KIDNEY FAILURE a. Provide foods high in potassium.

b. Restrict fluids based on urine output.

Which descriptions characterize AKI? Select all that c. Monitor output from peritoneal dialysis.
apply d. Offer high-protein snacks between meals.

a. primary cause of death is infection B

When caring for a patient during the oliguric phase of

b. it almost always affects older people
acute kidney injury (AKI), which nursing action is
c. disease course is potentially reversible appropriate?

d. most common cause is diabetic nephropathy a. Weigh patient three times weekly.
b. Increase dietary sodium and potassium.
e. cardiovascular disease is most common cause of c. Provide a low-protein, high-carbohydrate diet.
death
d. Restrict fluids according to previous daily loss
a D
c
Which patient diagnosis or treatment is most consistent
During the oliguric phase of AKI, the nurse monitors the with prerenal acute kidney injury (AKI)?
patient for Select all that apply
a. IV tobramycin
a. hypotension
b. Incompatible blood transfusion
b. ECG changes
c. Poststreptococcal glomerulonephritis
c. hypernatremia
d. Dissecting abdominal aortic aneurysm
d. pulmonary edema
d
e. urine with high specific gravity
The patient has rapidly progressing glomerular
b inflammation. Weight has increased and urine output is
d steadily declining. What is the priority nursing
intervention?
If a patient is in the diuretic phase of AKI, the nurse
must monitor for which serum electrolyte imbalances?
a. Monitor the patient's cardiac status.
b. Teach the patient about hand washing.
a. hyperkalemia and hyponatremia
c. Obtain a serum specimen for electrolytes.
b. hyperkalemia and hypernatremia
d. Increase direct observation of the patient.
c. hypokalemia and hyponatremia
d. hypokalemia and hypernatremia A

C
Which assessment findings would alert the nurse that
the patient has entered the diuretic phase of acute
The nurse is caring for a 68-yr-old man who had
kidney injury (AKI)? Select all that apply
coronary artery bypass surgery 3 weeks ago. During the
oliguric phase of acute kidney disease, which action a. Dehydration
would be appropriate to include in the plan of care?
b. Hypokalemia a
b
c. Hypernatremia d
e
d. BUN increases
For which patient is the nurse most concerned about
e. Urine output increases
the risk for developing kidney disease?
a
a. A 25-year-old patient who developed a urinary tract
b infection (UTI) during pregnancy
e
b. A 55-year-old patient with a history of kidney stones
An unlicensed assistive personnel (UAP) reports to the
RN that a patient with acute kidney failure had a urine c. A 63-year-old patient with type 2 diabetes
output of 350 mL over the past 24 hours after receiving
furosemide 40 mg IV push. The UAP asks the nurse how d. A 79-year-old patient with stress urinary incontinence
this can happen. What is the nurse's best response?
c
a. "During the oliguric phase of acute kidney failure,
patients often do not respond well to either fluid A patient with acute kidney injury (AKI) has an arterial
challenges or diuretics." blood pH of 7.30. The nurse will assess the patient for

b. "There must be some sort of error. Someone must

a. vasodilation.
have failed to record the urine output."
b. poor skin turgor.
c. "A patient with acute kidney failure retains sodium c. bounding pulses.
and water, which counteracts the action of the d. rapid respirations.
furosemide."
D
d. "The gradual accumulation of nitrogenous waste
products results in the retention of water and sodium." A patient with severe heart failure develops elevated
blood urea nitrogen (BUN) and creatinine levels. The
nurse will plan care to meet the goal of
A
a. replacing fluid volume.
The RN supervising a senior nursing student is b. preventing hypertension.
discussing methods for preventing acute kidney injury c. maintaining cardiac output.
(AKI). Which points would the RN be sure to include in d. diluting nephrotoxic substances.
this discussion? Select all that apply

a. Encourage patients to avoid dehydration by drinking C

adequate fluids.
A patient who has acute glomerulonephritis is
b. Instruct patients to drink extra fluids during periods hospitalized with acute kidney injury (AKI) and
of strenuous exercise. hyperkalemia. Which information will the nurse obtain
to evaluate the effectiveness of the prescribed calcium
c. Immediately report a urine output of less than 2
mL/kg/hr. gluconate IV?

d. Record intake and output and weigh patients daily. a. Urine output
b. Calcium level
e. Monitor laboratory values that reflect kidney c. Cardiac rhythm
function. d. Neurologic status
C When caring for a dehydrated patient with acute kidney
injury who is oliguric, anemic, and hyperkalemic, which
Which information will be most useful to the nurse in
of the following prescribed actions should the nurse
evaluating improvement in kidney function for a patient take first?
who is hospitalized with acute kidney injury (AKI)?
a. Insert a urinary retention catheter.
a. Blood urea nitrogen (BUN) level
b. Place the patient on a cardiac monitor.
b. Urine output c. Administer epoetin alfa (Epogen, Procrit).
c. Creatinine level d. Give sodium polystyrene sulfonate (Kayexalate).
d. Calculated glomerular filtration rate (GFR)
B
D
What are intrarenal causes of AKI? Select all that apply
In a patient with acute kidney injury (AKI) who requires
hemodialysis, a temporary vascular access is obtained
a. anaphylaxis
by placing a catheter in the left femoral vein. Which
intervention will be included in the plan of care? b. renal stones

a. Place the patient on bed rest. c. nephrotoxic drugs

b. Start continuous pulse oximetry.
c. Discontinue the retention catheter.
d. Restrict the patients oral protein intake.
A
Which information about a patient who was admitted
10 days previously with acute kidney injury (AKI) caused
by dehydration will be most important for the nurse to
report to the health care provider?
a. The blood urea nitrogen (BUN) level is 67 mg/dL.
b. The creatinine level is 3.0 mg/dL.
c. Urine output over an 8-hour period is 2500 mL.
d. The glomerular filtration rate is <30 mL/min/1.73m2.
d. acute glomerulonephritis
e. tubular obstruction by myoglobin
c
d
e
An 83 year old female patient was found lying on the
bathroom floor. She said she fell 2 days ago and has not
been able to take her heart medicine or eat or drink
anything since then. What conditions could be causing
prerenal AKI in this patient? Select all that apply
a. anaphylaxis

C b. renal calculi
After noting lengthening QRS intervals in a patient with
c. hypovolemia
acute kidney injury (AKI), which action should the nurse
take first? d. nephrotoxic drugs

a. Document the QRS interval. e. decreased cardiac output

b. Notify the patients health care provider.
c. Look at the patients current blood urea nitrogen c
(BUN) and creatinine levels. e
d. Check the chart for the most recent blood potassium
ATN is the most common cause of intrarenal AKI. Which
level.
patient is most likely to develop ATN?
D
a. patient with DM
b. patient with hypertensive crisis
c. patient who tried to overdose on acetaminophen
d. patient with major surgery who required a blood
transfusion
D metabolic acidosis
What indicates to the nurse that a patient with oliguria
has prerenal oliguria?
a. urine testing reveals a low specific gravity
b. causative factor is malignant hypertension
c. urine testing reveals a high sodium concentration
d. reversal of oliguria occurs with fluid replacement
D
Metabolic acidosis occurs in the oliguric phase of AKI as
a result of impairment of
a. excretion of sodium
b. excretion of bicarbonate
c. conservation of potassium
d. excretion of hydrogen ions
D
What indicates to the nurse that a patient with AKI is in
the recovery phase?
a. a return to normal weight
b. a urine output of 3,700 mL/day
c. decreasing sodium and potassium levels
d. decreasing BUN and creatinine levels
D PaO2: 86, HCO3: 18. The nurse recognizes that
While caring for the patient in the oliguric phase of AKI,
the nurse monitors the patient for associated
collaborative problems. When should the nurse notify
the HCP?
a. urine output is 300 ml/day
b. edema occurs in the feet, legs, and sacral area
c. cardiac monitor reveals a depressed T wave and
elevated ST segment
d. the patient experiences increasing muscle weakness
and abdominal cramping
D
In caring for the patient with AKI, of what should the
nurse be aware?
a. the most common cause of death is irreversible
b. during the oliguric phase, daily fluid intake is limited
to 1,000 ml plus the prior day's measured fluid loss
c. dietary sodium and potassium during the oliguric
phase of AKI are managed according to the patient's
urinary output
d. one of the most important nursing measures in
managing fluid balance in the patient with AKI is taking
accurate daily weights
D
A 68 year old man with a history of HF resulting from
HTN has AKI as a result of the effects of nephrotoxic
diuretics. Currently his serum potassium is 6.2 with
cardiac changes, BUN is 108, serum creatinine 4.1, and
serum HCO3 13. He is somnolent and disoriented.
Which treatment should the nurse expect to be used for
him?
a. loop diuretics
b. renal replacement therapy
c. insulin and sodium bicarbonate
d. sodium polystyrene sulfonate (kayexalate)
B
A patient with AKI has a serum potassium level of 6.7
and the following ABG results: pH: 7.28, PaCO2: 30,
treatment of the acid-base problem with sodium
bicarbonate would cause a decrease in which value?
a. pH
b. potassium level
c. bicarbonate level
d. carbon dioxide level
B
A patient with AKI is a candidate for continuous renal
replacement therapy (CRRT). What is the most common
indication for use of CRRT?
a. pericarditis e. contact the hemodialysis unit

b. hyperkalemia a
b
c. fluid overload c
d
d. hypernatremia
Which initial manifestation of acute renal failure is most
c
common?
A nurse is planning care for a client who has prerenal
a. dysuria
AKI following abdominal aortic aneurysm repair. Urinary
output is 60 ml in the past 2 hours, and BP is 92/58. The b. anuria
nurse should expect which of the following
interventions? c. hematuria

a. prepare the client for a CT scan with contrast dye d. oliguria

b. plan to administer nitroprusside
c. prepare to administer a fluid challenge d
d. plan to position the client in Trendelenburg
The client who is in acute renal failure has an elevated
C BUN. What is the likely cause of this finding?

A nurse is assessing a client who has prerenal AKI. a. fluid retention

Which of the following findings should the nurse
expect? Select all that apply b. hemolysis of RBCs

a. reduced BUN c. below-normal metabolic rate

b. elevated cardiac enzymes d. reduced renal blood flow

c. reduced urine output d

A client with acute renal failure has an increase in the

d. elevated blood creatinine
serum potassium level. The nurse should monitor the
e. elevated blood calcium client for

c a. cardiac arrest
d b. pulmonary edema
c. circulatory collapse
A client has been admitted with acute renal failure. d. hemorrhage
What should the nurse do? Select all that apply
A
a. elevate the HOB 30-45 degrees
A high-carbohydrate, low-protein diet is prescribed for
b. take vital signs the client with acute renal failure. The intended
outcome of this diet is to
c. establish an IV site
a. act as a diuretic
d. call the admitting healthcare provider for b. reduce demands on the liver
prescriptions
c. help maintain urine acidity d. place the client in Trendelenburg's positio
d. prevent the development of ketosis
b

D Which abnormal blood value would not be improved by

dialysis treatment?
The client with acute renal failure asks the nurse for a
snack. Because the client's potassium level is elevated, a. elevated serum creatinine level
which snack is most appropriate?
b. hyperkalemia
c. decreased hemoglobin concentration
a. a gelatin dessert
d. hypernatremia
b. yogurt
C
c. an orange
The client with acute renal failure is recovering and asks
d. peanuts the nurse, "will my kidneys ever function normally
again?" The nurse's response is based on the knowledge
a that the client's renal status will most likely

In the oliguric phase of acute renal failure, the nurse a. continue to improve over a period of weeks
should assess the client for
b. result in the need for permanent hemodialysis
a. pulmonary edema c. improve only if the client receives a renal transplant
b. metabolic alkalosis
c. hypotension d. result in end-stage renal failure
d. hypokalemia
a
A
A client with AKI has a serum potassium level of 7.0. The
The client in acute renal failure has an external cannula
nurse should plan which actions as a priority? Select all
inserted in the forearm for hemodialysis. Which nursing that apply
measure is appropriate for the care of this client?
a. place the client on a cardiac monitor
a. use the unaffected arm for blood pressure
measurements b. notify the HCP
b. draw blood from the cannula for routine laboratory
c. put the client on NPO status except for ice chips
work
c. percuss the cannula for bruits each shift d. review the client's medications to determine if any
d. inject heparin into the cannula each shift contain or retain potassium
A e. allow an extra 500 ml of IV fluid intake to dilute the
electrolyte concentration
During dialysis, the client has disequilibrium syndrome.
The nurse should first a
b
a. administer oxygen per nasal cannula
d
b. slow the rate of dialysis Which assessment finding is commonly found in the
oliguric phase of acute kidney injury (AKI)?
c. reassure the client that the symptoms are normal
 (rationale: Major trauma, heart failure, and hemorrhage
a. Hypovolemia are all possible risks and causes for AKI because they
b. Hyperkalemia can reduce blood flow to the kidneys. Radiologic
c. Hypernatremia contrast media can be nephrotoxic and cause AKI.
d. Thrombocytopenia Cerebrovascular disease is not a risk factor for AKI
because it does not reduce blood flow to the kidneys
B
and it does not cause nephrotoxicity.)
Which patient has the greatest risk for prerenal AKI? The nurse preceptor is teaching a new graduate about
conditions that can cause damage to the renal
a. The patient who is hypovolemic because of
parenchyma and nephrons resulting in acute kidney
hemorrhage.
injury (AKI). Which condition should the nurse
b. The patient who relates a history of chronic urinary preceptor include? (Select all that apply.)
tract obstruction.
c. The patient with vascular changes related to
A. Glomerulonephritis
coagulopathies. B. Hemolysis
d. The patient receiving antibiotics such as gentamicin. C. Dehydration
A D. Hypertension
E. Vasculitis
Important nursing interventions for the patient with AKI
a, b, d, e
are Select all that apply

a. careful monitoring of intake and output. (rationale: Hypertension, hemolysis,

glomerulonephritis, and vasculitis cause acute damage
b. daily patient weights. to the renal parenchyma and nephrons, leading to
intrarenal AKI. Dehydration causes prerenal AKI and
c. meticulous aseptic technique. does not cause damage to the renal parenchyma and
nephrons.)
d. increase intake of vitamin A and D.
The nurse is explaining to the client the most common
e. frequent mouth care. causes of acute kidney injury (AKI). Which cause should
the nurse present? (Select all that apply)
a
A. Chemical imbalance
b
B. Dehydration
c
C. Exposure to nephrotoxins
e
D. Fluid overload
The nurse is caring for a client with acute kidney injury E. Insufficient blood supply
(AKI). Which condition should the nurse recognize as a
c, e
possible cause for this disease? (Select all that apply.)

(rationale: The most common causes of acute kidney

A. Severe heart failure
injury (AKI) are ischemia (insufficient blood supply) and
B. Major trauma
exposure to nephrotoxins (substances that damage
C. Radiologic contrast media
nerves or nerve tissue). Because of the amount of blood
D. Hemorrhage
that passes through them, the kidneys are particularly
E. Cerebrovascular disease
vulnerable to these factors. A fall in blood pressure or
a, b, c, d volume can cause ischemia of kidney tissues.
Nephrotoxins in the blood damage renal tissue directly.
Other causes of AKI include major surgery, sepsis, and
severe pneumonia.)
The nurse is caring for a critically-ill client who
experienced significant blood loss during surgery. Which
concern related to the client's risk for prerenal acute
kidney injury (AKI) should the nurse consider the
priority?
A. Fluid overload
B. Hyperperfusion
C. Urinary obstruction
D. Diminished cardiac output
d
(rationale: Prerenal AKI results from conditions that
affect renal blood flow and perfusion. Any disorder that
significantly decreases vascular volume, cardiac output,
or systemic vascular resistance can affect renal blood
flow. Prerenal AKI is common, particularly in clients who
experience trauma or surgery or are critically ill. The
kidneys normally receive
20-25% of the cardiac output to maintain the
glomerular filtration rate (GFR), the rate at which fluid is
filtered through the kidneys. A drop in renal blood flow
to less than 20% of normal causes the GFR to fall.
Hypoperfusion, not hyperperfusion, would be a
concern. Obstruction is a concern with postrenal AKI,
not prerenal. Dehydration due to fluid loss would be the
concern, not fluid overload.)
The nurse is describing to a colleague how the
accumulation of metabolites in the blood from renal
failure affects the body. Which effect should the nurse
include?
A. Decreased levels of nitrogenous wastes in blood
B. Increased pain
C. Altered electrolyte balance
D. Bradycardia
c apply.)
(rationale: Renal failure is a condition in which the
kidneys are unable to remove accumulated metabolites
from the blood, resulting in altered fluid and electrolyte
balance and
aciddash-base balance. Increased pain in a client with
renal failure would not cause an alteration in the
amount of metabolites. Heart palpitations are caused
by stress, physical exertion, too much caffeine, and the
use of stimulants. Decreased blood volume is usually
caused by bleeding or dehydration.)
A nurse is caring for a pregnant woman. Which
physiologic condition may occur during pregnancy and
is related to the development of acute kidney injury
(AKI) that should concern the nurse? (Select all that
apply.)
A. Preeclampsia
B. Hypoglycemia
C. Hypertension
D. Hyperemesis gravidarum
E. Hydronephrosis
a, d, e
(rationale: During pregnancy, glomerular filtration rate
increases significantly, perhaps by as much as 50%. This
leads to a decrease in baseline serum creatinine and
other changes associated with the increased blood
volume that pregnancy brings. AKI in pregnant women
is often related to the same etiologies as are identified
in the general population. However, there are unique
etiologies that manifest themselves throughout the
pregnancy cycle. Over 90% of women develop a
physiologic hydronephrosis of pregnancy, and this can
promote urinary stasis, lead to urinary tract infection,
and ultimately lead to AKI. In addition, in the first
trimester, hyperemesis gravidarum and placenta previa
may lead to AKI, and as pregnancy progresses,
pregnancy-induced hypertension, preeclampsia, and
eclampsia stress the kidneys, leading to proteinuria,
hydronephrosis, and AKI.)
The nurse is reviewing discharge instructions with a
client with acute renal injury (AKI). Which diet
instruction should the nurse include? (Select all that
A. Eat high-calcium foods.
B. Eat foods low in saturated fat.
C. Eat foods high in potassium.
D. Eat low-phosphorus foods.
E. Eat foods low in potassium
a, b, d, e,
(Rationale: Clients with AKI experience electrolyte
imbalances. The client with AKI is at particular risk for
hyperkalemia caused by impaired potassium excretion
and hyperphosphatemia. Calcium and phosphate have a
reciprocal relationship in the body; as the level of one
rises, the level of the other falls. Therefore, the client
should eat foods high in calcium and low in phosphate.
Saturated fats are known to raise the levels of
cholesterol and therefore should be eaten in
moderation.)
The nurse is discussing management of acute kidney
injury (AKI) with the client. Which would describe the
key goal to managing this condition?
A. Maintaining fluid and electrolyte balance
B. Avoiding the use of diuretics
C. Eating more vegetables that are low in iron
D. Drinking more fluids
a
(Rationale: If a client develops AKI, maintaining the fluid
and electrolyte balance is a key goal in managing the
condition. Drinking more fluids could place the client at
risk for fluid overload. Diuretics may be ordered for a
client who is retaining a significant amount of fluid.
Increasing the amount of iron in the diet is necessary if
the client is not getting the daily requirement in the
foods they are consuming.)
The nurse is discussing medications with a client with
acute kidney injury (AKI) upon discharge. Which should
be included in the teaching?
A. Avoid taking acetaminophen (Tylenol).
B. Avoid taking NSAIDS.
C. Avoid taking blood pressure medication at night.
D. Avoid taking iron supplementation.
b of output. How much fluid should the client receive
(Rationale: All drugs that either are directly nephrotoxic
or may interfere with renal perfusion (e.g., potent
vasoconstrictors) should be avoided. NSAIDs,
nephrotoxic antibiotics, and other potentially harmful
drugs are avoided throughout the course of AKI. Iron
supplementation can be continued if the client is not
receiving the required amount in the foods they
consume. Acetaminophen can be taken for discomfort,
as it does not contain the same chemical make-up as
the NSAIDS. The client should take their blood pressure
medication as ordered by the healthcare provider.)
The nurse describes the increased risk of
gastrointestinal bleeding to a client with AKI. Which
factor should the nurse inform the client about with
regard to medication? (Select all that apply.)
A. "Avoid magnesium-based antacids."
B. "Regular doses of antacids are indicated."
C. "Take antacids at bedtime."
D. "Over-the-counter calcium carbonate (Tums) is
helpful."
E. "Drink milk to coat the stomach prior to taking
medication."
a, b
(Rationale: The client with AKI has an increased risk of
GI bleeding, probably related to the stress response and
impaired platelet function. Regular doses of antacids
(although not ones that are magnesium based),
histamine H2-receptor antagonists (e.g., famotidine,
ranitidine), or a proton pump inhibitor (e.g., omeprazole
[Prilosec]) are often ordered to prevent GI hemorrhage.
All medications, including over-the-counter
medications, should be discussed with the healthcare
provider to see if they are contraindicated in their
medical condition. Milk will not coat the stomach or
protect the gastric mucosa.)
A 63-year-old man is admitted with postrenal acute
kidney injury (AKI) because of a kidney stone. Vascular
volume and renal perfusion have been restored and he
is on fluid restriction. During the past 24 hours, he has
voided 250 mL of urine. He has not had any other type
over the next 24 hours?
A. 2750 mL
B. 1250 mL
C. 750 mL
D. 3000 mL
c
(Rationale: Once vascular and renal perfusion has been
restored, fluid intake for clients with AKI is usually
restricted because the kidneys cannot eliminate fluids
normally. Fluid intake is calculated for these clients by
adding the amount of output for the previous 24 hours
to 500 mL to allow for insensible losses. The client's
output for the past 24 hours was 250 mL; added to 500
mL, the fluid volume calculation equals 750 mL. A fluid
intake of 1250, 2750, or 3000 mL would be too much
fluid for the client and would put the client at risk for
fluid overload.)
A client diagnosed with acute kidney injury (AKI) is
experiencing hyperkalemia. Which medication should
the nurse anticipate being prescribed to this client?
(Select all that apply.)
A. Angiotensin-converting enzyme (ACE) inhibitors
B. Glucose
C. Insulin
D. Sodium bicarbonate
E. Calcium chloride
b, c, d, e
(Rationale: The nurse should anticipate that calcium
chloride, sodium bicarbonate, insulin, and glucose
would be prescribed to treat the client's hyperkalemia.
Calcium chloride, sodium bicarbonate, and insulin can
be used to reduce serum potassium levels by moving
potassium into the cells. Calcium is also administered to
correct hypocalcemia and reduce hyperphosphatemia.
(Calcium and phosphate have a reciprocal relationship
in the body; as the level of one rises, the level of the
other falls.) An ACE inhibitor is used to treat
hypertension, not hyperkalemia.)
A client experiencing hyperkalemia is scheduled for
dialysis. The nurse anticipates an order for insulin to
help lower the serum potassium level. Which beneficial
action does this medication have for this client?
A. Pulls fluid from the cells
B. Lowers the blood glucose rate
C. Drives the potassium back into the cells
D. Acts as an anticoagulant
c
(Rationale: Glucose and insulin are administered to the
client with hyperkalemia to help drive potassium back
into the intracellular fluid, reducing the amount of
potassium in the blood. Potassium supplements would
only increase the client's potassium levels. Insulin is
used to control the blood glucose rate in a diabetic
client. Insulin is not known to draw fluid from the cells
or act as an anticoagulant.)
The nurse is treating a client with a serum potassium
level of 6.7mEq/L who is already on restricted
potassium intake. Which medication may be ordered to
reduce the neuromuscular effects of this increased
serum level?
A. Antibiotic
B. H2-receptor antagonist
C. Calcium chloride
D. Lactated Ringer
c
(Rationale: Hyperkalemia may require active
intervention as well as restricted potassium intake.
When the serum potassium level is greater than 6.0-6.5
mEq/L, manifestations of its effect on neuromuscular
function develop, including muscle weakness, nausea
and diarrhea, electrocardiographic changes, and
possible cardiac arrest. With significant hyperkalemia,
calcium chloride, bicarbonate, and insulin and glucose
may be given intravenously to reduce serum potassium
levels by moving potassium into the cells. An H2-
receptor antagonist helps prevent gastrointestinal
hemorrhage by decreasing gastric acid production. An
antibiotic would be used to treat infection. Lactated
Ringer would be used in children with AKI for fluid
replacement.)
A client is being discharged following the placement of
an AV fistula. The nurse is providing discharge
instructions to the client regarding the fistula. Which
should the nurse share during this session?
A. "The fistula will not be functional for dialysis for a
month."
B. "The fistula will heal within a week."
C. "This is temporary access for dialysis."
D. "This fistula is created by joining two arteries
together."
a [NSAIDs] and some chemotherapeutic drugs); previous
(Rationale: For longer-term vascular access, an
arteriovenous (AV) fistula (an artificial connection
between a vein and an artery) is created. In preparation
for fistula formation, the nondominant arm is not used
for venipuncture or blood pressure measurement
during renal failure. The fistula is created by surgical
anastomosis of an artery and vein, usually the radial
artery and cephalic vein. It takes about a month for the
fistula to mature so that it can be used.)
Which data should the nurse collect when completing a
physical examination on a client experiencing acute
kidney injury (AKI)? (Select all that apply.)
A. Weight
B. Reports of edema
C. Lung sounds
D. History of diabetes mellitus
E. Skin color
a, c, e
(Rationale: When completing a physical examination on
a client experiencing acute renal failure, the nurse
needs to note the client's weight, skin color, and lung
sounds, which may indicate fluid volume excess.
Reports of edema and having a history of diabetes
mellitus are information collected when obtaining a
client's health history.)
The nurse is completing a health history on a client
admitted with acute renal failure. Which information
should the nurse collect? (Select all that apply.)
A. Recent exposure to nephrotoxic medications
B. Reports of weight loss
C. Reports of anorexia
D. Previous transfusion reactions
E. Chronic diseases
a, c, d, e
(Rationale: When completing a health history on a client
with acute renal failure, the nurse needs to collect
information on recent exposure to nephrotoxic
medications (e.g., nonsteroidal anti-inflammatory drugs
transfusion reactions; chronic diseases such as diabetes
mellitus, heart failure, and kidney disease; and reports
of anorexia. The nurse needs to collect information on
reports of weight gain, not weight loss.)
The nurse is providing discharge instructions to a client
going home on 80mg of furosemide (Lasix), a loop
diuretic, twice a day. Which teaching should be included
in these instructions? (Select all that apply.)
A. Take with water only."
B. "Avoid using nonsteroidal anti-inflammatory drugs
(NSAIDs)."
C. "Rise slowly from lying or sitting position."
D. "Do not take at the same time as other medications."
E. "Take in the morning and at bedtime."
b, c
(Rationale: Teaching for the client and the family of the
client who is prescribed furosemide includes the
following:
- Unless contraindicated, maintain a fluid intake of 2 to
3 L/day.
- Rise slowly from lying or sitting positions because a fall
in blood pressure may cause lightheadedness.
- Take it in the morning and, if ordered twice a day, in
the late afternoon to avoid sleep disturbance.
- Take it with food or milk to prevent gastric distress.
- NSAIDs interfere with the effectiveness of loop
diuretics and should be avoided.)
For which reason did the nurse place a chair scale in the
room of a client who has been admitted with acute
kidney injury (AKI)? (Select all that apply.)
A. Because equipment calibration can vary
B. To ensure an accurate weight
C. Limited availability of equipment
D. To utilize standard technique
E. Because chair scales are the most accurate
a, b, d
(Rationale: Weigh the client daily or more frequently as
ordered. Use standard technique (same scale, clothing,
or coverings) to ensure accuracy. Rapid weight changes
are an accurate indicator of fluid volume status,
particularly in the client with oliguria. Any drastic shift
in weight of a client with AKI indicates some
malfunction and can adversely affect other organs and
the treatment program.)
The nurse notes that the plan of care for a client with
acute kidney injury (AKI) instructs them to reposition
the client every 2 hours while in bed. Which is the
rationale behind this instruction?
A. To avoid skin breakdown
B. To keep skin dry
C. To avoid bone fractures
D. To keep the client awake
a
(Rationale: Turning the client frequently and providing
good skin care help to avoid skin breakdown. Edema
decreases tissue perfusion and increases the risk of skin
breakdown, especially in clients who are older or
debilitated. Frequent repositioning has no bearing on
bone fractures. The client should be kept dry to assist in
avoiding skin breakdown. Repositioning is not done to
disturb or keep the client awake.)
A client with acute renal failure develops sever
hyperkalemia. What would the nurse anticipate to be
used to treat this imbalance?
1) Furosemide (Lasix)
2) Amphojel (aluminum hydroxide)
3) 50% glucose and regular insulin
4) Epoetin (Procrit)
3: Hyperkalemia can develop into an emergency
situation (Cardia Arrest). It is important to quickly move
the potassium back into the cells by administering 50%
glucose and regular insulin, usually in conjunction with
some type of base to correct the acidosis, such as
sodium bicarbonate or calcium gluconate given IV.
Insulin assists in the movement of potassium into the
cells and helps to reduce the serum potassium level.
Amphojel is used for the treatment of
hyperphosphatemia that occurs with ARF. Procrit is
used for the treatment of anemia caused by a decrease
in erythropoietin production by the kidneys. A diuretic,
such as Lasix, may lead to a loss of potassium, but the
rate is too slow.
A cllient with chronic renal failure has been prescribed
calcium carbonate. What is the rationale for this
particular medication?
1) Diminishes incidence of gastric ulcer formation
2) Alleviates constipation
3) Binds with phosphorus to lower concentration
4) Increase tubular reabsorption of sodium
3: Clients with ARF have hyperphosphatemia. Clients
are prescribed calcium-based phosphate binders to
improve excretion of phosphorus.
A client with chronic renal failure has an internal venous
access site for hemodialysis on her left forearm. What
action will the nurse take to protect this access site?
1) Irrigate with heparin and NS q8 hrs
2) Apply warm moist packs to the area after
hemodialysis
3) Do not use the left arm to take blood pressure
readings.
4) Keep the arm elevated above the level of the heart.
3: Protect the arm with the functioning shunt. No blood
pressure readings should be taken from that arm, and
there should be no needle sticks. The access is not
irrigated with Heparin.
After the insertion of an arteriovenous graft (AVG)
in the right forearm, a patient complains of pain
and coldness of the right fingers. Which action
should the nurse take?
a. Elevate the patient's arm above the level of the
heart.
b. Report the patient's symptoms to the health
care provider.
c. Remind the patient about the need to take a
daily low-dose aspirin tablet.
d. Educate the patient about the normal vascular
response after AVG insertion.
ANS: B
The patient's complaints suggest the development
of distal ischemia (steal syndrome) and may
require revision of the AVG. Elevation of the arm
above the heart will decrease perfusion. Pain and
coolness are not normal after AVG insertion.
Aspirin therapy is not used to maintain grafts.
A patient with acute kidney injury (AKI) has an
arterial blood pH of 7.30. The nurse will assess the
patient for
a. vasodilation.
b. poor skin turgor.
c. bounding pulses.
d. rapid respirations.
ANS: D
Patients with metabolic acidosis caused by AKI may
have Kussmaul respirations as the lungs try to
regulate carbon dioxide. Bounding pulses and
vasodilation are not associated with metabolic
acidosis. Because the patient is likely to have fluid
retention, poor skin turgor would not be a finding
in AKI.
A patient with severe heart failure develops
elevated blood urea nitrogen (BUN) and creatinine
levels. The nurse will plan care to meet the goal of
a. replacing fluid volume.
b. preventing hypertension.
c. maintaining cardiac output.
d. diluting nephrotoxic substances.
ANS: C
The primary goal of treatment for acute kidney
injury (AKI) is to eliminate the cause and provide
supportive care while the kidneys recover. Because
this patient's heart failure is causing AKI, the care
will be directed toward treatment of the heart
failure. For renal failure caused by hypertension,
hypovolemia, or nephrotoxins, the other responses
would be correct.
A patient who has acute glomerulonephritis is
hospitalized with acute kidney injury (AKI) and
hyperkalemia. Which information will the nurse
obtain to evaluate the effectiveness of the
prescribed calcium gluconate IV?
a. Urine output
b. Calcium level
c. Cardiac rhythm
d. Neurologic status
ANS: C
The calcium gluconate helps prevent dysrhythmias
that might be caused by the hyperkalemia. The
nurse will monitor the other data as well, but these
will not be helpful in determining the effectiveness
of the calcium gluconate.
A patient with stage 2 chronic kidney disease (CKD)
is scheduled for an intravenous pyelogram (IVP).
Which of these orders for the patient will the nurse
question?
a. NPO for 6 hours before IVP procedure
b. Normal saline 500 mL IV before procedure
c. Ibuprofen (Advil) 400 mg PO PRN for pain
d. Dulcolax suppository 4 hours before IVP
procedure
ANS: C
The contrast dye used in IVPs is potentially
nephrotoxic, and concurrent use of other
nephrotoxic medications such as the NSAIDs should
be avoided. The suppository and NPO status are
necessary to ensure adequate visualization during
the IVP. IV fluids are used to ensure adequate
hydration, which helps reduce the risk for contrast-
induced renal failure.
Which statement by a patient with stage 5 chronic
kidney disease (CKD) indicates that the nurse's
teaching about management of CKD has been
effective?
a. "I need to try to get more protein from dairy
products."
b. "I will try to increase my intake of fruits and
vegetables."
c. "I will measure my urinary output each day to
help calculate the amount I can drink."
d. "I need to take the erythropoietin to boost my
immune system and help prevent infection."
ANS: C
The patient with end-stage renal disease is taught
to measure urine output as a means of determining
an appropriate oral fluid intake. Erythropoietin is
given to increase the red blood cell count and will
not offer any benefit for immune function. Dairy
products are restricted because of the high
phosphate level. Many fruits and vegetables are
high in potassium and should be restricted in the
patient with CKD.
Which patient information will the nurse plan to
obtain in order to determine the effectiveness of
the prescribed calcium carbonate (Caltrate) for a
patient with chronic kidney disease (CKD)?
a. Blood pressure
b. Phosphate level
c. Neurologic status
d. Creatinine clearance
ANS: B
Calcium carbonate is prescribed to bind
phosphorus and prevent mineral and bone disease
in patients with CKD. The other data will not be
helpful in evaluating the effectiveness of calcium
carbonate
Before administering sodium polystyrene sulfonate
(Kayexalate) to a patient with hyperkalemia, the
nurse should assess the
a. blood urea nitrogen (BUN) and creatinine.
b. blood glucose level.
c. patient's bowel sounds.
d. level of consciousness (LOC).
ANS: C
Sodium polystyrene sulfonate (Kayexalate) should
not be given to a patient with a paralytic ileus (as
indicated by absent bowel sounds) because bowel
necrosis can occur. The BUN and creatinine, blood
glucose, and LOC would not affect the nurse's
decision to give the medication.
The nurse has instructed a patient who is receiving
hemodialysis about appropriate dietary choices.
Which menu choice by the patient indicates that
the teaching has been successful?
a. Scrambled eggs, English muffin, and apple juice
b. Oatmeal with cream, half a banana, and herbal
tea
c. Split-pea soup, whole-wheat toast, and nonfat
milk
d. Cheese sandwich, tomato soup, and cranberry
juice
ANS: A
Scrambled eggs would provide high-quality protein,
and apple juice is low in potassium. Cheese is high
in salt and phosphate, and tomato soup would be
high in potassium. Split-pea soup is high in
potassium, and dairy products are high in
phosphate. Bananas are high in potassium, and the
cream would be high in phosphate.
Before administration of calcium carbonate
(Caltrate) to a patient with chronic kidney disease
(CKD), the nurse should check the laboratory value
for
a. creatinine.
b. potassium.
c. total cholesterol.
d. serum phosphate.
ANS: D
If serum phosphate is elevated, the calcium and
phosphate can cause soft tissue calcification. The
calcium carbonate should not be given until the
phosphate level is lowered. Total cholesterol,
creatinine, and potassium values do not affect
whether calcium carbonate should be
administered.
Which information will be most useful to the nurse
in evaluating improvement in kidney function for a
patient who is hospitalized with acute kidney injury
(AKI)?
a. Blood urea nitrogen (BUN) level
b. Urine output
c. Creatinine level
d. Calculated glomerular filtration rate (GFR)
ANS: D
GFR is the preferred method for evaluating kidney
function. BUN levels can fluctuate based on factors
such as fluid volume status. Urine output can be
normal or high in patients with AKI and does not
accurately reflect kidney function. Creatinine alone
is not an accurate reflection of renal function.
A patient needing vascular access for hemodialysis
asks the nurse what the differences are between
an arteriovenous (AV) fistula and a graft. The nurse
explains that one advantage of the fistula is that it
a. is much less likely to clot.
b. increases patient mobility.
c. can accommodate larger needles.
d. can be used sooner after surgery.
ANS: A
AV fistulas are much less likely to clot than grafts,
although it takes longer for them to mature to the
point where they can be used for dialysis. The
choice of an AV fistula or a graft does not have an
impact on needle size or patient mobility.
When caring for a patient with a left arm
arteriovenous fistula, which action will the nurse
include in the plan of care to maintain the patency
of the fistula?
a. Check the fistula site for a bruit and thrill.
b. Assess the rate and quality of the left radial
pulse.
c. Compare blood pressures in the left and right
arms.
d. Irrigate the fistula site with saline every 8 to 12
hours.
ANS: A
The presence of a thrill and bruit indicates
adequate blood flow through the fistula. Pulse rate
and quality are not good indicators of fistula
patency. Blood pressures should never be obtained
on the arm with a fistula. Irrigation of the fistula
might damage the fistula, and typically only dialysis
staff would access the fistula.
When a patient who has had progressive chronic
kidney disease (CKD) for several years is started on
hemodialysis, which information about diet will the
nurse include in patient teaching?
a. Increased calories are needed because glucose is
lost during hemodialysis.
b. Unlimited fluids are allowed since retained fluid
is removed during dialysis.
c. More protein will be allowed because of the
removal of urea and creatinine by dialysis.
d. Dietary sodium and potassium are unrestricted
because these levels are normalized by dialysis.
ANS: C
Once the patient is started on dialysis and
nitrogenous wastes are removed, more protein in
the diet is encouraged. Fluids are still restricted to
avoid excessive weight gain and complications such
as shortness of breath. Glucose is not lost during
hemodialysis. Sodium and potassium intake
continues to be restricted to avoid the
complications associated with high levels of these
electrolytes
Which action by a patient who is using peritoneal
dialysis (PD) indicates that the nurse should
provide more teaching about PD?
a. The patient slows the inflow rate when
experiencing pain.
b. The patient leaves the catheter exit site without
a dressing.
c. The patient plans 30 to 60 minutes for a dialysate
exchange.
d. The patient cleans the catheter while taking a
bath every day.
ANS: D
Patients are encouraged to take showers rather
than baths to avoid infections at the catheter
insertion side. The other patient actions indicate
good understanding of peritoneal dialysis.
When the nurse is taking a history for a patient
who is a possible candidate for a kidney transplant,
which information about the patient indicates that
the patient is not an appropriate candidate for
transplantation?
a. The patient has metastatic lung cancer.
b. The patient has poorly controlled type 1
diabetes.
c. The patient has a history of chronic hepatitis C
infection.
d. The patient is infected with the human
immunodeficiency virus.
ANS: A
Disseminated malignancies are a contraindication
to transplantation. The conditions of the other
patients are not contraindications for kidney
transplant.
The nurse is caring for a patient who had kidney
transplantation several years ago. Which
assessment finding may indicate that the patient is
experiencing adverse effects to the prescribed
corticosteroid?
a. Joint pain
b. Tachycardia
c. Postural hypotension
d. Increase in creatinine level
ANS: A
Aseptic necrosis of the weight-bearing joints can
occur when patients take corticosteroids over a
prolonged period. Increased creatinine level,
orthostatic dizziness, and tachycardia are not
caused by corticosteroid use.
Which data obtained when assessing a patient who
had a kidney transplant 8 years ago and who is
receiving the immunosuppressants tacrolimus
(Prograf), cyclosporine (Sandimmune), and
prednisone (Deltasone) will be of most concern to
the nurse?
a. The blood glucose is 144 mg/dL.
b. The patient's blood pressure is 150/92.
c. There is a nontender lump in the axilla.
d. The patient has a round, moonlike face.
ANS: C
A nontender lump suggests a malignancy such as a
lymphoma, which could occur as a result of chronic
immunosuppressive therapy. The elevated glucose,
moon face, and hypertension are possible side
effects of the prednisone and should be addressed,
but they are not as great a concern as the
possibility of a malignancy
A patient with chronic kidney disease (CKD) brings
all home medications to the clinic to be reviewed
by the nurse. Which medication being used by the
patient indicates that patient teaching is required?
a. Multivitamin with iron
b. Milk of magnesia 30 mL
c. Calcium phosphate (PhosLo)
d. Acetaminophen (Tylenol) 650 mg
ANS: B
Magnesium is excreted by the kidneys, and
patients with CKD should not use over-the-counter
products containing magnesium. The other
medications are appropriate for a patient with
CKD.
A patient with hypertension and stage 2 chronic
kidney disease (CKD) is receiving captopril
(Capoten). Before administration of the
medication, the nurse will check the patient's
a. glucose.
b. potassium.
c. creatinine.
d. phosphate.
ANS: B
Angiotensin-converting enzyme (ACE) inhibitors are
frequently used in patients with CKD because they
delay the progression of the CKD, but they cause
potassium retention. Therefore, careful monitoring
of potassium levels is needed in patients who are
at risk for hyperkalemia. The other laboratory
values also would be monitored in patients with
CKD but would not affect whether the captopril
was given or not.
A new order for IV gentamicin (Garamycin) 60 mg
BID is received for a patient with diabetes who has
pneumonia. When evaluating for adverse effects of
the medication, the nurse will plan to monitor the
patient's
a. urine osmolality.
b. serum potassium.
c. blood glucose level.
d. blood urea nitrogen (BUN) and creatinine.
ANS: D
When a patient at risk for chronic kidney disease
(CKD) receives a nephrotoxic medication, it is
important to monitor renal function with BUN and
creatinine levels. The other laboratory values
would not be useful in determining the effect of
the gentamicin
Which of the following information obtained by the
nurse who is caring for a patient with end-stage
renal disease (ESRD) indicates the nurse should
consult with the health care provider before giving
the prescribed epoetin alfa (Procrit)?
a. Creatinine 1.2 mg/dL
b. Oxygen saturation 89%
c. Hemoglobin level 13 g/dL
d. Blood pressure 98/56 mm Hg
ANS: C
High hemoglobin levels are associated with a
higher rate of thromboembolic events and
increased risk of death from serious cardiovascular
events (heart attack, heart failure, stroke) when
EPO is administered to a target hemoglobin of >12
g/dL. Hemoglobin levels higher than 12 g/dL
indicate a need for a decrease in epoetin alfa dose.
The other information also will be reported to the
health care provider, but will not affect whether
the medication is administered
In a patient with acute kidney injury (AKI) who
requires hemodialysis, a temporary vascular access
is obtained by placing a catheter in the left femoral
vein. Which intervention will be included in the
plan of care?
a. Place the patient on bed rest.
b. Start continuous pulse oximetry.
c. Discontinue the retention catheter.
d. Restrict the patient's oral protein intake.
ANS: A
The patient with a femoral vein catheter must be
on bed rest to prevent trauma to the vein. Protein
intake is likely to be increased when the patient is
receiving dialysis. The retention catheter is likely to
remain in place because accurate measurement of
output will be needed. There is no indication that
the patient needs continuous pulse oximetry
When the nurse is caring for a patient who has
been admitted with a severe crushing injury after
an industrial accident, which laboratory result will
be most important to report to the health care
provider?
a. Serum creatinine level 2.1 mg/dL
b. Serum potassium level 6.5 mEq/L
c. White blood cell count 11,500/µL
d. Blood urea nitrogen (BUN) 56 mg/dL
ANS: B
The hyperkalemia associated with crushing injuries
may cause cardiac arrest and should be treated
immediately. The nurse also will report the other
laboratory values, but abnormalities in these are
not immediately life threatening.
A patient with a history of benign prostatic
hyperplasia (BPH) is admitted with acute urinary
retention and an elevated blood urea nitrogen
(BUN) and creatinine. Which of these prescribed
therapies should the nurse implement first?
a. Obtain renal ultrasound.
b. Insert retention catheter.
c. Infuse normal saline at 50 mL/hour.
d. Draw blood for complete blood count.
ANS: B
The patient's elevation in BUN is most likely
associated with hydronephrosis caused by the
acute urinary retention, so the insertion of a
retention catheter is the first action to prevent
ongoing postrenal failure for this patient. The other
actions also are appropriate, but should be
implemented after the retention catheter
Which information about a patient who was
admitted 10 days previously with acute kidney
injury (AKI) caused by dehydration will be most
important for the nurse to report to the health care
provider?
a. The blood urea nitrogen (BUN) level is 67 mg/dL.
b. The creatinine level is 3.0 mg/dL.
c. Urine output over an 8-hour period is 2500 mL.
d. The glomerular filtration rate is <30
mL/min/1.73m2.
ANS: C
The high urine output indicates a need to increase
fluid intake to prevent hypovolemia. The other
information is typical of AKI and will not require a
change in therapy
After noting lengthening QRS intervals in a patient
with acute kidney injury (AKI), which action should
the nurse take first?
a. Document the QRS interval.
b. Notify the patient's health care provider.
c. Look at the patient's current blood urea nitrogen
(BUN) and creatinine levels.
d. Check the chart for the most recent blood
potassium level.
ANS: D
The increasing QRS interval is suggestive of
hyperkalemia, so the nurse should check the most
recent potassium and then notify the patient's
health care provider. The BUN and creatinine will
be elevated in a patient with AKI, but they would
not directly affect the electrocardiogram (ECG).
Documentation of the QRS interval also is
appropriate, but interventions to decrease the
potassium level are needed to prevent life-
threatening bradycardia.
When caring for a dehydrated patient with acute
kidney injury who is oliguric, anemic, and
hyperkalemic, which of the following prescribed
actions should the nurse take first?
a. Insert a urinary retention catheter.
b. Place the patient on a cardiac monitor.
c. Administer epoetin alfa (Epogen, Procrit).
d. Give sodium polystyrene sulfonate (Kayexalate).
ANS: B
Since hyperkalemia can cause fatal cardiac
dysrhythmias, the initial action should be to
monitor the cardiac rhythm. Kayexalate and
Epogen will take time to correct the hyperkalemia
and anemia. The catheter allows monitoring of the
urine output, but does not correct the cause of the
renal failure.
Which nursing action for a patient who has arrived
for a scheduled hemodialysis session is most
appropriate for the RN to delegate to a dialysis
technician?
a. Educate patient about fluid restrictions.
b. Check blood pressure before starting dialysis.
c. Assess for reasons for increase in predialysis
weight.
d. Determine the ultrafiltration rate for the
hemodialysis.
ANS: B
Dialysis technicians are educated in monitoring for
blood pressure. Assessment, adjustment of the
appropriate ultrafiltration rate, and patient
teaching require the education and scope of
practice of an RN.
The RN observes an LPN/LVN carrying out all of the
following actions while caring for a patient with
stage 2 chronic kidney disease. Which action
requires the RN to intervene?
a. The LPN/LVN administers erythropoietin
subcutaneously.
b. The LPN/LVN assists the patient to ambulate in
the hallway.
c. The LPN/LVN gives the iron supplement and
phosphate binder with lunch.
d. The LPN/LVN carries a tray containing low-
protein foods into the patient's room.
ANS: C
Oral phosphate binders should not be given at the
same time as iron because they prevent the iron
from being absorbed. The phosphate binder should
be given with a meal and the iron given at a
different time. The other actions by the LPN/LVN
are appropriate for a patient with renal
insufficiency.
The nurse is assessing a patient who is receiving
peritoneal dialysis with 2 L inflows. Which
information should be reported immediately to the
health care provider?
a. The patient has an outflow volume of 1800 mL.
b. The patient's peritoneal effluent appears cloudy.
c. The patient has abdominal pain during the inflow
phase.
d. The patient complains of feeling bloated after
the inflow.
ANS: B
Cloudy appearing peritoneal effluent is a sign of
peritonitis and should be reported immediately so
that treatment with antibiotics can be started. The
other problems can be addressed through nursing
interventions such as slowing the inflow and
repositioning the patient.
Two hours after a kidney transplant, the nurse
obtains all of the following data when assessing the
patient. Which information is most important to
communicate to the health care provider?
a. The urine output is 900 to 1100 mL/hr.
b. The blood urea nitrogen (BUN) and creatinine
levels are elevated.
c. The patient's central venous pressure (CVP) is
decreased.
d. The patient has level 8 (on a 10-point scale)
incisional pain.
ANS: C
The decrease in CVP suggests hypovolemia, which
must be rapidly corrected to prevent renal
hypoperfusion and acute tubular necrosis. The
other information is not unusual in a patient after a
transplant.
A patient in the oliguric phase of acute renal failure
has a 24-hour fluid output of 150 mL emesis and
250 mL urine. The nurse plans a fluid replacement
for the following day of ___ mL.
a. 400
b. 800
c. 1000
d. 1400
ANS: C
Usually fluid replacement should be based on the
patient's measured output plus 600 mL/day for
insensible losses.
During hemodialysis, a patient complains of nausea
and dizziness. Which action should the nurse take
first?
a. Slow down the rate of dialysis.
b. Obtain blood to check the blood urea nitrogen
(BUN) level.
c. Check the patient's blood pressure.
d. Give prescribed PRN antiemetic drugs.
ANS: C
The patient's complaints of nausea and dizziness
suggest hypotension, so the initial action should be
to check the BP. The other actions also may be
appropriate, based on the blood pressure
obtained.
Which parameter will be most important for the
nurse to consider when titrating the IV fluid
infusion rate immediately after a patient has had
kidney transplantation?
a. Heart rate
b. Blood urea nitrogen (BUN) level
c. Urine output
d. Creatinine clearance
ANS: C
Fluid volume is replaced based on urine output
after transplant because the urine output can be as
high as a liter an hour. The other data will be
monitored but are not the most important
determinants of fluid infusion rate.
A patient complains of leg cramps during
hemodialysis. The nurse should first
a. reposition the patient.
b. massage the patient's legs.
c. give acetaminophen (Tylenol).
d. infuse a bolus of normal saline.
ANS: D
Muscle cramps during dialysis are caused by rapid
removal of sodium and water. Treatment includes
infusion of normal saline. The other actions do not
address the reason for the cramps.
A patient is admitted to the hospital with CKD. The
nurse understands that this condition is characterized
by
a. progressive irreversible destruction of the kidneys
b. a rapid decrease in urine output with an elevated
BUN
c. an increasing creatinine clearance with a decrease in
urine output
d. prostration, somnolence, and confusion with coma
and imminent death
A
Patients with CKD experience an increase incidence
of cardiovascular disease related to Select all that
apply
a. hypertension
b. vascular calcifications
c. a genetic predisposition
d. hyperinsulinemia causing dyslipidemia
e. increased high-density lipoprotein levels
a
b
d
An ESRD patient receiving HD is considering asking
a relative to donate a kidney for transplantation. In
assisting the patient to make a decision about
treatment, the nurse informs the patient that
a. successful transplantation usually provides a
better quality of life than that offered by dialysis
b. if rejection of the transplanted kidney occurs, no
further treatment for the renal failure is available
c. HD replaces the normal function of the kidneys,
and patients do not have to live with the continual
fear of rejection
d. the immunosuppressive therapy following
transplantation makes the person ineligible to
receive other forms of treatment if the kidney fails
A
To assess the patency of a newly placed
arteriovenous graft for dialysis, the nurse should
Select all that apply
a. monitor the BP in the affected arm
b. irrigate the graft daily with low-dose heparin
c. palpate the area of the graft to feel a normal
thrill
d. listen with a stethoscope over the graft to detect
a bruit
e. frequently monitor the pulses and neurovascular
status distal to the graft
c The patient with CKD is receiving dialysis, and the
d nurse observes excoriations on the patient's skin.
e What pathophysiologic changes in CKD most likely
occur that can contribute to this finding? Select all
A major advantage of peritoneal dialysis is that apply

