Lewis ch 47 Renal Disorders NCLEX

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Lewis ch 47 Renal Disorders NCLEXWhat are intrarenal causes of acute kidney injury (AKI) (select all diac apply)?a. Anaphylaxisb. Renal stonesc. Bladder cancerd.Nephrotoxic drugse. Acute glomemlor.ephritisf.Tubular obstructionbymyoglobin -d,e, f. Intrarenal causes of acute kidney injury (AKI)include conditions that cause direct damage to rhekidney tissue, including nephrotoxic drugs, acuteglomerulonephritis, and tubular obstruction by myoglobin, or prolonged ischemia.Anaphylaxis and ocher prerenal problems are frequently rhe initial cause of AKI. Renal stonesand bladder cancer are among the posrrenal causes of AKI.An 83-year-old female patient was found hung on the bathroom floor. She said she fell 2days 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. Anaphylaxisb. Renal calculic. Hypovolemiad. Nephrotoxic drugse. Decreased cardiac output -c, e.Because the patient has had nothing to eat or drinkfor 2 days, she is probably dehydrated and hypovolemic. Decreased cardiac output (CO) ismost likely because she is older and cakes heart medicine, which is probably for heart failureor hypertension. Both hypovolemia and decreased CO cause prerenal AKI. Anaphylaxis isalso a cause of prerer.al AKI bur is not likely in this situation. Nephrotoxic drugs wouldcontribute 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 ismost likely todevelop ATN?a. Patient with diabetes mellitusb. Patient with hypertensive crisisc. Patient who tried co overdose on acetaminophend. Patient with major surgery who required a blood transfusion -d.Acute tubular necrosis (ATN) is primarily the resultof ischemia, nephrotoxins, or sepsis. Major surgeryis most likely to cause severe kidney ischemia in thepatient requiring a blood transfusion. A blood transfusion hemoh tic reaction producesnephrotoxic injury if it occurs. Diabetes mellitus, hypertension, and acetaminophen overdosewill not contribute to ATN.Priority Decision: A dehydrated patient is in the Injury stage of the RIFLE staging of AKI.What would ±e nurse

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first anticipate in the treatment of this patient?a. Assess daily weightb.IVadministration of fluid and furosemide (Lasix)c.IVadministration of insulin and sodium bicarbonated.Urinalysis to check for sediment, osmolality, sodium, and specific gravity -b. IV administration of fluid and furosemide (Lasix)Injur,' is the stage of RIFLE classification when urineoutput is less than 0.5 mL kg hr for 12 hours, the serumcreatinine is increased times two or the glomerularfiltration rate (GFR) is decreased by 50%. This stage maybe reversible by treating the cause or, in this patient, the dehydration by administering IVfluid and a low dose of a loop diuretic, furosemide (Lasix). Assessing the daily weight will bedone to monitor fluid changes but it is not the first treatment the nurse should anticipate. IVadministration of insulin and sodium bicarbonate would be used for hyperkalemia. Checkingthe urinalysis will help to determine if the AKI has a prerenal, intrarenal, or postrenal causeby what is seen in the urine but with this patient's dehydration, it is thought to be prerenal tobegin 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 decreasein circulating blood volume and there is no damageyet to the renal tissue. It can be reversed by correctingthe precipitating factor, such as fluid replacement forhypovolemia. Prerenal oliguria is characterized by urinewith a high specific gravity and a low sodium concentration,whereas oliguria of intrarenal failure is characterizedby urine with a low specific gravity and a high sodiumconcentration. Malignant hypertension causes damage torenal tissue and intrarenal oliguria.Metabolic acidosis occurs in the oliguric phase of AKI as a result of impairment ofa. ammonia synthesis.b. excretion of sodium.c. excretion of bicarbonate.d. conservation of potassium. -a. Metabolic acidosis occurs in AKI because the kidney’scannot synthesize ammonia or excrete acid products ofmetabolism, resulting in ar. increased acid load. Sodiumis lost in urine because the kidney's cannot conservesodium. Impaired excretion of potassium results inhyperkalemia. Bicarbonate is normally generated andreabsorbed 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

