m2. The other choices represent stage 3, 4, and 5, respectfully.

Which of the following phenomena contributes to the difficulties with absorption, distribution and elimination of drugs that is associated with kidney disease?

a) Reductions in plasma proteins increase the amount of free drug and decrease the amount of protein-bound drug.
b) Acute tubular necrosis is associated with impaired drug reabsorption through the tubular epithelium.
c) Decreased retention by the kidneys often renders normal drug dosages ineffective.
d) Dialysis removes active metabolites from circulation minimizing therapeutic effect.

Reductions in plasma proteins increase the amount of free drug and decrease the amount of protein-bound drug. A decrease in plasma proteins, particularly albumin, that occurs in many persons with renal failure results in less protein-bound drug and greater amounts of free drug. -Drug elimination problems do not stem as directly from impaired tubular reabsorption, decreased retention or the process of dialysis.

The nurse is planning care for a client with chronic kidney disease (CKD). The nurse determines that an allowable fluid intake would be:

a) 500 to 800 mL/day
b) 1050 to 1200 mL/day
c) 400 to 600 mL/day
d) 850 to 1000 mL/day

500 to 800 mL/day It is a common practice to allow 500 to 800 mL, which is equal to insensible water loss plus a quantity equal to the 24-hour urine output. -Fluid intake in excess of what the kidneys can excrete causes circulatory overload, edema, and water intoxication. -Inadequate intake, on the other hand, causes volume depletion and hypotension and can cause further decreases in the already compromised GFR.

Which of the following patients scheduled for an interventional radiology procedure requiring administration of radiocontrast dye would be considered high risk for nephrotoxicity? Select all that apply.

a) 25 year old with a history of glomerular nephritis who is complaining of severe flank pain.
b) 14 year old with severe abdominal pain.
c) 67 year old diabetic undergoing diagnostic testing for new-onset proteinuria.
d) 45 year old with elevated liver enzymes possibly due to fatty liver cirrhosis.
e) 53 year old male undergoing biopsy for a suspicious "spot" on their chest x-ray.

• 25 year old with a history of glomerular nephritis who is complaining of severe flank pain. • 67 year old diabetic undergoing diagnostic testing for new-onset proteinuria. Radiocontrast media-induced nephrotoxicity is thought to result from direct tubular toxicity and renal ischemia. The risk for renal damage caused by radiocontrast media is greatest in older adults and those with pre-existing kidney disease, volume depletion, diabetes mellitus, and recent exposure to other nephrotoxic agents

The nurse knows that a patient with chronic kidney disease (CKD) may experience which of the following changes in skin integrity? Select all that apply.

a) Pale skin
b) Decreased perspiration
c) Brittle fingernails
d) Moist skin and mucous membranes
e) Increased oil gland secretion

• Pale skin • Brittle fingernails • Decreased perspiration In CKD, anemia due to loss of erythropoietin activity causes pale skin. Perspiration and oil secretion are decreased, leading to dry skin. Fingernails become brittle.

The nurse knows that a patient with chronic kidney disease (CKD) may develop renal osteodystrophy (skeletal damage). Which of the following are characteristic of both high-bone-turnover and low-bone-turnover osteodystrophy? Select all that apply.

a) Decreased osteoblast and osteoclast proliferation
b) Bone marrow fibrosis
c) Defective bone remodeling
d) Abnormal bone resorption
e) Increased osteoblast and osteoclast proliferation

• Abnormal bone resorption • Defective bone remodeling Abnormal bone resorption and defective bone remodeling are characteristic of both high-bone-turnover and low-bone-turnover osteodystrophy. In high-turnover, there is increased osteoblast and osteoclast proliferation while in low-turnover there is decreased proliferation. Bone marrow fibrosis is characteristic of high-bone turnover.

A client diagnosed with chronic kidney disease (CKD) is experiencing nausea and vomiting. Which would be the best instruction for the nurse to provide?

a) Restrict intake of dietary fat
b) Increase intake of fruit juice
c) Increase intake of carbohydrates
d) Restrict intake of dietary protein

Restrict intake of dietary protein Early morning nausea is common in CKD. Nausea and vomiting often improve with the restriction of dietary protein and after initiation of dialysis and disappears after kidney transplant. The other options will not improve the symptoms.

A 72-year-old patient is scheduled for a kidney transplant. The nurse knows that which aspect of advanced age has a positive effect on the success of kidney transplant survival?

a) Decreased muscle mass
b) Psychological maturity
c) Reduction in T-lymphocyte function
d) Acceptance of immunosuppressive therapy

Reduction in T-lymphocyte function The general reduction in T-lymphocyte function with subsequent decrease in immune system activity that occurs with aging would foster transplant survival. The other options would not have a direct effect on rejection of the transplant. -Acceptance of immunosuppressive therapy is not a specific characteristic of advanced age. -Psychological maturity and decreased muscle mass have little to no effect on transplant survival.

A 42 year-old male has been diagnosed with renal failure secondary to diabetes mellitus and is scheduled to begin dialysis soon. Which of the following statements by the client reflects an accurate understanding of the process of hemodialysis?

a) "I won't be able to go about my normal routine during treatment."
b) "It's stressful knowing that committing to dialysis means I can't qualify for a kidney transplant."
c) "Changing my schedule to accommodate 3 or 4 hours of hemodialysis each day will be difficult."
d) "I know I'll have to go to a hospital or dialysis center for treatment."

"I won't be able to go about my normal routine during treatment." Hemodialysis requires the client to remain connected to dialysis machinery, whereas peritoneal dialysis allows for activity during treatment. -Dialysis does not disqualify an individual from receiving a transplant. -Dialysis does not require attendance at a dialysis center, patients can be taught to perform the dialysis in their home with a family member in attendance. -Hemodialysis is normally conducted 3 times weekly, not once per day.

Which of the following data would a clinician consider as most indicative of acute renal failure?

a) Decreased serum creatinine and blood urea nitrogen (BUN); decreased potassium and calcium levels
b) Decreased urine output; hematuria; increased GFR
c) Alterations in blood pH; peripheral edema
d) Increased nitrogenous waste levels; decreased glomerular filtration rate (GFR).

Increased nitrogenous waste levels; decreased glomerular filtration rate (GFR). The hallmark of acute renal injury is azotemia, an accumulation of nitrogenous wastes such as creatinine, urea nitrogen, and uric acid plus a decrease in the GFR of the kidneys. While pH alterations, edema, electrolyte imbalances and decreased urine output may accompany acute renal failure, they are all potentially attributable to other pathologies. Creatinine, GFR and BUN would be unlikely to rise during renal failure.

A client with chronic kidney disease has developed cardiac calcification. On admission the priority assessment would be for the nurse to:

a) place on a heart monitor to watch for arrhythmias.
b) assess for pulses in the feet bilaterally.
c) listen to the heart for extra clicking sounds.
d) check the BP in both arms and compare.

place on a heart monitor to watch for arrhythmias. Visceral calcification may be found in the myocardium, lungs, and stomach. In cardiac calcification, the deposits usually develop in the conduction system and may result in serious cardiac arrhythmias. -The other assessments are valid, however watching for arrhythmias is the priority.

A client who has developed stage 3 renal failure has been diagnosed with high phosphate levels. To avoid the development of osteodystrophy, the physician may prescribe a phosphate-binding agent that does not contain:

a) Aluminum
b) Sevelamer hydrochloride
c) Calcium acetate
d) Calcium carbonate

Aluminum Aluminum-containing antacids can contribute to the development of osteodystrophy, whereas calcium-containing phosphate binders can lead to hypercalcemia, thus worsening soft tissue calcification, especially in persons receiving vitamin D therapy. Sevelamer hydrochloride is a newer phosphate-binding agent that does not contain calcium or aluminum.

A patient is diagnosed with chronic kidney disease (CKD). The nurse recognizes that this patient will experience which of the following? Select all that apply.

a) Decreased tubular reabsorption
b) Hypophospatemia
c) Decreased glomerular filtration
d) Proliferation of nephrons
e) Decreased renal endocrine function

• Decreased renal endocrine function • Decreased tubular reabsorption • Decreased glomerular filtration Chronic kidney disease results in loss of nephrons, with a decrease in tubular reabsorption, glomerular filtration, and endocrine function. -Phosphate accumulates in the blood, as the kidneys lose their ability to excrete this electrolyte.