a. the diet is less restricted and dialysis can be a. dry skin

performed at home
b. the dialysate is biocompatible and causes no b. sensory neuropathy
long-term consequences
c. high glucose concentrations of the dialysate c. vascular calcifications
causes a reduction in appetite, promoting weight
loss d. calcium-phosphate skin deposits
d. no medications are required because of the
enhances efficiency of the peritoneal membrane in e. uremic crystallization from high BUN
removing toxins
a
A b
d
A kidney transplant recipient complains of having
fever, chills, and dysuria over the past 2 weeks. What causes the GI manifestation of stomatitis in
What is the first action the nurse should take? the patient with CKD?

a. assess temperature and initiate workup to rule
out infection
b. reassure the patient that this is common after
transplantation
c. provide warm cover for the patient and give 1 g
acetaminophen orally
a. high serum sodium levels
b. irritation of the GI tract from creatinine
c. increased ammonia from bacterial breakdown of
urea
d. iron salts, calcium-containing phosphate binders,
and limited fluid intake
C

d. notify the nephrologist that the patient has The patient with CKD is brought to the ED with
developed symptoms of acute rejection Kussmaul respirations. What does the nurse know
about CKD that could cause this patient's Kussmaul
a respirations?

In replying to a patient's questions about the a. uremic pleuritis is occurring

seriousness of her CKD, the nurse knows that the b. there is decreased pulmonary macrophage
stage of CKD is based on what? activity
c. they are caused by respiratory compensation for
a. total daily urine output metabolic acidosis
b. GFR d. pulmonary edema from HF and fluid overload is
c. degree of altered mental status occurring
d. serum creatinine and urea levels
C
B
Which serum laboratory value indicates to the The patient with CKD is considering whether to use
nurse that the patient's CKD is getting worse? PD or HD. What are advantages of PD when
compared to HD? Select all that apply
a. decreased BUN
b. decreased sodium a. less protein loss
c. decreased creatinine
d. decreased calculated GFR b. rapid fluid removal

D c. less cardiovascular stress

What is the most serious electrolyte disorder d. decreased hyperlipidemia

associated with kidney disease?
e. requires fewer dietary restrictions
a. hypocalcemia
c
b. hyperkalemia
e
c. hyponatremia
To prevent the most common serious complication
d. hypermagnesemia of PD, what is most important for the nurse to do?

b a. infuse the dialysate slowly

b. use strict aseptic technique in the dialysis
What is the most appropriate snack for the nurse procedures
to offer a patient with stage 4 CKD? c. have the patient empty the bowel before the
inflow phase
a. raisins d. reposition the patient frequently and promote
deep breathing
b. ice cream
B
c. dill pickles
A man with ESRD is scheduled for HD following
d. hard candy healing of an arteriovenous fistula. What should
the nurse explain to him that will occur during
d dialysis?

Which complication of CKD is treated with a. he will be able to visit, read, sleep, or watch TV
erythropoietin? while reclining in a chair
b. he will be placed on a cardiac monitor to detect
a. anemia any adverse effects that may occur
b. hypertension c. the dialyzer will remove and hold part of his
c. hyperkalemia blood for 20-30 minutes to remove the waste
d. mineral and bone disorder products
d. a large catheter with two lumens will be inserted
A into the fistula to send blood to and return it from
the dialyzer

A
A patient rapidly progressing toward ESRD asks
about the possibility of a kidney transplant. In
responding to the patient, the nurse knows that
what is a contraindication to kidney
transplantation?
a. hepatitis C infection
b. coronary artery disease
c. refractory hypertension
d. extensive vascular disease
D was achieved?
During the immediate postoperative care of a
recipient of a kidney transplant, what is a priority
for the nurse to do?
a. regulate fluid intake hourly based on urine
output
b. monitor urine-tinged drainage on abdominal
dressing
c. medicate the patient frequently for incisional
flank pain
d. remove the urinary catheter to evaluate the
ureteral implant
a c. "You will be allowed a more liberal protein diet
A patient received a kidney transplant last month.
Because of the effects of immunosuppressive drugs
and CKD, what complication of transplantation
should the nurse be assessing the patient for?
a. infection
b. rejection
c. malignancy
d. cardiovascular disease
A
The home care nurse visits a 34-yr-old woman
receiving peritoneal dialysis. Which statement
indicates a need for immediate follow-up by the
nurse?
a. "Drain time is faster if I rub my abdomen."
b. "The fluid draining from the catheter is cloudy."
c. "The drainage is bloody when I have my period."
d. "I wash around the catheter with soap and
water."
B
The nurse preparing to administer a dose of
calcium acetate to a patient with chronic kidney
disease (CKD). Which laboratory result will the
nurse monitor to determine if the desired effect
a. Sodium
b. Potassium
c. Magnesium
d. Phosphorus
D
Which statement regarding continuous ambulatory
peritoneal dialysis (CAPD) would be most
important when teaching a patient new to the
treatment?
a. "Maintain a daily written record of blood
pressure and weight."
b. "It is essential that you maintain aseptic
technique to prevent peritonitis."
once you complete CAPD."
d. "Continue regular medical and nursing follow-up
visits while performing CAPD."
B
A patient with end-stage renal disease (ESRD)
secondary to diabetes mellitus has arrived at the
outpatient dialysis unit for hemodialysis. Which
assessments should the nurse perform as a priority
before, during, and after the treatment?
a. Level of consciousness
b. Blood pressure and fluid balance
c. Temperature, heart rate, and blood pressure
d. Assessment for signs and symptoms of infection
b b. Administer a blood transfusion.
A patient is recovering in the intensive care unit
(ICU) 24 hours after receiving a kidney transplant.
What is an expected assessment finding during the
earliest stage of recovery?
a. Hypokalemia
b. Hyponatremia
c. Large urine output
d. Leukocytosis with cloudy urine output
C nurse respond?
A patient with a 25-year history of type 1 diabetes
mellitus is reporting fatigue, edema, and an
irregular heartbeat. On assessment, the nurse
notes newly developed hypertension and
uncontrolled blood sugars. Which diagnostic study
is most indicative of chronic kidney disease (CKD)?
a. Serum creatinine
b. Serum potassium
c. Microalbuminuria
d. Calculated glomerular filtration rate (GFR)
d a. Anemia
A 78-yr-old patient has stage 3 CKD and is being
taught about a low-potassium diet. The nurse
knows the patient understands the diet when the
patient selects which foods to eat?
a. Apple, green beans, and a roast beef sandwich
b. Granola made with dried fruits, nuts, and seeds
c. Watermelon and ice cream with chocolate sauce
d. Bran cereal with ½ banana and milk and orange
juice
A
During hemodialysis, the patient develops light-
headedness and nausea. What should the nurse do
first?
a. Administer hypertonic saline.
c. Decrease the rate of fluid removal.
d. Administer antiemetic medications.
C
A 24-yr-old woman donated a kidney via a
laparoscopic donor nephrectomy to a nonrelated
recipient. The patient is experiencing significant
pain and refuses to get up to walk. How should the
a. Have the transplant psychologist convince her to
walk.
b. Encourage even a short walk to avoid
complications of surgery.
c. Tell the patient that no other patients have ever
refused to walk.
d. Tell the patient she is lucky she did not have an
open nephrectomy.
B
Which findings will the nurse expect when caring
for a patient with chronic kidney disease (CKD)?
Select all that apply
b. Dehydration
c. Hypertension
d. Hypercalcemia
e. Increased risk for fractures
a
c
e
The nurse is caring for a patient with chronic
kidney disease after hemodialysis. Which patient
care action should the nurse delegate to the
experienced unlicensed assistive personnel (UAP)?

a. Assess the patient's access site for a thrill and
bruit.
b. Monitor for signs and symptoms of postdialysis
bleeding.
c. Check the patient's postdialysis blood pressure
and weight.
d. Instruct the patient to report signs of dialysis
disequilibrium syndrome immediately.
C B
After the insertion of an arteriovenous graft (AVG)
in the right forearm, a patient complains of pain
and coldness of the right fingers. Which action
should the nurse take?
a. Elevate the patients arm above the level of the
heart.
b. Report the patients symptoms to the health care
provider.
c. Remind the patient about the need to take a
daily low-dose aspirin tablet.
d. Educate the patient about the normal vascular
response after AVG insertion.
B the teaching has been successful?
Which statement by a patient with stage 5 chronic
kidney disease (CKD) indicates that the nurses
teaching about management of CKD has been
effective?
a. I need to try to get more protein from dairy
products.
b. I will try to increase my intake of fruits and
vegetables.
c. I will measure my urinary output each day to
help calculate the amount I can drink.
d. I need to take the erythropoietin to boost my
immune system and help prevent infection.
C
Which patient information will the nurse plan to
obtain in order to determine the effectiveness of
the prescribed calcium carbonate (Caltrate) for a
patient with chronic kidney disease (CKD)?
a. Blood pressure
b. Phosphate level
c. Neurologic status
d. Creatinine clearance
Before administering sodium polystyrene sulfonate
(Kayexalate) to a patient with hyperkalemia, the
nurse should assess the
a. blood urea nitrogen (BUN) and creatinine.
b. blood glucose level.
c. patients bowel sounds.
d. level of consciousness (LOC).
C
The nurse has instructed a patient who is receiving
hemodialysis about appropriate dietary choices.
Which menu choice by the patient indicates that
a. Scrambled eggs, English muffin, and apple juice
b. Oatmeal with cream, half a banana, and herbal
tea
c. Split-pea soup, whole-wheat toast, and nonfat
milk
d. Cheese sandwich, tomato soup, and cranberry
juice
A
A patient needing vascular access for hemodialysis
asks the nurse what the differences are between
an arteriovenous (AV) fistula and a graft. The nurse
explains that one advantage of the fistula is that it
a. is much less likely to clot.
b. increases patient mobility.
c. can accommodate larger needles.
d. can be used sooner after surgery.
A
When caring for a patient with a left arm
arteriovenous fistula, which action will the nurse
include in the plan of care to maintain the patency
of the fistula?
a. Check the fistula site for a bruit and thrill.
b. Assess the rate and quality of the left radial
pulse.
c. Compare blood pressures in the left and right
arms.
d. Irrigate the fistula site with saline every 8 to 12
hours.
A
When a patient who has had progressive chronic
kidney disease (CKD) for several years is started on
hemodialysis, which information about diet will the
nurse include in patient teaching?
a. Increased calories are needed because glucose is
lost during hemodialysis.
b. Unlimited fluids are allowed since retained fluid
is removed during dialysis.
c. More protein will be allowed because of the
removal of urea and creatinine by dialysis.
d. Dietary sodium and potassium are unrestricted
because these levels are normalized by dialysis.
C Which data obtained when assessing a patient who
Which action by a patient who is using peritoneal
dialysis (PD) indicates that the nurse should
provide more teaching about PD?
a. The patient slows the inflow rate when
experiencing pain.
b. The patient leaves the catheter exit site without
a dressing.
c. The patient plans 30 to 60 minutes for a dialysate
exchange.
d. The patient cleans the catheter while taking a
bath every day.
D all home medications to the clinic to be reviewed
When the nurse is taking a history for a patient
who is a possible candidate for a kidney transplant,
which information about the patient indicates that
the patient is not an appropriate candidate for
transplantation?
a. The patient has metastatic lung cancer.
b. The patient has poorly controlled type 1
diabetes.
c. The patient has a history of chronic hepatitis C
infection.
d. The patient is infected with the human
immunodeficiency virus.
A
The nurse is caring for a patient who had kidney
transplantation several years ago. Which
assessment finding may indicate that the patient is
experiencing adverse effects to the prescribed
corticosteroid?
a. Joint pain
b. Tachycardia
c. Postural hypotension
d. Increase in creatinine level
A
had a kidney transplant 8 years ago and who is
receiving the immunosuppressants tacrolimus
(Prograf), cyclosporine (Sandimmune), and
prednisone (Deltasone) will be of most concern to
the nurse?
a. The blood glucose is 144 mg/dL.
b. The patients blood pressure is 150/92.
c. There is a nontender lump in the axilla.
d. The patient has a round, moonlike face.
C
A patient with chronic kidney disease (CKD) brings
by the nurse. Which medication being used by the
patient indicates that patient teaching is required?
a. Multivitamin with iron
b. Milk of magnesia 30 mL
c. Calcium phosphate (PhosLo)
d. Acetaminophen (Tylenol) 650 mg
b patient. Which information is most important to
(This increases the magnesium level in the patient
whom already has problems with
hypermagnesemia)
Which of the following information obtained by the
nurse who is caring for a patient with end-stage
renal disease (ESRD) indicates the nurse should
consult with the health care provider before giving
the prescribed epoetin alfa (Procrit)?
a. Creatinine 1.2 mg/dL
b. Oxygen saturation 89%
c. Hemoglobin level 13 g/dL
d. Blood pressure 98/56 mm Hg
C a. Slow down the rate of dialysis.
Which nursing action for a patient who has arrived
for a scheduled hemodialysis session is most
appropriate for the RN to delegate to a dialysis
technician?
a. Educate patient about fluid restrictions.
b. Check blood pressure before starting dialysis.
c. Assess for reasons for increase in predialysis
weight.
d. Determine the ultrafiltration rate for the
hemodialysis.
B kidney transplantation?
The nurse is assessing a patient who is receiving
peritoneal dialysis with 2 L inflows. Which
information should be reported immediately to the
health care provider?
a. The patient has an outflow volume of 1800 mL.
b. The patients peritoneal effluent appears cloudy.
c. The patient has abdominal pain during the inflow
phase.
d. The patient complains of feeling bloated after
the inflow.
B
Two hours after a kidney transplant, the nurse
obtains all of the following data when assessing the
communicate to the health care provider?
a. The urine output is 900 to 1100 mL/hr.
b. The blood urea nitrogen (BUN) and creatinine
levels are elevated.
c. The patients central venous pressure (CVP) is
decreased.
d. The patient has level 8 (on a 10-point scale)
incisional pain.
C
During hemodialysis, a patient complains of nausea
and dizziness. Which action should the nurse take
first?
b. Obtain blood to check the blood urea nitrogen
(BUN) level.
c. Check the patients blood pressure.
d. Give prescribed PRN antiemetic drugs.
C
Which parameter will be most important for the
nurse to consider when titrating the IV fluid
infusion rate immediately after a patient has had
a. Heart rate
b. Blood urea nitrogen (BUN) level
c. Urine output
d. Creatinine clearance
C
A patient complains of leg cramps during
hemodialysis. The nurse should first
a. reposition the patient.
b. massage the patients legs.
c. give acetaminophen (Tylenol).
d. infuse a bolus of normal saline.
D
A client with end-stage renal failure has an internal
arteriovenous fistula in the left arm for vascular
access during hemodialysis. What should the nurse
instruct the client do to? Select all that apply
a. remind the HCPs to draw blood from veins on
the left side
b. avoid sleeping on the left arm
c. wear wristwatch on the right arm
d. assess fingers on the left arm for warmth
e. obtain BP from the left arm
bcd
A client with chronic renal failure is receiving
hemodialysis three times a week. In order to
protect the fistula, the nurse should
a. take the BP in the arm with the fistula
b. report the loss of a thrill or bruit on the arm with
the fistula
c. maintain a pressure dressing on the shunt
d. start a second IV in the arm with the fistula
B
A client with chronic renal failure who receives
hemodialysis 3 times a week is experiencing severe
nausea. What should the nurse advise the client to
do to manage the nausea? Select all that apply
a. drink fluids before eating solid foods
b. have limited amounts of fluids only when thirsty
c. limit activity
d. keep all dialysis appointments
e. eat smaller, more frequent meals
b
d
e
The dialysis solution is warmed before use in
peritoneal dialysis primarily to
a. encourage the removal of serum urea
b. force potassium back into the cells
c. add extra warmth to the body
d. promote abdominal muscle relaxation
a
A client is receiving peritoneal dialysis. While the
dialysis solution is dwelling in the client's abdomen,
the nurse should
a. assess for urticaria
b. observe respiratory status
c. check capillary refill time
d. monitor electrolyte status
B
During the PD, the nurse observes that the solution
draining from the client's abdomen is consistently
blood tinged. The client has a permanent
peritoneal catheter in place. The nurse should
recognize that the bleeding
a. is expected with a permanent peritoneal
catheter
b. indicates abdominal blood vessel damage
c. can indicate kidney damage
d. is caused by too-rapid infusion of the dialysate
B
During PD, the nurse observes that the flow of
dialysate stops before all the solution has drained
out. The nurse should
a. have the client sit in a chair
b. turn the client from side to side
c. reposition the peritoneal catheter
d. have the client walk
B After completion of PD, the nurse should assess the
A client undergoing long term PD at home is
currently experiencing a reduced outflow from the
dialysis catheter. To determine if the catheter is
obstructed, the nurse should inquire whether the
client has
a. diarrhea
b. vomiting
c. flatulence
d. constipation
D
Which should be included in the client's plan of
care during dialysis therapy?
a. limit the client's visitors
b. monitor the client's blood pressure
c. pad the side rails of the bed
d. keep the client on NPO status
B
The client performs self PD. What should the nurse
teach the client about preventing peritonitis?
Select all that apply
a. broad-spectrum antibiotics may be administered
to prevent infection
b. antibiotics may be added to the dialysate to
treat peritonitis
c. clean technique is permissible for prevention of
peritonitis
d. peritonitis is characterized by cloudy dialysate
drainage and abdominal discomfort
e. peritonitis is the most common and serious
complication of peritoneal dialysis
a c. poor drainage of the dialysate fluid
b d. redness at the catheter insertion site
d
e
client for
a. hematuria
b. weight loss
c. hypertension
d. increased urine output
B
The nurse is instructing the client with chronic
renal failure to maintain adequate nutritional
intake. Which diet would be most appropriate?
a. high-carbohydrate, high-protein
b. high-calcium, high-potassium, high-protein
c. low-protein, low-sodium, low-potassium
d. low-protein, high-potassium
c
A client with chronic renal failure has asked to be
evaluated for a home continuous ambulatory PD
program (CAPD). The nurse should explain that the
major advantage of this approach is that it
a. is relatively low in cost
b. allows the client to be more independent
c. is faster and more efficient than standard PD
d. has fewer potential complications than does
standard PD
B
A client is receiving continuous ambulatory peritoneal
dialysis (CAPD). The nurse should assess the client for
which sign of peritoneal infection?
a. cloudy dialysate fluid
b. swelling in the legs
A a
b
A nurse is teaching a client who has chronic kidney
c
disease and is to begin hemodialysis. Which of the d
following information should the nurse include in the
teaching? A nurse is caring for a client who develops
disequilibrium syndrome after receiving hemodialysis.
a. hemodialysis restores kidney function Which of the following actions should the nurse take?
b. hemodialysis replaces hormonal function of the renal
system a. administer an opioid medication
c. hemodialysis allows an unrestricted diet b. monitor for hypertension
d. hemodialysis returns a balance to blood electrolytes c. assess level of consiousness
d. increase the dialysis exchange rate
D
C
A nurse is preparing to initiate hemodialysis for a
client who has AKI. Which of the following actions A nurse is planning care for a client who will
should the nurse take? Select all that apply undergo PD. Which of the following actions should
the nurse take? Select all that apply
a. review the medications the client currently takes
a. monitor blood glucose levels
b. assess the AV fistula for a bruit
b. report cloudy dialysate return
c. calculate the client's hourly urine output
c. warm the dialysate in a microwave oven
d. measure the client's weight
d. assess for SOB
e. check blood electrolytes
e. check the access site dressing for wetness
a
b a
d b
e d
e
A nurse is planning postprocedure care for a client
who received hemodialysis. Which of the following A nurse is assessing a client who has end-stage
interventions should the nurse include in the plan kidney disease. Which of the following findings
of care? Select all that apply should the nurse expect? Select all that apply

a. check BUN and blood creatinine a. anuria

b. administer medications the nurse withheld prior b. marked azotemia

to dialysis
c. crackles in the lungs
c. observe for findings of hypovolemia
d. increased calcium level
d. assess the access site for bleeding
e. proteinuria
e. evaluate BP on the arm with AV access
a The nurse is assessing the patency of a client's left arm
b AV fistula prior to initiating HD. Which findings indicate
c that the fistula is patent?
e
a. palpation of a thrill over the fistula
A nurse is planning postoperative care for a client b. presence of a radial pulse in the left wrist
following a kidney transplant. Which of the c. visualization of enlarged blood vessels at the fistula
following actions should the nurse include? Select site
all that apply d. capillary refill <3 seconds in the nail beds of the
fingers on the left hand
a. obtain daily weights
A
b. assess dressings for bloody drainage
The nurse monitoring the client receiving PD notes
c. replace hourly urine output with IV fluids that the client's outflow is less than the inflow.
Which actions should the nurse take? Select all
d. expect oliguria in the first 4 hours that apply