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b. A urine output of 3700 mL/dayc. Decreasing sodium and potassium levelsd. Decreasing blood urea nitrogen (BUN) and creatinine levels -d. The blood urea nitrogen (BUN) and creatinine levelsremain high during the oliguric and diuretic phases ofAKI . The recovery phase begins when the glomerularfiltration returns to a rate at which BUN and creatininestabilize and then decrease. Urinary output of 3 to 5 Uday, decreasing sodium and potassium levels, andfluid weight loss are characteristic of the diureticphase of AKI.While caring for the patient in the oliguric phase of AKI, the nurse monitors the patient forassociated collaborative problems. When should the nurse notify die health care prorider?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-threateningcomplication of AKI in the oliguric phase. Muscleweakness and abdominal cramping are signs of theneuromuscular impairment that occurs with hyperkalemia. Jr. addition, h}'perkalemia car.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 expectedduring the oliguric phase, as is rhe development of peripheral edema.In caring for rhe patient with AKI, what should the nurse be aware of?a. The most common cause of death in xAKI is irreversible metabolic acidosis.b. During the oliguric phase of AKI, daily fluid intake is limited co 1000 mL plus the priorday's measured fluid loss.c. Dietar}7sodium and potassium during the oliguric phase of AKI are managed according tothe patient's urinary output.d.One of the most important nursing measures in managing fluid balance in the patient withAKI 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 orlosses. Infection is the leading cause of death in AKI, so meticulous aseptic technique iscritical. The fluid limitation in the oliguric phase is 600 mL plus the prior day's measuredfluid loss. Dietar}7sodium 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 aresult of the effects of nephrotoxic diuretics. Currently his serum potassium is 6.2 iriEq.'L (6.2mmol L) with cardiac changes, his BUN is 108 mg-’dL (38.6 mmoL'L), his serum creatinine is4.1 mg dL (362 mmol L), and his serum HCO3- is 14 mEq.'L (14 mmol L). He is somnolentand disoriented. Which treatment should the nurse expect to be used for him?a. Loop diureticsb. Renal replacement therapyc. Insulin and sodium bicarbonated. Sodium polystyrene sulfonate (Kayexalate) -b. This patient has at least three of the six common

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indications for renal replacement therapy (RRT), including (1) high potassium level, (2)metabolic acidosis, and (3) changed mental stams. The other indications are (4) volumeoverload, resulting in compromised cardiac status (this patient has a history of hyq ertension),(5) BUN greater than 120 mg/dL, and (6) pericarditis, pericardial effusion, or cardiactamponade. Although the other treatments maybe used, they will not be as effective as RRT for this older patient. Loop diuretics andincreased fluid are used if the patient is dehydrated. Insulin ar.d sodium bicarbonate car. beused to temporarily drive the potassium into the cells. Sodium polystyrene sulfonate(Kayexalate) is used to actually decrease rhe amount of potassium in the body.Prevention of AKI is important because of the high mortality rate. Which patients are atincreased risk for AKI (select all that apply)?a. An 86-year-old woman scheduled for a cardiac catheterizationb. A 48-year-old man with multiple injuries from a motor vehicle accidentc. A 32-year-old woman following a C-section delivery7for abruptio placentaed. A 64-year-old woman with chronic heart failure admitted with bloody stoolse. A 58-year-old man with prostate cancer undergoing preoperative workup for prostatectomya, b, c, d, e. High-risk patients include those exposedto nephrotoxic agents and advanced age (a), massivetrauma (b), prolonged hypovolemia or hypotension(possibly b and c), obstetric complications (c), cardiacfailure (d), preexisting chronic kidney disease, extensive bums, or sepsis. Patients withprostate cancer may have obstruction of the outflow tract, which increases risk of postrenalAKI(e).Priority’Decision: A patient on a medical unit has a potassium level of 6.8 mEq L. What isthe 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 ay’oid high-potassium foods.d. Call the lab and request a redraw’of the lab to verify results. -a. Dy'srhylhmias may occur with an elevated potassiumlevel and are potentially’ lethal. Monitor the rhythm while contacting the physician or callingthe rapid response team. Vital signs should be checked. Depending on the patient's history7and cause of increased potassium, instruct rhe patient about dietary’sources of potassium;how7ever, this yvould not help at this point. The nurse may want to recheck the value but untilthen 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 thefollowing arterial blood gasresults: pH 7.28, PaCO2, 30 mm Hg, PaO2 86 mm Hg, HCO3- 18 rriEq-L (18 mmolL). Tnenurse recognizes that treatment of the acid-base problem with sodium bicarbonate wouldcause a decrease in which value?a. pHb. Potassium levelc. Bicarbonate leveld. Carbon dioxide ley’el -b. During acidosis, potassium moves out of the cell inexchange for H+