The nurse knows that a child with chronic kidney disease (CKD) may experience which of these manifestations? Select all that apply.

a) Mental retardation
b) Severe growth deficit
c) High bone turnover
d) Early sexual maturity
e) Bladder incontinence

• Severe growth deficit • High bone turnover Childhood CKD is manifested by delays in growth and sexual maturity as a result of the uremic effects on endocrine function and bone growth. High bone turnover is related to secondary hyperparathyroidism. -Intelligence and control of urinary tract function are not directly affected by renal failure.

A nurse is assessing a client for early manifestations of chronic kidney disease (CKD). Which would the nurse expect the client to display?

a) Terry nails
b) Hypertension
c) Asterixis
d) Impotence

Hypertension Hypertension is commonly an early manifestation of CKD. The mechanisms that cause the hypertension are multifactorial; they include increased vascular volume, increased peripheral vascular resistance, decreased levels of renal vasodilator prostaglandins, and increase activity of the renin-angiotensin-aldosterone system. -Impotence occurs in as many as 56% of males on dialysis. -Terry nails are dark band just behind the leading edge of a fingernail followed by a white band that occur in the late stages. -Asterixis, a sign of hepatic encephalopathy, is due to the inability of the liver to metabolize ammonia to urea.

A patient has developed acute tubular necrosis (ATN). The nurse knows that which of the following groups of drugs can cause this type of renal injury? Select all that apply.

a) Chemotherapy drugs
b) Radiocontrast dyes
c) Aminoglycoside anti-infectives
d) Nonsteroidal antiinflammatory drugs (NSAID)
e) Angiotensin converting enzyme inhibitors (ACEI)

• Radiocontrast dyes • Chemotherapy drugs • Aminoglycoside anti-infectives Aminoglycosides, radiocontrast agents and chemotherapy drugs such as cisplatin (Platinol) all are directly toxic to the nephron and ATN will occur. -NSAIDs inhibit the synthesis of prostaglandins needed to maintain renal blood flow, thus renal perfusion declines and prerenal failure can develop. -ACEI are generally not nephrotoxic and are often used to manage hypertension in persons with renal disease.

A chronic kidney disease client who has renal osteodystrophy should be assessed for which of the following complications? Select all that apply.

a) Stress fractures
b) Bone pain
c) Muscle weakness
d) Urosepsis
e) Kidney stones

• Muscle weakness • Bone pain • Stress fractures Both types of renal osteodystrophy are manifested by abnormal absorption and defective bone remodeling. Renal osteodystrophy is typically accompanied by reductions in bone mass, alterations in bone microstructure, bone pain, and skeletal fracture. There are changes in bone turnover, mineralization, and bone volume, accompanied by bone pain and muscle weakness, risk of fractures, and other skeletal complications. -Kidney stones and urosepsis are not associated with renal osteodystrophy.

A hospital client with a diagnosis of chronic renal failure has orders for measurement of her serum electrolyte levels three times per week. Which of the following statements best captures the relationship between renal failure and sodium regulation?

a) Clients with renal failure often maintain high sodium levels because of decreased excretion.
b) Clients with advanced renal failure are prone to hyponatremia because of impaired tubular reabsorption.
c) Renal clients often require a sodium-restricted diet to minimize the excretion load on remaining nephrons.
d) Restricting sodium intake helps to preserve nephron function and has the additional benefit of lowering blood pressure.

Clients with advanced renal failure are prone to hyponatremia because of impaired tubular reabsorption. The compromised ability of the tubular nephrons to reabsorb sodium predisposes renal clients to low serum sodium levels. A sodium restriction is thus not normally indicated.

A patient has developed chronic kidney disease (CKD). The nurse will advise the patient to be alert for the development of which hematologic signs and symptoms of this disorder? Select all that apply.

a) Fatigue
b) Bradycardia
c) Gastrointestinal bleeding
d) Bruising
e) Intravascular clotting

• Bruising • Gastrointestinal bleeding • Fatigue Explanation: In CKD, platelet function is impaired and bruising and gastrointestinal bleeding can occur. Intravascular clotting usually does not happen. Decreased renal production of erythropoietin results in decreased synthesis of red blood cells, resulting in anemia and fatigue. Decrease in red cells also decreases blood viscosity and decreases cerebral oxygen delivery, both of which contribute to tachycardia rather than bradycardia.

A 1-year-old baby boy with renal dysplasia risks end-stage renal disease unless intervention occurs. Which of the following treatment options is his care team most likely to reject?

a) Dietary restriction plus erythropoietin
b) Renal transplantation
c) Continuous cyclic peritoneal dialysis
d) Continuous ambulatory peritoneal dialysis

Dietary restriction plus erythropoietin Renal transplantation and dialysis are recommended for children; of these, transplantation is the preferred treatment. Conservative measures are inappropriate in this age group because of the importance of fostering proper bone growth, especially in the first two years, and appropriate cognitive development, which is at risk due to issues such as uremic encephalopathy and the effect of renal failure upon the central nervous system of the developing child.

A patient with a recent diagnosis of renal failure that will require hemodialysis is being educated by the nurse in the dietary management of the disease. Which of the patient's following statements shows an accurate understanding of this component of treatment? Select all that apply.

a) "I'm going to try a high-protein, low-carbohydrate diet."
b) "I've made a list of high-phosphate foods so that I can try to avoid them."
c) "I don't think I've been drinking enough, so I want to include 8 to 10 glasses of water each day."
d) "I'll increase the carbohydrates in my diet to provide sufficient energy."
e) "I'm making a point of trying to eat lots of bananas and other food rich in potassium."

• "I'll increase the carbohydrates in my diet to provide sufficient energy." • "I've made a list of high-phosphate foods so that I can try to avoid them." Persons with chronic kidney disease (CKD) are usually encouraged to limit their dietary phosphorus as a means of preventing secondary hyperparathyroidism, renal osteodystrophy, and hypocalcemia. Excessive protein, potassium, and fluids can be detrimental in individuals whose kidney disease requires hemodialysis. Because protein intake is limited, carbohydrate consumption should increase to meet daily energy requirements.

A child has received a kidney transplant at the age of 3. Knowing he will be on immunosuppressive agents like corticosteroids, the nurse should educate the parents about which long-term side effects? Select all that apply.

a) Growth retardation
b) Excess weight loss
c) Development of cataracts
d) Hypertension
e) Frequent hematuria

• Hypertension • Growth retardation • Development of cataracts Early transplantation in young children is regarded as the best way to promote physical growth, improve cognitive function, and foster psychosocial development. Immunosuppressive therapy in children is similar to that used in adults. All immunosuppressive agents have side effects, including increased risk for infection. Corticosteroids carry the risk for hypertension, orthopedic complications (especially aseptic necrosis), cataracts, and growth retardation. Steroids usually are associated with weight gain. -Frequent hematuria is caused by something other than steroids and should be reported.

If a CKD client is developing uremic encephalopathy, the earliest manifestations may include: Select all that apply.

a) Delirium and hallucinations
b) New-onset seizures
c) Diminished awareness
d) Decreased alertness

• Decreased alertness • Diminished awareness Reductions in alertness and awareness are the earliest and most significant indications of uremic encephalopathy. - Late in the disease process, the client may develop delirium, coma, and seizures.

A client with chronic kidney disease (CKD) has developed asterixis. The nurse knows that asterixis is which of the following?

a) Burning sensation in feet
b) Dorsiflexion of hands and feet
c) Demyelination of nerve fibers
d) Unsteady gait

Dorsiflexion of hands and feet Asterixis, which is involuntary dorsiflexion of hands and feet, can develop as CKD worsens. -Burning sensation in feet, unsteady gait and demyelination of nerves can also accompany CKD, but are not part of asterixis.

Anemia frequently occurs in clients with chronic kidney disease (CKD). The nurse will monitor these clients for which of the following contributors to anemia? Select all that apply.

a) Decreased erythropoietin production
b) Chronic blood loss
c) Iron overload
d) Anorexia
e) Bone marrow suppression

• Decreased erythropoietin production • Anorexia • Bone marrow suppression • Chronic blood loss Production of erythropoietin, which stimulates red cell synthesis, becomes deficient as the kidneys fail. Iron deficiency can develop as anorexia decreases ingestion of foods containing this mineral. Bone marrow production of red cells is suppressed as uremia develops. Clients on dialysis will experience chronic blood loss

The nurse recognizes that acute renal injury is characterized by which of the following?

a) Rapid decline in renal function

b) Irreversible damage to nephrons

c) Decreased blood urea nitrogen (BUN)

d) Low incidence of mortality

Rapid decline in renal function Acute renal injury is a rapid decline in kidney function. BUN rises as nitrogenous wastes are not removed from the circulation. If the cause can be ameliorated, the injury is usually reversible. Most at risk are seriously ill clients; the mortality rate is between 40% and 90% in these clients.