e. monitor blood electrolytes a. check the level of the drainage bag

a b. reposition the client to their side

b
c c. contact the HCP
e
d. place the client in good body alignment
A nurse is teaching a client who is scheduled for a
kidney transplant about organ rejection. Which of e. check the PD system for kinks
the following statements should the nurse include?
Select all that apply a
b
a. "expect an immediate removal of the donor d
kidney for a hyperacute rejection" e

b. "you might need to begin dialysis to monitor A HD client with a left arm fistula is at risk for arterial
your kidney function for a hyperacute reaction" steal syndrome. The nurse should assess for which
manifestations of this complication?
c. "a fever is a manifestation of an acute rejection"
a. warmth, redness, and pain in the left hand
d. "fluid retention is a manifestation of an acute b. ecchymosis and audible bruit over the fistula
rejection" c. edema and reddish discoloration of the left arm
d. pallor, diminished pulse, and pain in the left hand
e. "your provider will increase your
immunosuppressive medications for a chronic D
rejection"
The nurse is reviewing a client's record and notes that
a the HCP has documented that the client has CKD. On
c review of the laboratory results, the nurse most likely
d would expect to note which finding?
a. elevated creatinine level
b. decreased hemoglobin level
c. decreased RBC
d. increased number of WBC in the urine
A
A client with CKD returns to the nursing unit following a
HD treatment. On assessment, the nurse notes that the
client's temperature is 101.2. Which nursing action is
most appropriate?
a. encourage fluid intake
b. notify the HCP
c. continue to monitor vital signs
d. monitor the site of the shunt for infection
B a. Sodium
The nurse is performing an assessment on a client
who has returned from the dialysis unit following
HD. The client is complaining of headache and
nausea and is extremely restless. Which is the
priority nursing action?
a. monitor the client
b. elevate the HOB
c. assess the fistula site and dressing
d. notify the HCP
d carbohydrate intake.
A week after kidney transplantation, a client develops a
temperature of 101, the BP is elevated, and there is
tenderness over the transplanted kidney. The serum
creatinine is rising and urine output is decreased. The x-
ray indicates that the transplanted kidney is enlarged.
Based on these assessment findings, the nurse
anticipates which treatment?
a. antibiotic therapy
b. peritoneal dialysis
c. removal of the transplanted kidney
d. increased immunosuppression therapy
D
The client newly diagnosed with CKD recently has begun
HD. Knowing that the client is at risk for disequilibrium
syndrome, the nurse should assess the client during
dialysis for which associated manifestations?
a. hypertension, tachycardia, and fever
b. hypotension, bradycardia, and hypothermia
c. restlessness, irritability, and generalized weakness
d. headache, deteriorating LOC, and twitching
D
The nurse is preparing to administer a dose of PhosLo to
a patient with chronic kidney disease. This medication
should have a beneficial effect on which laboratory
value?
b. Potassium
c. Magnesium
d. Phosphorus
D
Measures indicated in the conservative therapy of CKD
include
a. decreased fluid intake, carbohydrate intake, and
protein intake.
b. increased fluid intake; decreased carbohydrate intake
and protein intake.
c. decreased fluid intake and protein intake; increased
d. decreased fluid intake and carbohydrate intake;
increased protein intake.
C
The advantage of continuous replacement therapy over
hemodialysis is its ability to
a. remove fluid without the use of a dialysate.
b. remove fluid in less than 24 hours.
c. allow the patient to receive the therapy at the work
site.
d. be administered through a peripheral line.
A
The client newly diagnosed with chronic kidney
disease recently has begun hemodialysis. Knowing
that the client is at risk for disequilibrium
syndrome, the nurse should assess the client
during dialysis for which associated
manifestations?
A. Hypertension, tachycardia, and fever
B. Hypotension, bradycardia, and hypothermia
C. Restlessness, irritability, and generalized
weakness
D. Headache, deteriorating level of consciousness,
and twitching
D. Headache, deteriorating level of consciousness,
and twitching
Disequilibrium syndrome is characterized by
headache, mental confusion, decreasing level of
consciousness, nausea, vomiting, twitching, and
possible seizure activity. Disequilibrium syndrome
is caused by rapid removal of solutes from the
body during hemodialysis. At the same time, the
blood-brain barrier interferes with the efficient
removal of wastes from brain tissue. As a result,
water goes into cerebral cells because of the
osmotic gradient, causing increased intracranial
pressure and onset of symptoms. The syndrome
most often occurs in clients who are new to dialysis
and is prevented by dialyzing for shorter times or
at reduced blood flow rates.
A client has developed acute kidney injury (AKI) as
a complication of glomerulonephritis. The nurse
should assess the client for which expected
manifestation of AKI?
A. Bradycardia
B. Hypertension
C. Decreased cardiac output
D. Decreased central venous pressure
B. Hypertension
AKI caused by glomerulonephritis is classified as
intrinsic or intrarenal failure. This form of AKI
commonly manifests with hypertension,
tachycardia, oliguria, lethargy, edema, and other
signs of fluid overload. AKI from prerenal causes is
characterized by decreased blood pressure or a
recent history of the same, tachycardia, and
decreased cardiac output and central venous
pressure. Bradycardia is not part of the clinical
picture for any form of renal failure.
The nurse is analyzing the post-hemodialysis
laboratory test results for a client with chronic
kidney disease. The nurse interprets that the
dialysis is having an expected but nontherapeutic
effect if which value is decreased?
A. Potassium
B. Creatinine
C. Phosphorus
D. Red blood cell (RBC) count
D. Red blood cell (RBC) count
Hemodialysis typically lowers the amounts of fluid,
sodium, potassium, urea nitrogen, creatinine, uric
acid, magnesium, and phosphate levels in the
blood. Hemodialysis also worsens anemia because
RBCs are lost during dialysis from blood sampling
and anticoagulation and from residual blood left in
the dialyzer. Although all of these results are
expected, only the lowered RBC count is
nontherapeutic and worsens the anemia already
caused by the disease process.
A client with an arteriovenous fistula in the left arm
and who is undergoing hemodialysis is at risk for
infection. Which should the nurse formulate as the
best outcome goal for this client problem?
A. The client washes hands at least once per day.
B. The client's temperature remains lower than
101° F.
C. The client avoids blood pressure (BP)
measurement in the left arm.
D. The client's white blood cell (WBC) count
remains within normal limits.
D. The client's white blood cell (WBC) count
remains within normal limits.
General indicators that the client is not
experiencing infection include a temperature and
WBC count within normal limits. The client also
should use proper hand washing technique as a
general preventive measure. Hand washing once
per day is insufficient. It is true that the client
should avoid BP measurement in the affected arm;
however, this would relate more closely to the
problem of risk for injury.
The nurse is giving general instructions to a client
receiving hemodialysis. Which statement would be
most appropriate for the nurse to include?
A. "It is acceptable to eat whatever you want on
the day before hemodialysis."
B. "It is acceptable to exceed the fluid restriction
on the day before hemodialysis."
C. "Medications should be double-dosed on the
morning of hemodialysis because of potential loss."
D. "Several types of medications should be
withheld on the day of dialysis until after the
procedure."
D. "Several types of medications should be
withheld on the day of dialysis until after the
procedure."
Many medications are dialyzable, which means
that they are extracted from the bloodstream
during dialysis. Therefore many medications may
be withheld on the day of dialysis until after the
procedure. It is not typical for medications to be
double-dosed, because there is no way to be
certain how much of each medication is cleared by
dialysis. Clients receiving hemodialysis are not
routinely taught that it is acceptable to disregard
dietary and fluid restrictions
A client undergoing hemodialysis is at risk for
bleeding from the heparin used during the
hemodialysis treatment. The nurse assesses for this
occurrence by periodically checking the results of
which laboratory test?
A. Bleeding time
B. Thrombin time
C. Prothrombin time (PT)
D. Partial thromboplastin time (PTT)
D. Partial thromboplastin time (PTT)
Heparin is the anticoagulant used most often
during hemodialysis. The hemodialysis nurse
monitors the extent of anticoagulation by checking
the PTT, which is the appropriate measure of
heparin effect. Thrombin and bleeding times are
not used to measure the effect of heparin therapy,
although they are useful in the diagnosis of other
clotting abnormalities. The PT is one test used to
monitor the effect of warfarin (Coumadin) therapy
The nurse is monitoring the fluid balance of an
assigned client. The nurse determines that the
client has proper fluid balance if which 24-hour
intake and output totals are noted?
A. Intake 1500 mL, output 800 mL
B. Intake 3000 mL, output 2000 mL
C. Intake 2400 mL, output 2900 mL
D. Intake 1800 mL, output 1750 mL
D. Intake 1800 mL, output 1750 mL
For the client taking a normal diet, the normal fluid
intake is approximately 1200 to 1800 mL of
measurable fluids per day. The client's output in
the same period should be about the same and
does not include insensible losses, which are extra.
Insensible losses are offset by the fluid in solid
foods, which also is not measured.
The registered nurse is instructing a new nursing
graduate about hemodialysis. Which statement, if
made by the new nursing graduate, would indicate
an understanding of the procedure for
hemodialysis? Select all that apply.
A. "Sterile dialysate must be used."
B. "Dialysate contains metabolic waste products."
C. "Heparin sodium is administered during dialysis."
D. "Dialysis cleanses the blood of accumulated
waste products."
E. "Warming the dialysate increases the efficiency
of diffusion."
C. "Heparin sodium is administered during dialysis."
D. "Dialysis cleanses the blood of accumulated
waste products."
E. "Warming the dialysate increases the efficiency
of diffusion."
Heparin sodium is used during dialysis, and it
inhibits the tendency of blood to clot when it
comes in contact with foreign substances. Option 4
is the purpose of dialysis. The dialysate is warmed
to approximately 100° F to increase the efficiency
of diffusion and to prevent a decrease in the
client's blood temperature. Dialysate is made from
clear water and chemicals and is free from any
metabolic waste products or medications. Bacteria
and other microorganisms are too large to pass
through the membrane; therefore the dialysate
does not need to be sterile.
The nurse is caring for a client with acute kidney
injury (AKI). When performing an assessment, the
nurse would expect to note which breathing
pattern?
A. Apnea
B. Kussmaul's respirations
C. Decreased respirations
D. Cheyne-Stokes respirations
B. Kussmaul's respirations
Clinical manifestations associated with AKI occur as
a result of metabolic acidosis. The nurse would
expect to note Kussmaul's respirations as a result
of the metabolic acidosis because the bodily
response is to exhale excess carbon dioxide. The
breathing patterns noted in options 1, 3, and 4 are
not characteristic of AKI.
The nursing student is assigned to care for a client
with a diagnosis of acute kidney injury (AKI),
diuretic phase. The nursing instructor asks the
student about the primary goal of the treatment
plan for this client. Which goal, if stated by the
nursing student, would indicate an adequate
understanding of the treatment plan for this client?
A. Prevent fluid overload.
B. Prevent loss of electrolytes.
C. Promote the excretion of wastes.
D. Reduce the urine specific gravity.
B. Prevent loss of electrolytes.
In the diuretic phase, fluids and electrolytes are
lost in the urine. As a result, the plan of care
focuses on fluid and electrolyte replacement and
monitoring. Options 1, 3, and 4 are not the primary
concerns in this phase of acute kidney injury.
The nurse instructs a client about continuous
ambulatory peritoneal dialysis (CAPD). Which
statement, if made by the client, indicates an
accurate understanding of CAPD?

A. "No machinery is involved, and I can pursue my
usual activities."
B. "A cycling machine is used, so the risk for
infection is minimized."
C. "The drainage system can be used once during
the day and a cycling machine for three cycles at
night."
D. "A portable hemodialysis machine is used so
that I will be able to ambulate during the
treatment."
A. "No machinery is involved, and I can pursue my
usual activities."
CAPD closely approximates normal renal function,
and the client will need to infuse and drain the
dialysis solution several times a day. No machinery
is used, and CAPD is a manual procedure.
The nurse tests the urine of a client with acute
kidney injury (AKI) with a multitest reagent strip.
The strip tests highly positive for proteinuria. The
nurse plans care, knowing that this result is
consistent with which type of AKI?
A. Prerenal
B. Postrenal
C. Intrinsic
D. Atypical
C. Intrinsic
With intrinsic failure, there is a fixed specific gravity
and the urine tests positive for proteinuria. In
prerenal failure, the specific gravity is high and
there is very little or no proteinuria. In postrenal
failure, there is a fixed specific gravity and little or
no proteinuria. There is no disorder known as
atypical renal failure.
A client with chronic kidney disease (CKD) is about
to begin hemodialysis therapy. The client asks the
nurse about the frequency and scheduling of
hemodialysis treatments. The nurse's response is
based on an understanding that which represents
the typical schedule?
A. 5 hours of treatment 2 days per week
B. 2 hours of treatment 6 days per week
C. 3 to 4 hours of treatment 3 days per week
D. 2 to 3 hours of treatment 5 days per week
C. 3 to 4 hours of treatment 3 days per week
The typical schedule for hemodialysis is 3 to 4
hours of treatment 3 days per week. Individual
adjustments are made according to variables such
as the size of the client, type of dialyzer, rate of
blood flow, personal client preferences, and other
factors.
A client is about to begin hemodialysis. Which
measure(s) should the nurse employ in the care of
the client? Select all that apply.
A. Using sterile technique for needle insertion
B. Using standard precautions in the care of the
client
C. Giving the client a mask to wear during
connection to the machine
D. Wearing full protective clothing such as goggles,
mask, gloves, and apron
E. Covering the connection site with a bath blanket
to enhance extremity warmth
A. Using sterile technique for needle insertion
B. Using standard precautions in the care of the
client
C. Giving the client a mask to wear during
connection to the machine
D. Wearing full protective clothing such as goggles,
mask, gloves, and apron
Infection is a major concern with hemodialysis. For
that reason, the use of sterile technique and the
application of a face mask for both nurse and client
are extremely important. It also is imperative that
standard precautions be followed, which includes
the use of goggles, mask, gloves, and an apron. The
connection site should not be covered; it should be
visible so that the nurse can assess for bleeding,
ischemia, and infection at the site during the
hemodialysis procedure.
The nurse is working on a medical-surgical nursing
unit and is caring for several clients with chronic
kidney disease. The nurse interprets that which
client is best suited for peritoneal dialysis as a
treatment option?
A. A client with severe heart failure
B. A client with a history of ruptured diverticula
C. A client with a history of herniated lumbar disk
D. A client with a history of three previous
abdominal surgeries
A. A client with severe heart failure
Peritoneal dialysis may be the treatment option of
choice for clients with severe cardiovascular
disease. Severe cardiac disease can be worsened by
the rapid shifts in fluid, electrolytes, urea, and
glucose that occur with hemodialysis. For the same
reason, peritoneal dialysis may be indicated for the
client with diabetes mellitus. Contraindications to
peritoneal dialysis include diseases of the abdomen
such as ruptured diverticula or malignancies;
extensive abdominal surgeries; history of
peritonitis; obesity; and a history of back problems,
which could be aggravated by the fluid weight of
the dialysate. Severe disease of the vascular system
also may be a relative contraindication.
A client is being discharged to home while
recovering from acute kidney injury (AKI). A
reduction in which substance indicates to the nurse
that the client understands the dietary teaching?
A. Fats
B. Vitamins
C. Potassium
D. Carbohydrates
C. Potassium
The excretion of potassium and maintenance of
potassium balance are normal functions of the
kidneys. In the client with acute kidney injury or
chronic kidney disease, potassium intake must be
restricted as much as possible (to 60 to 70
mEq/day). The primary mechanism of potassium
removal during AKI is dialysis. Vitamins,
carbohydrates, and fats are not normally restricted
in the client with AKI unless a secondary health
problem warrants the need to do so. The amount
of fluid permitted is generally calculated to be
equal to the urine volume plus the insensible loss
volume of 500 mL.
Before providing care for a client in the late stages
of chronic kidney disease (CKD), the nurse should
review the results of which most relevant
laboratory study?
A. Urinalysis, hematocrit, hemoglobin
B. Culture and sensitivity testing, serum sodium
C. Urine specific gravity, intravenous pyelogram
D. Fasting blood glucose, serum potassium, serum
calcium
D. Fasting blood glucose, serum potassium, serum
calcium
Because of the potentially life-threatening
outcomes associated with hyperglycemia,
hyperkalemia, and hypocalcemia, they are the
most relevant to nursing management of the client
with CKD. The diagnostic tests in the remaining
options may be helpful in diagnosing CKD or in
monitoring treatment but are not the most
relevant. Additionally, decreased hematocrit and
hemoglobin occur in CKD because of the decreased
level of erythropoietin. However, a decrease in
hematocrit and hemoglobin may be reflective of
various health alterations.
In performing a physical assessment of a client with
chronic kidney disease (CKD), which finding should
the nurse anticipate to note?
A. Glycosuria
B. Polyphagia
C. Crackles auscultated in lungs
D. Blood pressure 98/58 mm Hg
C. Crackles auscultated in lungs
Chronic kidney disease is a condition in which the
kidneys have progressive problems in clearing
nitrogenous waste products and controlling fluid
and electrolyte balance within the body.
Cardiovascular symptoms of heart failure and
hypertension are caused by the fluid volume
overload resulting from the kidney's inability to
excrete water. Signs and symptoms of heart failure
include jugular venous distention, S3 heart sound,
pedal edema, increased weight, shortness of
breath, and crackles auscultated in the lungs. The
typical signs and symptoms of CKD include
proteinuria or hematuria, not glycosuria. The nurse
would observe anorexia and nausea in this client,
not polyphagia.
Which descriptions characterize acute kidney injury
(select all that apply)?
a. Primary cause of death is infection
b. It almost always affects older people
c. Disease course is potentially reversible
d. Most common cause is diabetic nephropathy
e. Cardiovascular disease is most common cause of
death
a. Primary cause of death is infection
c. Disease course is potentially reversible
Rationale: Acute kidney injury (AKI) is potentially
reversible. AKI has a high mortality rate, and the
primary cause of death in patients with AKI is
infection. The primary cause of death in patients
with chronic kidney failure is cardiovascular
disease. Most commonly, AKI follows severe,
prolonged hypotension or hypovolemia or
exposure to a nephrotoxic agent. Older adults are
more susceptible to AKI because the number of
functioning nephrons decrease with age, but AKI
can occur at any age.
RIFLE defines three stages of AKI based on changes
in
a. blood pressure and urine osmolality
b. fractional excretion of urinary sodium
c. estimation of GFR with the MDRD equation
d. serum creatinine or urine output from baseline
d. serum creatinine or urine output from baseline
Rationale: The RIFLE classification is used to
describe the stages of AKI. RIFLE standardizes the
diagnosis of AKI. Risk (R) is the first stage of AKI,
followed by injury (I), which is the second stage,
and then increasing in severity to the final or third
stage of failure (F). The two outcome variables are
loss (L) and end-stage renal disease (E). The first
three stages are characterized by the serum
creatinine level and urine output.
During the oliguric phase of AKI, the nurse
monitors the patient for (select all that apply)
a. hypotension
b. ECG changes
c. hypernatremia
d. pulmonary edema
e. urine with high specific gravity
b. ECG changes
d. pulmonary edema
Rationale: The nurse monitors the patient in the
oliguric phase of acute renal injury for the
following:
-Hypertension and pulmonary edema: When
urinary output decreases, fluid retention occurs.
The severity of the symptoms depends on the
extent of the fluid overload. In the case of reduced
urine output (i.e., anuria, oliguria), the neck veins
may become distended with a bounding pulse.
Edema and hypertension may develop. Fluid
overload can eventually lead to heart failure (HF),
pulmonary edema, and pericardial and pleural
effusions.
-Hyponatremia: Damaged tubules cannot conserve
sodium. Consequently, the urinary excretion of
sodium may increase, which results in normal or
below-normal serum levels of sodium.
-Electrocardiographic changes and hyperkalemia:
Initially, clinical signs of hyperkalemia are apparent
on electrocardiogram (ECG) demonstrating peaked
T waves, widening of the QRS complex, and ST-
segment depression.
-Urinary specific gravity: Urinary specific gravity is
fixed at about 1.010.
If a patient is in the diuretic phase of AKI, the nurse
must monitor for which serum electrolyte
imbalances?
a. Hyperkalemia and hyponatremia
b. Hyperkalemia and hypernatremia
c. Hypokalemia and hyponatremia
d. Hypokalemia and hypernatremia
c. Hypokalemia and hyponatremia
Rationale: In the diuretic phase of AKI, the kidneys
have recovered the ability to excrete wastes but
not the ability to concentrate urine. Hypovolemia
and hypotension can result from massive fluid
losses. Because of the large losses of fluid and
electrolytes, the patient must be monitored for
hyponatremia, hypokalemia, and dehydration.
A patient is admitted to the hospital with chronic
kidney disease. The nurse understands that this
condition is characterized by
a. progressive irreversible destruction of the
kidneys
b. a rapid decrease in urine output with an
elevated BUN
c. an increasing creatinine clearance with a
decrease in urine output
d. prostration, somnolence, and confusion with
coma and imminent death
a. progressive irreversible destruction of the
kidneys
Rationale: Chronic kidney disease (CKD) involves
progressive, irreversible loss of kidney function.
Nurses must teach patients at risk for developing
chronic kidney disease. Individuals considered to
be at increased risk include (select all that apply)
a. older African Americans
b. patients more than 60 years old
c. those with a history of pancreatitis
d. those with a history of hypertension
e. those with a history of type 2 diabetes
a. older African Americans
b. patients more than 60 years old
d. those with a history of hypertension
e. those with a history of type 2 diabetes
Rationale: Risk factors for CKD include diabetes
mellitus, hypertension, age older than 60 years,
cardiovascular disease, family history of CKD,
exposure to nephrotoxic drugs, and ethnic minority
(e.g., African American, Native American).
Patients with chronic kidney disease experience an
increased incidence of cardiovascular disease
related to (select all that apply)
a. hypertension
b. vascular calcifications
c. a genetic predisposition
d. hyperinsulinemia causing dyslipidemia
e. increased high-density lipoprotein levels
a. hypertension
b. vascular calcifications
d. hyperinsulinemia causing dyslipidemia
Rationale: CKD patients have traditional
cardiovascular (CV) risk factors, such as
hypertension and elevated lipids. Hyperinsulinemia
stimulates hepatic production of triglycerides.
Most patients with uremia develop dyslipidemia.
CV disease may be related to nontraditional CV risk
factors, such as vascular calcification and arterial
stiffness, which are major contributors to CV
disease in CKD. Calcium deposits in the vascular
medial layer are associated with stiffening of the
blood vessels. The mechanisms involved are
multifactorial and incompletely understood, but
they include (1) change of vascular smooth muscle
cells into chondrocytes or osteoblast-like cells, (2)
high total-body amounts of calcium and phosphate
as a result of abnormal bone metabolism, (3)
impaired renal excretion, and (4) drug therapies to
treat the bone disease (e.g., calcium phosphate
binders).
Nutritional support and management are essential
across the entire continuum of chronic kidney
disease. Which statements would be considered
true related to nutritional therapy (select all that
apply)?
a. Fluid is not usually restricted for patients
receiving peritoneal dialysis
b. Sodium and potassium may be restricted in
someone with advanced CKD
c. Decreased fluid intake and a low-potassium diet
are hallmarks of the diet for a patient receiving
hemodialysis
d. Decreased fluid intake and a low-potassium diet
are hallmarks of the diet for a patient receiving
peritoneal dialysis
e. Decreased fluid intake and a diet with
phosphate-rich foods are hallmarks of a diet for a
patient receiving hemodialysis
a. Fluid is not usually restricted for patients
receiving peritoneal dialysis
b. Sodium and potassium may be restricted in
someone with advanced CKD
c. Decreased fluid intake and a low-potassium diet
are hallmarks of the diet for a patient receiving
hemodialysis
Rationale: Water and any other fluids are not
routinely restricted before Stage 5 end-stage renal
disease (ESRD). Patients receiving hemodialysis
have a more restricted diet than do patients
receiving peritoneal dialysis. Patients receiving
hemodialysis are frequently educated about the
need for a dietary restriction of potassium- and
phosphate-rich foods. However, patients receiving
peritoneal dialysis may actually require
replacement of potassium because of the higher
losses of potassium with peritoneal dialysis.
Sodium and salt restriction is common for all
patients with CKD. For those receiving
hemodialysis, as their urinary output diminishes,
fluid restrictions are enhanced. Intake depends on
the daily urine output. In general, 600 mL (from
insensible loss) plus an amount equal to the
previous day's urine output is allowed for a patient
receiving hemodialysis. Patients are advised to limit
fluid intake so that weight gains between dialysis
sessions (i.e., interdialytic weight gain) are no more
than 1 to 2 kg. For the patient who is undergoing
dialysis, protein is not routinely restricted. The
beneficial role of protein restriction in CKD stages 1
through 4 as a means to reduce the decline in
kidney function is controversial. Historically,
dietary counseling often encouraged restriction of
protein for individuals with CKD. Although there is
some evidence that protein restriction has
benefits, many patients find these diets difficult to
adhere to. For CKD stages 1 through 4, many
clinicians encourage a diet with normal protein
intake. However, patients must be taught to avoid
high-protein diets and supplements because they
may overstress the diseased kidneys.
An ESRD patient receiving hemodialysis is
considering asking a relative to donate a kidney for
transplantation. In assisting the patient to make a
decision about treatment, the nurse informs the
patient that
a. successful transplantation usually provides
better quality of life than that offered by dialysis
b. if rejection of the transplanted kidney occurs, no
further treatment for the renal failure is available
c. hemodialysis replaces the normal functions of
the kidneys, and patients do not have to live with
the continual fear of rejection
d. the immunosuppressive therapy following
transplantation makes the person ineligible to
receive other forms of treatment if the kidney fails
a. successful transplantation usually provides
better quality of life than that offered by dialysis
Rationale: Kidney transplantation is extremely
successful, with 1-year graft survival rates of about
90% for deceased donor organs and 95% for live
donor organs. An advantage of kidney
transplantation over dialysis is that it reverses
many of the pathophysiologic changes associated
with renal failure when normal kidney function is
restored. It also eliminates the dependence on
dialysis and the need for the accompanying dietary
and lifestyle restrictions. Transplantation is less
expensive than dialysis after the first year.
To assess the potency of a newly placed
arteriovenous graft for dialysis, the nurse should
(select all that apply)
a. monitor the BP in the affected arm
b. irrigate the graft daily with low-dose heparin
c. palpate the area of the graft to feel a normal
thrill
d. listen with a stethoscope over the graft to detect
a bruit
e. frequently monitor the pulses and neurovascular
status distal to the graft
c. palpate the area of the graft to feel a normal
thrill
d. listen with a stethoscope over the graft to detect
a bruit
e. frequently monitor the pulses and neurovascular
status distal to the graft
Rationale: A thrill can be felt on palpation of the
area of anastomosis of the arteriovenous graft, and
a bruit can be heard with a stethoscope. The bruit
and thrill are created by arterial blood rushing into
the vein. The BP should not be taken in the arm
with the AV graft.
A major advantage of peritoneal dialysis is
a. the diet is less restricted and dialysis can be
performed at home
b. the dialysate is biocompatible and causes no
long-term consequences
c. high glucose concentrations of the dialysate
cause a reduction in appetite, promoting weight
loss
d. no medications are required because of the
enhanced efficiency of the peritoneal membrane in
removing toxins
a. the diet is less restricted and dialysis can be
performed at home
Rationale: Advantages of peritoneal dialysis include
fewer dietary restrictions and the possibility of
home dialysis.
A kidney transplant recipient complains of having
fever, chills, and dysuria over the past 2 days. What
is the first action that the nurse should take?
a. Assess temperature and initiate workup to rule
out infection
b. Reassure the patient that this is common after
transplantation
c. Provide warm cover for the patient and give 1 g
acetaminophen orally
d. Notify the nephrologist that the patient has
developed symptoms of acute rejection
a. Assess temperature and initiate workup to rule
out infection
Rationale: The nurse must be astute in the
observation and assessment of kidney transplant
recipients because prompt diagnosis and treatment
of infections can improve patient outcomes. Fever,
chills, and dysuria indicate an infection. The
temperature should be assessed, and the patient
should undergo diagnostic testing to rule out an
infection.
1. Which descriptions characterize acute kidney
injury (select all that apply)?
a. Primary cause of death is infection.
b. It almost always affects older people.
c. Disease course is potentially reversible.
d. Most common cause is diabetic nephropathy.
e. Cardiovascular disease is most common cause of
death.
a. Primary cause of death is infection.
c. Disease course is potentially reversible.
2. RIFLE defines three stages of AKI based on
changes in
a. blood pressure and urine osmolality.
b. fractional excretion of urinary sodium.
c. estimation of GFR with the MDRD equation.
d. serum creatinine or urine output from baseline.
d. serum creatinine or urine output from baseline
3. During the oliguric phase of AKI, the nurse
monitors the patient for (select all that apply)
a. hypotension.
b. ECG changes.
c. hypernatremia.
d. pulmonary edema.
e. urine with high specific gravity.
b. ECG changes.
d. pulmonary edema.
4. If a patient is in the diuretic phase of AKI, the
nurse must monitor for which serum electrolyte
imbalances?
a. Hyperkalemia and hyponatremia
b. Hyperkalemia and hypernatremia
c. Hypokalemia and hyponatremia
d. Hypokalemia and hypernatremia
c. Hypokalemia and hyponatremia
5. A patient is admitted to the hospital with chronic
kidney disease. The nurse understands that this
condition is characterized by
a. progressive irreversible destruction of the
kidneys.
b. a rapid decrease in urine output with an
elevated BUN.
c. an increasing creatinine clearance with a
decrease in urine output.
d. prostration, somnolence, and confusion with
coma and imminent death.
a. progressive irreversible destruction of the
kidneys.
6. Nurses must teach patients at risk for developing
chronic kidney disease. Individuals considered to
be at increased risk include (select all that apply)
a. older African Americans.
b. patients more than 60 years old.
c. those with a history of pancreatitis.
d. those with a history of hypertension.
e. those with a history of type 2 diabetes.
a. older African Americans.
b. patients more than 60 years old.
d. those with a history of hypertension.
e. those with a history of type 2 diabetes.
7. Patients with chronic kidney disease experience
an increased incidence of cardiovascular disease
related to (select all that apply)
a. hypertension.
b. vascular calcifications.
c. a genetic predisposition.
d. hyperinsulinemia causing dyslipidemia.
e. increased high-density lipoprotein levels.
a. hypertension.
b. vascular calcifications.
d. hyperinsulinemia causing dyslipidemia.
8. Nutritional support and management are
essential across the entire continuum of chronic
kidney disease. Which statements would be
considered true related to nutritional therapy
(select all that apply)?
a. Fluid is not usually restricted for patients
receiving peritoneal dialysis.
b. Sodium and potassium may be restricted in
someone with advanced CKD.
c. Decreased fluid intake and a low-potassium diet
are hallmarks of the diet for a patient receiving
hemodialysis.
d. Decreased fluid intake and a low-potassium diet
are hallmarks of the diet for a patient receiving
peritoneal dialysis.
e. Decreased fluid intake and a diet with
phosphate-rich foods are hallmarks of a diet for a
patient receiving hemodialysis.
a. Fluid is not usually restricted for patients
receiving peritoneal dialysis.
b. Sodium and potassium may be restricted in
someone with advanced CKD.
c. Decreased fluid intake and a low-potassium diet
are hallmarks of the diet for a patient receiving
hemodialysis.
9. An ESRD patient receiving hemodialysis is
considering asking a relative to donate a kidney for
transplantation. In assisting the patient to make a
decision about treatment, the nurse informs the
patient that
a. successful transplantation usually provides
better quality of life than that offered by dialysis.
b. if rejection of the transplanted kidney occurs, no
further treatment for the renal failure is available.
c. hemodialysis replaces the normal functions of
the kidneys, and patients do not have to live with
the continual fear of rejection.
d. the immunosuppressive therapy following
transplantation makes the person ineligible to
receive other forms of treatment if the kidney fails.
a. successful transplantation usually provides
better quality of life than that offered by dialysis.
10. To assess the patency of a newly placed
arteriovenous graft for dialysis, the nurse should
(select all that apply)
a. monitor the BP in the affected arm.
b. irrigate the graft daily with low-dose heparin.
c. palpate the area of the graft to feel a normal
thrill.
d. listen with a stethoscope over the graft to detect
a bruit.
e. frequently monitor the pulses and neurovascular
status distal to the graft.
c. palpate the area of the graft to feel a normal
thrill.
d. listen with a stethoscope over the graft to detect
a bruit.
e. frequently monitor the pulses and neurovascular
status distal to the graft.
11. A major advantage of peritoneal dialysis is
a. the diet is less restricted and dialysis can be
performed at home.
b. the dialysate is biocompatible and causes no
long-term consequences.
c. high glucose concentrations of the dialysate
cause a reduction in appetite, promoting weight
loss.
d. no medications are required because of the
enhanced efficiency of the peritoneal membrane in
removing toxins.
a. the diet is less restricted and dialysis can be
performed at home.
12. A kidney transplant recipient complains of
having fever, chills, and dysuria over the past 2
days. What is the first action that the nurse should
take?
a. Assess temperature and initiate workup to rule
out infection.
b. Reassure the patient that this is common after
transplantation.
c. Provide warm cover for the patient and give 1 g
acetaminophen orally.
d. Notify the nephrologist that the patient has
developed symptoms of acute rejection.
a. Assess temperature and initiate workup to rule
out infection.
1. A 52-year-old man with stage 2 chronic kidney
disease is scheduled for an outpatient diagnostic
procedure using contrast media. Which action
should the nurse take?
a. Assess skin turgor to determine hydration status.
b. Insert a urinary catheter for the expected
diuresis.
c. Evaluate the patient’s lower extremities for
edema.
d. Check the patient’s urine for the presence of
ketones.
a. Assess skin turgor to determine hydration status.
Preexisting kidney disease is the most important
risk factor for the development of contrast-
associated nephropathy and nephrotoxic injury. If
contrast media must be administered to a high-risk
patient, the patient needs to have optimal
hydration. The nurse should assess the hydration
status of the patient before the procedure is
performed. Indwelling catheter use should be
avoided whenever possible to decrease the risk of
infection.
2. A frail 72-year-old woman with stage 3 chronic
kidney disease is cared for at home by her family.
The patient has a history of taking many over-the-
counter medications. Which over-the-counter
medications should the nurse teach the patient to
avoid?
a. Aspirin
b. Acetaminophen (Tylenol)
c. Diphenhydramine (Benadryl)
d. Aluminum hydroxide (Amphogel)
d. Aluminum hydroxide (Amphogel)
Antacids (that contain magnesium and aluminum)
should be avoided because patients with kidney
disease are unable to excrete these substances.
Also, some antacids contain high levels of sodium
that further increase blood pressure.
Acetaminophen and aspirin (if taken for a short
period of time) are usually safe for patients with
kidney disease. Antihistamines may be used, but
combination drugs that contain pseudoephedrine
may increase blood pressure and should be
avoided.
3. The nurse is caring for a 68-year-old man who
had coronary artery bypass surgery 3 weeks ago. If
the patient is now is in the oliguric phase of acute
kidney disease, which action would be appropriate
to include in the plan of care?
a. Provide foods high in potassium.
b. Restrict fluids based on urine output.
c. Monitor output from peritoneal dialysis.
d. Offer high protein snacks between meals.
b. Restrict fluids based on urine output.
Fluid intake is monitored during the oliguric phase.
Fluid intake is determined by adding all losses for
the previous 24 hours plus 600 mL. Potassium and
protein intake may be limited in the oliguric phase
to avoid hyperkalemia and elevated urea nitrogen.
Hemodialysis, not peritoneal dialysis, is indicated in
acute kidney injury if dialysis is needed.
4. A 56-year-old woman with type 2 diabetes
mellitus and chronic kidney disease has a serum
potassium level of 6.8 mEq/L. The nurse should
assess the patient for
a. fatigue.
b. flank tenderness.
c. cardiac dysrhythmias.
d. elevated triglycerides.
c. cardiac dysrhythmias.
Hyperkalemia is the most serious electrolyte
disorder associated with kidney disease. Fatal
dysrhythmias can occur when the serum potassium
level reaches 7 to 8 mEq/L. Fatigue and
hypertriglyceridemia may be present but do not
require urgent intervention. Tenderness or pain
over the kidneys is not expected in CKD.
5. The home care nurse visits a 34-year-old woman
receiving peritoneal dialysis. Which statement, if
made by the patient, indicates a need for
immediate follow-up by the nurse?
a. “Drain time is faster if I rub my abdomen.”
b. “The fluid draining from the catheter is cloudy.”
c. “The drainage is bloody when I have my period.”
d. “I wash around the catheter with soap and
water.”
b. “The fluid draining from the catheter is cloudy.”
The primary clinical manifestation of peritonitis is a
cloudy peritoneal effluent. Blood may be present in
the effluent of women who are menstruating, and
no intervention is indicated. Daily catheter care
may include washing around the catheter with
soap and water. Drain time may be facilitated by
gently massaging the abdomen.
1. The patient has had type 1 diabetes mellitus for
25 years and is now reporting fatigue, edema, and
an irregular heartbeat. On assessment, the nurse
finds that the patient has newly developed
hypertension and difficulty with blood glucose
control. The nurse should know that which
diagnostic study will be most indicative of chronic
kidney disease (CKD) in this patient?
a. Serum creatinine
b. Serum potassium
c. Microalbuminuria
d. Calculated glomerular filtration rate (GFR)
d. Calculated glomerular filtration rate (GFR)
The best study to determine kidney function or
chronic kidney disease (CKD) that would be
expected in the patient with diabetes is the
calculated GFR that is obtained from the patient's
age, gender, race, and serum creatinine. It would
need to be abnormal for 3 months to establish a
diagnosis of CKD. A creatinine clearance test done
with a blood sample and a 24-hour urine collection
is also important. Serum creatinine is not the best
test for CKD because the level varies with different
patients. Serum potassium levels could explain why
the patient has an irregular heartbeat. The finding
of microalbuminuria can alert the patient with
diabetes about potential renal involvement and
potentially failing kidneys. However, urine albumin
levels are not used for diagnosis of CKD.
2. Which statement by the nurse regarding
continuous ambulatory peritoneal dialysis (CAPD)
would be of highest priority when teaching a
patient new to this procedure?
a. "It is essential that you maintain aseptic
technique to prevent peritonitis."
b. "You will be allowed a more liberal protein diet
once you complete CAPD."
c. "It is important for you to maintain a daily
written record of blood pressure and weight."
d. "You will need to continue regular medical and
nursing follow-up visits while performing CAPD."
a. "It is essential that you maintain aseptic
technique to prevent peritonitis."
Peritonitis is a potentially fatal complication of
peritoneal dialysis, and thus it is imperative to
teach the patient methods of preventing this from
occurring. Although the other teaching statements
are accurate, they do not have the potential for
morbidity and mortality as does peritonitis, thus
making that statement of highest priority.
3. Which assessment finding is a consequence of
the oliguric phase of AKI?
a. Hypovolemia
b. Hyperkalemia
c. Hypernatremia
d. Thrombocytopenia
b. Hyperkalemia
In AKI the serum potassium levels increase because
the normal ability of the kidneys to excrete
potassium is impaired. Sodium levels are typically
normal or diminished, whereas fluid volume is
normally increased because of decreased urine
output. Thrombocytopenia is not a consequence of
AKI, although altered platelet function may occur in
AKI.
4. The patient has a form of glomerular
inflammation that is progressing rapidly. She is
gaining weight, and the urine output is steadily
declining. What is the priority nursing intervention?
a. Monitor the patient's cardiac status.
b. Teach the patient about hand washing.
c. Obtain a serum specimen for electrolytes.
d. Increase direct observation of the patient.
a. Monitor the patient's cardiac status.
The nurse's priority is to monitor the patient's
cardiac status. With the rapidly progressing
glomerulonephritis, renal function begins to fail
and fluid, potassium, and hydrogen retention lead
to hypervolemia, hyperkalemia, and metabolic
acidosis. Excess fluid increases the workload of the
heart, and hyperkalemia can lead to life-
threatening dysrhythmias. Teaching about hand
washing and observation of the patient are
important nursing interventions but are not the
priority. Electrolyte measurement is a collaborative
intervention that will be done as ordered by the
health care provider.
5. A 78-year-old patient has Stage 3 CKD and is
being taught about a low potassium diet. The nurse
knows the patient understands the diet when the
patient selects which foods to eat?
a. Apple, green beans, and a roast beef sandwich
b. Granola made with dried fruits, nuts, and seeds
c. Watermelon and ice cream with chocolate sauce
d. Bran cereal with ½ banana and milk and orange
juice
a. Apple, green beans, and a roast beef sandwich
When the patient selects an apple, green beans,
and a roast beef sandwich, the patient
demonstrates understanding of the low potassium
diet. Granola, dried fruits, nuts and seeds, milk
products, chocolate sauce, bran cereal, banana,
and orange juice all have elevated levels of
potassium, at or above 200 mg per 1/2 cup.
6. The patient was diagnosed with prerenal AKI.
The nurse should know that what is most likely the
cause of the patient's diagnosis?
a. IV tobramycin (Nebcin)
b. Incompatible blood transfusion
c. Poststreptococcal glomerulonephritis
d. Dissecting abdominal aortic aneurysm
d. Dissecting abdominal aortic aneurysm
A dissecting abdominal aortic aneurysm is a
prerenal cause of AKI because it can decrease renal
artery perfusion and therefore the glomerular
filtrate rate. Aminoglycoside antibiotic
administration, a hemolytic blood transfusion
reaction, and poststretpcoccal glomerulonephritis
are intrarenal causes of AKI.
7. Which patient should be taught preventive
measures for CKD by the nurse because this patient
is most likely to develop CKD?
a. A 50-year-old white female with hypertension
b. A 61-year-old Native American male with
diabetes
c. A 40-year-old Hispanic female with
cardiovascular disease
d. A 28-year-old African American female with a
urinary tract infection
b. A 61-year-old Native American male with
diabetes
It is especially important for the nurse to teach CKD
prevention to the 61-year-old Native American
with diabetes. This patient is at highest risk
because diabetes causes about 50% of CKD. This
patient is the oldest, and Native Americans with
diabetes develop CKD 6 times more frequently
than other ethnic groups. Hypertension causes
about 25% of CKD. Hispanics have CKD about 1.5
times more than non-Hispanics. African Americans
have the highest rate of CKD because hypertension
is significantly increased in African Americans. A
UTI will not cause CKD unless it is not treated or
UTIs occur recurrently.
8. When caring for a patient during the oliguric
phase of acute kidney injury (AKI), what is an
appropriate nursing intervention?
a. Weigh patient three times weekly.
b. Increase dietary sodium and potassium.
c. Provide a low-protein, high-carbohydrate diet.

d. Restrict fluids according to previous daily loss.
d. Restrict fluids according to previous daily loss.
Patients in the oliguric phase of acute kidney injury
will have fluid volume excess with potassium and
sodium retention. Therefore they will need to have
dietary sodium, potassium, and fluids restricted.
Daily fluid intake is based on the previous 24-hour
fluid loss (measured output plus 600 ml for
insensible loss). The diet also needs to provide
adequate, not low, protein intake to prevent
catabolism. The patient should also be weighed
daily, not just three times each week.
9. A 24-year-old female donated a kidney via a
laparoscopic donor nephrectomy to a non-related
recipient. The patient is experiencing a lot of pain
and refuses to get up to walk. How should the
nurse handle this situation?
a. Have the transplant psychologist convince her to
walk.
b. Encourage even a short walk to avoid
complications of surgery.
c. Tell the patient that no other patients have ever
refused to walk.
d. Tell the patient she is lucky she did not have an
open nephrectomy.
b. Encourage even a short walk to avoid
complications of surgery.
Because ambulating will improve bowel, lung, and
kidney function with improved circulation, even a
short walk with assistance should be encouraged
after pain medication. The transplant psychologist
or social worker's role is to determine if the patient
is emotionally stable enough to handle donating a
kidney, while postoperative care is the nurse's role.
Trying to shame the patient into walking by telling
her that other patients have not refused and telling
the patient she is lucky she did not have an open
nephrectomy (implying how much more pain she
would be having if it had been open) will not be
beneficial to the patient or her postoperative
recovery.
10. A patient is recovering in the intensive care unit
(ICU) after receiving a kidney transplant
approximately 24 hours ago. What is an expected
assessment finding for this patient during this early
stage of recovery?
a. Hypokalemia
b. Hyponatremia
c. Large urine output
d. Leukocytosis with cloudy urine output
c. Large urine output
Patients frequently experience diuresis in the hours
and days immediately following a kidney
transplant. Electrolyte imbalances and signs of
infection are unexpected findings that warrant
prompt intervention.
11. The nurse preparing to administer a dose of
calcium acetate (PhosLo) to a patient with chronic
kidney disease (CKD) should know that this
medication should have a beneficial effect on
which laboratory value?
a. Sodium
b. Potassium
c. Magnesium
d. Phosphorus
d. Phosphorus
Phosphorus and calcium have inverse or reciprocal
relationships, meaning that when phosphorus
levels are high, calcium levels tend to be low.
Therefore administration of calcium should help to
reduce a patient's abnormally high phosphorus
level, as seen with CKD. PhosLo will not have an
effect on sodium, potassium, or magnesium levels.
12. Diffusion, osmosis, and ultrafiltration occur in
both hemodialysis and peritoneal dialysis. The
nurse should know that ultrafiltration in peritoneal
dialysis is achieved by which method?
a. Increasing the pressure gradient
b. Increasing osmolality of the dialysate
c. Decreasing the glucose in the dialysate
d. Decreasing the concentration of the dialysate
b. Increasing osmolality of the dialysate
Ultrafiltration in peritoneal dialysis is achieved by
increasing the osmolality of the dialysate with
additional glucose. In hemodialysis the increased
pressure gradient from increased pressure in the
blood compartment or decreased pressure in the
dialysate compartment causes ultrafiltration.
Decreasing the concentration of the dialysate in
either peritoneal or hemodialysis will decrease the
amount of fluid removed from the blood stream.
13. During hemodialysis, the patient develops light-
headedness and nausea. What should the nurse do
for the patient?
a. Administer hypertonic saline.
b. Administer a blood transfusion.
c. Decrease the rate of fluid removal.
d. Administer antiemetic medications.
c. Decrease the rate of fluid removal.
The patient is experiencing hypotension from a
rapid removal of vascular volume. The rate and
volume of fluid removal will be decreased, and
0.9% saline solution may be infused. Hypertonic
saline is not used because of the high sodium load.
A blood transfusion is not indicated. Antiemetic
medications may help the nausea but would not
help the hypovolemia.
14. The nurse knows the patient with AKI has
entered the diuretic phase when what assessments
occur (select all that apply)?
a. Dehydration
b. Hypokalemia
c. Hypernatremia
d. BUN increases
e. Serum creatinine increases
a. Dehydration
b. Hypokalemia
Dehydration, hypokalemia, and hyponatremia
occur in the diuretic phase of AKI because the
nephrons can excrete wastes but not concentrate
urine. Therefore the serum BUN and serum
creatinine levels also begin to decrease.
15. A patient with a history of end-stage kidney
disease secondary to diabetes mellitus has
presented to the outpatient dialysis unit for his
scheduled hemodialysis. Which assessments should
the nurse prioritize before, during, and after his
treatment?
a. Level of consciousness
b. Blood pressure and fluid balance
c. Temperature, heart rate, and blood pressure
d. Assessment for signs and symptoms of infection
b. Blood pressure and fluid balance
Although all of the assessments are relevant to the
care of a patient receiving hemodialysis, the nature
of the procedure indicates a particular need to
monitor the patient's blood pressure and fluid
balance.
16. The physician has decided to use renal
replacement therapy to remove large volumes of
fluid from a patient who is hemodynamically
unstable in the intensive care unit. The nurse
should expect which treatment to be used for this
patient?
a. Hemodialysis (HD) 3 times per week
b. Automated peritoneal dialysis (APD)
c. Continuous venovenous hemofiltration (CVVH)
d. Continuous ambulatory peritoneal dialysis
(CAPD)
D. Report a bruit or thrill over the fistula to the
doctor.
8. Your patient becomes restless and tells you she
has a headache and feels nauseous during
hemodialysis. Which complication do you suspect?

c. Continuous venovenous hemofiltration (CVVH) A. Infection

B. Disequilibrium syndrome
CVVH removes large volumes of water and solutes C. Air embolus
from the patient over a longer period of time by D. Acute hemolysis
using ultrafiltration and convection. HD 3 times per
week would not be used for this patient because 9. Your patient is complaining of muscle cramps
fluid and solutes build up and then are rapidly while undergoing hemodialysis. Which intervention
removed. With APD (used at night instead of during is effective in relieving muscle cramps?
the day) fluid and solutes build up during the day
and would not benefit this patient as much. CAPD A. Increase the rate of dialysis
will not as rapidly remove large amounts of fluid as B. Infuse normal saline solution
CVVH can do. C. Administer a 5% dextrose solution
D. Encourage active ROM exercises
5. You have a patient that is receiving peritoneal
dialysis. What should you do when you notice the 10. Your patient with chronic renal failure reports
return fluid is slowly draining? pruritus. Which instruction should you include in
this patient’s teaching plan?
A. Check for kinks in the outflow tubing.
B. Raise the drainage bag above the level of A. Rub the skin vigorously with a towel
the abdomen. B. Take frequent baths
C. Place the patient in a reverse C. Apply alcohol-based emollients to the skin
Trendelenburg position. D. Keep fingernails short and clean
D. Ask the patient to cough.
11. Which intervention do you plan to include with
6. What is the appropriate infusion time for the a patient who has renal calculi?
dialysate in your 38 y.o. patient with chronic renal
failure? A. Maintain bed rest
B. Increase dietary purines
A. 15 minutes C. Restrict fluids
B. 30 minutes D. Strain all urine
C. 1 hour
D. 2 to 3 hours 12. An 18 y.o. student is admitted with dark urine,
fever, and flank pain and is diagnosed with acute
7. A 30 y.o. female patient is undergoing glomerulonephritis. Which would most likely be in
hemodialysis with an internal arteriovenous fistula this student’s health history?
in place. What do you do to prevent complications
associated with this device? A. Renal calculi
B. Renal trauma
A. Insert I.V. lines above the fistula. C. Recent sore throat
B. Avoid taking blood pressures in the arm D. Family history of acute glomerulonephritis
with the fistula.
C. Palpate pulses above the fistula.
13. Which drug is indicated for pain related to D. Urge
acute renal calculi?
19. Immediately post-op after a prostatectomy,
A. Narcotic analgesics which complications requires priority assessment
B. Nonsteroidal anti-inflammatory drugs of your patient?
(NSAIDS)
C. Muscle relaxants A. Pneumonia
D. Salicylates B. Hemorrhage
C. Urine retention
14. Which of the following causes the majority of D. Deep vein thrombosis
UTI’s in hospitalized patients?
20. The most indicative test for prostate cancer is:
A. Lack of fluid intake
B. Inadequate perineal care A. A thorough digital rectal examination
C. Invasive procedures B. Magnetic resonance imaging (MRI)
D. Immunosuppression C. Excretory urography
D. Prostate-specific antigen
15. Clinical manifestations of acute
glomerulonephritis include which of the following? 21. A 22 y.o. patient with diabetic nephropathy
says, “I have two kidneys and I’m still young. If I
A. Chills and flank pain stick to my insulin schedule, I don’t have to worry
B. Oliguria and generalized edema about kidney damage, right?” Which of the
C. Hematuria and proteinuria following statements is the best response?
D. Dysuria and hypotension
A. “You have little to worry about as long as
16. You expect a patient in the oliguric phase of your kidneys keep making urine.”
renal failure to have a 24 hour urine output less B. “You should talk to your doctor because
than: statistics show that you’re being
unrealistic.”
A. 200ml C. “You would be correct if your diabetes
B. 400ml could be managed with insulin.”
C. 800ml D. “Even with insulin, kidney damage is still a
D. 1000ml concern.”

17. The most common early sign of kidney disease 22. A patient diagnosed with sepsis from a UTI is
is: being discharged. What do you plan to include in
her discharge teaching?
A. Sodium retention
B. Elevated BUN level A. Take cool baths
C. Development of metabolic acidosis B. Avoid tampon use
D. Inability to dilute or concentrate urine C. Avoid sexual activity
D. Drink 8 to 10 eight-oz glasses of water daily
18. A patient is experiencing which type of
incontinence if she experiences leaking urine when 23. You’re planning your medication teaching for
she coughs, sneezes, or lifts heavy objects? your patient with a UTI prescribed phenazopyridine
(Pyridium). What do you include?
A. Overflow
B. Reflex A. “Your urine might turn bright orange.”
C. Stress B. “You need to take this antibiotic for 7 days.”
 C. “Take this drug between meals and at
bedtime.”
D. “Don’t take this drug if you’re allergic to
penicillin.”
24. Which finding leads you to suspect acute
glomerulonephritis in your 32 y.o. patient?
B. The patient feels best immediately after the
dialysis treatment
C. Using a stethoscope for auscultating the
fistula is contraindicated
D. Taking a blood pressure reading on the
affected arm can cause clotting of the
fistula

A. Dysuria, frequency, and urgency 30. A patient with diabetes mellitus and renal
B. Back pain, nausea, and vomiting failure begins hemodialysis. Which diet is best on
C. Hypertension, oliguria, and fatigue days between dialysis treatments?
D. Fever, chills, and right upper quadrant pain
radiating to the back A. Low-protein diet with unlimited amounts of
water
25. What is the priority nursing diagnosis with your B. Low-protein diet with a prescribed amount
patient diagnosed with end-stage renal disease? of water
C. No protein in the diet and use of a salt
A. Activity intolerance substitute
B. Fluid volume excess D. No restrictions
C. Knowledge deficit
D. Pain 31. After the first hemodialysis treatment, your
patient develops a headache, hypertension,
26. A patient with ESRD has an arteriovenous restlessness, mental confusion, nausea, and
fistula in the left arm for hemodialysis. Which vomiting. Which condition is indicated?
intervention do you include in his plan of care?
A. Disequilibrium syndrome
A. Apply pressure to the needle site upon B. Respiratory distress
discontinuing hemodialysis C. Hypervolemia
B. Keep the ehad of the bed elevated 45 D. Peritonitis
degrees
C. Place the left arm on an arm board for at 32. Which action is most important during bladder
least 30 minutes training in a patient with a neurogenic bladder?
D. Keep the left arm dry
A. Encourage the use of an indwelling urinary
28. Which sign indicated the second phase of catheter
acute renal failure? B. Set up specific times to empty the bladder
C. Encourage Kegel exercises
A. Daily doubling of urine output (4 to 5 L/day) D. Force fluids
B. Urine output less than 400 ml/day
C. Urine output less than 100 ml/day 33. A patient with diabetes has had many renal
D. Stabilization of renal function calculi over the past 20 years and now has chronic
renal failure. Which substance must be reduced in
29. Your patient had surgery to form an this patient’s diet?
arteriovenous fistula for hemodialysis. Which
information is important for providing care for the A. Carbohydrates
patient? B. Fats
C. Protein
A. The patient shouldn’t feel pain during D. Vitamin C
initiation of dialysis
34. What is the best way to check for patency of B. Consumed with fear after the life-
the arteriovenous fistula for hemodialysis? threatening experience of having a
transplant
A. Pinch the fistula and note the speed of C. At increased risk for tumors because of the
filling on release kidney transplant
B. Use a needle and syringe to aspirate blood D. At decreased risk for cancer, so the lump is
from the fistula most likely benign
C. Check for capillary refill of the nail beds on
that extremity 39. You’re developing a care plan with the nursing
D. Palpate the fistula throughout its length to diagnosis risk for infection for your patient that
assess for a thrill received a kidney transplant. A goal for this patient
is to:
35. You have a paraplegic patient with renal
calculi. Which factor contributes to the A. Remain afebrile and have negative cultures
development of calculi? B. Resume normal fluid intake within 2 to 3
days
A. Increased calcium loss from the bones C. Resume the patient’s normal job within 2 to
B. Decreased kidney function 3 weeks
C. Decreased calcium intake D. Try to discontinue cyclosporine (Neoral) as
D. High fluid intake quickly as possible

36. What is the most important nursing diagnosis 40. You suspect kidney transplant rejection when
for a patient in end-stage renal disease? the patient shows which symptoms?

A. Risk for injury A. Pain in the incision, general malaise, and

B. Fluid volume excess hypotension
C. Altered nutrition: less than body B. Pain in the incision, general malaise, and
requirements depression
D. Activity intolerance C. Fever, weight gain, and diminished urine
output
37. Frequent PVCs are noted on the cardiac D. Diminished urine output and hypotension
monitor of a patient with end-stage renal disease.
The priority intervention is: 41. Your patient returns from the operating room
after abdominal aortic aneurysm repair. Which
A. Call the doctor immediately symptom is a sign of acute renal failure?
B. Give the patient IV lidocaine (Xylocaine)
C. Prepare to defibrillate the patient A. Anuria
D. Check the patient’s latest potassium level B. Diarrhea
C. Oliguria
38. A patient who received a kidney transplant D. Vomiting
returns for a follow-up visit to the outpatient clinic
and reports a lump in her breast. Transplant 42. Which cause of hypertension is the most
recipients are: common in acute renal failure?

A. At increased risk for cancer due to A. Pulmonary edema

immunosuppression caused by cyclosporine B. Hypervolemia
(Neoral) C. Hypovolemia
D. Anemia
43. A patient returns from surgery with an
indwelling urinary catheter in place and empty. Six
hours later, the volume is 120ml. The drainage
system has no obstructions. Which intervention
has priority?
A. Give a 500ml bolus of isotonic saline
B. Evaluate the patient’s circulation and vital
signs
C. Flush the urinary catheter with sterile water
or saline
D. Place the patient in the shock position, and
notify the surgeon
44. You’re preparing for urinary catheterization of
a trauma patient and you observe bleeding at the
urethral meatus. Which action has priority?
A. Irrigate and clean the meatus before
catheterization
B. Check the discharge for occult blood before
catheterization
C. Heavily lubricate the catheter before
insertion
D. Delay catheterization and notify the doctor
45. What change indicates recovery in a patient
with nephritic syndrome?
A. Disappearance of protein from the urine
B. Decrease in blood pressure to normal
C. Increase in serum lipid levels
D. Gain in body weight
46. Which statement correctly distinguishes renal
failure from prerenal failure?
A. With prerenal failure, vasoactive substances
such as dopamine (Intropin) increase blood
pressure
B. With prerenal failure, there is less response
to such diuretics as furosemide (Lasix)
C. With prerenal failure, an IV isotonic saline
infusion increases urine output
D. With prerenal failure, hemodialysis reduces
the BUN level
47. Which criterion is required before a patient
can be considered for continuous peritoneal
dialysis?
A. The patient must be hemodynamically
stable
B. The vascular access must have healed
C. The patient must be in a home setting
D. Hemodialysis must have failed
48. Polystyrene sulfonate (Kayexalate) is used in
renal failure to:
A. Correct acidosis
B. Reduce serum phosphate levels
C. Exchange potassium for sodium
D. Prevent constipation from sorbitol use
49. Your patient has complaints of severe right-
sided flank pain, nausea, vomiting and restlessness.
He appears slightly pale and is diaphoretic. Vital
signs are BP 140/90 mmHg, Pulse 118 beats/min.,
respirations 33 breaths/minute, and temperature,
98.0F. Which subjective data supports a diagnosis
of renal calculi?
A. Pain radiating to the right upper quadrant
B. History of mild flu symptoms last week
C. Dark-colored coffee-ground emesis
D. Dark, scant urine output
50. Immunosuppression following Kidney
transplantation is continued:
A. For life
B. 24 hours after transplantation
C. A week after transplantation
D. Until the kidney is not anymore rejected
1. Dialysis allows for the exchange of particles
across a semipermeable membrane by which of the
following actions?
A. Osmosis and diffusion
B. Passage of fluid toward a solution with a
lower solute concentration
C. Allowing the passage of blood cells and
protein molecules through it.
 D. Passage of solute particles toward a
solution with a higher concentration.
2. A client is diagnosed with chronic renal failure
and told she must start hemodialysis. Client
teaching would include which of the following
instructions?
A. Follow a high potassium diet
B. Strictly follow the hemodialysis schedule
C. There will be a few changes in your lifestyle.
D. Use alcohol on the skin and clean it due to
integumentary changes.
3. A client is undergoing peritoneal dialysis. The
dialysate dwell time is completed, and the dwell
clamp is opened to allow the dialysate to drain. The
nurse notes that the drainage has stopped and only
500 ml has drained; the amount the dialysate
instilled was 1,500 ml. Which of the following
interventions would be done first?
A. Change the client’s position.
B. Call the physician.
C. Check the catheter for kinks or obstruction.
D. Clamp the catheter and instill more
dialysate at the next exchange time.
4. A client receiving hemodialysis treatment arrives
at the hospital with a blood pressure of 200/100, a
heart rate of 110, and a respiratory rate of 36.
Oxygen saturation on room air is 89%. He
complains of shortness of breath, and +2 pedal
edema is noted. His last hemodialysis treatment
was yesterday. Which of the following
interventions should be done first?
A. Administer oxygen
B. Elevate the foot of the bed
C. Restrict the client’s fluids
D. Prepare the client for hemodialysis.
5. A client has a history of chronic renal failure and
received hemodialysis treatments three times per
week through an arteriovenous (AV) fistula in the
left arm. Which of the following interventions is
included in this client’s plan of care?
A. Keep the AV fistula site dry.
B. Keep the AV fistula wrapped in gauze.
C. Take the blood pressure in the left arm
D. Assess the AV fistula for a bruit and thrill
6. Which of the following factors causes the nausea
associated with renal failure?
A. Oliguria
B. Gastric ulcers
C. Electrolyte imbalances
D. Accumulation of waste products
7. Which of the following clients is at greatest risk
for developing acute renal failure?
A. A dialysis client who gets influenza
B. A teenager who has an appendectomy
C. A pregnant woman who has a fractured
femur
D. A client with diabetes who has a heart
catherization
8. In a client in renal failure, which assessment
finding may indicate hypocalcemia?
A. Headache
B. Serum calcium level of 5 mEq/L
C. Increased blood coagulation
D. Diarrhea
9. A nurse is assessing the patency of an
arteriovenous fistula in the left arm of a client who
is receiving hemodialysis for the treatment of
chronic renal failure. Which finding indicates that
the fistula is patent?
A. Absence of bruit on auscultation of the
fistula.
B. Palpation of a thrill over the fistula
C. Presence of a radial pulse in the left wrist
D. Capillary refill time less than 3 seconds in
the nail beds of the fingers on the left hand.
10. The client with chronic renal failure is at risk of
developing dementia related to excessive
absorption of aluminum. The nurse teaches that
this is the reason that the client is being prescribed
which of the following phosphate binding agents?
 A. Alu-cap (aluminum hydroxide) C. Oliguria
B. Tums (calcium carbonate) D. Anuria
C. Amphojel (aluminum hydroxide)
D. Basaljel (aluminum hydroxide) 15. The client with chronic renal failure returns to
the nursing unit following a hemodialysis
11. The client newly diagnosed with chronic renal treatment. On assessment the nurse notes that the
failure recently has begun hemodialysis. Knowing client’s temperature is 100.2. Which of the
that the client is at risk for disequilibrium following is the most appropriate nursing action?
syndrome, the nurse assesses the client during
dialysis for: A. Encourage fluids
B. Notify the physician
A. Hypertension, tachycardia, and fever C. Monitor the site of the shunt for infection
B. Hypotension, bradycardia, and hypothermia D. Continue to monitor vital signs
C. restlessness, irritability, and generalized
weakness 16. The nurse is performing an assessment on a
D. Headache, deteriorating level of client who has returned from the dialysis unit
consciousness, and twitching. following hemodialysis. The client is complaining of
a headache and nausea and is extremely restless.
12. A client with chronic renal failure has Which of the following is the most appropriate
completed a hemodialysis treatment. The nurse nursing action?
would use which of the following standard
indicators to evaluate the client’s status after A. Notify the physician
dialysis? B. Monitor the client
C. Elevate the head of the bed
A. Potassium level and weight D. Medicate the client for nausea
B. BUN and creatinine levels
C. VS and BUN 17. The nurse is assisting a client on a low-
D. VS and weight. potassium diet to select food items from the menu.
Which of the following food items, if selected by
13. The hemodialysis client with a left arm fistula is the client, would indicate an understanding of this
at risk for steal syndrome. The nurse assesses this dietary restriction?
client for which of the following clinical
manifestations? A. Cantaloupe
B. Spinach
A. Warmth, redness, and pain in the left hand. C. Lima beans
B. Pallor, diminished pulse, and pain in the left D. Strawberries
hand.
C. Edema and reddish discoloration of the left 18. The nurse is reviewing a list of components
arm contained in the peritoneal dialysis solution with
D. Aching pain, pallor, and edema in the left the client. The client asks the nurse about the
arm. purpose of the glucose contained in the solution.
The nurse bases the response knowing that the
14. A client is admitted to the hospital and has a glucose:
diagnosis of early stage chronic renal failure. Which
of the following would the nurse expect to note on A. Prevents excess glucose from being
assessment of the client? removed from the client.
B. Decreases risk of peritonitis.
A. Polyuria C. Prevents disequilibrium syndrome
B. Polydipsia
 D. Increases osmotic pressure to produce
ultrafiltration.
19. The nurse is preparing to care for a client
receiving peritoneal dialysis. Which of the following
would be included in the nursing plan of care to
prevent the major complication associated with
peritoneal dialysis?
A. Monitor the clients level of consciousness
B. Maintain strict aseptic technique
C. Add heparin to the dialysate solution
D. Change the catheter site dressing daily
20. A client newly diagnosed with renal failure is
receiving peritoneal dialysis. During the infusion of
the dialysate the client complains of abdominal
pain. Which action by the nurse is most
appropriate?
A. Slow the infusion
B. Decrease the amount to be infused
C. Explain that the pain will subside after the
first few exchanges
D. Stop the dialysis
21. The nurse is instructing a client with diabetes
mellitus about peritoneal dialysis. The nurse tells
the client that it is important to maintain the dwell
time for the dialysis at the prescribed time because
of the risk of:
A. Infection
B. Hyperglycemia
C. Fluid overload
D. Disequilibrium syndrome
22. The client with acute renal failure has a serum
potassium level of 5.8 mEq/L. The nurse would plan
which of the following as a priority action?
A. Allow an extra 500 ml of fluid intake to
dilute the electrolyte concentration.
B. Encourage increased vegetables in the diet
C. Place the client on a cardiac monitor
D. Check the sodium level
23. The client with chronic renal failure who is
scheduled for hemodialysis this morning is due to
receive a daily dose of enalapril (Vasotec). The
nurse should plan to administer this medication:
A. Just before dialysis
B. During dialysis
C. On return from dialysis
D. The day after dialysis
24. The client with chronic renal failure has an
indwelling catheter for peritoneal dialysis in the
abdomen. The client spills water on the catheter
dressing while bathing. The nurse should
immediately:
A. Reinforce the dressing
B. Change the dressing
C. Flush the peritoneal dialysis catheter
D. Scrub the catheter with providone-iodine
25. The client being hemodialyzed suddenly
becomes short of breath and complains of chest
pain. The client is tachycardic, pale, and anxious.
The nurse suspects air embolism. The nurse should:
A. Continue the dialysis at a slower rate after
checking the lines for air
B. Discontinue dialysis and notify the physician
C. Monitor vital signs every 15 minutes for the
next hour
D. Bolus the client with 500 ml of normal
saline to break up the air embolism.
26. The nurse has completed client teaching with
the hemodialysis client about self-monitoring
between hemodialysis treatments. The nurse
determines that the client best understands the
information given if the client states to record the
daily:
A. Pulse and respiratory rate
B. Intake, output, and weight
C. BUN and creatinine levels
D. Activity log
27. The client with an arteriovenous shunt in place
for hemodialysis is at risk for bleeding. The nurse
would do which of the following as a priority action
to prevent this complication from occurring?
 A. Check the results of the PT time as they are
ordered.
B. Observe the site once per shift
C. Check the shunt for the presence of a bruit
and thrill
D. Ensure that small clamps are attached to
the AV shunt dressing.
28. The nurse is monitoring a client receiving
peritoneal dialysis and nurse notes that a client’s
outflow is less than the inflow. Select actions that
the nurse should take.
A. Place the client in good body alignment
B. Check the level of the drainage bag
C. Contact the physician
D. Check the peritoneal dialysis system for
kinks
E. Reposition the client to his or her side.
29. The nurse assesses the client who has chronic
renal failure and notes the following: crackles in
the lung bases, elevated blood pressure, and
weight gain of 2 pounds in one day. Based on these
data, which of the following nursing diagnoses is
appropriate?
A. Excess fluid volume related to the kidney’s
inability to maintain fluid balance.
B. Increased cardiac output related to fluid
overload.
C. Ineffective tissue perfusion related to
interrupted arterial blood flow.
D. Ineffective therapeutic Regimen
Management related to lack of knowledge
about therapy.
30. The nurse is caring for a hospitalized client who
has chronic renal failure. Which of the following
nursing diagnoses are most appropriate for this
client? Select all that apply.
A. Excess Fluid Volume
B. Imbalanced Nutrition; Less than Body
Requirements
C. Activity Intolerance
D. Impaired Gas Exchange
E. Pain.
31. What is the primary disadvantage of using
peritoneal dialysis for long term management of
chronic renal failure?
A. The danger of hemorrhage is high.
B. It cannot correct severe imbalances.
C. It is a time consuming method of treatment.
D. The risk of contacting hepatitis is high.
32. The dialysis solution is warmed before use in
peritoneal dialysis primarily to:
A. Encourage the removal of serum urea.
B. Force potassium back into the cells.
C. Add extra warmth into the body.
D. Promote abdominal muscle relaxation.
33. During the client’s dialysis, the nurse observes
that the solution draining from the abdomen is
consistently blood tinged. The client has a
permanent peritoneal catheter in place. Which
interpretation of this observation would be
correct?
A. Bleeding is expected with a permanent
peritoneal catheter
B. Bleeding indicates abdominal blood vessel
damage
C. Bleeding can indicate kidney damage.
D. Bleeding is caused by too-rapid infusion of
the dialysate.
34. Which of the following nursing interventions
should be included in the client’s care plan during
dialysis therapy?
A. Limit the client’s visitors
B. Monitor the client’s blood pressure
C. Pad the side rails of the bed
D. Keep the client NPO.
35. Aluminum hydroxide gel (Amphojel) is
prescribed for the client with chronic renal failure
to take at home. What is the purpose of giving this
drug to a client with chronic renal failure?
A. To relieve the pain of gastric hyperacidity
B. To prevent Curling’s stress ulcers
C. To bind phosphorus in the intestine
 D. To reverse metabolic acidosis.
36. The nurse teaches the client with chronic renal
failure when to take the aluminum hydroxide gel.
Which of the following statements would indicate
that the client understands the teaching?
A. “I’ll take it every 4 hours around the clock.”
B. “I’ll take it between meals and at bedtime.”
C. “I’ll take it when I have a sour stomach.”
D. “I’ll take it with meals and bedtime snacks.”
37. The client with chronic renal failure tells the
nurse he takes magnesium hydroxide (milk of
magnesium) at home for constipation. The nurse
suggests that the client switch to psyllium
hydrophilic mucilloid (Metamucil) because:
A. MOM can cause magnesium toxicity
B. MOM is too harsh on the bowel
C. Metamucil is more palatable
D. MOM is high in sodium
38. In planning teaching strategies for the client
with chronic renal failure, the nurse must keep in
mind the neurologic impact of uremia. Which
teaching strategy would be most appropriate?
A. Providing all needed teaching in one
extended session.
B. Validating frequently the client’s
understanding of the material.
C. Conducting a one-on-one session with the
client.
D. Using videotapes to reinforce the material
as needed.
39. The nurse helps the client with chronic renal
failure develop a home diet plan with the goal of
helping the client maintain adequate nutritional
intake. Which of the following diets would be most
appropriate for a client with chronic renal failure?
A. High carbohydrate, high protein
B. High calcium, high potassium, high protein
C. Low protein, low sodium, low potassium
D. Low protein, high potassium
40. A client with chronic renal failure has asked to
be evaluated for a home continuous ambulatory
peritoneal dialysis (CAPD) program. The nurse
should explain that the major advantage of this
approach is that it:
A. Is relatively low in cost
B. Allows the client to be more independent
C. Is faster and more efficient than standard
peritoneal dialysis
D. Has fewer potential complications than
standard peritoneal dialysis
41. The client asks whether her diet would change
on CAPD. Which of the following would be the
nurse’s best response?
A. “Diet restrictions are more rigid with CAPD
because standard peritoneal dialysis is a
more effective technique.”
B. “Diet restrictions are the same for both
CAPD and standard peritoneal dialysis.”
C. “Diet restrictions with CAPD are fewer than
with standard peritoneal dialysis because
dialysis is constant.”
D. “Diet restrictions with CAPD are fewer than
with standard peritoneal dialysis because
CAPD works more quickly.”
42. Which of the following is the most significant
sign of peritoneal infection?
A. Cloudy dialysate fluid
B. Swelling in the legs
C. Poor drainage of the dialysate fluid
D. Redness at the catheter insertion site
43. The main indicator of the need for hemodialysis
is:
A. Ascites
B. Acidosis
C. Hypertension
D. Hyperkalemia
44. To gain access to the vein and artery, an AV
shunt was used for Mr. Roberto. The most serious
problem with regards to the AV shunt is:
 A. Septicemia b. Patient with hypertensive crisis
B. Clot formation c. Patient who tried to overdose on acetaminophen
C. Exsanguination d. Patient with major surgery who required a blood
D. Vessel sclerosis transfusion