As nitrogenous wastes increase in the blood, the CKD client may exhibit which of the following clinical manifestations? Select all that apply.

a) Pruritis

b) Extremely low platelet counts

c) Photophobia

d) Numbness in lower extremities

e) Restless leg syndrome

• Numbness in lower extremities • Restless leg syndrome • Pruritis The uremic state is characterized by signs and symptoms of altered neuromuscular function (e.g., fatigue, peripheral neuropathy, restless leg syndrome, sleep disturbances, uremic encephalopathy); gastrointestinal disturbances such as anorexia and nausea; white blood cell and immune dysfunction, and dermatologic manifestations such as pruritus. Photophobia and thrombocytopenia are usually not associated with CKD.

Acute tubular necrosis (ATN) is the most common cause of intrinsic renal failure. One of the causes of ATN is ischemia. What are the most common causes of ischemic ATN? (Select all that apply.)

• Severe hypovolemia • Burns • Overwhelming sepsis Ischemic ATN occurs most frequently in persons who have major surgery, severe hypovolemia, overwhelming sepsis, trauma, and burns. Hypervolemia and hypertension are not considered contributing factors to ischemic ATN.

Chapter 26- Acute Kidney Injury and Chronic Kidney Disease- Patho - Subjecto.com

Chapter 26- Acute Kidney Injury and Chronic Kidney Disease- Patho

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An 86-year-old female client has been admitted to the hospital for the treatment of dehydration and hyponatremia after she curtailed her fluid intake to minimize urinary incontinence. The client’s admitting laboratory results are suggestive of prerenal failure. The nurse should be assessing this client for which of the following early signs of prerenal injury?

a) Intermittent periods of confusion
b) Excessive voiding of clear urine
c) Acute hypertensive crisis
d) Sharp decrease in urine output

Sharp decrease in urine output Dehydration and its consequent hypovolemia can result in acute renal failure that is prerenal in etiology. The kidney normally responds to a decrease in GFR with a decrease in urine output. Thus, an early sign of prerenal injury is a sharp decrease in urine output. Post-renal failure is obstructive in etiology, and intrinsic (or intrarenal) renal failure is reflective of deficits in the function of the kidneys themselves.

The primary care provider for a newly admitted hospital client has added the glomerular filtration rate (GFR) to the blood work scheduled for this morning. The client’s GFR results return as 50 mL/minute/1.73 m2. The nurse explains to the client that this result represents:

a) Concentrated urine
b) A loss of over half the client’s normal kidney function
c) A need to increase water intake
d) The kidneys are functioning normally

A loss of over half the client’s normal kidney function In clinical practice, GFR is usually estimated using the serum creatinine concentration. A GFR below 60 mL/minute/1.73 m2 represents a loss of one half or more of the level of normal adult kidney function. -The GFR is not diagnostic for concentrated urine or the need to drink more water

Bruising of the skin is a manifestation of bleeding disorders in patients with CKD.

a) True
b) False

True Bleeding disorders manifested by persons with CKD include epistaxis, menorrhagia, gastrointestinal bleeding, and bruising of skin and subcutaneous tissues.

A patient has an obstructive urine outflow related to benign prostatic hyperplasia. Due to the inability to excrete adequate amounts of urine, which of the following types of renal failure should the nurse closely monitor for?

a) Postrenal failure
b) Intrarenal failure
c) Prerenal failure
d) Chronic renal failure

Postrenal failure Postrenal failure results from obstruction of urine outflow from the kidneys. The obstruction can occur in the ureter, bladder, or urethra. Due to the increased urine not being able to be excreted due to the obstruction, retrograde pressure occurs throughout the tubules and nephrons, which ultimately damages the nephrons. Prostatic hyperplasia is the most common underlying problem

A nurse is collecting a urine specimen prior to measuring the albumin level in a client’s urine. A colleague questions the rationale for the test, stating, "I thought albumin was related to liver function, not kidney function." How can the nurse best respond to this statement?

a) "A urine test for albumin allows us to estimate the client’s GFR quite accurately."
b) "Urine should normally be free of any proteins, and albumin is one of the more common proteins to be excreted in chronic renal failure."
c) "Urine albumin levels are useful for diagnosing diabetic kidney disease."
d) "A urine dipstick test will tell us exactly how much albumin is being spilled by the client’s kidneys."

"Urine albumin levels are useful for diagnosing diabetic kidney disease." In clients with diabetes, albumin tests are useful adjunctive test of nephron injury and repair. -Urine is not normally completely free of proteins and a urine dipstick does not allow for the quantification of how much albumin is in a sample. -Albumin tests do not allow for an accurate indirect indication of GFR.

A patient has a marked decrease in the glomerular filtration rate (GFR) and has elevations in blood urea nitrogen, potassium, and creatinine levels. The patient’s urine output has decreased to 10 mL/hr and has 3+ pitting edema in the lower extremities. In which of the following phases of acute tubular necrosis does the nurse determine the patient is in relating to this assessment data?

a) Maintenance phase
b) Onset phase
c) Initiating phase
d) Recovery phase

Maintenance phase The maintenance phase of acute tubular necrosis is characterized by a marked decrease in the GFR causing sudden retention of endogenous metabolites—such as urea, potassium, sulfate, and creatinine—that normally are cleared by the kidneys. Urine output usually is lowest at this point. Fluid retention gives rise to edema, water intoxication, and pulmonary congestion. If the period of oliguria is prolonged, hypertension frequently develops and with it signs of uremia.

A client with chronic kidney disease (CKD) is anemic. The nurse will attempt to alleviate the anemia in order to prevent which of the following? Select all that apply.

a) Decreased myocardial oxygen
b) Increased blood viscosity
c) Hypersomnia
d) Tachycardia
e) Fatigue

• Tachycardia • Fatigue • Decreased myocardial oxygen Uncorrected anemia provokes fatigue and insomnia, a decrease in blood viscosity, a decrease in myocardial oxygen supply, and tachycardia as the heart attempts to supply sufficient oxygen to the heart and brain

The health care provider has prescribed an aminoglycoside (gentamicin) for a client. The nurse is aware that the client is at risk for:

a) Ischemic acute tubular necrosis
b) Nephrotoxic acute tubular necrosis
c) Postrenal failure
d) Chronic kidney disease

Nephrotoxic acute tubular necrosis Pharmacologic agents that are directly toxic to the renal tubule include aminoglycosides (e.g., gentamicin), cancer chemotherapeutic agents such as cystplastin and ifosfamide, and radiocontrast agents. Nephrotoxic agents cause tubular injury by inducing varying combinations of renal vasoconstriction, direct tubular damage, or intratubular obstruction. -Postrenal failure results from obstruction of outflow of the kidneys. -CKD and its treatment can interfere with the absorption, distribution, and elimination of drugs. -Acute tubular necrosis (ATN) occurs most frequently in clients who have major trauma, severe hypovolemia, overwhelming sepsis, trauma, or burns.

The GFR is considered to be the best measure of renal function. What is used to estimate the GFR?

a) BUN
b) Serum creatinine
c) Serum protein
d) Albumin level

Serum creatinine In clinical practice, GFR is usually estimated using the serum creatinine concentration. The other answers are not used to estimate the GFR.

A client is diagnosed with chronic kidney disease (CKD). The nurse knows that which of the following statements regarding CKD are correct? Select all that apply

a) Onset is abrupt.
b) Symptoms appear with 50% of nephrons lost.
c) Renal damage is irreversible.
d) Hypertension is a major cause.
e) Less than 1% of population is affected.

• Renal damage is irreversible. • Hypertension is a major cause. CKD usually develops slowly, often over many years. Irreversible damage occurs, as symptoms do not appear until 80% of the nephrons cease to function. Approximately 10% of the United States population has CKD. Hypertension and diabetes are major causes of CKD.

Vitamin D metabolism is deranged in clients with chronic kidney disease (CKD). The nurse recognizes that which of the following statements regarding vitamin D is correct?

a) Calcitriol stimulates release of parathyroid hormone (PTH).
b) Calcitriol blocks gastrointestinal absorption of calcium.
c) Suppression of parathyroid hormone release is characteristic of CKD.
d) Kidneys convert inactive vitamin D to its active form, calcitriol.

Kidneys convert inactive vitamin D to its active form, calcitriol. Inactive vitamin D is converted to active calcitriol in the kidneys. Calcitriol enhances gastrointestinal absorption of calcium, and suppresses release of PTH. Elevated levels of PTH are characteristic of CKD as blood levels of phosphate rise and levels of calcium fall.