45. When caring for Mr. Roberto’s AV shunt on his
right arm, you should:
A. Cover the entire cannula with an elastic
bandage
B. Notify the physician if a bruit and thrill are
present
C. User surgical aseptic technique when giving
shunt care
D. Take the blood pressure on the right arm
instead
An 83-year-old female patient was found lying on
the bathroom floor. She said she fell 2 days ago
and has not been
able to take her heart medicine or eat or drink
anything since then. What conditions could be
causing prerenal AKI in
this patient (select all that apply)?
d. Acute tubular necrosis (ATN) is primarily the
result of ischemia, nephrotoxins, or sepsis. Major
surgery is most likely to cause severe kidney
ischemia in the patient requiring a blood
transfusion. A blood transfusion
hemolytic reaction produces nephrotoxic injury if it
occurs. Diabetes mellitus, hypertension, and
acetaminophen overdose will not contribute to
ATN.
What indicates to the nurse that a patient with
oliguria has prerenal oliguria?
a. Urine testing reveals a low specific gravity.
b. Causative factor is malignant hypertension.
c. Urine testing reveals a high sodium
concentration.
d. Reversal of oliguria occurs with fluid
replacement.

a. Anaphylaxis d. In prerenal oliguria, the oliguria is caused by a

b. Renal calculi
c. Hypovolemia
d. Nephrotoxic drugs
e. Decreased cardiac output
c, e. Because the patient has had nothing to eat or
drink
for 2 days, she is probably dehydrated and
hypovolemic.
Decreased cardiac output (CO) is most likely
because she is older and takes heart medicine,
which is probably for heart failure or hypertension.
Both hypovolemia and decreased CO cause
prerenal AKI. Anaphylaxis is also a cause of
prerenal AKI but is not likely in this situation.
Nephrotoxic drugs would contribute to intrarenal
causes of AKI and renal calculi would be a postrenal
cause of AKI.
Acute tubular necrosis (ATN) is the most common
cause of intrarenal AKI. Which patient is most likely
to develop ATN?
a. Patient with diabetes mellitus
decrease in circulating blood volume and there is
no damage yet to the renal tissue. It can be
reversed by correcting the precipitating factor,
such as fluid replacement for hypovolemia.
Prerenal oliguria is characterized by urine
with a high specific gravity and a low sodium
concentration, whereas oliguria of intrarenal
failure is characterized by urine with a low specific
gravity and a high sodium concentration. Malignant
hypertension causes damage to
renal tissue and intrarenal oliguria.
In a patient with AKI, which laboratory urinalysis
result indicates tubular damage?
a. Hematuria
b. Specific gravity fixed at 1.010
c. Urine sodium of 12 mEq/L (12 mmol/L)
d. Osmolality of 1000 mOsm/kg (1000 mmol/kg)
b. A urine specific gravity that is consistently 1.010
and a urine osmolality of about 300 mOsm/kg is
the same specific gravity and osmolality as plasma.
This indicates that tubules are damaged and unable
to concentrate urine. Hematuria is more common
with postrenal damage. Tubular damage is
associated with a high sodium concentration
(greater than 40 mEq/L).
Metabolic acidosis occurs in the oliguric phase of
AKI as a result of impairment of
a. ammonia synthesis.
b. excretion of sodium.
c. excretion of bicarbonate.
d. conservation of potassium.
a. Metabolic acidosis occurs in AKI because the
kidneys cannot synthesize ammonia or excrete acid
products of metabolism, resulting in an increased
acid load. Sodium is lost in urine because the
kidneys cannot conserve sodium. Impaired
excretion of potassium results in
hyperkalemia. Bicarbonate is normally generated
and reabsorbed by the functioning kidney to
maintain acidbase balance.
What indicates to the nurse that a patient with AKI
is in the recovery phase?
a. A return to normal weight
b. A urine output of 3700 mL/day
c. Decreasing sodium and potassium levels
d. Decreasing blood urea nitrogen (BUN) and
creatinine levels
d. The blood urea nitrogen (BUN) and creatinine
levels remain high during the oliguric and diuretic
phases of AKI. The recovery phase begins when the
glomerular filtration returns to a rate at which BUN
and creatinine stabilize and then decrease. Urinary
output of 3 to 5 L/day, decreasing sodium and
potassium levels, and
fluid weight loss are characteristic of the diuretic
phase of AKI.
While caring for the patient in the oliguric phase of
AKI, the nurse monitors the patient for associated
collaborative problems. When should the nurse
notify the health care provider?
a. Urine output is 300 mL/day.
b. Edema occurs in the feet, legs, and sacral area.
c. Cardiac monitor reveals a depressed T wave and
elevated ST segment.
d. The patient experiences increasing muscle
weakness and abdominal cramping.
d. Hyperkalemia is a potentially life-threatening
complication of AKI in the oliguric phase. Muscle
weakness and abdominal cramping are signs of the
neuromuscular impairment that occurs with
hyperkalemia. In addition, hyperkalemia can cause
the cardiac conduction abnormalities of peaked T
wave, prolonged PR interval, prolonged QRS
interval, and depressed ST segment. Urine
output of 300 mL/day is expected during the
oliguric phase, as is the development of peripheral
edema.
In caring for the patient with AKI, what should the
nurse be aware of?
a. The most common cause of death in AKI is
irreversible metabolic acidosis.
b. During the oliguric phase of AKI, daily fluid intake
is limited to 1000 mL plus the prior day's measured
fluid loss.
c. Dietary sodium and potassium during the oliguric
phase of AKI are managed according to the
patient's urinary
output.
d. One of the most important nursing measures in
managing fluid balance in the patient with AKI is
taking accurate daily weights.
d. Measuring daily weights with the same scale at
the same time each day allows for the evaluation
and detection of excessive body fluid gains or
losses. Infection is the leading cause of death in
AKI, so meticulous aseptic technique is critical. The
fluid limitation in the oliguric phase is 600 mL plus
the prior day's measured fluid loss. Dietary sodium
and potassium intake are managed
according to the plasma levels.
A 68-year-old man with a history of heart failure
resulting from hypertension has AKI as a result of
the effects of nephrotoxic diuretics. Currently his
serum potassium is 6.2 mEq/L (6.2 mmol/L) with
cardiac changes, his BUN is 108 mg/dL (38.6
mmol/L), his serum creatinine is 4.1 mg/dL (362
mmol/L), and his serum HCO3− is 14 mEq/L (14
mmol/L). He is somnolent and disoriented. Which
treatment should the nurse expect to be used for
him?
a. Loop diuretics
b. Renal replacement therapy
c. Insulin and sodium bicarbonate
d. Sodium polystyrene sulfonate (Kayexalate)
b. This patient has at least three of the six common
indications for renal replacement therapy (RRT),
including
(1) high potassium level, (2) metabolic acidosis, and
(3) changed mental status. The other indications
are (4) volume overload, resulting in compromised
cardiac status (this patient has a history of
hypertension), (5) BUN greater than 120 mg/dL,
and (6) pericarditis, pericardial effusion, or cardiac
tamponade. Although the other treatments may
be used, they will not be as effective as RRT for this
older patient. Loop diuretics and increased fluid are
used if the patient is dehydrated. Insulin and
sodium bicarbonate can be used to temporarily
drive the potassium into the cells.
Sodium polystyrene sulfonate (Kayexalate) is used
to actually decrease the amount of potassium in
the body.
Prevention of AKI is important because of the high
mortality rate. Which patients are at increased risk
for AKI (select all that apply)?
a. An 86-year-old woman scheduled for a cardiac
catheterization
b. A 48-year-old man with multiple injuries from a
motor vehicle accident
c. A 32-year-old woman following a C-section
delivery for abruptio placentae
d. A 64-year-old woman with chronic heart failure
admitted with bloody stools
e. A 58-year-old man with prostate cancer
undergoing preoperative workup for
prostatectomy
a, b, c, d, e. High-risk patients include those
exposed to nephrotoxic agents and advanced age
(a), massive
trauma (b), prolonged hypovolemia or hypotension
(possibly b and c), obstetric complications (c),
cardiac failure (d), preexisting chronic kidney
disease, extensive burns, or sepsis. Patients with
prostate cancer may have obstruction of the
outflow tract, which increases risk of
postrenal AKI (e).
A patient with AKI has a serum potassium level of
6.7 mEq/L (6.7 mmol/L) and the following arterial
blood gas results: pH 7.28, PaCO230 mm Hg, PaO2
86 mm Hg, HCO3−18 mEq/L (18 mmol/L). The
nurse recognizes that treatment of the acid-base
problem with sodium bicarbonate would cause a
decrease in which value?
a. pH
b. Potassium level
c. Bicarbonate level
d. Carbon dioxide level
b. During acidosis, potassium moves out of the cell
in exchange for H+ions, increasing the serum
potassium level. Correction of the acidosis with
sodium bicarbonate will help to shift the potassium
back into the cells. A decrease in pH and the
bicarbonate and PaCO2levels would indicate
worsening acidosis.
A patient with AKI is a candidate for continuous
renal replacement therapy (CRRT). What is the
most common indication for use of CRRT?
a. Azotemia
b. Pericarditis
c. Fluid overload
d. Hyperkalemia
c. Continuous renal replacement therapy (CRRT) is
indicated for the patient with AKI as an alternative
or adjunct to hemodialysis to slowly remove
solutes and fluid in the hemodynamically unstable
patient. It is especially useful for treatment of fluid
overload, but hemodialysis is indicated for
treatment of hyperkalemia, pericarditis, or
other serious effects of uremia.
In replying to a patient's questions about the
seriousness of her chronic kidney disease (CKD),
the nurse knows that the stage of CKD is based on
what?
a. Total daily urine output
b. Glomerular filtration rate
c. Degree of altered mental status
d. Serum creatinine and urea levels
b. Stages of chronic kidney disease are based on
the GFR. No specific markers of urinary output,
mental status, or azotemia classify the degree of
chronic kidney disease (CKD).
The patient with CKD is receiving dialysis, and the
nurse observes excoriations on the patient's skin.
What pathophysiologic changes in CKD can
contribute to this finding (select all that apply)?
a. Dry skin
b. Sensory neuropathy
c. Vascular calcifications
d. Calcium-phosphate skin deposits
e. Uremic crystallization from high BUN
a, b, d. Pruritus is common in patients receiving
dialysis. It causes scratching from dry skin, sensory
neuropathy, and calcium-phosphate deposition in
the skin. Vascular calcifications contribute to
cardiovascular disease, not to itching skin. Uremic
frost rarely occurs without BUN levels greater than
200 mg/dL, which should not occur in a patient
on dialysis; urea crystallizes on the skin and also
causes pruritis.
What causes the gastrointestinal (GI) manifestation
of stomatitis in the patient with CKD?
a. High serum sodium levels
b. Irritation of the GI tract from creatinine
c. Increased ammonia from bacterial breakdown of
urea
d. Iron salts, calcium-containing phosphate binders,
and limited fluid intake
c. Uremic fetor, or the urine odor of the breath, is
caused by high urea content in the blood.
Increased ammonia from
bacterial breakdown of urea leads to stomatitis and
mucosal ulcerations. Irritation of the
gastrointestinal (GI) tract from
urea in CKD contributes to anorexia, nausea, and
vomiting. Ingestion of iron salts and calcium-
containing phosphate binders, limited fluid intake,
and limited activity cause
constipation.
The patient with CKD is brought to the emergency
department with Kussmaul respirations. What does
the nurse know about CKD that could cause this
patient's Kussmaul respirations?
a. Uremic pleuritis is occurring.
b. There is decreased pulmonary macrophage
activity.
c. They are caused by respiratory compensation for
metabolic acidosis.
d. Pulmonary edema from heart failure and fluid
overload is occurring.
c. Kussmaul respirations occur with severe
metabolic acidosis when the respiratory system is
attempting to compensate by removing carbon
dioxide with exhalations. Uremic pleuritis would
cause a pleural friction rub. Decreased pulmonary
macrophage activity increases the risk of
pulmonary infection. Dyspnea would occur with
pulmonary edema.
Which serum laboratory value indicates to the
nurse that the patient's CKD is getting worse?
a. Decreased BUN
b. Decreased sodium
c. Decreased creatinine
d. Decreased calculated glomerular filtration rate
(GFR)
d. As GFR decreases, BUN and serum creatinine
levels increase. Although elevated BUN and
creatinine indicate that waste products are
accumulating, the calculated GFR
is considered a more accurate indicator of kidney
function than BUN or serum creatinine.
What is the most serious electrolyte disorder
associated with kidney disease?
a. Hypocalcemia
b. Hyperkalemia
c. Hyponatremia
d. Hypermagnesemia
b. Hyperkalemia can lead to life-threatening
dysrhythmias. Hypocalcemia leads to an
accelerated rate of bone remodeling and
potentially to tetany. Hyponatremia may
lead to confusion. Elevated sodium levels lead to
edema, hypertension, and heart failure.
Hypermagnesemia may decrease reflexes, mental
status, and blood pressure.
For a patient with CKD the nurse identifies a
nursing diagnosis of risk for injury: fracture related
to alterations in calcium and phosphorus
metabolism. What is the pathologic process
directly related to the increased risk for
fractures?
a. Loss of aluminum through the impaired kidneys
b. Deposition of calcium phosphate in soft tissues
of the body
c. Impaired vitamin D activation resulting in
decreased GI absorption of calcium
d. Increased release of parathyroid hormone in
response to decreased calcium levels
c. The calcium-phosphorus imbalances that occur
in CKD result in hypocalcemia, from a deficiency of
active vitamin D and increased phosphorus levels.
This leads to an increased rate of bone remodeling
with a weakened bone matrix. Aluminum
accumulation is also believed to
contribute to the osteomalacia. Osteitis fibrosa
involves replacement of calcium in the bone with
fibrous tissue and is primarily a result of elevated
levels of parathyroid hormone resulting from
hypocalcemia.
Priority Decision: What is the most appropriate
snack for the nurse to offer a patient with stage 4
CKD?
a. Raisins
b. Ice cream
c. Dill pickles
d. Hard candy
d. A patient with CKD may have unlimited intake of
sugars and starches (unless the patient is diabetic)
and hard candy is an appropriate snack and may
help to relieve the metallic and urine taste that is
common in the mouth. Raisins are a high-
potassium food. Ice cream contains protein and
phosphate and counts as fluid. Pickled foods have
high sodium content.
Which complication of chronic kidney disease is
treated with erythropoietin (EPO)?
a. Anemia
b. Hypertension
c. Hyperkalemia
d. Mineral and bone disorder
a. Erythropoietin is used to treat anemia, as it
stimulates the bone marrow to produce red blood
cells.
The patient with CKD asks why she is receiving
nifedipine (Procardia) and furosemide (Lasix). The
nurse understands that these drugs are being used
to treat the patient's
a. anemia.
b. hypertension.
c. hyperkalemia.
d. mineral and bone disorder.
b. Nifedipine (Procardia) is a calcium channel
blocker and furosemide (Lasix) is a loop diuretic.
Both are used to treat hypertension.
Which drugs will be used to treat the patient with
CKD for mineral and bone disorder (select all that
apply)?
a. Cinacalcet (Sensipar)
b. Sevelamer (Renagel)
c. IV glucose and insulin
d. Calcium acetate (PhosLo)
e. IV 10% calcium gluconate
a, b, d. Cinacalcet (Sensipar), a calcimimetic
agent to control secondary
hyperparathyroidism; sevelamer
(Renagel), a noncalcium phosphate binder;
and calcium acetate (PhosLo), a calcium-
based phosphate binder are
used to treat mineral and bone disorder in
CKD. IV glucose and insulin and IV 10%
calcium gluconate along with
sodium polystyrene sulfonate (Kayexalate)
are used to treat
the hyperkalemia of CKD.
What accurately describes the care of the
patient with CKD?
a. A nutrient that is commonly
supplemented for the patient on dialysis
because it is dialyzable is iron.
b. The syndrome that includes all of the
signs and symptoms seen in the various
body systems in CKD is azotemia.
c. The use of morphine is contraindicated in
the patient with CKD because accumulation
of its metabolites may
cause seizures.
d. The use of calcium-based phosphate
binders in the patient with CKD is
contraindicated when serum calcium
levels are increased.
d. In the patient with CKD, when serum
calcium levels are increased, calcium-based
phosphate binders are not used. The
nutrient supplemented for patients on
dialysis is folic acid. The various body
system manifestations occur with uremia,
which includes azotemia. Meperidine is
contraindicated in patients with CKD related
to possible seizures.
During the nursing assessment of the
patient with renal insufficiency, the nurse
asks the patient specifically about a
history of
a. angina.
b. asthma.
c. hypertension.
d. rheumatoid arthritis.
c. The most common causes of CKD in the
United States are diabetes mellitus and
hypertension. The nurse should
obtain information on long-term health
problems that are related to kidney disease.
The other disorders are not
closely associated with renal disease.
The patient with chronic kidney disease is
considering whether to use peritoneal
dialysis (PD) or hemodialysis (HD).
What are advantages of PD when compared
to HD (select all that apply)?
a. Less protein loss
b. Rapid fluid removal
c. Less cardiovascular stress
d. Decreased hyperlipidemia
e. Requires fewer dietary restrictions
c, e. Peritoneal dialysis is less stressful for
the cardiovascular system and requires
fewer dietary restrictions. Peritoneal
dialysis actually contributes to more
protein loss and increased hyperlipidemia.
The fluid and creatinine removal are slower
with peritoneal dialysis than
hemodialysis.
What does the dialysate for PD routinely
contain?
a. Calcium in a lower concentration than in
the blood
b. Sodium in a higher concentration than in
the blood
c. Dextrose in a higher concentration than
in the blood
d. Electrolytes in an equal concentration to
that of the blood
c. Dextrose or icodextrin or amino acid is
added to dialysate fluid to create an
osmotic gradient across the membrane
to remove excess fluid from the blood. The
dialysate fluid
has no potassium so that potassium will
diffuse into the dialysate from the blood.
Dialysate also usually contains higher
calcium to promote its movement into the
blood. Dialysate sodium is usually less than
or equal to that of
blood to prevent sodium and fluid
retention.
Number the following in the order of the
phases of exchange in PD. Begin with 1 and
end with 3.
a. Drain
b. Dwell
c. Inflow
a. 3; b. 2; c. 1
In which type of dialysis does the patient
dialyze during sleep and leave the fluid in
the abdomen during the day?
a. Long nocturnal hemodialysis
b. Automated peritoneal dialysis (APD)
c. Continuous venovenous hemofiltration
(CVVH)
d. Continuous ambulatory peritoneal
dialysis (CAPD)
b. Automated peritoneal dialysis (APD) is
the type of dialysis in which the patient
dialyzes during sleep and leaves the fluid in
the abdomen during the day. Long
nocturnal hemodialysis occurs while the
patient is sleeping and is done up to six
times per week. Continuous venovenous
hemofiltration (CVVH) is a type of
continuous renal replacement therapy used
to treat AKI. Continuous ambulatory
peritoneal dialysis (CAPD) is dialysis that is
done with exchanges of 1.5 to 3 L of
dialysate at least four times daily.
To prevent the most common serious
complication of PD, what is important for
the nurse to do?
a. Infuse the dialysate slowly.
b. Use strict aseptic technique in the dialysis
procedures.
c. Have the patient empty the bowel before
the inflow phase.
d. Reposition the patient frequently and
promote deep breathing.
b. Peritonitis is a common complication of
peritoneal dialysis (PD) and may require
catheter removal and termination of
dialysis. Infection occurs from
contamination of the dialysate or tubing or
from progression of exit-site or tunnel
infections and strict sterile technique must
be used by health professionals as
well as the patient to prevent
contamination. Too-rapid infusion may
cause shoulder pain and pain may be
caused if the catheter tip touches the
bowel. Difficulty breathing,
atelectasis, and pneumonia may occur from
pressure of the fluid on the diaphragm,
which may be prevented by
elevating the head of the bed and
promoting repositioning
and deep breathing.
A patient on hemodialysis develops a
thrombus of a subcutaneous arteriovenous
(AV) graft, requiring its removal.
While waiting for a replacement graft or
fistula, the patient is most likely to have
what done for treatment?
a. Peritoneal dialysis
b. Peripheral vascular access using radial
artery
c. Silastic catheter tunneled subcutaneously
to the jugular vein
d. Peripherally inserted central catheter
(PICC) line inserted into subclavian vein
c. A more permanent, soft, flexible Silastic
double-lumen
catheter is used for long-term access when
other forms of vascular access have failed.
These catheters are tunneled
subcutaneously and have Dacron cuffs that
prevent infection from tracking along the
catheter.
A man with end-stage kidney disease is
scheduled for hemodialysis following
healing of an arteriovenous fistula
(AVF). What should the nurse explain to him
that will occur during dialysis?
a. He will be able to visit, read, sleep, or
watch TV while reclining in a chair.
b. He will be placed on a cardiac monitor to
detect any adverse effects that might occur.
c. The dialyzer will remove and hold part of
his blood for 20 to 30 minutes to remove
the waste products.
d. A large catheter with two lumens will be
inserted into the fistula to send blood to
and return it from the dialyzer.
a. While patients are undergoing
hemodialysis, they can perform quiet
activities that do not require the limb that
has the vascular access. Blood pressure is
monitored frequently and the dialyzer
monitors dialysis function but cardiac
monitoring is not usually indicated. The
hemodialysis machine continuously
circulates both the blood and the
dialysate past the semipermeable
membrane in the machine. Graft and fistula
access involve the insertion of two needles
into the site: one to remove blood from and
the other to
return blood to the dialyzer.
What is the primary way that a nurse will
evaluate the patency of an AVF?
a. Palpate for pulses distal to the graft site.
b. Auscultate for the presence of a bruit at
the site.
c. Evaluate the color and temperature of
the extremity.
d. Assess for the presence of numbness and
tingling distal to the site.
b. A patent arteriovenous fistula (AVF)
creates turbulent blood flow that can be
assessed by listening for a bruit or palpated
for a thrill as the blood passes through the
graft. Assessment of neurovascular status in
the extremity distal to the graft site is
important to determine that the
graft does not impair circulation to the
extremity but the neurovascular status does
not indicate whether the graft
is open.
A patient rapidly progressing toward end-
stage kidney disease asks about the
possibility of a kidney transplant. In
responding to the patient, the nurse knows
that what is a contraindication to kidney
transplantation?
a. Hepatitis C infection
b. Coronary artery disease
c. Refractory hypertension
d. Extensive vascular disease
d. Extensive vascular disease is a
contraindication for renal transplantation,
primarily because adequate blood
supply is essential for the health of the new
kidney. Other contraindications include
disseminated malignancies,
refractory or untreated cardiac disease,
chronic respiratory failure, chronic
infection, or unresolved psychosocial
disorders. Coronary artery disease (CAD)
may be treated with bypass surgery before
transplantation and
transplantation can relieve hypertension.
Hepatitis B or C
infection is not a contraindication.
Priority Decision: During the immediate
postoperative care of a recipient of a kidney
transplant, what should the
nurse expect to do?
a. Regulate fluid intake hourly based on
urine output.
b. Monitor urine-tinged drainage on
abdominal dressing.
c. Medicate the patient frequently for
incisional flank pain.
d. Remove the urinary catheter to evaluate
the ureteral implant.
a. Fluid and electrolyte balance is critical in
the transplant recipient patient, especially
because diuresis often begins
soon after surgery. Fluid replacement is
adjusted hourly based on kidney function
and urine output. Urine-tinged
drainage on the abdominal dressing may
indicate leakage from the ureter implanted
into the bladder and the health
care provider should be notified. The donor
patient may have a flank or laparoscopic
incision(s) where the kidney
was removed. The recipient has an
abdominal incision where the kidney was
placed in the iliac fossa. The urinary
catheter is usually used for 2 to 3 days to
monitor urine
output and kidney function.
A patient received a kidney transplant last
month. Because of the effects of
immunosuppressive drugs and CKD,
what complication of transplantation
should the nurse be assessing the patient
for to decrease the risk of mortality?
a. Infection
b. Rejection
c. Malignancy
d. Cardiovascular disease
a. Infection is a significant cause of
morbidity and mortality after
transplantation because the surgery,
the immunosuppressive drugs, and the
effects of CKD all suppress the body's
normal defense mechanisms,
thus increasing the risk of infection. The
nurse must assess the patient as well as use
aseptic technique to
prevent infections. Rejection may occur but
for other reasons. Malignancy occurrence
increases later due to immunosuppressive
therapy. Cardiovascular disease is the
leading cause of death after renal
transplantation but this would not be
expected to cause death within the first
month after transplantation.
What are intrarenal causes of acute kidney
injury (AKI) (select all that apply)?
a. Anaphylaxis
b. Renal stones
c. Bladder cancer
d. Nephrotoxic drugs
e. Acute glomerulonephritis
f. Tubular obstruction by myoglobin
d, e, f. Intrarenal causes of acute kidney
injury (AKI)include conditions that cause
direct damage to the kidney tissue,
including nephrotoxic drugs, acute
glomerulonephritis, and tubular obstruction
by myoglobin, or prolonged ischemia.
Anaphylaxis and other prerenal problems
are frequently the initial cause of AKI. Renal
stones and bladder cancer are among the
postrenal causes of AKI.
Acute tubular necrosis (ATN) is the most
common cause of intrarenal AKI. Which
patient is most likely to develop ATN?
a. Patient with diabetes mellitus
b. Patient with hypertensive crisis
c. Patient who tried to overdose on
acetaminophen
d. Patient with major surgery who required
a blood transfusion
d. Acute tubular necrosis (ATN) is primarily
the resultof ischemia, nephrotoxins, or
sepsis. Major surgery is most likely to cause
severe kidney ischemia in the patient
requiring a blood transfusion. A blood
transfusion hemolytic reaction produces
nephrotoxic injury if it occurs.
Diabetes mellitus, hypertension, and
acetaminophen
overdose will not contribute to ATN.
Priority Decision: A dehydrated patient is in
the Injury stage of the RIFLE staging of AKI.
What would the nurse first anticipate in the
treatment of this patient?
a. Assess daily weight
b. IV administration of fluid and furosemide
(Lasix)
c. IV administration of insulin and sodium
bicarbonate
d. Urinalysis to check for sediment,
osmolality, sodium, and specific gravity
b. Injury is the stage of RIFLE classification
when urine output is less than 0.5 mL/kg/hr
for 12 hours, the serum creatinine is
increased times two or the glomerular
filtration rate (GFR) is decreased by 50%.
This stage may be reversible by treating the
cause or, in this patient, the dehydration by
administering IV fluid and a low dose of a
loop diuretic, furosemide (Lasix). Assessing
the daily weight will be done to monitor
fluid changes but it is not the first
treatment the nurse should anticipate. IV
administration of insulin and sodium
bicarbonate would be used for
hyperkalemia. Checking the urinalysis will
help to determine if the AKI has a prerenal,
intrarenal, or postrenal cause by what is
seen in the urine but with this patient's
dehydration, it is thought to be prerenal to
begin treatment.
What indicates to the nurse that a patient
with oliguria has prerenal oliguria?
a. Urine testing reveals a low specific
gravity.
b. Causative factor is malignant
hypertension.
c. Urine testing reveals a high sodium
concentration.
d. Reversal of oliguria occurs with fluid
replacement.
d. In prerenal oliguria, the oliguria is caused
by a decrease in circulating blood volume
and there is no damage yet to the renal
tissue. It can be reversed by correcting the
precipitating factor, such as fluid
replacement for hypovolemia. Prerenal
oliguria is characterized by urine with a high
specific gravity and a low sodium
concentration, whereas oliguria of
intrarenal failure is characterized by urine
with a low specific gravity and a high
sodium concentration. Malignant
hypertension causes damage to
renal tissue and intrarenal oliguria.
In a patient with AKI, which laboratory
urinalysis result indicates tubular damage?
a. Hematuria
b. Specific gravity fixed at 1.010
c. Urine sodium of 12 mEq/L (12 mmol/L)
d. Osmolality of 1000 mOsm/kg (1000
mmol/kg)
b. A urine specific gravity that is
consistently 1.010 and a urine osmolality of
about 300 mOsm/kg is the same specific
gravity and osmolality as plasma. This
indicates that tubules are damaged and
unable to concentrate urine. Hematuria is
more common with postrenal damage.
Tubular damage is associated with a high
sodium concentration (greater than 40
mEq/L).
Metabolic acidosis occurs in the oliguric
phase of AKI as a result of impairment of
a. ammonia synthesis.
b. excretion of sodium.
c. excretion of bicarbonate.
d. conservation of potassium.
a. Metabolic acidosis occurs in AKI because the
kidneys cannot synthesize ammonia or excrete
acid products of metabolism, resulting in an
increased acid load. Sodium is lost in urine
because the kidneys cannot conserve sodium.
Impaired excretion of potassium results in
 hyperkalemia. Bicarbonate is normally
generated and reabsorbed by the functioning
kidney to maintain acid/base balance.
What indicates to the nurse that a patient with AKI
is in the recovery phase?
a. A return to normal weight
b. A urine output of 3700 mL/day
c. Decreasing sodium and potassium levels
d. Decreasing blood urea nitrogen (BUN) and
creatinine levels
d. The blood urea nitrogen (BUN) and creatinine
levels remain high during the oliguric and diuretic
phases of AKI. The recovery phase begins when the
glomerular filtration returns to a rate at which BUN
and creatinine stabilize and then decrease. Urinary
output of 3 to 5 L/ day, decreasing sodium and
potassium levels, and fluid weight loss are
characteristic of the diuretic phase of AKI.
While caring for the patient in the oliguric phase of
AKI, the nurse monitors the patient for associated
collaborative problems. When should the nurse
notify the health care provider?
a. Urine output is 300 mL/day.
b. Edema occurs in the feet, legs, and sacral area.
c. Cardiac monitor reveals a depressed T wave and
elevated ST segment.
d. The patient experiences increasing muscle
weakness and abdominal cramping.
d. Hyperkalemia is a potentially life-threatening
complication of AKI in the oliguric phase. Muscle
weakness and abdominal cramping are signs of the
neuromuscular impairment that occurs with
hyperkalemia. In addition, hyperkalemia can cause
the cardiac conduction abnormalities of peaked T
wave, prolonged PR interval, prolonged QRS
interval, and depressed ST segment. Urine output
of 300 mL/day is expected during the oliguric
phase, as is the development of peripheral edema.
In caring for the patient with AKI, what should the
nurse be aware of?
a. The most common cause of death in AKI is
irreversible metabolic acidosis.
b. During the oliguric phase of AKI, daily fluid intake
is limited to 1000 mL plus the prior day's measured
fluid loss.
c. Dietary sodium and potassium during the oliguric
phase of AKI are managed according to the
patient's urinary output.
d. One of the most important nursing measures in
managing fluid balance in the patient with AKI is
taking accurate daily weights.
d. Measuring daily weights with the same scale at
thesame time each day allows for the evaluation
and detection of excessive body fluid gains or
losses. Infection is the leading cause of death in
AKI, so meticulous aseptic technique is critical. The
fluid limitation in the oliguric phase is 600 mL plus
the prior day's measured fluid loss. Dietary sodium
and potassium intake are managed according to
the plasma levels.
A 68-year-old man with a history of heart failure
resulting from hypertension has AKI as a result of
the effects of nephrotoxic diuretics. Currently his
serum potassium is 6.2 mEq/L (6.2 mmol/L) with
cardiac changes, his BUN is 108 mg/dL (38.6
mmol/L), his serum creatinine is 4.1 mg/dL (362
mmol/L), and his serum HCO3 − is 14 mEq/L (14
mmol/L). He is somnolent and disoriented. Which
treatment should the nurse expect to be used for
him?
a. Loop diuretics
b. Renal replacement therapy
c. Insulin and sodium bicarbonate
d. Sodium polystyrene sulfonate (Kayexalate)
b. This patient has at least three of the six common
indications for renal replacement therapy (RRT),
including (1) high potassium level, (2) metabolic
acidosis, and (3) changed mental status. The other
indications are (4) volume overload, resulting in
compromised cardiac status (this patient has a
history of hypertension), (5) BUN greater than 120
mg/dL, and (6) pericarditis, pericardial effusion, or
cardiac tamponade. Although the other treatments
maybe used, they will not be as effective as RRT for
this older patient. Loop diuretics and increased
fluid are used if the patient is dehydrated. Insulin
and sodium bicarbonate can be used to
temporarily drive the potassium into the cells.
Sodium polystyrene sulfonate (Kayexalate) is used
to actually decrease the amount of potassium in
the body.
Prevention of AKI is important because of the high
mortality rate. Which patients are at increased risk
for AKI (select all that apply)?
a. An 86-year-old woman scheduled for a cardiac
catheterization
b. A 48-year-old man with multiple injuries from a
motor vehicle accident
c. A 32-year-old woman following a C-section
delivery for abruptio placentae
d. A 64-year-old woman with chronic heart failure
admitted with bloody stools
e. A 58-year-old man with prostate cancer
undergoing preoperative workup for
prostatectomy
a, b, c, d, e. High-risk patients include those
exposed
to nephrotoxic agents and advanced age (a),
massive trauma (b), prolonged hypovolemia or
hypotension (possibly b and c), obstetric
complications (c), cardiac failure (d), preexisting
chronic kidney disease, extensive burns, or sepsis.
Patients with prostate cancer may have obstruction
of the outflow tract, which increases risk of
postrenal AKI (e).
Priority Decision: A patient on a medical unit has a
potassium level of 6.8 mEq/L. What is the priority
action that the nurse should take?
a. Place the patient on a cardiac monitor.
b. Check the patient's blood pressure (BP).
c. Instruct the patient to avoid high-potassium
foods.
d. Call the lab and request a redraw of the lab to
verify results.
a. Dysrhythmias may occur with an elevated
potassium level and are potentially lethal. Monitor
the rhythm while contacting the physician or calling
the rapid response team. Vital signs should be
checked. Depending on the patient's history and
cause of increased potassium, instruct the patient
about dietary sources of potassium; however, this
would not help at this point. The nurse may want
to recheck the value but until then the heart
rhythm needs to be monitored.
A patient with AKI has a serum potassium level of
6.7 mEq/L (6.7 mmol/L) and the following arterial
blood gasresults: pH 7.28, PaCO2 30 mm Hg, PaO2
86 mm Hg, HCO3 − 18 mEq/L (18 mmol/L). The
nurse recognizes that treatment of the acid-base
problem with sodium bicarbonate would cause a
decrease in which value?
a. pH
b. Potassium level
c. Bicarbonate level
d. Carbon dioxide level
b. During acidosis, potassium moves out of the cell
inexchange for H+ ions, increasing the serum
potassium level. Correction of the acidosis with
sodium bicarbonate will help to shift the potassium
back into the cells. A decrease in pH and the
bicarbonate and PaCO2 levels would indicate
worsening acidosis.
In replying to a patient's questions about the
seriousness of her chronic kidney disease (CKD),
the nurse knows that the stage of CKD is based on
what?
a. Total daily urine output
b. Glomerular filtration rate
c. Degree of altered mental status
d. Serum creatinine and urea levels
b. Stages of chronic kidney disease are based on
theGFR. No specific markers of urinary output,
mental status, or azotemia classify the degree of
chronic kidney disease (CKD).
The patient with CKD is receiving dialysis, and the
nurse observes excoriations on the patient's skin.
What pathophysiologic changes in CKD can
contribute to this finding (select all that apply)?
a. Dry skin
b. Sensory neuropathy
c. Vascular calcifications
d. Calcium-phosphate skin deposits
e. Uremic crystallization from high BUN
a, b, d. Pruritus is common in patients receiving
dialysis. It causes scratching from dry skin, sensory
neuropathy, and calcium-phosphate deposition in
the skin. Vascular calcifications contribute to
cardiovascular disease, not to itching skin. Uremic
frost rarely occurs without BUN levels greater than
200 mg/dL, which should not occur in a patient on
dialysis; urea crystallizes on the skin and also
causes pruritis.
What causes the gastrointestinal (GI) manifestation
of stomatitis in the patient with CKD?
a. High serum sodium levels
b. Irritation of the GI tract from creatinine
c. Increased ammonia from bacterial breakdown of
urea
d. Iron salts, calcium-containing phosphate binders,
and limited fluid intake
c. Uremic fetor, or the urine odor of the breath, is
caused by high urea content in the blood.
Increased ammonia from bacterial breakdown of
urea leads to stomatitis and mucosal ulcerations.
Irritation of the gastrointestinal (GI) tract from urea
in CKD contributes to anorexia, nausea, and
vomiting. Ingestion of iron salts and calcium-
containing phosphate binders, limited fluid intake,
and limited activity cause constipation.
The patient with CKD is brought to the emergency
department with Kussmaul respirations. What does
the nurse know about CKD that could cause this
patient's Kussmaul respirations?
a. Uremic pleuritis is occurring.
b. There is decreased pulmonary macrophage
activity.
c. They are caused by respiratory compensation for
metabolic acidosis.
d. Pulmonary edema from heart failure and fluid
overload is occurring.
c. Kussmaul respirations occur with severe
metabolic acidosis when the respiratory system is
attempting to compensate by removing carbon
dioxide with exhalations. Uremic pleuritis would
cause a pleural friction rub. Decreased pulmonary
macrophage activity increases the risk of
pulmonary infection. Dyspnea would occur with
pulmonary edema.
Which serum laboratory value indicates to the
nurse that the patient's CKD is getting worse?
a. Decreased BUN
b. Decreased sodium
c. Decreased creatinine
d. Decreased calculated glomerular filtration rate
(GFR)
d. As GFR decreases, BUN and serum creatinine
levels increase. Although elevated BUN and
creatinine indicate that waste products are
accumulating, the calculated GFR is considered a
more accurate indicator of kidney function than
BUN or serum creatinine.
What is the most serious electrolyte disorder
associated with kidney disease?
a. Hypocalcemia
b. Hyperkalemia
c. Hyponatremia
d. Hypermagnesemia
b. Hyperkalemia can lead to life-threatening
dysrhythmias. Hypocalcemia leads to an
accelerated rate of bone remodeling and
potentially to tetany. Hyponatremia may lead to
confusion. Elevated sodium levels lead to edema,
hypertension, and heart failure. Hypermagnesemia
may decrease reflexes, mental status, and blood
pressure.
For a patient with CKD the nurse identifies a
nursing diagnosis of risk for injury: fracture related
to alterations in calcium and phosphorus
metabolism. What is the pathologic process
directly related to the increased risk for fractures?
a. Loss of aluminum through the impaired kidneys
b. Deposition of calcium phosphate in soft tissues
of the body
c. Impaired vitamin D activation resulting in
decreased GI absorption of calcium
d. Increased release of parathyroid hormone in
response to decreased calcium levels
c. The calcium-phosphorus imbalances that occur
in CKD result in hypocalcemia, from a deficiency of
activevitamin D and increased phosphorus levels.
This leads to an increased rate of bone remodeling
with a weakened bone matrix. Aluminum
accumulation is also believed to contribute to the
osteomalacia. Osteitis fibrosa involves replacement
of calcium in the bone with fibrous tissue and is
primarily a result of elevated levels of parathyroid
hormone resulting from hypocalcemia.
Priority Decision: What is the most appropriate
snack for the nurse to offer a patient with stage 4
CKD?
a. Raisins
b. Ice cream
c. Dill pickles
d. Hard candy
d. A patient with CKD may have unlimited intake of
sugars and starches (unless the patient is diabetic)
and hard candy is an appropriate snack and may
help to relieve the metallic and urine taste that is
common in the mouth. Raisins are a high-
potassium food. Ice cream contains protein and
phosphate and counts as fluid. Pickled foods have
high sodium content.
The patient with CKD asks why she is receiving
nifedipine (Procardia) and furosemide (Lasix). The
nurse understands that these drugs are being used
to treat the patient's
a. anemia.
b. hypertension.
c. hyperkalemia.
d. mineral and bone disorder.
b. Nifedipine (Procardia) is a calcium channel
blocker and furosemide (Lasix) is a loop diuretic.
Both are used to treat hypertension.
What accurately describes the care of the
patient with CKD?
a. A nutrient that is commonly
supplemented for the patient on dialysis
because it is dialyzable is iron.
b. The syndrome that includes all of the
signs and symptoms seen in the various
body systems in CKD is azotemia.
c. The use of morphine is contraindicated in
the patient with CKD because accumulation
of its metabolites may
cause seizures.
d. The use of calcium-based phosphate
binders in the patient with CKD is
contraindicated when serum calcium levels
are increased.
d. In the patient with CKD, when serum
calcium levels
are increased, calcium-based phosphate
binders are not used. The nutrient
supplemented for patients on dialysis is
folic acid. The various body system
manifestations occur with uremia, which
includes azotemia. Meperidine is
contraindicated in patients with CKD related
to possible seizures.
During the nursing assessment of the
patient with renal insufficiency, the nurse
asks the patient specifically about a history
of
a. angina.
b. asthma.
c. hypertension.
d. rheumatoid arthritis.
c. The most common causes of CKD in the
United States are diabetes mellitus and
hypertension. The nurse should obtain
information on long-term health problems
that are related to kidney disease. The
other disorders are not closely associated
with renal disease.
The patient with chronic kidney disease is
considering whether to use peritoneal
dialysis (PD) or hemodialysis (HD). What are
advantages of PD when compared to HD
(select all that apply)?
a. Less protein loss
b. Rapid fluid removal
c. Less cardiovascular stress
d. Decreased hyperlipidemia
e. Requires fewer dietary restrictions
c, e. Peritoneal dialysis is less stressful for
the cardiovascular system and requires
fewer dietary restrictions. Peritoneal
dialysis actually contributes to more protein
loss and increased hyperlipidemia. The fluid
and creatinine removal are slower with
peritoneal dialysis than hemodialysis.
What does the dialysate for PD routinely
contain?
a. Calcium in a lower concentration than in
the blood
b. Sodium in a higher concentration than in
the blood
c. Dextrose in a higher concentration than
in the blood
d. Electrolytes in an equal concentration to
that of the blood
c. Dextrose or icodextrin or amino acid is
added to dialysate fluid to create an
osmotic gradient across the membrane to
remove excess fluid from the blood. The
dialysate fluid has no potassium so that
potassium will diffuse into the dialysate
from the blood. Dialysate also usually
contains higher calcium to promote its
movement into the blood. Dialysate sodium
is usually less than or equal to that of blood
to prevent sodium and fluid retention.
In which type of dialysis does the patient
dialyze during sleep and leave the fluid in
the abdomen during the day?
a. Long nocturnal hemodialysis
b. Automated peritoneal dialysis (APD)
c. Continuous venovenous hemofiltration
(CVVH)
d. Continuous ambulatory peritoneal
dialysis (CAPD)
b. Automated peritoneal dialysis (APD) is
the type of dialysis in which the patient
dialyzes during sleep and leaves the fluid in
the abdomen during the day. Long
nocturnal hemodialysis occurs while the
patient is sleeping and is done up to six
times per week. Continuous venovenous
hemofiltration (CVVH) is a type of
continuous renal replacement therapy used
to treat AKI. Continuous ambulatory
peritoneal dialysis (CAPD) is dialysis that is
done with exchanges of 1.5 to 3 L of
dialysate at least four times daily.
To prevent the most common serious
complication of PD, what is important for
the nurse to do?
a. Infuse the dialysate slowly.
b. Use strict aseptic technique in the dialysis
procedures.
c. Have the patient empty the bowel before
the inflow phase.
d. Reposition the patient frequently and
promote deep breathing.
b. Peritonitis is a common complication of
peritoneal dialysis (PD) and may require
catheter removal and termination of
dialysis. Infection occurs from
contamination of the dialysate or tubing or
from progression of exit-site or tunnel
infections and strict sterile technique must
be used by health professionals as well as
the patient to prevent contamination. Too-
rapid infusion may cause shoulder pain and
pain may be caused if the catheter tip
touches the bowel. Difficulty breathing,
atelectasis, and pneumonia may occur from
pressure of the fluid on the diaphragm,
which may be prevented by elevating the
head of the bed and promoting
repositioning and deep breathing.
 A patient on hemodialysis develops a
thrombus of a subcutaneous arteriovenous
(AV) graft, requiring its removal. While
waiting for a replacement graft or fistula,
the patient is most likely to have what done
for treatment?
a. Peritoneal dialysis
b. Peripheral vascular access using radial
artery
c. Silastic catheter tunneled subcutaneously
to the jugular vein
d. Peripherally inserted central catheter
(PICC) line inserted into subclavian vein
c. A more permanent, soft, flexible Silastic
double-lumen catheter is used for long-
term access when other forms of vascular
access have failed. These catheters are
tunneled subcutaneously and have Dacron
cuffs that prevent infection from tracking
along the catheter.
A patient with AKI is a candidate for continuous
renal replacement therapy (CRRT). What is the
most common
indication for use of CRRT?
a. Azotemia
b. Pericarditis
c. Fluid overload
d. Hyperkalemia
c. Continuous renal replacement therapy (CRRT) is
indicated for the patient with AKI as an alternative
or adjunct to hemodialysis to slowly remove
solutes and fluid in the hemodynamically unstable
patient. It is especially useful for treatment of fluid
overload, but hemodialysis is indicated for
treatment of hyperkalemia, pericarditis, or other
serious effects of uremia.
During the immediate postoperative care of
a recipient of a kidney transplant, what
should the nurse expect to do?
a. Regulate fluid intake hourly based on
urine output.
b. Monitor urine-tinged drainage on
abdominal dressing.
c. Medicate the patient frequently for
incisional flank pain.
d. Remove the urinary catheter to evaluate
the ureteral implant.
a. Fluid and electrolyte balance is critical in
the transplant recipient patient, especially
because diuresis often begins soon after
surgery. Fluid replacement is adjusted
hourly based on kidney function and urine
output. Urine-tinged drainage on the
abdominal dressing may indicate leakage
from the ureter implanted into the bladder
and the health care provider should be
notified. The donor patient may have a
flank or laparoscopic incision(s) where the
kidney was removed. The recipient has an
abdominal incision where the kidney was
placed in the iliac fossa. The urinary
catheter is usually used for 2 to 3 days to
monitor urine output and kidney function.
The nurse instructs a client with renal
failure who is receiving hemodialysis about
dietary modifications. The nurse determines
that the client understands these dietary
modifications if the client selects which
items from the menu?
a. Cream of wheat, blueberries, coffee
b. Sausage and eggs, banana, orange juice.
c. Bacon, cantaloupe melon, tomato juice.
d. Cured pork, grits, strawberries, orange
juice.
A
The diet for a client with renal failure who is
receiving hemodialysis should include
controlled amounts of sodium, phosphorus,
calcium, potassium, and fluids. Options 2, 3,
and 4 are high in sodium, phosphorus and
potassium.
The client with chronic renal failure is
scheduled for hemodialysis this morning is
due to receive a daily dose of enalapril
(Vasotec). The nurse should plan to
administer this medication:
a. During dialysis.
b. Just before dialysis.
c. The day after dialysis.
d. On return from dialysis.
D and measuring weight daily. Ideally, the
Antihypertensive medications such as
enalapril are given to the client following
hemodialysis. This prevents the client from
becoming hypotensive during dialysis and
also from having the medication removed
from the bloodstream by dialysis. No
rationale exists for waiting an entire day to
resume the medication. This would lead to
ineffective control of the blood pressure.
The client being hemodialyzed suddenly
becomes short of breath and complains of
chest pain. The client is tachycardic, pale,
and anxious. The nurse suspects air
embolism. The priority action for the nurse
is to:
a. Discontinue dialysis and notify the
physician.
b. Monitor vital signs every 15 minutes for
the next hour.
c. Continue dialysis at a slower rate after
checking the lines for air.
d. Bolus the client with 500 mL of normal
saline to break up the embolus.
A small clamps are attached to the dressing
If the client experiences air embolus during
hemodialysis, the nurse should terminate
dialysis immediately, notify the physician,
and administer oxygen as needed. Options
2, 3, and 4 are incorrect.
The nurse has completed client teaching
with the hemodialysis client about self-
monitoring between hemodialysis
treatments. The nurse determines that the
client best understands the information if
the client states to record daily the:
a. Amount of activity.
b. Pulse and respiratory rate.
c. Intake and output and weight.
d. Blood urea nitrogen and creatinine levels.
C The client on hemodialysis should monitor
fluid status between hemodialysis
treatments by recording intake and output
hemodialysis client should not gain more
than 0.5 kg of weight/day.
The client with an external arteriovenous
shunt in place for hemodialysis is at risk for
bleeding. The priority nurse action would be
to:
a. Check the shunt for the presence of bruit
and thrill.
b. Observe the site once as time permits
during the shift.
c. Check the results of the prothrombin
times as they are determined.
d. Ensure that small clamps are attached to
the arteriovenous shunt dressing.
D
An arteriovenous shunt is a less common
form of access site but carries a risk for
bleeding when it is used because two ends
of an external cannula are tunneled
subcutaneously into an artery and a vein,
and the ends of the cannula are joined. If
accidental disconnection occurs, the client
could lose blood rapidly. For this reason,
that covers the insertion site for use if
needed. The shunt site also should be
assessed at least every 4 hours.
A nurse is assessing the patency of a client's
left arm arteriovenous fistula prior to
initiating hemodialysis. Which finding
indicates that the fistula is patent?
a. Palpation of a thrill over the fistula.
b. Presence of a radial pulse in the left
wrist.
c. Absence of a bruit on auscultation of the
fistula.
d. Capillary refill less than 3 seconds in the
nail beds of the fingers of the left hand.

A Steal syndrome results from vascular
The nurse assesses the patency of the
fistula by palpating for the presence of a
thrill or auscultating for a bruit. The
presence of a thrill and bruit indicate
patency of the fistula. Although the
presence of a radial pulse in the left wrist
and capillary refill shorter than 3 seconds in
the nail beds of the fingers on the left hand
are normal findings, they do not assess
fistula patency.
A client with chronic renal failure has
completed a hemodialysis treatment. The
nurse would use which of the following
standard indicators to evaluate the client's
status after dialysis?
a. Vital signs and weight.
b. Potassium level and weight.
c. Vital signs and BUN.
d. BUN and creatinine levels.
A
Following dialysis, the client's vital signs are
monitored to determine whether the client
is remaining hemodynamically stable.
Weight is measured and compared with the
client's predialysis weight to determine
effectiveness of fluid extraction. Laboratory
studies are done as per protocol but are not
necessarily done after the hemodialysis
treatment has ended.
The hemodialysis client with a left arm
fistula is at risk for arterial steal syndrome.
The nurse assesses this client for which of
the following manifestations?
a. Warmth, redness, and pain in the left
hand.
b. Pallor, diminished pulse, and pain in the
left hand.
c. Edema and reddish discoloration of the
left arm.
d. Aching pain, pallor, and edema of the left
arm.
B
insufficiency after creation of a fistula. The
client exhibits pallor and a diminished pulse
distal to the fistula. The client also
complains of pain distal to the fistula,
caused by tissue ischemia. Warmth,
redness, and pain probably would
characterize a problem with infection. The
manifestations described in options 3 and 4
are incorrect.
The client with chronic renal failure returns
to the nursing unit following a hemodialysis
treatment. On assessment, the nurse notes
that the client's temperature is 100.2F.
Which of the following is the appropriate
nursing action?
a. Encourage fluids.
b. Notify the physician.
c. Continue to monitor vital signs.
d. Monitor the site of the shunt for
infection.
C
The client may have an elevated
temperature following dialysis because the
dialysis machine warms the blood slightly. If
the temperature is elevated excessively and
remains elevated, sepsis would be
suspected and a blood sample would be
obtained as prescribed for culture and
sensitivity determinations.
The nurse is performing an assessment on a
client who has returned from the dialysis
unit following hemodialysis. The client is
complaining of headache and nausea and is
extremely restless. Which of the following is
the most appropriate nursing action?
a. Monitor the client.
b. Notify the physician.
c. Elevate the head of the bed.
d. Medicate the client for nausea.
B
Disequilibrium syndrome may be caused by
the rapid decreases in the blood urea
nitrogen level during hemodialysis. These
changes can cause cerebral edema that
leads to increased intracranial pressure. The
client is exhibiting early signs of
disequilibrium syndrome and appropriate
treatments with anticonvulsive medications
and barbiturates may be necessary to
prevent a life-threatening situation. The
physician must be notified.
A nurse is analyzing the posthemodialysis
lab test results for a client with chronic
renal failure (CRF). The nurse interprets that
the dialysis is having an expected but
nontherapeutic effect if the results indicate
a decreased:
a. Phosphorus.
b. Creatinine.
c. Potassium.
d. Red blood cell count
D c. Anger
Hemodialysis typically lowers the amounts
of fluid, sodium, potassium, urea nitrogen,
creatinine, uric acid, magnesium, and
phosphate levels in the blood. Hemodialysis
also worsens anemia, because RBCs are lost
in dialysis from blood sampling and
anticoagulation during the procedure, and
from residual blood that is left in the
dialyzer. Although all of these results are
expected, only the lowered RBC count is
nontherapeutic and worsens the anemia
already caused by the disease process.
A client diagnosed with chronic renal failure
(CRF) is scheduled to begin hemodialysis.
The nurse assesses that which of the
following neurological and psychosocial
manifestations if exhibited by this client
would be unrelated to the CRF?
a. Labile emotions.
b. Withdrawal.
c. Euphoria.
d. Depression.
C
The client with CRF often experiences a
variety of psychosocial changes. These are
related to uremia, as well as the stress
associated with living with a chronic disease
that is life-threatening. Clients with CRF
may have labile emotions or personality
changes and may exhibit withdrawal,
depression, or agitation. Delusions and
psychosis also can occur. Euphoria is not
part of the clinical picture for the client in
renal failure.
A nurse is working with the client newly
diagnosed with chronic renal failure (CRF)
to set up a schedule for hemodialysis. The
client states, "This is impossible! How can I
even think about leading a normal life again
if this is what I'm going to have to do?" The
nurse assesses that the client is exhibiting:
a. Withdrawal
b. Depression
d. Projection
C
Psychosocial reactions to CRF and
hemodialysis are varied and may include
anger. Other reactions include personality
changes, emotional lability, withdrawal, and
depression. The individual client's response
may vary depending on the client's
personality and support systems. The client
in this question is exhibiting anger. The
client has not projected blame on the
nurse, nor does the client statement reflect
withdrawal or depression.
A client undergoing hemodialysis has an
arteriovenous (AV) fistula in the left arm. A
related nursing diagnosis for the client is
risk for infection. The nurse should
formulate which of the following outcome
goals as most appropriate for this nursing
diagnosis?
a. The client's temperature remains less
than 101F
b. The client's WBC count remains within
normal limits.
c. The client washes hands at least once per
day.
d. The client states to avoid blood pressure
measurement in the left arm.
B a. Partial thromboplastin time (PTT)
General indicators that the client is not
experiencing infection include a
temperature and WBC count within normal
limits. The client also should use proper
hand-washing technique as a general
preventive measure. Hand washing once
per day is insufficient. It is true that the
client should avoid BP measurement in the
affected arm; however, this would relate
more closely to the nursing diagnosis risk
for injury.
A nurse is giving general instructions to a
client receiving hemodialysis. Which of the
following statements would be appropriate
for the nurse to include?
a. Several types of medications should be
withheld on the day of dialysis until after
the procedure.
b. Medications should be double-dosed on
the morning of hemodialysis to prevent
loss.
c. It's acceptable to exceed the fluid
restriction on the day before hemodialysis.
d. It's acceptable to eat whatever you want
on the day before hemodialysis.
A dialysis.
Many medications are dialyzable, which
means they are extracted from the
bloodstream during dialysis. Therefore,
many medications may be withheld on the
day of dialysis until after the procedure. It is
not typical for medications to be "double-
dosed," because there is no way to be
certain how much of each medication is
cleared by dialysis. Clients receiving
hemodialysis are not routinely taught that it
is acceptable to disregard dietary and fluid
restrictions.
A client undergoing hemodialysis is at risk
for bleeding from the heparin used during
the hemodialysis treatment. The nurse
assesses for this occurrence by periodically
checking the results of which of the
following lab tests?
b. Prothrombin time (PT)
c. Thrombin time (TT)
d. Bleeding time
A
Heparin is the anticoagulant used most
often during hemodialysis. The
hemodialysis nurse monitors the extent of
anticoagulation by checking the PTT, which
is the appropriate measure of heparin
effect. The PT is used to monitor the effect
of warfarin (Coumadin) therapy. Thrombin
and bleeding times are not used to measure
the effect of heparin therapy, although they
are useful in the diagnosis of other clotting
abnormalities.
A registered nurse is instructing a new
nursing graduate about hemodialysis.
Which statement if made by the new
nursing graduate would indicate an
inaccurate understanding of the procedure
for hemodialysis?
a. Sterile dialysate must be used.
b. Warming the dialysate increases the
efficiency of diffusion.
c. Heparin sodium is administered during
d. Dialysis cleanses the blood from
accumulated waste products.
A
Dialysate is made from clear water and
chemicals and is free from any metabolic
waste products or medications. Bacteria
and other microorganisms are too large to
pass through the membrane; therefore, the
dialysate does not need to be sterile. The
dialysate is warmed to approximately 100°
F to increase the efficiency of diffusion and
to prevent a decrease in the client's blood
temperature. Heparin sodium inhibits the
tendency of blood to clot when it comes in
contact with foreign substances. Option 4 is
the purpose of dialysis.
A client with chronic renal failure is about
to begin hemodialysis therapy. The client
asks the nurse about the frequency and
scheduling of hemodialysis treatments. The
nurse's response is based on an
understanding that the typical schedule is:
a. 5 hours of treatment 2 days per week.
b. 3 to 4 hours of treatment 3 days per
week
c. 2 to 3 hours of treatment 5 days per
week
d. 2 hours of treatment 6 days per week
B be used for dialysis. The choice of an AV
The typical schedule for hemodialysis is 3 to
4 hours of treatment three days per week.
Individual adjustments may be made
according to variables such as the size of
the client, type of dialyzer, the rate of blood
flow, personal client preferences, and
others.
The nurse has instructed a patient who is
receiving hemodialysis about dietary
management. Which diet choices by the
patient indicate that the teaching has been
successful?
a. Scrambled eggs, English muffin, and
apple juice
b. Cheese sandwich, tomato soup, and
cranberry juice
c. Split-pea soup, whole-wheat toast, and
nonfat milk
d. Oatmeal with cream, half a banana, and
herbal tea
A might damage the fistula, and typically only
Rationale: Scrambled eggs would provide
high-quality protein, and apple juice is low
in potassium. Cheese is high in salt and
phosphate, and tomato soup would be high
in potassium. Split-pea soup is high in
potassium, and dairy products are high in
phosphate. Bananas are high in potassium,
and the cream would be high in phosphate.
A patient needing vascular access for
hemodialysis asks the nurse what the
differences are between an arteriovenous
(AV) fistula and a graft. The nurse explains
that one advantage of the fistula is that it
a. can accommodate larger needles.
b. increases patient mobility.
c. is much less likely to clot.
d. can be used sooner after surgery.
C
Rationale: AV fistulas are much less likely to
clot than grafts, although it takes longer for
them to mature to the point where they can
fistula or a graft does not impact on needle
size or patient mobility.
In preparation for hemodialysis, a patient
has an AV native fistula created in the left
forearm. When caring for the fistula
postoperatively, the nurse should
a. check the fistula site for a bruit and thrill.
b. assess the rate and quality of the left
radial pulse.
c. compare blood pressures in the left and
right arms.
d. irrigate the fistula site daily with low-
dose heparin.
A
Rationale: The presence of a thrill and bruit
indicates adequate blood flow through the
fistula. Pulse rate and quality are not good
indicators of fistula patency. Blood
pressures should never be obtained on the
arm with a fistula. Irrigation of the fistula
dialysis staff would access the fistula.
A patient begins hemodialysis after having
had conservative management of chronic
kidney disease. The nurse explains that one
dietary regulation that will be changed
when hemodialysis is started is that
a. unlimited fluids are allowed since
retained fluid is removed during dialysis.
b. increased calories are needed because
glucose is lost during hemodialysis.
c. more protein will be allowed because of
the removal of urea and creatinine by
dialysis.
d. dietary sodium and potassium are
unrestricted because these levels are
normalized by dialysis.
C catheter in the left femoral vein. The nurse
Rationale: Once the patient is started on
dialysis and nitrogenous wastes are
removed, more protein in the diet is
allowed. Fluids are still restricted to avoid
excessive weight gain and complications
such as shortness of breath. Glucose is not
lost during hemodialysis. Sodium and
potassium intake continues to be restricted
to avoid the complications associated with
high levels of these electrolytes.
A patient with chronic kidney disease (CKD)
is started on hemodialysis, and after the
first treatment, the patient complains of
nausea and a headache. The nurse notes
mild jerking and twitching of the patient's
extremities. The nurse will anticipate the
need to
a. increase the time for the next dialysis to
remove wastes more completely.
b. switch to continuous renal replacement
therapy (CRRT) to improve dialysis
efficiency.
c. administer medications to control these
symptoms before the next dialysis.
d. slow the rate for the next dialysis to
decrease the speed of solute removal.
D c. ensure that small clamps are attached to
Rationale: The patient has symptoms of
disequilibrium syndrome, which can be
prevented by slowing the rate of dialysis so
that fewer solutes are removed during the
dialysis. Increasing the time of the dialysis
to remove wastes more completely will
increase the risk for disequilibrium
syndrome. CRRT is a less efficient means of
removing wastes and, because it is
continuous, would not be used for a patient
with CKD. Administration of medications to
control the symptoms is not an appropriate
action; rather, the disequilibrium syndrome
should be avoided.
A patient with acute renal failure (ARF)
requires hemodialysis and temporary
vascular access is obtained by placing a
will plan to
a. restrict the patient's oral protein intake.
b. discontinue the retention catheter.
c. place the patient on bed rest.
d. start continuous pulse oximetry.
C
Rationale: The patient with a femoral vein
catheter must be on bed rest to prevent
trauma to the vein. Protein intake is likely
to be increased when the patient is
receiving dialysis. The retention catheter is
likely to remain in place because accurate
measurement of output will be needed.
There is no indication that the patient
needs continuous pulse oximetry.
A client has an arteriovenous (AV) fistula in
place in the right upper extremity for
hemodialysis treatments. When planning
care for this client, which of the following
measures should the nurse implement to
promote client safely?
a. take blood pressures only on the right
arm to ensure accuracy
b. use the fistula for all venipunctures and
intravenous infusions
the AV fistula dressing
d. assess the fistula for the presence of a
bruit and thrill every 4 hours
D initial nursing action?
assess the fistula for the presence of a bruit
and thrill every 4 hours
The client with chronic renal failure is on
chronic hemodialysis. Which of the
following indicate improvement of the
client's condition due to hemodialysis?
Select all that apply
a) the client's BP is 130/90
b) the client's serum potassium is 4.8 mEq/L
c) the client's hemoglobin level is 10 g/dL
d) the client's serum calcium is 7.7 mg/dL
e) the client's serum sodium is 140 mEg/L
f) the client's serum magnesium is 4 mEq/L
g) the client's weight has increased from 60
kg to 63 kg
a) the client's BP is 130/90
b) the client's serum potassium is 4.8 mEq/L
e) the client's serum sodium is 140 mEg/L
The client had been diagnosed to have
chronic renal failure. He had undergone
hemodialysis for the first time. What signs
and symptoms when experienced by the
client suggest that he is experiencing
disequilibrium syndrome?
a) restlessness, hypotension, headache
b) nausea and vomiting, hypertension,
dizziness
c) lethargy, hypotension, dizziness
d) thachycardia, hypotension, headache
b) nausea and vomiting, hypertension,
dizziness
disequilibrium syndrome is caused by more
rapid removal of waste products from the
blood from the brain. This is due to the
presence of blood-brain barrier. This causes
increased intracranial pressure.
The client with continuous ambulatory
peritoneal dialysis (CAPD) has cloudy
dialysate. Which of the following is the best
a) send fluid to the laboratory for culture
b) administer antibiotic
c) do nothing, this is expected
d) stop drainage of fluid
a) send fluid to the laboratory for culture
cloudy diasylate indicates infection
(peritonitis). Culture of the fluid must be
done to determine the microorganism
present.
Which of the following client responses
shows a correct understanding of
continuous ambulatory peritoneal dialysis
(CAPD)?
a) I am expected to perform the procedure
at home
b) the procedure lasts for one hour
c) I have to sit and raise my legs during the
procedure
d) I have to go to the hospital for this
procedure
a) I am expected to perform the procedure
at home
The client with chronic renal failure is
undergoing peritoneal dialysis. He asks why
the nurse monitors his blood glucose levels.
Which of the following will be the most
appropriate response by the nurse?
a) I have to check if you have diabetes
mellitus
b) the dialysate contains glucose
c) the procedure may lower your blood
glucose levels
d) it is a routine procedure for every client
who undergoes the treatment
b) the dialysate contains glucose
A client with end-stage renal disease is
receiving continuous ambulatory peritoneal
dialysis. The nurse is monitoring the client
for signs of complications associated with
peritoneal dialysis. Select all that apply.
1. Pruritus
2. Oliguria
3. Tachycardia
4. Cloudy outflow
5. Abdominal pain
Answer: 3, 4, 5
Rationale: Tachycardia can be caused by
peritonitis, a complication of peritoneal
dialysis; the heart rate increases to meet
the metabolic demands associated with
infection. Cloudy or opaque dialysate
outflow (effluent) is the earliest sign of
peritonitis; it is caused by the constituents
associated with an infectious process.
Abdominal pain is associated with
peritonitis, a complication of peritoneal
dialysis; pain results from peritoneal
inflammation, abdominal distention, and
involuntary muscle spasms. Severe itching
(pruritus) is caused by metabolic waste
products that are deposited in the skin;
dialysis removes metabolic waste products,
preventing this adaptation associated with
kidney failure. The production of
abnormally small amounts of urine
(oliguria) is a sign of kidney failure, not a
complication of peritoneal dialysis.
The nurse is reviewing the list of
components contained in the peritoneal
dialysis solution with the client. The client
asks the nurse about the purpose of the
glucose contained in the solution. The nurse
bases the response on knowing that the
glucose:
1. Decreases the risk of peritonitis.
2. Prevents disequilibrium syndrome.
3. Increases osmotic pressure to produce
ultrafiltration.
4. Prevents excess glucose from being
removed from the client.
3. Increasing the glucose concentration
makes the solution more hypertonic. The
more hypertonic the solution, the higher
the osmotic pressure for ultrafiltration and
thus the greater the amount of fluid
removed from the client during an
exchange. Options 1, 2, and 4 do not
identify the purpose of the glucose.
The nurse is preparing to care for a client
receiving peritoneal dialysis. Which of the
following would be included in the nursing
plan of care to prevent the major
complication associated with peritoneal
dialysis?
1. Maintain strict aseptic technique.
2. Add heparin to the dialysate solution.
3. Change the catheter site dressing daily.
4. Monitor the client's level of
consciousness.
1. The major complication of peritoneal
dialysis is peritonitis. Strict aseptic
technique is required in caring for the client
receiving this treatment. Although option 3
may assist in preventing infection, this
option relates to an external site. Options 2
and 4 are unrelated to the major
complication of peritoneal dialysis.
A client newly diagnosed with renal failure
has just been started on peritoneal dialysis.
During the infusion of the dialysate, the
client complains of abdominal pain. Which
action by the nurse is appropriate?
1. Stop the dialysis.
2. Slow the infusion.
3. Decrease the amount to be infused.
4. Explain that the pain will subside after
the first few exchanges.
4. Pain during the inflow of dialysate is
common during the first few exchanges
because of peritoneal irritation; however,
the pain usually disappears after 1 to 2
weeks of treatment. The infusion amount
should not be decreased, and the infusion
should not be slowed or stopped.
The nurse is instructing a client with
diabetes mellitus about peritoneal dialysis.
The nurse tells the client that it is important
to maintain the prescribed dwell time for
the dialysis because of the risk of:
1. Infection.
2. Hyperglycemia.
3. Hypophosphatemia.
4. Disequilibrium syndrome.
2. An extended dwell time increases the risk
of hyperglycemia in the client with diabetes
mellitus as a result of absorption of glucose
from the dialysate and electrolyte changes.
Diabetic clients may require extra insulin
when receiving peritoneal dialysis.
The nurse monitoring a client receiving
peritoneal dialysis notes that the clietn's
outflow is less than the inflow. Select all
nursing actions in the situation that apply.
1. Contact the physician.
2. Check the level of the drainage bag.
3. Reposition the client to his or her side.
4. Place the client in good body alignment.
5. Check the peritoneal dialysis system for
kinks.
6. Increase the flow rate of the peritoneal
dialysis solution.
2, 3, 4, 5. If outflow drainage is inadequate,
the nurse attempts to stimulate outflow by
changing the client's position. Turning the
client to the other side or making sure that
the client is in good body alignment may
assist with outflow drainage. The drainage
bag needs to be lower than the client's
abdomen to enhance gravity drainage. The
connecting tubing and peritoneal dialysis
system are also checked for kinks or
twisting and the clamps on the system are
checked to ensure that they are open.
There is no reason to contact the physician.
Increasing the flow rate is an inappropriate
action and is not associated with the
amount of outflow solution.
A nurse instructs a client about continuous
ambulatory peritoneal dialysis (CAPD).
Which of the following statements if made
by the client indicates an accurate
understanding of CAPD?
1. A portable hemodialysis machine is used
so that I will be able to ambulate during the
treatment.
2. A cycling machine is used so the risk for
infection is minimized.
3. No machinery is involved, and I can
pursue my usual activities.
4. The drainage system can be used once
during the day and a cycling machine for 3
cycles at night.
3. CAPD closely approximates normal renal
function, and the client will need to infuse
and drain the dialysis solution several times
a day. No machinery is used, and CAPD is a
manual procedure.
A patient with diabetes who has chronic
kidney disease (CKD) is considering using
continuous ambulatory peritoneal dialysis
(CAPD). In discussing this treatment option
with the patient, the nurse informs the
patient that
a. patients with diabetes who use CAPD
have fewer dialysis-related complications
than those on hemodialysis.
b. home CAPD requires more extensive
equipment than does home hemodialysis.
c. CAPD is contraindicated for patients who
might eventually want a kidney transplant.
d. dietary restrictions are stricter for
patients using CAPD than for those having
hemodialysis.
Answer: A
Rationale: Patients with diabetes have
better control of blood pressure, less
hemodynamic instability, and fewer
problems with retinal hemorrhages when
using peritoneal dialysis than when using
hemodialysis. CAPD is less expensive and
has fewer dietary restrictions than
hemodialysis. CAPD is not a
contraindication for a kidney transplant.
A patient who has been on continuous
ambulatory peritoneal dialysis (CAPD) is
hospitalized and is receiving CAPD with four
exchanges a day. During the dialysate
inflow, the patient complains of having
abdominal pain and pain in the right
shoulder. The nurse should
a. massage the patient's abdomen and
back.
b. decrease the rate of dialysate infusion.
c. stop the infusion and notify the health
care provider.
d. administer the PRN acetaminophen
(Tylenol).
Answer: B
Rationale: Abdominal pain and referred
shoulder pain can be caused by a rapid
infusion of dialysate; the nurse should slow
the rate of the infusion. Massage and
administration of acetaminophen (Tylenol)
would not address the reason for the pain.
There is no need to notify the health care
provider.
The nurse is assessing a patient who is
receiving peritoneal dialysis with 2-L
inflows. Which information should be
reported immediately to the health care
provider?
a. The patient complains of feeling bloated
after the inflow.
b. The patient's peritoneal effluent appears
cloudy.
c. The patient has abdominal pain during
the inflow phase.
d. The patient has an outflow volume of
1600 ml.
Answer: B
Rationale: Cloudy-appearing peritoneal
effluent is a sign of peritonitis and should
be reported immediately so that treatment
with antibiotics can be started. The other
problems can be addressed through nursing
interventions such as slowing the inflow
and repositioning the patient.
A patient receiving peritoneal dialysis using
2 L of dialysate per exchange has an outflow
of 1200 ml. Which action should the nurse
take first?
a. Infuse 1200 ml of dialysate during the
inflow.
b. Assist the patient in changing position.
c. Administer a laxative to the patient.
d. Notify the health care provider about the
outflow problem.
Answer: B
Rationale: Outflow problems may occur
because the peritoneal catheter is collapsed
by a portion of the intestine, and
repositioning the patient will move the
catheter and allow outflow to occur. If less
than the ordered 2 L of dialysate is infused,
the dialysis will be less effective.
Administration of a laxative may also help if
the patient's colon is full, but this should be
tried after repositioning the patient. If the
problem with outflow persists after the
patient is repositioned, the health care
provider should be notified.
After teaching a group of students about
how to perform peritoneal dialysis, which
statement would indicate to the instructor
that the students need additional teaching?
a) "The effluent should be allowed to drain
by gravity."
b) "It is important to use strict aseptic
technique."
c) "The infusion clamp should be open
during infusion."
d) "It is appropriate to warm the dialysate
in a microwave."
D) It is appropriate to warm the dialysate in
a microwave
Explanation: The dialysate should be
warmed in a commercial warmer and never
in a microwave oven. Strict aseptic
technique is essential. The infusion clamp is
opened during the infusion and clamped
after the infusion. When the dwell time is
done, the drain clamp is opened and the
fluid is allowed to drain by gravity into the
drainage bag.
A client with renal failure is undergoing
continuous ambulatory peritoneal dialysis.
Which nursing diagnosis is the most
appropriate for this client?
a) Impaired urinary elimination
b) Toileting self-care deficit
c) Risk for infection
d) Activity intolerance
C) Risk for infection
Explanation: The peritoneal dialysis
catheter and regular exchanges of the
dialysis bag provide a direct portal for
bacteria to enter the body. If the client
experiences repeated peritoneal infections,
continuous ambulatory peritoneal dialysis
may no longer be effective in clearing waste
products. Impaired urinary elimination,
Toileting self-care deficit, and Activity
intolerance may be pertinent but are
secondary to the risk of infection.
A male client has doubts about performing
peritoneal dialysis at home. He informs the
nurse about his existing upper respiratory
infection. Which of the following
suggestions can the nurse offer to the client
while performing an at-home peritoneal
dialysis?
a) Perform deep-breathing exercises
vigorously.
b) Avoid carrying heavy items.
c) Auscultate the lungs frequently.
d) Wear a mask when performing
exchanges.
D) Wear a mask when performing
exchanges
The nurse should advise the client to wear a
mask while performing exchanges. This
prevents contamination of the dialysis
catheter and tubing, and is usually advised
to clients with upper respiratory infection.
Auscultation of the lungs will not prevent
contamination of the catheter or tubing.
The client may also be advised to perform
deep-breathing exercises to promote
optimal lung expansion, but this will not
prevent contamination. Clients with a
fistula or graft in the arm should be advised
against carrying heavy items.
A client with chronic renal failure who is not
receiving dialysis is suffering from uremia.
What nutrient will the nurse tell this client
to limit in an attempt to control the
uremia?
a. carbohydrate
c. potassium
b. magnesium
d. protein
D . Protein
Uremia is a condition in which protein
wastes that should normally have been
excreted are instead circulating in the
blood. The diet may limit protein to as little
as 40 grams a day for predialysis clients.
The nurse at the dialysis clinic notes when
she reviews a client's labs that the labs
indicated hyperkalemia. She makes a note
to make sure the client is adhering to all
dietary restrictions. Of the following
possibilities, which might the nurse ask
about?
a. fiber supplements
b. intake of whole grains
c. salt substitutes
d. sugar substitutes
C . Salt Substitutes
Potassium may be restricted in some clients
because hyperkalemia tends to occur in
end-stage renal disease. Excess potassium
can cause cardiac arrest. Because of this
danger, renal clients should not use salt
substitutes or low-sodium milk because the
sodium in these products is replaced with
potassium.
The nurse is assessing a dialysis patient who
is asking to receive continuous ambulatory
peritoneal dialysis (CAPD) instead of
hemodialysis. Which of the following
complications of CAPD will the nurse review
with the client?
a. hypercalcemia
b. hypertension
c. hyponatremia
d. hypotension
D. hypotension
Clients on CAPD have a more normal
lifestyle than do clients on either
hemodialysis or peritoneal dialysis.
Complications associated with CAPD include
peritonitis, hypotension, and weight gain.
The nurse is calculating the protein
requirement for a client who is switching
from peritoneal dialysis to hemodialysis.
The client is 5'5" tall and weighs 140
pounds. How many grams of protein does
this client need per day?
a. 42 to 63
b. 51 to 62
c. 64 to 76
d. 76 to 96
C. 64 to 76
A client on hemodialysis requires 1.0 to 1.2
grams of protein per kilogram of body
weight.The client weighs 64 kg so the
requirement is 64 to 76.
The nurse is assessing an otherwise healthy
client with renal disease. The client is taking
several supplements that are not indicated
for clients who have renal disease. Which of
the following will the nurse think should be
discontinued? Select all that apply.
a. iron
b. vitamin A
c. vitamin C
d. vitamin D
e. vitamin E
f. vitamin K
B. Vitamin A
E. Vitamin E
F. Vitamin K
Renal clients often have an increased need
for vitamins B, C, and D, and supplements
are often given. Vitamin A should not be
given because the blood level of vitamin A
tends to be elevated in uremia. If a client is
receiving antibiotics, a vitamin K
supplement may be given. Otherwise,
supplements of vitamins E and K are not
necessary.
The diet order for a client receiving
hemodialysis is written as 80-3-3. When the
nurse explains the diet to the client, which
of the following will be included in the
teaching? Select all that apply.
a. 80 grams of fat are allowed per day
b. 80 grams of protein are allowed per day
c. potassium is restricted to 3 grams a day
d. phosphorus is restricted to 3 grams a day
e. potassium is restricted to 80 mg per day
f. sodium is restricted to 3 grams per day
B. 80 grams of protein are allowed per day
C. potassium is restricted to 3 grams a day
F. sodium is restricted to 3 grams per day
A typical renal diet could be written as "80-
3-3," which means 80 grams of protein, 3
grams of sodium, and 3 grams of potassium
are allowed per day.
The nurse is educating a client who recently
had a kidney transplant about the dietary
changes that will be necessary. Which of
the following statements could the nurse
make to the client? Select all that apply.
a. additional calcium may be needed
b. carbohydrates may be restricted
c. extra protein may be needed
d. fats may be limited
e. protein may be restricted
f. sodium may be restricted
ALL--> A, B, C, D, E, F
After kidney transplant, there may be a
need for extra protein or for the restriction
of protein. Carbohydrate and sodium may
be restricted. The appropriate amounts of
these nutrients will depend largely on the
medications given at the time. Additional
calcium and phosphorus may be necessary
if there was substantial bone loss before
the transplant. There may be an increased
appetite after transplant, so fats and simple
carbohydrates may be limited to prevent
excessive weight gain.
The nurse is educating the client about diet
after the client was treated for calcium
oxalate renal stones. The nurse tells the
client about foods that should be avoided
to reduce the risk of development of future
renal stones. Which of the following foods
could the nurse tell the client to avoid?
Select all that apply.
a. cheese
b. chocolate
c. milk
d. spinach
e. strawberries
f. tea
B. chocolate
D. spinach
E. strawberries
F. tea
About 80% of the renal stones formed
contain calcium oxalate. Recent studies
provide no support for the theory that a
diet low in calcium can reduce the risk of
calcium oxalate renal stones. In fact, higher
dietary calcium intake may decrease the
incidence of renal stones for most people.
Stones containing oxalate are thought to be
partially caused by a diet especially rich in
oxalate, which is found in beets, wheat
bran, chocolate, tea, rhubarb, strawberries,
and spinach.
A client who has a renal mass asks the nurse
why an ultrasound has been scheduled, as
opposed to other diagnostic tests that may
be ordered. The nurse formulates a
response based on the understanding that:
a) all other tests are more invasive than an
ultrasound
b) all other tests require more elaborate
postprocedure care
c) an ultrasound can differentiate a solid
mass from a fluid-filled cyst
d) an ultrasound is much more cost
effective than other diagnostic tests
c) an ultrasound can differentiate a solid
mass from a fluid-filled cyst
A client has been admitted to the hospital
with a diagnosis of acute
glomerulonephritis. During history-taking
the nurse first asks the client about a recent
history of:
a) bleeding ulcer
b) deep vein thrombosis
c) myocardial infarction
d) streptococcal infection
d) streptococcal infection
A nurse is assigned to care for a client with
nephrotic syndrome. The nurse assesses
which important parameter on a daily
basis?
a) weight
b) albumin levels
c) activity tolerance
d) blood urea nitrogen (BUN) level
a) weight
A client with renal failure is receiving
epoetin alfa (Epogen) to support
erythropoiesis. The nurse questions the
client about compliance with taking which
of the following medications that supports
red blood cell (RBC) production?
a) iron supplement
b) zinc supplement
c) calcium supplement
d) magnesium supplement
a) iron supplement
A client has an arteriovenous (AV) fistula in
place in the right upper extremity for
hemodialysis treatments. When planning
care for this client, which of the following
measures should the nurse implement to
promote client safely?
a) take blood pressures only on the right
arm to ensure accuracy
b) use the fistula for all venipunctures and
intravenous infusions
c) ensure that small clamps are attached to
the AV fistula dressing
d) assess the fistula for the presence of a
bruit and thrill every 4 hours
d) assess the fistula for the presence of a
bruit and thrill every 4 hours
d) ensure that small clamps are attached to the
arteriovenous shunt dressing
The home care nurse is making follow-up
visits to a client following renal transplant.
The nurse assesses the client for which
signs of acute graft rejection?
a) hypotension, graft tenderness, and
anemia
b) hypertension, oliguria, thirst, and
hypothermia
c) fever, hypertension, graft tenderness,
and malaise
d) fever, vomiting, hypotension, and
copious amounts of dilute urine
c) fever, hypertension, graft tenderness,
and malaise
A client is scheduled for computed
tomography (CT) of the kidneys to rule out
renal disease. As an essential preprocedure
component of the nursing assessment, the
nurse plans to ask the client about a history
of:
a) familial renal disease
b) frequent antibiotic use
c) long-term diuretic therapy
d) allergy to shellfish or iodine
d) allergy to shellfish or iodine
The client with an external arteriovenous
shunt in place for hemodialysis is at risk for
bleeding. The priority nurse action would be
to:
a) check the shunt for the presence of bruit
and thrill
b) observe the site once as time permits
during the shift
c) check the results of the prothrombin time
as they are determined
d) ensure that small clamps are attached to
the arteriovenous shunt dressing
- An arteriovenous shunt is a less common form of
access site but carries a risk for bleeding when it is
used because two ends of an external cannula are
tunneled subcutaneously into an artery and a vein,
and the ends of the cannula are joined. If
accidental disconnection occurs, the client could
lose blood rapidly. For this reason, small clamps are
attached to the dressing that covers the insertion
site for use if needed. The shunt site also should be
assessed at least every 4 hours.
The nurse develops a post-procedure plan of care
for a client who had a renal biopsy. The nurse
avoids documenting which intervention in the
plan?
a) administering analgesics as needed
b) encouraging fluids to at least 3L in the first 24
hours
c) testing serial urine samples with dipstick for
occult blood
d) ambulating the client in the room and hall for
short distances
d) ambulating the client in the room and hall for
short distances
The client arrives at the emergency department
with complaints of low abdominal pain and
hematuria. The client is afebrile. The nurse next
assesses the client to determine a history of:
a) pyelonephritis
b) glomerulonephritis
c) trauma to the bladder or abdomen
d) renal cancer in the client's family
c) trauma to the bladder or abdomen
Use the process of elimination. Eliminate options A
and B, knowing that any inflammatory disease or
infection is accompanied by fever. Because this
client is afebrile, these are not possible options.
Use knowledge of anatomy and pain assessment to
select option C. Pain from renal cancer is a later
finding and is localized in the flank area.
The client with acute renal failure has a
serum potassium of 6.0 mEq/L. The nurse
would plan which of the following as a
priority action?
a) check the sodium level
b) place the client on a cardiac monitor
c) encourage increased vegetables in the
diet
d) allow an extra 500 ml of fluid intake to
dilute the electrolyte concentration
b) place the client on a cardiac monitor
The client hemodialyzed suddenly becomes
short of breath and complains of chest pain.
The client is tachycardic, pale and anxious.
The nurse suspects air embolism. The
priority action for the nurse is to:
a) discontinue dialysis and notify the
physician
b) monitor vital signs every 15 minutes for
the next hour
c) continue dialysis at a slower rate after
checking the lines for air
d) bolus the client with 500 ml of normal
saline to break up the air embolus
a) discontinue dialysis and notify the
physician
The nurse has completed client teaching
with the hemodialysis client about self-
monitoring between hemodialysis
treatments. The nurse determines that the
best understands the information if the
client states to record daily the:
a) amount of activity
b) pulse and respiratory rate
c) intake and output and weight
d) blood urea nitrogen and creatinine levels
c) intake and output and weight
 Which of the following should be
considered in the diet of the client with
end-stage-renal-disease (ESRD)?
a) limit fluid intake during anuric phase
b) limit phosphorus and vitamin D-rich food
c) limit calcium-rich food
d) limit carbohydrates
a) limit fluid intake during anuric phase
during ESRD, fluid intake of the client
should be limited during anuric phase to
prevent fluid overload. Fluid overload
increases renal workload, pulmonary
edema, and congestive heart failure.
1. A adult client has had laboratory work done
as part of a routine physical examination.
The nurse interprets that the client may
have a mild degree of renal insufficiency if
which of the following serum creatinine
levels is noted?
a) 0.2 mg/dlL
b) 0.5 mg/dL
c) 1.9 mg/dL
d) 3.5 mg/dL
c) 1.9 mg/dL
the normal serum creatinine level foadults
is 0.6 to 1.3 mg/dL.
The client with a mild degree of renal
insufficiency would have a slight elevated
level. A creatinie level of 0.2 mg/dL is low,
and a level of 0.5 mg/dL is just below
normal. A creeatinie level of 3.5 mg/dL may
be associated with acute or chronic renal
failure.
The nurse instructs a client with renal
failure who is receiving hemodialysis about
dietary modifications. The nurse determines
that the client understands these dietary
modifications if the client selects which
items from the dietary menu?
a) cream of wheat, blueberries, coffee
b) sausage and eggs, banana, orange juice
c) bacon, cantaloupe melon, tomato juice
d) cured pork, strawberries, orange juice
a) cream of wheat, blueberries, coffee
- the diet for a client with renal failure who
is receiving hemodialysis should include
controlled amounts of sodium, phosphorus,
calcium, potassium, and fluids. Option B, C,
and D are high in sodium, phosphorus, and
potassium.
The client with continuous ambulatory
peritoneal dialysis (CAPD) has cloudy
dialysate. Which of the following is the best
initial nursing action?
a) send fluid to the laboratory for culture
b) administer antibiotic
c) do nothing, this is expected
d) stop drainage of fluid
a) send fluid to the laboratory for culture
cloudy diasylate indicates infection
(peritonitis). Culture of the fluid must be
done to determine the microorganism
present.
Which of the following may be included in
the diet of the client with chronic renal
failure?
a) orange slices
b) watermelon slices
c) cantaloupe slices
d) apple slices
d) apple slices
the client with renal failure should be given
low potassium diet because of
hyperkalemia. Apple contains very little
potassium. So, it can be given to the client.
The client with chronic renal failure is on
chronic hemodialysis. Which of the
following indicate improvement of the
client's condition due to hemodialysis?
Select all that apply