The nurse is caring for a patient who has had acute blood loss from ruptured esophageal varices. Which of the following does the nurse recognize is an early sign of prerenal failure?

a) Baseline blood pressure of 150/90 mm Hg that is now 130/80 mm Hg
b) Baseline heart rate of 100 bpm that has increased to 120 bpm
c) Foul smelling, cloudy urine
d) Baseline urine output of 50 mL/hr that is now 10 mL/hr

Baseline urine output of 50 mL/hr that is now 10 mL/hr The kidney normally responds to a decrease in the glomerular filtration rate with a decrease in urine output. Thus, an early sign of prerenal failure is a sharp decrease in urine output.

The nurse knows that a patient with which glomerular filtration rate (GFR) would be classified as "decreased GFR"?

a) 120 mL/min
b) 70 mL/min
c) 100 mL/min
d) 40 mL/min

70 mL/min Normal GFR is 120-130 mL/min. Persons with a GFR of 60-89 mL/min who have no discernible renal damage are classified as "decreased GFR." Causes for this condition include removal of one kidney, fluid volume depletion, and advanced age. GFR below 60 mL/min for greater than three months is defined as chronic kidney disease

A patient in renal failure has marked decrease in renal blood flow caused by hypovolemia, caused by gastrointestinal bleeding. The nurse is aware that this form of renal failure can be reversed if the bleeding is under control. Which of the following forms of acute renal injury does this patient have?

a) Postrenal failure
b) Chronic renal failure
c) Prerenal failure
d) Intrarenal failure

Prerenal failure Prerenal failure, the most common form of acute renal failure, is characterized by a marked decrease in renal blood flow. It is reversible if the cause of the decreased renal blood flow can be identified and corrected before kidney damage occurs.

The nurse is reviewing the diagnosis of four male clients. Select the diagnosis that places the clients at risk for developing postrenal kidney failure.

a) Severe hypovolemia
b) Acute pyelonephritis
c) Intratubular obstruction
d) Prostatic hyperplasia

Prostatic hyperplasia The most common cause of postrenal kidney failure is prostatic hyperplasia. Postrenal failure results from conditions that obstruct urine outflow. The obstruction can occur in the ureter, bladder, or urethra. -Intratubular obstruction and acute pyelonephritis are intrarenal causes of kidney failure, and severe hypovolemia is a prerenal cause.

The nurse is instructing a patient with advanced kidney disease (AKD) about a dietary regimen. Which of the following restrictions should the nurse be sure to include in the treatment plan to decrease the progress of renal impairment in people with AKD?

a) Dietary protein
b) Fats
c) Foods high in calcium
d) Carbohydrates

Dietary protein Restriction of dietary proteins may decrease the progress of renal impairment in people with advanced renal disease. Proteins are broken down to form nitrogenous wastes, and reducing the amount of protein in the diet lowers the blood urea nitrogen and reduces symptoms.

A 35-year-old client is diagnosed with acute kidney injury (AKI) and is started on hemodialysis. The client is concerned with the diagnosis and wants to know what to expect in the progression of this disorder. Which statement best addresses the client’s concern?

a) "You will need to have a renal transplant to live a productive, healthy life."
b) "Once your condition improves you can be placed on peritoneal dialysis for the rest of your life."
c) "The occurrence of acute kidney injury will always eventually result in chronic renal failure."
d) "Acute kidney injury is abrupt in onset and often reversible if recognized early and treated appropriately."

"Acute kidney injury is abrupt in onset and often reversible if recognized early and treated appropriately." AKI is the result of a rapid decline in kidney function that increases blood levels of nitrogenous wastes. Once the underlying cause is treated, AKI is potentially reversible if the precipitating factors can be corrected or removed before permanent damage occurs.

A client is diagnosed with acute renal injury. The nurse will evaluate the client for which of the following possible causes for this disorder? Select all that apply.

a) Hormonal imbalance
b) Ischemic injury
c) Obstruction of urinary outflow
d) Nephrotoxic substances
e) Nonischemic reduced renal blood flow

• Ischemic injury • Nonischemic reduced renal blood flow • Obstruction of urinary outflow • Nephrotoxic substances Acute renal injury can result from ischemia, reduced renal blood without ischemia, nephrotoxic substances including some drugs, and obstruction of urinary outflow. Hormonal imbalance usually does not cause renal injury.

A drug abuser was found unconscious after shooting up heroin 2 days prior. Because of the pressure placed on the hip and arm, the client has developed rhabdomyolysis. The nurse knows this can:

a) Be cured by administering an anticoagulant immediately
b) Cause the kidney to develop renal stones due to stasis
c) Cause compartment syndrome in the lower extremities
d) Obstruct the renal tubules with myoglobin and damage tubular cells

Obstruct the renal tubules with myoglobin and damage tubular cells Myoglobin normally is not found in the serum or urine. It has a low molecular weight; if it escapes into the circulation, it is rapidly filtered in the glomerulus. A life-threatening condition known as rhabdomyolysis occurs when increasing myoglobinuria levels cause myoglobin to precipitate in the renal tubules, leading to obstruction and damage to surrounding tubular cells. Myoglobinuria most commonly results from muscle trauma but may result from exertion, hyperthermia, sepsis, prolonged seizures, and alcoholism or drug abuse. -Rhabdomyolysis is not cured with anticoagulation administration nor does it cause kidney stones. -Compartment syndrome occurs when there is insufficient blood supply to muscles and nerves due to increased pressure within one of the body’s compartments.

A child is diagnosed with chronic kidney disease (CKD). The nurse knows that which of the following statements regarding supportive renal therapy in children are true? Select all that apply.

• Early transplantation is the preferred treatment when considering long-term effects. • Children older than 12 years will benefit from hemodialysis. • Peritoneal dialysis is generally most appropriate for children younger than 6. Children between birth and 5 years of age often are managed with peritoneal dialysis. -For those older than 12 years of age hemodialysis is usually preferred. -Early transplantation in young children is the best choice to promote physical growth, improve cognitive function, and foster psychosocial development. -Immunosuppressive therapy in children is similar to that required in adults. -Corticosteroids such as prednisone have risk for growth retardation.

Which of the following patients does the nurse need to monitor for the development of intense intrarenal vasoconstriction that may induce prerenal failure? Select all that apply.

a) Patient taking cyclosporine to prevent rejection for a liver transplant

b) Patient who is HIV positive

c) Patient undergoing cardiac catheterization

d) Patient with an elevated blood urea nitrogen who is taking ibuprofen every 6 hours for back pain

e) Patient taking acetaminophen for fever

• Patient undergoing cardiac catheterization • Patient taking cyclosporine to prevent rejection for a liver transplant • Patient with an elevated blood urea nitrogen who is taking ibuprofen every 6 hours for back pain Some vasoactive mediators, drugs, and diagnostic agents stimulate intense intrarenal vasoconstriction and can induce glomerular hypoperfusion and prerenal failure. Examples include endotoxins, radiocontrast agents such as those used for cardiac catheterization, cyclosporine, and nonsteroidal anti-inflammatory drugs. -NSAIDs can reduce renal blood flow by inhibiting prostaglandin syntheses. In some persons with diminished renal perfusion, NSAIDs can precipitate prerenal failure. -Acetaminophen for short-term use does not predispose a patient to prerenal failure. -An HIV+ client is at no more risk than any other patient.

A family physician is providing care for a 61 year-old obese male who has a history of diabetes and hypertension. Blood work has indicated that the man has a GFR of 51 mL/min with elevated serum creatinine levels. Which of the following statements will the physician most likely provide to the client in light of these results?

a) "You’re in kidney failure and I’ll be starting dialysis treatment immediately."

b) "Your chronic kidney disease has likely been caused by your diabetes and high blood pressure."

c) "You likely have chronic kidney disease and there may be urine in your blood until it is controlled."

d) "We will regularly monitor your kidney function, but most likely your kidneys will be able to compensate on their own and intervention is not required."

"Your chronic kidney disease has likely been caused by your diabetes and high blood pressure." Diabetes and hypertension are conditions that can cause chronic kidney disease (CKD). While the kidneys do have a remarkable ability to compensate for impaired function, this fact does not mean that treatment would not be undertaken. -Hematuria is not a common manifestation of CKD and the clients GFR of 51 mL/min does not indicate kidney failure or the need for dialysis.

Chronic kidney disease (CKD) can cause derangement of calcium and phosphate metabolism. The nurse will monitor a client with CKD for which of the following? Select all that apply.

a) Decreased blood levels of phosphate

b) Decreased blood levels of calcium

c) Excess calcium deposits in bone

d) Decreased release of parathyroid hormone (PTH)

e) Impaired phosphate excretion

• Impaired phosphate excretion • Decreased blood levels of calcium In CKD, renal ability to excrete phosphate declines. As blood levels of phosphate increase, levels of calcium inversely related to phosphate, fall. This provokes an increase in PTH, which stimulates mobilization of calcium from bone.

A patient has prerenal failure. The nurse knows that this type of failure is characterized by which relationship of blood urea nitrogen (BUN) to serum creatinine levels?

a) An elevated BUN level and decreased creatinine level

b) A BUN to creatinine level ratio of 20:1

c) A BUN to creatinine level ratio of 10:1

d) An elevated creatinine level and decreased BUN level

A BUN to creatinine level ratio of 20:1 In prerenal failure, glomerular filtration rate (GFR) decreases, allowing more filtered urea to be reabsorbed into the circulatory system. Creatinine is filtered but remains in the forming urine. Thus the BUN to creatinine ratio rises to 20:1. A ratio of 10:1 is normal.

A client is diagnosed with renal failure. The nurse must monitor for failure of which of the following functions? Select all that apply.

a) Electrolyte balance

b) Removal of metabolic waste from blood

c) Adrenal secretion

d) Acid-base balance

e) Maintenance of body water

• Maintenance of body water • Electrolyte balance • Acid-base balance • Removal of metabolic waste from blood Functions of the kidney include removal of metabolic end products and regulation of body water, electrolyte balance and acid-base balance. -Although the adrenal glands are located above the kidneys, the kidneys are not directly involved in their regulation.

The nurse is preparing to assess a client who has just been admitted to the hospital with a diagnosis of prerenal failure. Which would the nurse expect the client to manifest? Select all that apply.

a) BUN-to-serum creatinine ratio of greater than 20:1

b) Increased urinary output

c) Decreased urinary output

d) Increased BUN

e) Decreased BUN

f) BUN to serum creatinine ratio of 10:1

• Decreased urinary output • Increased BUN • BUN-to-serum creatinine ratio of greater than 20:1 Prerenal injury is manifested by a sharp decrease in urine output and a disproportionate elevation of blood urea nitrogen (BUN) in relation to serum creatinine levels. Consequently, there also is a disproportionate elevation in the ratio of BUN to serum creatinine, from a normal value of 10:1 to a ratio greater than 20:1.

The nurse will monitor clients with which of the following disorders for development of chronic kidney disease (CKD)? Select all that apply.

a) Diabetes

b) Polycycstic kidney disease

c) Systemic lupus erythematosus

d) Hyperlipidemia

e) Glomerulonephritis

• Systemic lupus erythematosus • Polycycstic kidney disease • Glomerulonephritis • Diabetes Permanent renal damage can result from systemic lupus erythematosus, polycycstic kidney disease, glomerulonephritis, or diabetes. Hypertension also is a frequent cause for CKD. Hyperlipidemia does not cause CKD but may develop in clients with CKD.

A nurse is assessing a client diagnosed with CKD for neuromuscular manifestation. Select the manifestations the nurse may expect to find. Select all that apply.

a) Loss of recent memory

b) Restless leg syndrome

c) Perceptual errors

d) Increased muscle strength

e) Increased alertness

f) Peripheral neuropathy

• Restless leg syndrome • Loss of recent memory • Peripheral neuropathy • Perceptual errors • Increased muscle strength Many persons with CKD have alterations in peripheral and central nervous system function. Restless leg syndrome is a manifestation of peripheral nerve involvement, and muscle weakness and atrophy are a manifestation of uremia. Reductions in alertness and awareness are the earliest and most significant indications of uremic encephalopathy. These often are followed by an inability to fix attention, loss of recent memory, and perceptual errors in identifying persons and objects.

Sexual dysfunction in people with CKD is thought to be multifactorial. What are thought to be causes of sexual dysfunction in people with CKD? (Select all that apply.)

a) Uremic toxins

b) Antihypertensive drugs

c) Psychological factors

d) Inability to vasodilate veins

e) High incidence of sexually transmitted diseases

• Antihypertensive drugs • Psychological factors • Uremic toxins The cause of sexual dysfunction in men and women with CKD is unclear. The cause probably is multifactorial and may result from high levels of uremic toxins, neuropathy, altered endocrine function, psychological factors, and medications (e.g., antihypertensive drugs). The other answers do not apply in this situation.

A client is diagnosed with chronic kidney disease (CKD). The nurse will monitor this client for which of the following Select all that apply.

a) Hyponatremia

b) Hypocalcemia

c) Polyuria

d) Hyperkalemia

e) Metabolic alkalosis

• Polyuria • Hyperkalemia • Hypocalcemia • Hyponatremia The failing kidneys lose ability to concentrate urine and to reabsorb sodium. Hyperkalemia develops late in CKD, as nephrons can no longer regulate potassium excretion. Metabolic acidosis occurs when balance between sodium and bicarbonate is lost. Hypocalcemia develops as excretion of phosphate fails and blood levels of phosphate rise.

A client has experienced severe hemorrhage and is in prerenal failure. The nurse anticipates the laboratory results of the client’s BUN and serum creatinine to identify:

a) BUN elevates and creatinine decreases.

b) Creatinine level rises and BUN decreases.

c) The BUN-to-creatinine ratio is 20:1.

d) The BUN-to-creatinine ratio is 10:1.

The BUN-to-creatinine ratio is 20:1. Prerenal injury is manifested by a sharp decrease in urine output and a disproportionate elevation of blood urea nitrogen (BUN) in relation to serum creatinine levels. The kidney normally responds to a decrease in the GFR with a decrease in urine output. An early sign of prerenal injury is a sharp decrease in urine output. A low GFR allows more time for small particles such as urea to be reabsorbed into the blood. Creatinine, which is larger and nondiffusible, remains in the tubular fluid, and the total amount of creatinine that is filtered, although small, is excreted in the urine. Consequently, there also is a disproportionate elevation in the ratio of BUN to serum creatinine, from a normal value of 10:1 to a ratio greater than 20:1.

Which of the following have the potential to cause chronic kidney disease? (Select all that apply.)

• Hypertension • Diabetes • Glomerulonephritis CKD can result from a number of conditions including diabetes, hypertension, glomerulonephritis as well as systemic lupus erythematosus, and polycystic kidney disease. These conditions slowly but steadily destroy renal tissue resulting in irreversible loss of function. Cardiomyopathies do not cause renal failure; they cause heart failure.

The nurse knows that uremia or "urine in the blood" is often used to describe the clinical manifestations of chronic kidney disease (CKD). Which of the following are early signs and symptoms of uremia? Select all that apply.

a) Elevated blood glucose

b) Nausea

c) Apathy

d) Fatigue

e) Weakness

• Fatigue • Nausea • Apathy • Weakness As nitrogenous wastes accumulate in the circulatory system, symptoms of fatigue, nausea, apathy, and weakness will appear. CKD does not immediately affect blood glucose.

A client is diagnosed with chronic kidney disease (CKD). The nurse recognizes that which of the following statements regarding CKD are correct? Select all that apply.

a) Functioning nephrons compensate for those that are damaged.

b) The rate of nephron destruction is the same in all clients.

c) Signs and symptoms develop gradually.

d) There is a reduction in glomerular filtration rate (GFR) as nephrons are destroyed.

e) Nephron destruction takes place over many months.

• Nephron destruction takes place over many months. • Signs and symptoms develop gradually. • Functioning nephrons compensate for those that are damaged. • There is a reduction in glomerular filtration rate (GFR) as nephrons are destroyed. In CKD, the rate of nephron destruction occurs over many months and is different among clients. Signs and symptoms develop gradually as nephrons are destroyed and functioning nephrons gradually lose the ability to compensate for this. As nephrons are destroyed, GFR declines. (

The clinical nurse educator on a nephrology unit of a large, urban hospital is orientating recent nursing graduates to the unit. Which of the following teaching points about acute tubular necrosis (ATN) should the educator include in the orientation session?

a) "Trauma, burns and major surgery are common precursors to ATN."

b) "The cardinal signs of ATN are oliguria and retention of potassium, creatinine and sulfates."

c) "Ureteral and bladder outlet obstructions are often contributors to ATN."

d) "Tubular epithelial cells are sensitive to ischemia and toxins, and damage is irreversible."

"Trauma, burns and major surgery are common precursors to ATN." ATN is often preceded by major surgery, burns or trauma. Many cases of ATN are nonoliguric, and obstructions that are postrenal in nature are not common causes of ATN. Damage to tubular epithelial cells is not necessarily irreversible.