a) the client's BP is 130/90
b) the client's serum potassium is 4.8 mEq/L
c) the client's hemoglobin level is 10 g/dL
d) the client's serum calcium is 7.7 mg/dL
e) the client's serum sodium is 140 mEg/L
f) the client's serum magnesium is 4 mEq/L
g) the client's weight has increased from 60
kg to 63 kg
a) the client's BP is 130/90
b) the client's serum potassium is 4.8 mEq/L
e) the client's serum sodium is 140 mEg/L
The client is in end-stage renal failure
(ESRD). Which of the following foods may
be allowed for the client?
a) banana
b) apple
c) carrot cake
d) cantaloupe
b) apple
APPLES ARE LOW IN POTASSIUM
The client has end-stage renal disease. He
had undergone kidney transplant 5 days
ago. Which of the following is the most
important intervention for the client to
prevent infection?
a) observe asepsis
b) increase fluid intake
c) avoid clients with flu
d) avoid crowded places
a) observe asepsis
Which of the following should the nurse
include in the nursing care plan of the client
who is diagnosed to have renal failure,
whose BUN is 32 mg/dl, serum creatinine is
4 mg/dl, hematocrit is 38%. He is
complaining of fatigue and edema.
a) low protein diet and fluid restriction
b) high protein diet and fluid restriction
c) low protein diet and increase in fiber
d) high protein diet and potassium
restriction
a) low protein diet and fluid restriction
The client in end-stage of renal failure had
undergone kidney transplant. Which of the
following assessment findings indicate
kidney transplant rejection?
a) increased urinary output, BUN = 15
mg/dL
b) HCT = 50%, Hgb = 17 g/dl
c) decreased urinary output, sudden weight
gain
d) decreased urinary output, sudden weight
loss
c) decreased urinary output, sudden weight
gain
Which of the following anti-hypertensive
medications is contraindicated for clients
with renal insufficiency?
a) beta-adrenergic blockers
b) calcium-channel blockers
c) direct-acting vasodilators
d) angiotensin-converting enzyme inhibitors
d) angiotensin-converting enzyme inhibitors
The client has been diagnosed to have
glomerulonephritis. What should the nurse
observe in the urine?
a) blood
b) pus
c) white blood cells
d) glucose
a) blood
A client has been diagnosed to have chronic
renal failure. Sodium polysterene sulfonate
(exchange resin kayexalate) is prescribed.
The action of the medication is that it
releases
a) bicarbonate in exchange for primarily
sodium ions
b) sodium ions in exchange for primarily
bicarbonate ions
c) sodium ions in exchange for primarily
potassium ions
d) potassium ions in exchange for primarily
sodium ions
c) sodium ions in exchange for primarily
potassium ions
Which of the following problems is
expected in a client who is in end-stage
renal failure?
a) anemia
b) thalassemia
c) renal calculi
d) hypotension
a) anemia
Which of the following client responses
shows a correct understanding of
continuous ambulatory peritoneal dialysis
(CAPD)?
a) I am expected to perform the procedure
at home
b) the procedure lasts for one hour
c) I have to sit and raise my legs during the
procedure
d) I have to go to the hospital for this
procedure
a) I am expected to perform the procedure
at home
The client with chronic renal failure is
undergoing peritoneal dialysis. He asks why
the nurse monitors his blood glucose levels.
Which of the following will be the most
appropriate response by the nurse?
a) I have to check if you have diabetes
mellitus
b) the dialysate contains glucose
c) the procedure may lower your blood
glucose levels
d) it is a routine procedure for every client
who undergoes the treatment
b) the dialysate contains glucose
Which of the following is an expected
finding in the client with chronic renal
failure?
a) anemia
b) polyuria
c) increased creatinine clearance
d) increased serum calcium levels
a) anemia
In the oliguric phase of renal failure, what is
the most appropriate nursing diagnosis?
a) fluid volume deficit
b) activity intolerance
c) ineffective breathing pattern
d) fluid volume excess
d) fluid volume excess
Which of the following complaints is
common in a client with pyelonephritis?
a) right upper quadrant pain
b) left upper quadrant pain
c) pain at the costovertebral region
d) pain at the suprapubic region
c) pain at the costovertebral region
The client had been diagnosed to have
chronic renal failure. He had undergone
hemodialysis for the first time. What signs
and symptoms when experienced by the
client suggest that he is experiencing
disequilibrium syndrome?
a) restlessness, hypotension, headache
b) nausea and vomiting, hypertension,
dizziness
c) lethargy, hypotension, dizziness
d) thachycardia, hypotension, headache
 b) nausea and vomiting, hypertension,
dizziness
disequilibrium syndrome is caused by more
rapid removal of waste products from the
blood from the brain. This is due to the
presence of blood-brain barrier. This causes
increased intracranial pressure.
Three year old Carlo has been admitted to
the pediatric unit with a tentative diagnosis
of nephrotic syndrome.
Carlo's potential for impairment of skin
integrity is related to:
a) joint inflammation
b) drug therapy
c) edema
d) generalized body rash
c) edema
2. Three year old Carlo has been admitted to
the pediatric unit with a tentative diagnosis
of nephrotic syndrome
Prednisone is prescribed for Carlo. The
nurse evaluate its effectiveness by
a) checking his BP every 4 hours
b) checking his urine for protein
c) weighing him each morning before
breakfast
d) observing him for behavioral changes
b) checking his urine for protein
3. The physician orders a combination of
Sulfamethoxazole and Phenazopyridine
hydrochloride (Azogantrisol) for a patient.
Which therapeutic effect should this
combination drug have:
a) plain relief and a decreased WBC count
b) equal fluid intake and output
c) polyuria with reddish stain
d) increased complaints of bladder spasm
after 20 minutes
a) plain relief and a decreased WBC count
The client is reporting chills, fever, and left
costovertebral pain. Which diagnostic test should the
nurse expect the HCP to prescribe first?
1.A midstream urine for culture.
2.A sonogram of the kidney.
3.An intravenous pyelogram for renal calculi.
4.A CT scan of the kidneys.
1 Fever, chills, and costovertebral pain are symptoms of
a urinary tract infection (acute pyelonephritis), which
requires a urine culture first to confirm the diagnosis.
The nurse is preparing a plan of care for the client
diagnosed with acute glomerulonephritis. Which
statement is an appropriate long-term goal?
1.The client will have a blood pressure within normal
limits.
2.The client will show no protein in the urine.
3.The client will maintain normal renal function.
4.The client will have clear lung sounds.
3
A long-term complication of glomerulonephritis is it can
become chronic if unresponsive to treatment,and this
can lead to end-stage renal disease. Maintaining renal
function is an appropriate long-term goal.
The elderly client is diagnosed with chronic
glomerulonephritis. Which laboratory value indicates to
the nurse the condition has become worse?
1.The blood urea nitrogen is 15 mg/dL.
2.The creatinine level is 1.2 mg/dL.
3.The glomerular filtration rate is 40 mL/min.
4.The 24-hour creatinine clearance is 100 mL/min.
3.Glomerular filtration rate (GFR) is approximately 120
mL/min. If the GFR is decreased to 40 mL/min, the
kidneys are functioning at about one-third filtration
capacity.
The nurse is caring for a client diagnosed with ARF.
Which laboratory values are most significant for
diagnosing ARF?
1.BUN and creatinine.
2.WBC and hemoglobin.
3.Potassium and sodium.
4.Bilirubin and ammonia level.