Glomerular filtration rate (GFR) is the best indicator of renal function. The nurse knows that GFR can vary with which of the following factors? Select all that apply.

a) Age

b) Body size

c) Diet

d) Ethnicity

e) Gender

• Gender • Age • Body size • Ethnicity GFR, the best indicator of overall renal function, varies with age, gender, body size, and ethnicity. Equations are available for calculating GFR based on serum creatinine and these variables. Diet, if it includes sufficient fluid intake to maintain hydration, should not affect GFR.

Following the diagnosis of acute renal failure, the nurse knows that one of the earliest manifestations of residual tubular damage is which of the following lab/diagnostic results?

a) Elevated blood urea nitrogen (BUN).

b) Serum creatinine elevation.

c) Inability to concentrate urine.

d) Reduced glomerular filtration rate.

Elevated blood urea nitrogen (BUN). Urine tests that measure urine osmolality, urinary sodium concentration, and fractional excretion of sodium help differentiate prerenal azotemia, in which the reabsorptive capacity of the tubular cells is maintained, from tubular necrosis, in which these functions are lost. One of the earliest manifestations of tubular damage is the inability to concentrate urine. Conventional markers of serum creatinine and urea nitrogen, fractional secretion of sodium to assess glomerular filtration rate (GFR), and urine output do not manifest for 1-2 days after the acute renal failure has begun.

A nurse educator is performing client education with a 51 year-old man who has been recently diagnosed with chronic kidney disease. Which of the following statements by the client would the nurse most likely want to correct or clarify?

a) "My heart rate might go up because of my kidney disease and my blood might be a lot thinner than it should be."

b) "My kidney problems increase my chance of developing high blood pressure or diabetes."

c) "I’ll be prone to anemia, since I’m not producing as much of the hormone that causes my bones to produce red blood cells."

d) "I’ll have a risk of either bleeding too easily or possibly clotting too quickly, though dialysis can help minimize these effects."

"My kidney problems increase my chance of developing high blood pressure or diabetes." While high blood pressure can be causative of- or consequent to- renal failure, diabetes is not normally a result of existing CKD. Persons with renal failure are indeed prone to anemia, increased heart rate, decreased blood viscosity, and coagulopathies. The risk of bleeding and thrombotic disorders can be partially mitigated by dialysis

A 45-year-old client with chronic kidney disease (CKD) voices concern about her dialysis treatment. The client would like to work and spend time with her family. Which type of dialysis will best fit this client’s lifestyle?

a) Hemodialysis

b) Continuous ambulatory peritoneal dialysis

c) Nocturnal intermittent peritoneal dialysis (NIPD)

d) Continuous cyclic peritoneal dialysis

Nocturnal intermittent peritoneal dialysis (NIPD) In NIPD, the client is given 10 hours of automatic cycling each night, with the abdomen left dry during the day. This is the most beneficial for this client. Individual preference, manual ability, lifestyle, knowledge of the procedure, and physiologic response to treatment are used to determine the type of dialysis that is used. Hemodialysis is generally three times a week for 3 to 4 hours a day. CAPD involves exchanging the dialysate four to six times per day. In CCPD, the last exchange remains in the abdomen during the day

Neuromuscular disorders can be triggered by CKD. For those clients on dialysis, approximately two thirds suffer from what peripheral neuropathy?

a) Raynaud syndrome

b) Tingling and loss of sensation in lower limbs

c) Burning hands and feet

d) Restless legs syndrome

Restless legs syndrome Restless legs syndrome is a manifestation of peripheral nerve involvement and can be seen in as many as two thirds of clients on dialysis. The other answers are not correct.

A client has acute pyelonephritis. The nurse will monitor the client for development of which of the following?

a) Prerenal failure

b) Post renal failure

c) Intrarenal failure

d) Chronic kidney disease

Intrarenal failure Acute pyelonephritis, an active bacterial infection, can cause tubular cell necrosis and intrarenal failure. Acute pyelonephritis does not cause prerenal or postrenal failure or chronic kidney disease unless it is not treated

A client is diagnosed with decreased gomerular filtration rate but has no renal damage. The nurse recognizes that this can occur with which of the following? Select all that apply.

a) Carbohydrate diet

b) Heart failure

c) Dehydration

d) Cirrhosis

e) Removal of one kidney

• Cirrhosis • Heart failure • Removal of one kidney • Dehydration Chronic reduction in glomerular filtration rate with no renal damage can be the result of depleted body fluid, removal of one kidney, and conditions such as heart failure and cirrhosis which decrease renal perfusion. A carbohydrate diet should not affect GFR.

A nurse is collecting a urine specimen prior to measuring the albumin level in a client’s urine. A colleague questions the rationale for the test, stating, "I thought albumin was related to liver function, not kidney function." How can the nurse best respond to this statement?

"Urine albumin levels are useful for diagnosing diabetic kidney disease." Explanation: In clients with diabetes, albumin tests are useful adjunctive test of nephron injury and repair. Urine is not normally completely free of proteins and a urine dipstick does not allow for the quantification of how much albumin is in a sample. Albumin tests do not allow for an accurate indirect indication of GFR.

The nurse knows that one of the earliest manifestations of acute renal failure (ARF) is which of the following?

a) Elevated plasma uric acid
b) Polyuria
c) Elevated urinary glucose
d) Hypokalemia

Polyuria One of the earliest signs of ARF is loss of ability to concentrate urine. The other answer selections are not notable markers of early renal failure; however, they may develop as renal failure progresses.

While assessing a peritoneal dialysis client in his or her home, the nurse notes that the fluid draining from the abdomen is cloudy, is white in color, and contains a strong odor. The nurse suspects this client has developed a serious complication known as:

a) Bladder erosion
b) Bowel perforation
c) Peritonitis
d) Too much sugar in the dialysis solution

Peritonitis Potential problems with peritoneal dialysis include infection, catheter malfunction, dehydration, hyperglycemia, and hernia. -Bowel perforation can occur, but the fluid would be stool colored. -The client may develop hyperglycemia; however, this will not cause the fluid to be cloudy. -If bladder erosion had occurred, the fluid would look like urine and not be cloudy and white.

The nurse recognizes that renal failure has many underlying causes, including which of the following? Select all that apply

a) Renal disease
b) Malnutrition
c) Systemic disease
d) Hepatic disease
e) Nonrenal urological abnormalities

• Systemic disease • Renal disease • Nonrenal urological abnormalities Underlying causes of renal failure include renal or systemic disease and nonrenal urologic abnormalities. -Hepatic disease and malnutrition might gradually influence renal function as they can influence many body functions, but are not considered direct causes of renal failure.

As chronic kidney disease progresses, the second stage (renal insufficiency) is identified by:

a) Decrease in GFR to 30 to 59 mL/minute/1.73 m2
b) Diminished GFR to less than 15 mL/minute/1.73 m2
c) Decrease in GFR of 60 to 89 mL/minute/1.73 m2
d) GFR decrease to 15 to 29 mL/minute/1.73 m2

Decrease in GFR of 60 to 89 mL/minute/1.73 m2 Diminished renal reserve is characteristic of renal insufficiency, when labs remain normal but there is renal insufficiency. Only the second stage, formerly known as renal insufficiency, is characterized by a decrease in GFR of 60 to 89 mL/minute/1.73 m2. The other choices represent stage 3, 4, and 5, respectfully.

Which of the following phenomena contributes to the difficulties with absorption, distribution and elimination of drugs that is associated with kidney disease?

a) Reductions in plasma proteins increase the amount of free drug and decrease the amount of protein-bound drug.
b) Acute tubular necrosis is associated with impaired drug reabsorption through the tubular epithelium.
c) Decreased retention by the kidneys often renders normal drug dosages ineffective.
d) Dialysis removes active metabolites from circulation minimizing therapeutic effect.

Reductions in plasma proteins increase the amount of free drug and decrease the amount of protein-bound drug. A decrease in plasma proteins, particularly albumin, that occurs in many persons with renal failure results in less protein-bound drug and greater amounts of free drug. -Drug elimination problems do not stem as directly from impaired tubular reabsorption, decreased retention or the process of dialysis.

The nurse is planning care for a client with chronic kidney disease (CKD). The nurse determines that an allowable fluid intake would be:

a) 500 to 800 mL/day
b) 1050 to 1200 mL/day
c) 400 to 600 mL/day
d) 850 to 1000 mL/day

500 to 800 mL/day It is a common practice to allow 500 to 800 mL, which is equal to insensible water loss plus a quantity equal to the 24-hour urine output. -Fluid intake in excess of what the kidneys can excrete causes circulatory overload, edema, and water intoxication. -Inadequate intake, on the other hand, causes volume depletion and hypotension and can cause further decreases in the already compromised GFR.

Which of the following patients scheduled for an interventional radiology procedure requiring administration of radiocontrast dye would be considered high risk for nephrotoxicity? Select all that apply.

a) 25 year old with a history of glomerular nephritis who is complaining of severe flank pain.
b) 14 year old with severe abdominal pain.
c) 67 year old diabetic undergoing diagnostic testing for new-onset proteinuria.
d) 45 year old with elevated liver enzymes possibly due to fatty liver cirrhosis.
e) 53 year old male undergoing biopsy for a suspicious "spot" on their chest x-ray.

• 25 year old with a history of glomerular nephritis who is complaining of severe flank pain. • 67 year old diabetic undergoing diagnostic testing for new-onset proteinuria. Radiocontrast media-induced nephrotoxicity is thought to result from direct tubular toxicity and renal ischemia. The risk for renal damage caused by radiocontrast media is greatest in older adults and those with pre-existing kidney disease, volume depletion, diabetes mellitus, and recent exposure to other nephrotoxic agents

The nurse knows that a patient with chronic kidney disease (CKD) may experience which of the following changes in skin integrity? Select all that apply.

a) Pale skin
b) Decreased perspiration
c) Brittle fingernails
d) Moist skin and mucous membranes
e) Increased oil gland secretion

• Pale skin • Brittle fingernails • Decreased perspiration In CKD, anemia due to loss of erythropoietin activity causes pale skin. Perspiration and oil secretion are decreased, leading to dry skin. Fingernails become brittle.

The nurse knows that a patient with chronic kidney disease (CKD) may develop renal osteodystrophy (skeletal damage). Which of the following are characteristic of both high-bone-turnover and low-bone-turnover osteodystrophy? Select all that apply.

a) Decreased osteoblast and osteoclast proliferation
b) Bone marrow fibrosis
c) Defective bone remodeling
d) Abnormal bone resorption
e) Increased osteoblast and osteoclast proliferation

• Abnormal bone resorption • Defective bone remodeling Abnormal bone resorption and defective bone remodeling are characteristic of both high-bone-turnover and low-bone-turnover osteodystrophy. In high-turnover, there is increased osteoblast and osteoclast proliferation while in low-turnover there is decreased proliferation. Bone marrow fibrosis is characteristic of high-bone turnover.

A client diagnosed with chronic kidney disease (CKD) is experiencing nausea and vomiting. Which would be the best instruction for the nurse to provide?

a) Restrict intake of dietary fat
b) Increase intake of fruit juice
c) Increase intake of carbohydrates
d) Restrict intake of dietary protein

Restrict intake of dietary protein Early morning nausea is common in CKD. Nausea and vomiting often improve with the restriction of dietary protein and after initiation of dialysis and disappears after kidney transplant. The other options will not improve the symptoms.

A 72-year-old patient is scheduled for a kidney transplant. The nurse knows that which aspect of advanced age has a positive effect on the success of kidney transplant survival?

a) Decreased muscle mass
b) Psychological maturity
c) Reduction in T-lymphocyte function
d) Acceptance of immunosuppressive therapy

Reduction in T-lymphocyte function The general reduction in T-lymphocyte function with subsequent decrease in immune system activity that occurs with aging would foster transplant survival. The other options would not have a direct effect on rejection of the transplant. -Acceptance of immunosuppressive therapy is not a specific characteristic of advanced age. -Psychological maturity and decreased muscle mass have little to no effect on transplant survival.

A 42 year-old male has been diagnosed with renal failure secondary to diabetes mellitus and is scheduled to begin dialysis soon. Which of the following statements by the client reflects an accurate understanding of the process of hemodialysis?

a) "I won’t be able to go about my normal routine during treatment."
b) "It’s stressful knowing that committing to dialysis means I can’t qualify for a kidney transplant."
c) "Changing my schedule to accommodate 3 or 4 hours of hemodialysis each day will be difficult."
d) "I know I’ll have to go to a hospital or dialysis center for treatment."

"I won’t be able to go about my normal routine during treatment." Hemodialysis requires the client to remain connected to dialysis machinery, whereas peritoneal dialysis allows for activity during treatment. -Dialysis does not disqualify an individual from receiving a transplant. -Dialysis does not require attendance at a dialysis center, patients can be taught to perform the dialysis in their home with a family member in attendance. -Hemodialysis is normally conducted 3 times weekly, not once per day.

Which of the following data would a clinician consider as most indicative of acute renal failure?

a) Decreased serum creatinine and blood urea nitrogen (BUN); decreased potassium and calcium levels
b) Decreased urine output; hematuria; increased GFR
c) Alterations in blood pH; peripheral edema
d) Increased nitrogenous waste levels; decreased glomerular filtration rate (GFR).

Increased nitrogenous waste levels; decreased glomerular filtration rate (GFR). The hallmark of acute renal injury is azotemia, an accumulation of nitrogenous wastes such as creatinine, urea nitrogen, and uric acid plus a decrease in the GFR of the kidneys. While pH alterations, edema, electrolyte imbalances and decreased urine output may accompany acute renal failure, they are all potentially attributable to other pathologies. Creatinine, GFR and BUN would be unlikely to rise during renal failure.

A client with chronic kidney disease has developed cardiac calcification. On admission the priority assessment would be for the nurse to:

a) place on a heart monitor to watch for arrhythmias.
b) assess for pulses in the feet bilaterally.
c) listen to the heart for extra clicking sounds.
d) check the BP in both arms and compare.

place on a heart monitor to watch for arrhythmias. Visceral calcification may be found in the myocardium, lungs, and stomach. In cardiac calcification, the deposits usually develop in the conduction system and may result in serious cardiac arrhythmias. -The other assessments are valid, however watching for arrhythmias is the priority.

A client who has developed stage 3 renal failure has been diagnosed with high phosphate levels. To avoid the development of osteodystrophy, the physician may prescribe a phosphate-binding agent that does not contain:

a) Aluminum
b) Sevelamer hydrochloride
c) Calcium acetate
d) Calcium carbonate

Aluminum Aluminum-containing antacids can contribute to the development of osteodystrophy, whereas calcium-containing phosphate binders can lead to hypercalcemia, thus worsening soft tissue calcification, especially in persons receiving vitamin D therapy. Sevelamer hydrochloride is a newer phosphate-binding agent that does not contain calcium or aluminum.

A patient is diagnosed with chronic kidney disease (CKD). The nurse recognizes that this patient will experience which of the following? Select all that apply.

a) Decreased tubular reabsorption
b) Hypophospatemia
c) Decreased glomerular filtration
d) Proliferation of nephrons
e) Decreased renal endocrine function

• Decreased renal endocrine function • Decreased tubular reabsorption • Decreased glomerular filtration Chronic kidney disease results in loss of nephrons, with a decrease in tubular reabsorption, glomerular filtration, and endocrine function. -Phosphate accumulates in the blood, as the kidneys lose their ability to excrete this electrolyte.

The nurse knows that a child with chronic kidney disease (CKD) may experience which of these manifestations? Select all that apply.

a) Mental retardation
b) Severe growth deficit
c) High bone turnover
d) Early sexual maturity
e) Bladder incontinence

• Severe growth deficit • High bone turnover Childhood CKD is manifested by delays in growth and sexual maturity as a result of the uremic effects on endocrine function and bone growth. High bone turnover is related to secondary hyperparathyroidism. -Intelligence and control of urinary tract function are not directly affected by renal failure.

A nurse is assessing a client for early manifestations of chronic kidney disease (CKD). Which would the nurse expect the client to display?

a) Terry nails
b) Hypertension
c) Asterixis
d) Impotence

Hypertension Hypertension is commonly an early manifestation of CKD. The mechanisms that cause the hypertension are multifactorial; they include increased vascular volume, increased peripheral vascular resistance, decreased levels of renal vasodilator prostaglandins, and increase activity of the renin-angiotensin-aldosterone system. -Impotence occurs in as many as 56% of males on dialysis. -Terry nails are dark band just behind the leading edge of a fingernail followed by a white band that occur in the late stages. -Asterixis, a sign of hepatic encephalopathy, is due to the inability of the liver to metabolize ammonia to urea.