1.
Blood urea nitrogen (BUN) levels reflect the balance
between the production and excretion of urea from the
kidneys. Creatinine is a by-product of the metabolism of
the muscles and is excreted by the kidneys. Creatinine is
the ideal sub-stance for determining renal clearance
because it is relatively constant in the body and is the
laboratory value most significant in diagnosing renal
failure.
The nurse is caring for a client diagnosed with rule-out
ARF. Which condition predisposes the client to
developing prerenal failure?
1.Diabetes mellitus.
2.Hypotension.
3.Aminoglycosides.
4.Benign prostatic hypertrophy
2.Hypotension, which causes a decreased blood supply
to the kidney, is one of the most common causes of pre-
renal failure(before the kidney).
The client diagnosed with ARF has a serum potassium
level of 6.8 mEq/L. Which collaborative treatment
should the nurse anticipate for the client?
1.Administer a phosphate binder.
2.Type and crossmatch for whole blood.
3.Assess the client for leg cramps.
4.Prepare the client for dialysis.
4.
Normal potassium level is 3.5 to5.5 mEq/L. A level of 6.8
mEq/L is life threatening and could lead to cardiac
dysrhythmias. Therefore, the client may be dialyzed to
decrease the potassium level quickly. This requires a
health-careprovider order, so it is a collaborative
intervention.
The client diagnosed with ARF is admitted to the
intensive care unit and placed on a therapeutic diet.
Which diet is most appropriate for the client?
1.A high-potassium and low-calcium diet.
2.A low-fat and low-cholesterol diet.
3.A high-carbohydrate and restricted-protein diet.
4.A regular diet with six (6) small feedings a day.
3.Carbohydrates are increased to provide for the
client's caloric intake and protein is restricted to
minimize protein breakdown and to prevent
accumulation of toxic waste products.
The client diagnosed with ARF is placed on bed rest. The
client asks the nurse, "Why do I have to stay in bed? I
don't feel bad." Which scientific rationale supports the
nurse's response?
1.Bed rest helps increase the blood return to the renal
circulation.
2.Bed rest reduces the metabolic rate during the acute
stage.
3.Bed rest decreases the workload of the left side of the
heart.
4.Bed rest aids in reduction of peripheral and sacral
edema.
2.Bed rest reduces exertion and the metabolic rate,
thereby reducing catabolism and subsequent release of
potassium and accumulation of endogenous waste
products (urea and creatinine).
The UAP tells the nurse the client with ARF has a white
crystal-like layer on top of the skin. Which intervention
should the nurse implement?
1.Have the assistant apply a moisture barrier cream to
the skin.
2.Instruct the UAP to bathe the client in cool water.
3.Tell the UAP not to turn the client in this condition.
4.Explain this is normal and do not do anything for the
client.
2.These crystals are uremic frost resulting from
irritating toxins deposited in the client's tissues. Bathing
in cool water will remove the crystals, promote client
comfort, and decrease the itching resulting from uremic
frost.
The client diagnosed with ARF is experiencing
hyperkalemia. Which medication should the nurse
prepare to administer to help decrease the potassium
level?
1.Erythropoietin.
2.Calcium gluconate.
3.Regular insulin.
4.Osmotic diuretic.
3.
Regular insulin, along with glucose, will drive potassium
into the cells,thereby lowering serum potassium levels
temporarily.
The nurse in the dialysis center is initiating the
morning dialysis run. Which client should the nurse
assess first?
1.The client who has hemoglobin of 9.8 g/dL and
hematocrit of 30%.
2.The client who does not have a palpable thrill or
auscultated bruit.
3.The client who is complaining of being exhausted
and is sleeping.
4.The client who did not take antihypertensive
medication this morning.
2.This client's dialysis access is compromised and he or
she should be assessed first.
The client receiving dialysis is complaining of being dizzy
and light-headed. Which action should the nurse
implement first?
1.Place the client in the Trendelenburg position.
2.Turn off the dialysis machine immediately.
3.Bolus the client with 500 mL of normal saline.
4.Notify the health-care provider as soon as possible.
1.
The nurse should place the client's chair with the head
lower than thebody, which will shunt blood to the
brain; this is the Trendelenburg position.
The client is admitted to a nursing unit from a long-term
care facility with a hematocrit of 56% and a serum
sodium level of 152 mEq/L. Which condition is a cause
for these findings?
1.Overhydration.
2.Anemia.
3.Dehydration.
4.Renal failure.
3.Dehydration results in concentrated serum, causing
laboratory values to increase because the blood has
normal constituents but not enough volume to dilute
the values to within normal range or possibly lower.
Which descriptions characterize acute kidney injury
(select all that apply)?
a. Primary cause of death is infection
b. It almost always affects older people
c. Disease course is potentially reversible
d. Most common cause is diabetic nephropathy
e. Cardiovascular disease is most common cause of
death
a. Primary cause of death is infection
c. Disease course is potentially reversible
Rationale: Acute kidney injury (AKI) is potentially
reversible. AKI has a high mortality rate, and the
primary cause of death in patients with AKI is
infection. The primary cause of death in patients
with chronic kidney failure is cardiovascular
disease. Most commonly, AKI follows severe,
prolonged hypotension or hypovolemia or exposure
to a nephrotoxic agent. Older adults are more
susceptible to AKI because the number of
functioning nephrons decrease with age, but AKI
can occur at any age.
RIFLE defines three stages of AKI based on
changes in
a. blood pressure and urine osmolality
b. fractional excretion of urinary sodium
c. estimation of GFR with the MDRD equation
d. serum creatinine or urine output from baseline
d. serum creatinine or urine output from baseline
Rationale: The RIFLE classification is used to
describe the stages of AKI. RIFLE standardizes the
diagnosis of AKI. Risk (R) is the first stage of AKI,
followed by injury (I), which is the second stage,
and then increasing in severity to the final or third
stage of failure (F). The two outcome variables are
loss (L) and end-stage renal disease (E). The first
three stages are characterized by the serum
creatinine level and urine output.
During the oliguric phase of AKI, the nurse
monitors the patient for (select all that apply)
a. hypotension
b. ECG changes
c. hypernatremia
d. pulmonary edema
e. urine with high specific gravity
b. ECG changes
d. pulmonary edema
Rationale: The nurse monitors the patient in the
oliguric phase of acute renal injury for the
following:
If a patient is in the diuretic phase of AKI, the
nurse must monitor for which serum electrolyte
imbalances?
a. Hyperkalemia and hyponatremia
b. Hyperkalemia and hypernatremia
c. Hypokalemia and hyponatremia
d. Hypokalemia and hypernatremia
c. Hypokalemia and hyponatremia
Rationale: In the diuretic phase of AKI, the kidneys
have recovered the ability to excrete wastes but not
the ability to concentrate urine. Hypovolemia and
hypotension can result from massive fluid losses.
Because of the large losses of fluid and electrolytes,
the patient must be monitored for hyponatremia,
hypokalemia, and dehydration.
A patient is admitted to the hospital with chronic
kidney disease. The nurse understands that this
condition is characterized by
a. progressive irreversible destruction of the kidneys
b. a rapid decrease in urine output with an elevated
BUN
c. an increasing creatinine clearance with a decrease
in urine output
d. prostration, somnolence, and confusion with
coma and imminent death
a. progressive irreversible destruction of the kidneys
Rationale: Chronic kidney disease (CKD) involves
progressive, irreversible loss of kidney function.
Nurses must teach patients at risk for developing
chronic kidney disease. Individuals considered to be
at increased risk include (select all that apply)
a. older African Americans
b. patients more than 60 years old
c. those with a history of pancreatitis
d. those with a history of hypertension
e. those with a history of type 2 diabetes
a. older African Americans
b. patients more than 60 years old
d. those with a history of hypertension
e. those with a history of type 2 diabetes
Rationale: Risk factors for CKD include diabetes
mellitus, hypertension, age older than 60 years,
cardiovascular disease, family history of CKD,
exposure to nephrotoxic drugs, and ethnic minority
(e.g., African American, Native American).
Patients with chronic kidney disease experience an
increased incidence of cardiovascular disease
related to (select all that apply)
a. hypertension
b. vascular calcifications
c. a genetic predisposition
d. hyperinsulinemia causing dyslipidemia
e. increased high-density lipoprotein levels
a. hypertension
b. vascular calcifications
d. hyperinsulinemia causing dyslipidemia
Rationale: CKD patients have traditional
cardiovascular (CV) risk factors, such as
hypertension and elevated lipids. Hyperinsulinemia
stimulates hepatic production of triglycerides. Most
patients with uremia develop dyslipidemia. CV
disease may be related to nontraditional CV risk
factors, such as vascular calcification and arterial
stiffness, which are major contributors to CV
disease in CKD. Calcium deposits in the vascular
medial layer are associated with stiffening of the
blood vessels. The mechanisms involved are
multifactorial and incompletely understood, but
they include (1) change of vascular smooth muscle
cells into chondrocytes or osteoblast-like cells, (2)
high total-body amounts of calcium and phosphate
as a result of abnormal bone metabolism, (3)
impaired renal excretion, and (4) drug therapies to
treat the bone disease (e.g., calcium phosphate
binders).
Nutritional support and management are essential
across the entire continuum of chronic kidney
disease. Which statements would be considered true
related to nutritional therapy (select all that apply)?
a. Fluid is not usually restricted for patients
receiving peritoneal dialysis
b. Sodium and potassium may be restricted in
someone with advanced CKD
c. Decreased fluid intake and a low-potassium diet
are hallmarks of the diet for a patient receiving
hemodialysis
d. Decreased fluid intake and a low-potassium diet
are hallmarks of the diet for a patient receiving
peritoneal dialysis
e. Decreased fluid intake and a diet with phosphate-
rich foods are hallmarks of a diet for a patient
receiving hemodialysis
a. Fluid is not usually restricted for patients
receiving peritoneal dialysis
b. Sodium and potassium may be restricted in
someone with advanced CKD
c. Decreased fluid intake and a low-potassium diet
are hallmarks of the diet for a patient receiving
hemodialysis
An ESRD patient receiving hemodialysis is
considering asking a relative to donate a kidney for
transplantation. In assisting the patient to make a
decision about treatment, the nurse informs the
patient that
a. successful transplantation usually provides better
quality of life than that offered by dialysis
b. if rejection of the transplanted kidney occurs, no
further treatment for the renal failure is available
c. hemodialysis replaces the normal functions of the
kidneys, and patients do not have to live with the
continual fear of rejection
d. the immunosuppressive therapy following
transplantation makes the person ineligible to
receive other forms of treatment if the kidney fails
a. successful transplantation usually provides better
quality of life than that offered by dialysis
Rationale: Kidney transplantation is extremely
successful, with 1-year graft survival rates of about
90% for deceased donor organs and 95% for live
donor organs. An advantage of kidney
transplantation over dialysis is that it reverses many
of the pathophysiologic changes associated with
renal failure when normal kidney function is
restored. It also eliminates the dependence on
dialysis and the need for the accompanying dietary
and lifestyle restrictions. Transplantation is less
expensive than dialysis after the first year.
To assess the potency of a newly placed
arteriovenous graft for dialysis, the nurse should
(select all that apply)
a. monitor the BP in the affected arm
b. irrigate the graft daily with low-dose heparin
c. palpate the area of the graft to feel a normal thrill
d. listen with a stethoscope over the graft to detect a
bruit
e. frequently monitor the pulses and neurovascular
status distal to the graft
c. palpate the area of the graft to feel a normal thrill
d. listen with a stethoscope over the graft to detect a
bruit
e. frequently monitor the pulses and neurovascular
status distal to the graft
Rationale: A thrill can be felt on palpation of the
area of anastomosis of the arteriovenous graft, and a
bruit can be heard with a stethoscope. The bruit and
thrill are created by arterial blood rushing into the
vein. The BP should not be taken in the arm with
the AV graft.
A major advantage of peritoneal dialysis is
a. the diet is less restricted and dialysis can be
performed at home
b. the dialysate is biocompatible and causes no
long-term consequences
c. high glucose concentrations of the dialysate cause
a reduction in appetite, promoting weight loss
d. no medications are required because of the
enhanced efficiency of the peritoneal membrane in
removing toxins
a. the diet is less restricted and dialysis can be
performed at home
Rationale: Advantages of peritoneal dialysis include
fewer dietary restrictions and the possibility of
home dialysis.
A kidney transplant recipient complains of having
fever, chills, and dysuria over the past 2 days. What
is the first action that the nurse should take?
a. Assess temperature and initiate workup to rule
out infection
b. Reassure the patient that this is common after
transplantation
c. Provide warm cover for the patient and give 1 g
acetaminophen orally
d. Notify the nephrologist that the patient has
developed symptoms of acute rejection
a. Assess temperature and initiate workup to rule
out infection
Rationale: The nurse must be astute in the
observation and assessment of kidney transplant
recipients because prompt diagnosis and treatment
of infections can improve patient outcomes. Fever,
chills, and dysuria indicate an infection. The
temperature should be assessed, and the patient
should undergo diagnostic testing to rule out an
infection.
SPINAL CORD INJURY
A patient with a spinal cord injury at the T1 level
complains of a severe headache and an "anxious
feeling." Which is the most appropriate initial
reaction by the nurse?
1. Try to calm the patient and make the
environment soothing.
2. Assess for a full bladder.
3. Notify the healthcare provider.
4. Prepare the patient for diagnostic radiography.
Correct Answer: 2
Rationale: Autonomic dysreflexia occurs in patients
with injury at level T6 or higher, and is a life-
threatening situation that will require immediate
intervention or the patient will die. The most
common cause is an overextended bladder or
bowel. Symptoms include hypertension, headache,
diaphoresis, bradycardia, visual changes, anxiety,
and nausea. A calm, soothing environment is fine,
though not what the patient needs in this case. The
nurse should recognize this as an emergency and
proceed accordingly. Once the assessment has
been completed, the findings will need to be
communicated to the healthcare provider.
A hospitalized patient with a C7 cord injury begins
to yell "I can't feel my legs anymore." Which is the
most appropriate action by the nurse?
1. Remind the patient of her injury and try to
comfort her.
2. Call the healthcare provider and get an order for
radiologic evaluation.
3. Prepare the patient for surgery, as her condition
is worsening.
4. Explain to the patient that this could be a
common, temporary problem.
Correct Answer: 4
Rationale: Spinal shock is a condition almost half
the people with acute spinal injury experience. It is
characterized by a temporary loss of reflex function
below level of injury, and includes the following
symptomatology: flaccid paralysis of skeletal
muscles, loss of sensation below the injury, and
possibly bowel and bladder dysfunction and loss of
ability to perspire below the injury level. In this
case, the nurse should explain to the patient what
is happening.
The nurse is caring for a patient with increased
intracranial pressure (IICP). The nurse realizes that
some nursing actions are contraindicated with IICP.
Which nursing action should be avoided?
1. Reposition the patient every two hours.
2. Position the patient with the head elevated 30
degrees.
3. Suction the airway every two hours per standing
orders.
4. Provide continuous oxygen as ordered.
Correct Answer: 3
Rationale: Suctioning further increases intracranial
pressure; therefore, suctioning should be done to
maintain a patent airway but not as a matter of
routine. Maintaining patient comfort by frequent
repositioning as well as keeping the head elevated
30 degrees will help to prevent (or even reduce)
IICP. Keeping the patient properly oxygenated may
also help to control ICP.
A patient with a spinal cord injury (SCI) is admitted
to the unit and placed in traction. Which of the
following actions is the nurse responsible for when
caring for this patient?
Select all that apply.
1. modifying the traction weights as needed
2. assessing the patient's skin integrity
3. applying the traction upon admission
4. administering pain medication
5. providing passive range of motion
Correct Answer: 2,4,5
Rationale: The healthcare provider is responsible
for initial applying of the traction device. The
weights on the traction device must not be
changed without the order of a healthcare
provider. When caring for a patient in traction, the
nurse is responsible for assessment and care of the
skin due to the increased risk of skin breakdown.
The patient in traction is likely to experience pain
and the nurse is responsible for assessing this pain
and administering the appropriate analgesic as
ordered. Passive range of motion helps prevent
contractures; this is often performed by a physical
therapist or a nurse.
A patient has manifestations of autonomic
dysreflexia. Which of these assessments would
indicate a possible cause for this condition?
Select all that apply.
1. hypertension
2. kinked catheter tubing
3. respiratory wheezes and stridor
4. diarrhea
5. fecal impaction
Correct Answer: 2,5
Rationale: Autonomic dysreflexia can be caused by
kinked catheter tubing allowing the bladder to
become full, triggering massive vasoconstriction
below the injury site, producing the manifestations
of this process. Acute symptoms of autonomic
dysreflexia, including a sustained elevated blood
pressure, may indicate fecal impaction. The other
answers will not cause autonomic dysreflexia.
An unconscious patient receiving emergency care
following an automobile crash accident has a
possible spinal cord injury. What guidelines for
emergency care will be followed?
Select all that apply.
1. Immobilize the neck using rolled towels or a
cervical collar.
2. The patient will be placed in a supine position
3. The patient will be placed on a ventilator.
4. The head of the bed will be elevated.
5. The patient's head will be secured with a belt or
tape secured to the stretcher.
Correct Answer: 1,2,5
Rationale: In the emergency setting, all patients
who have sustained a trauma to the head or spine,
or are unconscious should be treated as though
they have a spinal cord injury. Immobilizing the
neck, maintaining a supine position and securing
the patient's head to prevent movement are all
basic guidelines of emergency care. Placement on
the ventilator and raising the head of the bed will
be considered after admittance to the hospital.
A patient with a spinal cord injury is recovering
from spinal shock. The nurse realizes that the
patient should not develop a full bladder because
what emergency condition can occur if it is not
corrected quickly?
1. autonomic dysreflexia
2. autonomic crisis
3. autonomic shutdown
4. autonomic failure
Correct Answer: 1
Rationale: Be attuned to the prevention of a
distended bladder when caring for spinal cord
injury (SCI) patients in order to prevent this chain
of events that lead to autonomic dysreflexia. Track
urinary output carefully. Routine use of bladder
scanning can help prevent the occurrence. Other
causes of autonomic dysreflexia are impacted stool
and skin pressure. Autonomic crisis, autonomic
shutdown, and autonomic failure are not terms
used to describe common complications of spinal
injury associated with bladder distension.
Which patient is at highest risk for a spinal cord
injury?
1. 18-year-old male with a prior arrest for driving
while intoxicated (DWI)
2. 20-year-old female with a history of substance
abuse
3. 50-year-old female with osteoporosis
4. 35-year-old male who coaches a soccer team
Correct Answer: 1
Rationale: The three major risk factors for spinal
cord injuries (SCI) are age (young adults), gender
(higher incidence in males), and alcohol or drug
abuse. Females tend to engage in less risk-taking
behavior than young men.
The nurse understands that when the spinal cord is
injured, ischemia results and edema occurs. How
should the nurse explain to the patient the reason
that the extent of injury cannot be determined for
several days to a week?
1. "Tissue repair does not begin for 72 hours."
2. "The edema extends the level of injury for two
cord segments above and below the affected
level."
3. "Neurons need time to regenerate so stating the
injury early is not predictive of how the patient
progresses."
4. "Necrosis of gray and white matter does not
occur until days after the injury."
Correct Answer: 2
Rationale: Within 24 hours necrosis of both gray
and white matter begins if ischemia has been
prolonged and the function of nerves passing
through the injured area is lost. Because the edema
extends above and below the area affected, the
extent of injury cannot be determined until after
the edema is controlled. Neurons do not
regenerate, and the edema is the factor that limits
the ability to predict extent of injury.
A patient with a spinal cord injury (SCI) has
complete paralysis of the upper extremities and
complete paralysis of the lower part of the body.
The nurse should use which medical term to
adequately describe this in documentation?
1. hemiplegia
2. paresthesia
3. paraplegia
4. quadriplegia
Correct Answer: 4
Rationale: Quadriplegia describes complete
paralysis of the upper extremities and complete
paralysis of the lower part of the body. Hemiplegia
describes paralysis on one side of the body.
Paresthesia does not indicate paralysis. Paraplegia
is paralysis of the lower body.
Which of the following nursing actions is
appropriate for preventing skin breakdown in a
patient who has recently undergone a
laminectomy?
1. Provide the patient with an air mattress.
2. Place pillows under patient to help patient turn.
3. Teach the patient to grasp the side rail to turn.
4. Use the log roll to turn the patient to the side.
Correct Answer: 4
Rationale: A patient who has undergone a
laminectomy needs to be turned by log rolling to
prevent pressure on the area of surgery. An air
mattress will help prevent skin breakdown but the
patient still needs to be turned frequently. Placing
pillows under the patient can help take pressure off
of one side but the patient still needs to change
positions often. Teaching the patient to grasp the
side rail will cause the spine to twist, which needs
to be avoided.
The patient is admitted with injuries that were
sustained in a fall. During the nurse's first
assessment upon admission, the findings are: blood
pressure 90/60 (as compared to 136/66 in the
emergency department), flaccid paralysis on the
right, absent bowel sounds, zero urine output, and
palpation of a distended bladder. These signs are
consistent with which of the following?
1. paralysis
2. spinal shock
3. high cervical injury
4. temporary hypovolemia
Correct Answer: 2
Rationale: Spinal shock is common in acute spinal
cord injuries. In addition to the signs and
symptoms mentioned, the additional sign of
absence of the cremasteric reflex is associated with
spinal shock. Lack of respiratory effort is generally
associated with high cervical injury. The findings
describe paralysis that would be associated with
spinal shock in an spinal injured patient. The likely
cause of these findings is not hypovolemia, but
rather spinal shock.
While caring for the patient with spinal cord injury
(SCI), the nurse elevates the head of the bed,
removes compression stockings, and continues to
assess vital signs every two to three minutes while
searching for the cause in order to prevent loss of
consciousness or death. By practicing these
interventions, the nurse is avoiding the most
dangerous complication of autonomic dysreflexia,
which is which of the following?
1. hypoxia
2. bradycardia
3. elevated blood pressure
4. tachycardia
Correct Answer: 3
Rationale: Autonomic dysreflexia is an emergency
that requires immediate assessment and
intervention to prevent complications of extremely
high blood pressure. Additional nursing assistance
will be needed and a colleague needs to reach the
physician stat.
A patient is admitted to the hospital with a CD4
spinal cord injury after a motorcycle collision. The
patient's BP is 83/49, and his pulse is 39 beats/min,
and he remains orally intubated. The nurse
identifies this pathophysiologic response as caused
by
a. increased vasomotor tone after injury
b. a temporary loss of sensation and flaccid
paralysis below the level of injury
c. loss of parasympathetic nervous system
innervation resulting in vasoconstriction
d. loss of sympathetic nervous system innervation
resulting in peripheral vasodilation
D. loss of sympathetic nervous system innervation
resulting in peripheral vasodilation
A nurse is caring for a client with a spinal cord
injury who reports a severe headache and is
sweating profusely. vital signs include BP 220/110,
apical heart rate of 54/min. Which of the following
acctions should the nurse take first?
a. notify the provider
b. sit the client upright in bed
c. check the client's urinary catheter for blockage
d. administer antihypertensive medication
B. sit the client upright in bed
Rationale: The greatest risk to the client is
experiencing a cerebrovascular accident (stroke)
secondary to elevated BP. The first action by the
nurse is elevate the head of the bed until the client
is in an upright position. this will lower the BP
secondary to postural hypotension.
Following a T2 spinal cord injury, the patient
develops paralytic ileus. While this condition is
present, the nurse anticipates that the patient will
need
a. IV fluids
b. tube feedings
c. parenteral nutrition
d. nasogastric suctioning
D. nasogastric suctioning
Rationale: During the first 2 to 3 days after a spinal
cord injury, paralytic ileus may occur, and NG
suction must be used to remove secretions and gas
from the GI tract until peristalsis resumes. IV fluids
are used to maintain fluid balance but do not
specifically relate to paralytic ileus. Tube feedings
would be used only for patients who had difficulty
swallowing and not until peristalsis is returned; PN
would be used only if the paralytic ileus was
unusally prolonged.
An initial incomplete spinal cord injury often results
in complete cord damage because of
a. edematous compression of the cord above the
level of the injury
b. continued trauma to the cord resulting from
damage to stabilizing ligaments
c. infarction and necrosis of the cord caused by
edema, hemorrhage, and metabolites
d. mecheanical transection of the cord by sharp
vertebral bone fragments after the initial injury
c. infarction and necrosis of the cord caused by
edema, hemorrhage, and metabolites
Rationale: The primary injury of the spinal cord
rarely affects the entire cord, but the patho of
secondary injury may result in damage that is the
same as mechanical severance of the cord.
Complete cord dissolution occurs through
autodestruction of the cord by hemorrhage,
edema, and the presence of metabolites and
norepinephrine. resulting in anoxia and infarction
of the cord. Edema resulting from the
inflammatory response may increase the damage
as it extends above and below the injury site.
Two days following a spinal cord injury, a patient
asks continually about the extent of impairment
that will result from the injury. The best response
by the nurse is,
a. you will have more normal function when spinal
shock resolves and the reflex arc returns
b. the extent of your injury cannot be determined
until the secondary injury to the cord is resolved
c. when your condition is more stable, an MRI will
be done that can reveal the extent of the cord
damage
d. because long-term rehabilitation can affect the
return of tunction, it will be years before we can
tell when the complete effect will be
B. the extent of your injury cannot be determined
until the secondary injury to the cord is resolved
Rationale: Until the edema and necrosis at the site
of the injury are resolved in 72 hours to 1 week
after the injury, it is not possible to determine how
much cord damage is present from the initial
injury, how much secondary injury occurred, or
how much the cord was damaged by edema that
extended above the level of the original injury. The
return of reflexes signals only the end of spinal
shock, and the reflexes may be inappropriate and
excessive, causing spasms that complicate rehab.
A week following a spinal cord injury at T2, a
patient experiences movement in his leg and tells
the nurse he is recovering some function. The
nurses' best response to the patient is,
a. it is really still too soon to know if you will have a
return of function
b. the could be a really positive finding. can you
show me the movement
c. that's wonderful. we will start exercising your
legs more frequently now
d. im sorry, but the movement is only a reflex and
does not indicate normal function
B. the could be a really positive finding. can you
show me the movement
Rationale: in 1 week following a spinal cord injury,
there may be a resolution of the edema of the
injury and an end to spinal shock. When spinal
shock ends, reflex movement and spasms will
occur, which may be mistaken for return of
function, but with the resolution of edema, some
normal function may also occur. it is important
when movement occurs to determine whether the
movement is voluntary and can be consciously
controlled, which would indicate some return of
function.
Urinary function during the acute phase of spinal
cord injury is maintained with
a. an indwelling catheter
b. intermittent catheterization
c. insertion of a suprapubic catheter
d. use of incontinent pads to protect the skin
A. an indwelling catheterization
A nurse is caring for a client who has a C4 spinal
cord injury. which of the following should the nurse
recognize the client as being at the greatest risk
for?
a. neurogenic shock
b. paralytic ileus
c. stress ulcer
d. respiratory compromise
D. respiratory compromise
Rationale: Using the airway, breathing and
circulation priority framework, the greatest risk to
the client with a SCI at the level of C4 is respiratory
compromise secondary to involvement of the
phrenic nerve. Maintainance of an airway and
provision of ventilator support as needed is the
priority intervention.
During assessment of a patient with a spinal cord
injury, the nurse determines that the patient has a
poor cough with diaphragmatic breathing. Based
on this finding, the nurses' first action should be to
a. initiate frequent turning and repositioning
b. use tracheal suctioning to remove secretions
c. assess lung sounds and respiratory rate and
depth
d. prepare the patient for endotracheal intubation
and mechanical ventilation
C. assess lungs sounds and respiratory rate and
depth
Rationale: Because pneumonia and atelectasis are
potential problems RT ineffective coughing
function, the nurse should assess the patient's
breath sound and resp function to determine
whether secretions are being retained or whether
there is progression of resp impairment. Suctioning
is not indicated unless lung sounds indicate
retained secretions: position changes will help
mobilize secretions. Intubation and mechanical
ventilation are used if the patient becomes
exhausted from labored breathing or if ABGs
deteriorate.
The healthcare provider has ordered IV dopamine
(Intropin) for a patient in the emergency
deparement with a spinal cord injury. The nurse
determines that the drug is having the desired
effect when assessment findings include
a. pulse rate of 68
b. respiratory rate of 24
c. BP of 106/82
d. temperature of 96.8
C. BP of 106/82
Rationale: Dopamine is a vasopressor that is used
to maintain BP during states of hypotension that
occur during neurogenic shock associated with
spinal cord injury. Atropine would be used to treat
bradycardia. The T reflects some degree of
poikilothermism, but this is not treated with
medications.
A patient is admitted to the emergency
department with a spinal cord injury at the level of
T2. Which of the following findings is of most
concern to the nurse?
a. SpO2 of 92%
b. HR of 42 beats/min
c. BP of 88/60
d. loss of motor and sensory function in arms and
legs
b. HR of 42 beats/min
Rationale: Neurogenic shock associated with cord
injuries above the level of T6 greatly decrease the
effect of the sympathetic nervous system, and
bradycardia and hypotension occur. A heart rate of
42 is not adequate to meet oxygen needs of the
body, and while low, the BP is not at a critical
point. The O2 sat is ok, and the motor and sensory
loss are expected.
Without surgical stabilization, immobilization and
traction of the patient with a cervical spinal cord
injury most frequently requires the use of
a. kinetic beds
b. hard cervical collars
c. skeletal traction with skull tongs
d. sternal-occipital-mandibular immobilizer (SOMI)
brace
C. skeletal traction with skull tongs
Rationale: Cervical injuries usually require skeletal
traction with the use of Crutchfield, Vinke, or other
types of skull tongs to immobilize the cervical
vertebrae, even if fracture has not occurred. Hard
cervical collars are used for minor injuries or for
stabilization during emergency transport of the
patient. Sandbags are also used temporarily to
stabilize the neck during insertion of tongs or
during diagnostic testing immediately following the
injury. Special turning or kinetic beds may be used
to turn and mobilize patients who are in cervical
traction.
A patient with a spinal cord injury has spinal shock.
The nurse plans care for the patient based on the
knowledge that
a. rehabilitation measures cannot be initiated until
spinal shock has resolved
b. the patient will need continuous monitoring for
hypotension, tachycardia, and hypoxemia
c. resolution of spinal shock is manifested by
spasticity, hyperreflexia, and reflex emptying of the
bladder
d. the patient will have complete loss of motor and
sensory functions below the level of the injury, but
autonomic functions are not affected
c. resolution of spinal shock is manifested by
spasticity, hyperreflexia, and reflex emptying of the
bladder
Rationale: Spinal shock occurs in about half of all
people with acute spinal cord injury. In spinal
shock, the entire cord below the level of the lesion
fails to function, resulting in a flaccid paralysis and
hypomotility of most processes without any reflex
activity. Return of reflex activity signals the end of
spinal shock. Sympathetic function is impaired
belwo the level of the injury because sympathetic
nerves leave the spinal cord at the thoracic and
lumbar areas, and cranial parasympathetic nerves
predominate in control over respirations, heart,
and all vessels and organ below the injury.
Neurogenic shock results from loss of vascular tone
caused by the injury and is manifested by
hypotension, peripheral vasodilation, and
decreased CO. Rehab activities are not
contraindicated during spainl shock and should be
instituted if the patient's cardiopulmonary status is
stable.
A patient with a C7 spinal cord injury undergoing
rehabilitation tells the nurse he must have the flu
because he has a bad headache and nausea. The
initial action of the nurse is to
a. call the physician
b. check the patient's temperature
c. take the patient's BP
d. elevate the HOB to 90 degrees
c. Take the patient's BP
One indication for surgical therapy of the patient
with a spinal cord injury is when
a. there is incomplete cord lesion involvement
b. the ligaments that support the spine are torn
c. a high cervical injury causes loss of respiratory
function
d. evidence of continued compression of the cord
is apparent
D. evidence of continued compression of the cord
is apparent
Rationale: Although surgical treatment of spinal
cord injuries often depends on the preference of
the health care provider, surgery is usually
indicated when there is continued compression of
the cord by extrinsic forces or when there is
evidence of cord compression. Other indications
may include progressive neurologic deficit,
compound fracture of the vertebra, bony
fragments, and penetrating wounds of the cord.
A patient is admitted to the emergency
department with a possible cervical spinal cord
injury following an automobile crash. During the
admission of the patient, the nurse places the
highest priority on
a. maintaining a patent airway
b. assessing the patient for head and other injuries
c. maintaining immobilization of the cervical spine
d. assessing the patient's motor and sensory
function
a. maintaining a patent airway
Rationale: The need for a patent airway is the first
priority for any injured patient, and a high cervical
injury may decrease the gag reflex and ability to
maintain an airway, as well as the ability to
breathe. Maintaining cervical stability is then a
consideration, along with assessing for other
injuries and the patients neuro status.
A nurse is planning care for a client who suffered a
spinal cord injury (SCI) involving a T12 fracture 1
week ago. The client has no muscle control of the
lower limbs, bowel, or bladder. which of the
following should be the nurses' greatest priority?
a. prevention of further damage to the spinal cord
b. prevention of contractures of the lower
extremities
c. prevention of skin breakdown of areas that lack
sensation
d. prevention of postural hypotension when placing
the client in a wheelchair
A. prevention of further damage to the spinal cord
Rationale: The greatest risk to the client during the
acute phase of a SCI is further damage to the spinal
cord. Therefore, when planning care, the priority
should be the prevention of further damage to the
spinal cord by administration of corticosteroids,
minimizing movement of the client until spinal
stabilization is accomplished through either
traction or surgery, and adequate oxygenation of
the client to decrease ischemia of the spinal cord.
Goals of rehabilitation for the patient with an injury
at the C6 level include (select all that apply)
a. stand erect with leg brace
b. feed self with hand devices
c. drive an electric wheelchair
d. assist with transfer activities
e. drive adapted van from wheelchair
B, C, D, E
A nurse is caring for a client who experienced a
cervical spine injury 3 months ago. Which of the
following types of bladder management methods
should the nurse use for this client?
a. condom catheter
b. intermittent urinary catheterization
c. crede's method
d. indwelling urinary catheter
a. condom catheter
Rationale: a client who has a cervical spinal cord
injury will also have a upper motor neuron injury,
which is manifested by a spastic bladder. because
the bladder will empty on its own, a condom
catheter is an appropriate method and is
noninvasive. B & C are for flaccid bladder.
A patient is admitted with a spinal cord injury at
the C7 level. During assessment the nurse identifies
the presence of spinal shock on finding
a. paraplegia with flaccid paralysis
b. tetraplegia with total sensory loss
c. total hemiplegia with sensory and motor loss
d. spastic tetraplegia with loss of pressure
sensation
B. tetraplegia with total sensory loss
Rationale: At the C7 level, spinal shock is
manifested by tetraplegia and sensory loss. The
neurologic loss may be temporary or permanent.
Paraplegia with sensory loss would occur at the
level of T1. A hemiplegia occurs with central (brain)
lesions affecting motor neurons and spastic
tetraplegia occurs when spinal shock resolves.
During the patient's process of grieving for the
losses resulting from spinal cord injury, the nurse
a. helps the patient understand that working
through the grief will be a lifelong process
b. should assist the patient to move through all
stages of the mourning process to acceptance
c. lets the patient know that anger directed at the
staff or the family is not a positive coping
mechanism
d. facilitates the grieving process so that it is
completed by the time the patient is discharged
from rehabilitation
A. helps the patient understand that working
through the grief will be a lifelong process
In planning community education for prevention of
spinal cord injuries, the nurse targets
a. elderly men
b. teenage girls
c. elementary school-age children
d. adolescent and young adult men
D. adolescent and young adult men
Rationale: Spinnal cord injuries are highest in
young adult men between the ages of 15 and 30
and those who are impulsive or risk takers in daily
living. Other risk factors include alcohol and drug
abuse as well as participation in sports and
occupational exposure to trauma or violence.
In counseling patient with spinal cord lesions
regarding sexual function, the nurse advises a male
patient with a complete lower motor neuron lesion
that he
a. is most likely to have reflexogenic erections and
may experience orgasm if ejaculation occurs
b. may have uncontrolled reflex erections, but that
orgasm and ejaculation are usually not possible
c. has a lesion with the greatest possibility of
successful psychogenic erection with ejaculation
and orgasm
d. will probably be unable to have either
psychogenic or reflexogenic erections with no
ejaculation or orgasm
D. will probably be unable to have either
psychogenic or reflexogenic erections with no
ejaculation or orgasm
Rationale: Most patients with a complete lower
motor neuron lesion are unable to have either
psychogenic or reflexogenic erections, and
alterative methods of obtaining sexual satisfaction
may be suggested. Patients with incomplete lower
motor neuron lesions have the highest possibility
of successful psychogenic erections with
ejaculation, whereas patients with incomplete
upper motor neuron lesions are more likey to
experience reflexogeic erections with ejaculation.
Patients with complete upper motor neuron
lesions usually only have reflex sexual function with
rare ejaculation.
A patient with paraplegia has developed an
irritable bladder with reflex emptying. The nurse
teaches the patient
a. hygiene care for an indwelling urinary catheter
b. how to perform intermittent self-catheterization
c. to empty the bladder with manual pelvic
pressure in coordination with reflex voiding
patterns
d. that a urinary diversion, such as an ileal conduit,
is the easiest way to handle urinary elimination
b. how to perform intermittent self-catheterization
Rationale: Intermittent self cath five to six times a
day is the recommended method of bladder
management for the patient with a spinal cord
injury because it more closely mimics normal
emptying and has less potential for infectinon. The
patient and family should be taught the procedure
using clean technique, and if the patient has use of
the arms, self-cath is use during the acute phase to
prevent overdistention of the bladder and surgical
urinary diversions are used if urinary complications
occur.
A nurse is caring for a client who experienced a
cervical spine injury 24 hours ago. which of the
following types of prescribed medications should
the nurse clarify with the provider?
a. glucocorticoids
b. plasma expanders
c. H2 antagonists
d. muscle relaxants
D. muscle relaxants
Rationale: The client will still be in spinal shock 24
hours following the injury. the client will not
experience muscle spasms until after the spinal
shock has resolved, making muscle relaxants
unnecessary at this time.
When caring for a patient who was admitted 24
hours previously with a C5 spinal cord injury, which
nursing action has the highest priority?
a. Continuous cardiac monitoring for bradycardia
b. Administration of methylprednisolone (Solu-
Medrol) infusion
c. Assessment of respiratory rate and depth
d. Application of pneumatic compression devices to
both legs
Correct Answer: C
Rationale: Edema around the area of injury may
lead to damage above the C4 level, so the highest
priority is assessment of the patient's respiratory
function. The other actions are also appropriate
but are not as important as assessment of
respiratory effort.
22. A 26-year-old patient with a C8 spinal cord
injury tells the nurse, "My wife and I have always
had a very active sex life, and I am worried that she
may leave me if I cannot function sexually." The
most appropriate response by the nurse to the
patient's comment is to
a. advise the patient to talk to his wife to
determine how she feels about his sexual function.
b. tell the patient that sildenafil (Viagra) helps to
decrease erectile dysfunction in patients with
spinal cord injury.
c. inform the patient that most patients with upper
motor neuron injuries have reflex erections.
d. suggest that the patient and his wife work with a
nurse specially trained in sexual counseling.
Correct Answer: D
Rationale: Maintenance of sexuality is an important
aspect of rehabilitation after spinal cord injury and
should be handled by someone with expertise in
sexual counseling. Although the patient should
discuss these issues with his wife, open
communication about this issue may be difficult
without the assistance of a counselor. Sildenafil
does assist with erectile dysfunction after spinal
cord injury, but the patient's sexuality is not
determined solely by the ability to have an
erection. Reflex erections are common after upper
motor neuron injury, but these erections are
uncontrolled and cannot be maintained during
coitus.
13. A patient with a neck fracture at the C5 level is
admitted to the intensive care unit (ICU) following
initial treatment in the emergency room. During
initial assessment of the patient, the nurse
recognizes the presence of spinal shock on finding
a. hypotension, bradycardia, and warm extremities.
b. involuntary, spastic movements of the arms and
legs.
c. the presence of hyperactive reflex activity below
the level of the injury.
d. flaccid paralysis and lack of sensation below the
level of the injury.
Correct Answer: D
Rationale: Clinical manifestations of spinal shock
include decreased reflexes, loss of sensation, and
flaccid paralysis below the area of injury.
Hypotension, bradycardia, and warm extremities
are evidence of neurogenic shock. Involuntary
spastic movements and hyperactive reflexes are
not seen in the patient at this stage of spinal cord
injury.
1. When caring for a patient who experienced a T1
spinal cord transsection 2 days ago, which
collaborative and nursing actions will the nurse
include in the plan of care? (Select all that apply.)
a. Endotracheal suctioning
b. Continuous cardiac monitoring
c. Avoidance of cool room temperature
d. Nasogastric tube feeding
e. Retention catheter care
f. Administration of H2 receptor blockers
Correct Answer: B, C, E, F
Rationale: The patient is at risk for bradycardia and
poikilothermia caused by sympathetic nervous
system dysfunction and should have continuous
cardiac monitoring and maintenance of a relatively
warm room temperature. Gastrointestinal (GI)
motility is decreased initially and NG suctioning is
indicated. To avoid bladder distension, a retention
catheter is used during this acute phase. Stress
ulcers are a common complication but can be
avoided through the use of the H2 receptor
blockers such as famotidine.
16. A patient with a T1 spinal cord injury is
admitted to the intensive care unit (ICU). The nurse
will teach the patient and family that
a. use of the shoulders will be preserved.
b. full function of the patient's arms will be
retained.
c. total loss of respiratory function may occur
temporarily.
d. elevations in heart rate are common with this
type of injury.
Correct Answer: B
Rationale: The patient with a T1 injury can expect
to retain full motor and sensory function of the
arms. Use of only the shoulders is associated with
cervical spine injury. Total loss of respiratory
function occurs with injuries above the C4 level and
is permanent. Bradycardia is associated with
injuries above the T6 level.
1. In which order will the nurse perform the
following actions when caring for a patient with
possible cervical spinal cord trauma who is
admitted to the emergency department?
a. Administer O2 using a non-rebreathing mask.
b. Monitor cardiac rhythm and blood pressure.
c. Immobilize the patient's head, neck, and spine.
d. Transfer the patient to radiology for spinal CT.
Correct Answer: C, A, B, D
Rationale: The first action should be to prevent
further injury by stabilizing the patient's spinal
cord. Maintenance of oxygenation by
administration of 100% O2 is the second priority.
Because neurogenic shock is a possible
complication, continuous monitoring of heart
rhythm and BP is indicated. CT scan to determine
the extent and level of injury is needed once initial
assessment and stabilization is accomplished.
14. When caring for a patient who had a C8 spinal
cord injury 10 days ago and has a weak cough
effort, bibasilar crackles, and decreased breath
sounds, the initial intervention by the nurse should
be to
a. administer oxygen at 7 to 9 L/min with a face
mask.
b. place the hands on the epigastric area and push
upward when the patient coughs.
c. encourage the patient to use an incentive
spirometer every 2 hours during the day.
d. suction the patient's oral and pharyngeal airway.
Correct Answer: B
Rationale: The nurse has identified that the cough
effort is poor, so the initial action should be to use
assisted coughing techniques to improve the ability
to mobilize secretions. Administration of oxygen
will improve oxygenation, but the data do not
indicate hypoxemia, and oxygen will not help expel
respiratory secretions. The use of the spirometer
may improve respiratory status, but the patient's
ability to take deep breaths is limited by the loss of
intercostal muscle function. Suctioning may be
needed if the patient is unable to expel secretions
by coughing but should not be the nurse's first
action.
20. The nurse discusses long-range goals with a
patient with a C6 spinal cord injury. An appropriate
patient outcome is
a. transfers independently to a wheelchair.
b. drives a car with powered hand controls.
c. turns and repositions self independently when in
bed.
d. pushes a manual wheelchair on flat, smooth
surfaces.
Correct Answer: D
Rationale: The patient with a C6 injury will be able
to use the hands to push a wheelchair on flat,
smooth surfaces. Because flexion of the thumb and
fingers is minimal, the patient will not be able to
grasp a wheelchair during transfer, drive a car with
powered hand controls, or turn independently in
bed.
18. A patient with a paraplegia resulting from a T10
spinal cord injury has a neurogenic reflex bladder.
When the nurse develops a plan of care for this
problem, which nursing action will be most
appropriate?
a. Teaching the patient how to self-catheterize
b. Assisting the patient to the toilet q2-3hr
c. Use of the Credé method to empty the bladder
d. Catheterization for residual urine after voiding
Correct Answer: A
Rationale: Because the patient's bladder is spastic
and will empty in response to overstretching of the
bladder wall, the most appropriate method is to
avoid incontinence by emptying the bladder at
regular intervals through intermittent
catheterization. Assisting the patient to the toilet
will not be helpful because the bladder will not
empty. The Credé method is more appropriate for
a bladder that is flaccid, such as occurs with a
reflexic neurogenic bladder. Catheterization after
voiding will not resolve the patient's incontinence.
Which is most important to respond to in a patient
presenting with a T3 spinal injury?
A. Blood pressure of 88/60 mm Hg, pulse of 56
beats/minute
B. Deep tendon reflexes of 1+, muscle strength of
1+
C. Pain rated at 9
D. Warm, dry skin
A. Blood pressure of 88/60 mm Hg, pulse of 56
beats/minute
Neurogenic shock is a loss of vasomotor tone
caused by injury, and it is characterized by
hypotension and bradycardia. The loss of
sympathetic nervous system innervations causes
peripheral vasodilation, venous pooling, and a
decreased cardiac output. The other options can be
expected findings and are not as significant.
Patients in neurogenic shock have pink and dry
skin, instead of cold and clammy, but this sign is
not as important as the vital signs.
The patient arrives in the emergency department
from a motor vehicle accident, during which the car
ran into a tree. The patient was not wearing a seat
belt, and the windshield is shattered. What action
is most important for you to do?
A. Determine if the patient lost consciousness.
B. Assess the Glasgow Coma Scale (GCS) score.
C. Obtain a set of vital signs.
D. Use a logroll technique when moving the
patient.
D. Use a logroll technique when moving the
patient.
When the head hits the windshield with enough
force to shatter it, you must assume neck or
cervical spine trauma occurred and you need to
maintain spinal precautions. This includes moving
the patient in alignment as a unit or using a logroll
technique during transfers. The other options are
important and are done after spinal precautions
are applied.
One month after a spinal cord injury, which finding
is most important for you to monitor?
A. Bladder scan indicates 100 mL.
B. The left calf is 5 cm larger than the right calf.
C. The heel has a reddened, nonblanchable area.
D. Reflux bowel emptying.
B. The left calf is 5 cm larger than the right calf.
Deep vein thrombosis is a common problem
accompanying spinal cord injury during the first 3
months. Pulmonary embolism is one of the leading
causes of death. Common signs and symptoms are
absent. Assessment includes Doppler examination
and measurement of leg girth. The other options
are not as urgent to deal with as potential deep
vein thrombosis.
Which clinical manifestation do you interpret as
representing neurogenic shock in a patient with
acute spinal cord injury?
A. Bradycardia
B. Hypertension
C. Neurogenic spasticity
D. Bounding pedal pulses
A. Bradycardia
Neurogenic shock results from loss of vasomotor
tone caused by injury and is characterized by
hypotension and bradycardia. Loss of sympathetic
innervation causes peripheral vasodilation, venous
pooling, and a decreased cardiac output.
17. A male client with a spinal cord injury is prone
to experiencing automatic dysreflexia. The nurse
would avoid which of the following measures to
minimize the risk of recurrence?
a. Strict adherence to a bowel retraining program
b. Keeping the linen wrinkle-free under the client
c. Preventing unnecessary pressure on the lower
limbs
d. Limiting bladder catheterization to once every 12
hours
17. Answer D. The most frequent cause of
autonomic dysreflexia is a distended bladder.
Straight catheterization should be done every 4 to
6 hours, and foley catheters should be checked
frequently to prevent kinks in the tubing.
Constipation and fecal impaction are other causes,
so maintaining bowel regularity is important. Other
causes include stimulation of the skin from tactile,
thermal, or painful stimuli. The nurse administers
care to minimize risk in these areas.
A patient with a C7 SCI undergoing rehabilitation
tells the nurse he must have the flu because he has
a bad headache and nausea. The nurse's first
priority is to
a. call the HCP
b. check the patient's temperature
c. take the patient's blood pressure

During rehabilitation, a patient with spinal cord injury d. elevate the HOB to 90 degrees
begins to ambulate with long leg braces. Which level of
injury does the nurse associate with this degree of C
recovery?
The nurse is caring for a patient with a halo vest after
a. L1-2 cervical spine injury. Which care instructions should the
b. T6-7 nurse include in the patient's discharge plan?
c. T1-2
d. C7-8 a. Keep a wrench close or attached to the vest.
b. Use the frame and vest to assist in positioning.
A c. Clean around the pins using betadine swab sticks.
d. Loosen both sides of the vest to provide skin care
A patient with a T4 spinal cord injury experiences
neurogenic shock as a result of SNS dysfunction. What A
would the nurse recognize as characteristic of this
condition?

a. Tachycardia
b. Hypotension
c. Increased urine output
d. Peripheral vasoconstriction

A patient with spinal cord injury is experiencing

severe neurologic deficits. What is the most likely
mechanism of injury for this patient?

a. compression

b. hyperextension

c. flexion-rotation

d. extension-rotation