A patient has developed acute tubular necrosis (ATN). The nurse knows that which of the following groups of drugs can cause this type of renal injury? Select all that apply.

a) Chemotherapy drugs
b) Radiocontrast dyes
c) Aminoglycoside anti-infectives
d) Nonsteroidal antiinflammatory drugs (NSAID)
e) Angiotensin converting enzyme inhibitors (ACEI)

• Radiocontrast dyes • Chemotherapy drugs • Aminoglycoside anti-infectives Aminoglycosides, radiocontrast agents and chemotherapy drugs such as cisplatin (Platinol) all are directly toxic to the nephron and ATN will occur. -NSAIDs inhibit the synthesis of prostaglandins needed to maintain renal blood flow, thus renal perfusion declines and prerenal failure can develop. -ACEI are generally not nephrotoxic and are often used to manage hypertension in persons with renal disease.

A chronic kidney disease client who has renal osteodystrophy should be assessed for which of the following complications? Select all that apply.

a) Stress fractures
b) Bone pain
c) Muscle weakness
d) Urosepsis
e) Kidney stones

• Muscle weakness • Bone pain • Stress fractures Both types of renal osteodystrophy are manifested by abnormal absorption and defective bone remodeling. Renal osteodystrophy is typically accompanied by reductions in bone mass, alterations in bone microstructure, bone pain, and skeletal fracture. There are changes in bone turnover, mineralization, and bone volume, accompanied by bone pain and muscle weakness, risk of fractures, and other skeletal complications. -Kidney stones and urosepsis are not associated with renal osteodystrophy.

A hospital client with a diagnosis of chronic renal failure has orders for measurement of her serum electrolyte levels three times per week. Which of the following statements best captures the relationship between renal failure and sodium regulation?

a) Clients with renal failure often maintain high sodium levels because of decreased excretion.
b) Clients with advanced renal failure are prone to hyponatremia because of impaired tubular reabsorption.
c) Renal clients often require a sodium-restricted diet to minimize the excretion load on remaining nephrons.
d) Restricting sodium intake helps to preserve nephron function and has the additional benefit of lowering blood pressure.

Clients with advanced renal failure are prone to hyponatremia because of impaired tubular reabsorption. The compromised ability of the tubular nephrons to reabsorb sodium predisposes renal clients to low serum sodium levels. A sodium restriction is thus not normally indicated.

A patient has developed chronic kidney disease (CKD). The nurse will advise the patient to be alert for the development of which hematologic signs and symptoms of this disorder? Select all that apply.

a) Fatigue
b) Bradycardia
c) Gastrointestinal bleeding
d) Bruising
e) Intravascular clotting

• Bruising • Gastrointestinal bleeding • Fatigue Explanation: In CKD, platelet function is impaired and bruising and gastrointestinal bleeding can occur. Intravascular clotting usually does not happen. Decreased renal production of erythropoietin results in decreased synthesis of red blood cells, resulting in anemia and fatigue. Decrease in red cells also decreases blood viscosity and decreases cerebral oxygen delivery, both of which contribute to tachycardia rather than bradycardia.

A 1-year-old baby boy with renal dysplasia risks end-stage renal disease unless intervention occurs. Which of the following treatment options is his care team most likely to reject?

a) Dietary restriction plus erythropoietin
b) Renal transplantation
c) Continuous cyclic peritoneal dialysis
d) Continuous ambulatory peritoneal dialysis

Dietary restriction plus erythropoietin Renal transplantation and dialysis are recommended for children; of these, transplantation is the preferred treatment. Conservative measures are inappropriate in this age group because of the importance of fostering proper bone growth, especially in the first two years, and appropriate cognitive development, which is at risk due to issues such as uremic encephalopathy and the effect of renal failure upon the central nervous system of the developing child.

A patient with a recent diagnosis of renal failure that will require hemodialysis is being educated by the nurse in the dietary management of the disease. Which of the patient’s following statements shows an accurate understanding of this component of treatment? Select all that apply.

a) "I’m going to try a high-protein, low-carbohydrate diet."
b) "I’ve made a list of high-phosphate foods so that I can try to avoid them."
c) "I don’t think I’ve been drinking enough, so I want to include 8 to 10 glasses of water each day."
d) "I’ll increase the carbohydrates in my diet to provide sufficient energy."
e) "I’m making a point of trying to eat lots of bananas and other food rich in potassium."

• "I’ll increase the carbohydrates in my diet to provide sufficient energy." • "I’ve made a list of high-phosphate foods so that I can try to avoid them." Persons with chronic kidney disease (CKD) are usually encouraged to limit their dietary phosphorus as a means of preventing secondary hyperparathyroidism, renal osteodystrophy, and hypocalcemia. Excessive protein, potassium, and fluids can be detrimental in individuals whose kidney disease requires hemodialysis. Because protein intake is limited, carbohydrate consumption should increase to meet daily energy requirements.

A child has received a kidney transplant at the age of 3. Knowing he will be on immunosuppressive agents like corticosteroids, the nurse should educate the parents about which long-term side effects? Select all that apply.

a) Growth retardation
b) Excess weight loss
c) Development of cataracts
d) Hypertension
e) Frequent hematuria

• Hypertension • Growth retardation • Development of cataracts Early transplantation in young children is regarded as the best way to promote physical growth, improve cognitive function, and foster psychosocial development. Immunosuppressive therapy in children is similar to that used in adults. All immunosuppressive agents have side effects, including increased risk for infection. Corticosteroids carry the risk for hypertension, orthopedic complications (especially aseptic necrosis), cataracts, and growth retardation. Steroids usually are associated with weight gain. -Frequent hematuria is caused by something other than steroids and should be reported.

If a CKD client is developing uremic encephalopathy, the earliest manifestations may include: Select all that apply.

a) Delirium and hallucinations
b) New-onset seizures
c) Diminished awareness
d) Decreased alertness

• Decreased alertness • Diminished awareness Reductions in alertness and awareness are the earliest and most significant indications of uremic encephalopathy. – Late in the disease process, the client may develop delirium, coma, and seizures.

A client with chronic kidney disease (CKD) has developed asterixis. The nurse knows that asterixis is which of the following?

a) Burning sensation in feet
b) Dorsiflexion of hands and feet
c) Demyelination of nerve fibers
d) Unsteady gait

Dorsiflexion of hands and feet Asterixis, which is involuntary dorsiflexion of hands and feet, can develop as CKD worsens. -Burning sensation in feet, unsteady gait and demyelination of nerves can also accompany CKD, but are not part of asterixis.

Anemia frequently occurs in clients with chronic kidney disease (CKD). The nurse will monitor these clients for which of the following contributors to anemia? Select all that apply.

a) Decreased erythropoietin production
b) Chronic blood loss
c) Iron overload
d) Anorexia
e) Bone marrow suppression

• Decreased erythropoietin production • Anorexia • Bone marrow suppression • Chronic blood loss Production of erythropoietin, which stimulates red cell synthesis, becomes deficient as the kidneys fail. Iron deficiency can develop as anorexia decreases ingestion of foods containing this mineral. Bone marrow production of red cells is suppressed as uremia develops. Clients on dialysis will experience chronic blood loss

The nurse recognizes that acute renal injury is characterized by which of the following?

a) Rapid decline in renal function

b) Irreversible damage to nephrons

c) Decreased blood urea nitrogen (BUN)

d) Low incidence of mortality

Rapid decline in renal function Acute renal injury is a rapid decline in kidney function. BUN rises as nitrogenous wastes are not removed from the circulation. If the cause can be ameliorated, the injury is usually reversible. Most at risk are seriously ill clients; the mortality rate is between 40% and 90% in these clients.

As nitrogenous wastes increase in the blood, the CKD client may exhibit which of the following clinical manifestations? Select all that apply.

a) Pruritis

b) Extremely low platelet counts

c) Photophobia

d) Numbness in lower extremities

e) Restless leg syndrome

• Numbness in lower extremities • Restless leg syndrome • Pruritis The uremic state is characterized by signs and symptoms of altered neuromuscular function (e.g., fatigue, peripheral neuropathy, restless leg syndrome, sleep disturbances, uremic encephalopathy); gastrointestinal disturbances such as anorexia and nausea; white blood cell and immune dysfunction, and dermatologic manifestations such as pruritus. Photophobia and thrombocytopenia are usually not associated with CKD.

Acute tubular necrosis (ATN) is the most common cause of intrinsic renal failure. One of the causes of ATN is ischemia. What are the most common causes of ischemic ATN? (Select all that apply.)

• Severe hypovolemia • Burns • Overwhelming sepsis Ischemic ATN occurs most frequently in persons who have major surgery, severe hypovolemia, overwhelming sepsis, trauma, and burns. Hypervolemia and hypertension are not considered contributing factors to ischemic ATN.

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