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inns, increasing die serum potassium level.Correction of the acidosis with sodium bicarbonate willhelp to shift the potassium back into the cells. xAdecreasein pH and the bicarbonate ar.d PaCO2levels would indicateworsening 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 outputb. Glomerular filtration ratec. Degree of altered mental statusd. Serum creatinine ar.d urea levels -b. Stages of chronic kidney disease are based on theGFR. No specific markers of urinary output, mentalstatus, or azotemia classify the degree of chronic kidney7disease (CKD).The patient with CKD is receiving dialysis, and rhe nurse observes excoriations on thepatient's skin. Whatpathophysiologic changes in CKD can contribute to this finding (select all that apply)?a. Dry skinb. Sensom neuropathy7c. Vascular calcificationsd. Calcium-phosphate skin depositse. Uremic crystallization from high BUN -a, b, d. Pruritus is common in patients receiving dialysis.It causes scratching from dry’skin, sensory’ neuropathy7,and calcium-phosphate deposition in the skin. Vascularcalcifications contribute co cardiovascular disease, not to itching skin. Uremic frost rarelyoccurs without BUN levels greater than 200 mg dL, which should not occur in a patient ondialysis; urea crystallizes on the skin ar.d also causes pruritis.What causes the gastrointestinal (GI) manifestation of stomatitis in the patient with CKD?a. High serum sodium levelsb. Irritation of the GI tract from creatininec. Increased ammonia from bacterial breakdown of uread. Iron salts, calcium-containing phosphate binders, and limited fluid intake -c. Uremic fetor, or the urine odor of the breath, is causedby high urea content in the blood. Increased ammonia frombacterial breakdown of urea leads to stomatitis ar.d mucosalulcerations. Irritation of the gastrointestinal (GI) tract fromurea in CKD contributes to anorexia, nausea, and vomiting.Ingestion of iron salts and calcium-containing phosphatebinders, limited fluid intake, and limited activity7causeconstipation.The patient with CKD is brought to rhe emergency department with Kussmaul respirations.What does the nurse know about CKD that could cause this patient’s Kussmaul respirations?

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a. Uremic pleuiiris is occurring.b. There is decreased pulmonary macrophage activity.c. They are caused by respiratory compensation for metabolic acidosis.d. Pulmonan.7edema from heart failure and fluid overload is occurring. -c. Kussmaul respirations occur with severe metabolicacidosis when the respiratory system is attempting tocompensate by removing carbon dioxide with exhalations.Uremic pleuriris wrnuld cause a pleural friction nib.Decreased pulmonan,’ macrophage activity increases therisk of pulmonary infection. Dyspnea would occur withpulmonary edema.Which serum laboratory value indicates to the nurse that the patients CKD is getting worse?a. Decreased BUNb. Decreased sodiumc. Decreased creatinined. Decreased calculated glomerular filtration rate (GFR) -d. As GFR decreases., BUN and serum creatinine levelsincrease. Although elevated BUN and creatinine indicatethat waste products are accumulating. the calculated GFRis considered a more accurate indicator of kidney Functionthan BUN or serum creatinine.What is the most serious electrolyte disorder associated with kidney disease?a. Hypocalcemiab. Hyperkalemiac. Hyponatremiad. Hypermagnesemia -b. Hyperkalemia can lead to life-threatening dysrhythmias.Hypocalcemia leads to an accelerated rate of boneremodeling and potentially to tetany. Hyponatremia maylead to confusion. Elevated sodium levels lead to edema,hjpertension, and heart failure. Hypermagnesemia maydecrease reflexes, mental status, and blood pressure.For a patient with CKD the nurse identifies a nursing diagnosis of risk for injury: fracturerelated to alterationsin calcium and phosphorus metabolism. What is the pathologic process directly related to theincreased risk forfractures?a. Loss of aluminum through the impaired kidneysb. Deposition of calcium phosphate in soft tissues of the bodyc. Impaired vitamin D activation resulting in decreased GI absorption of calciumd. Increased release of parathyroid hormone in response to decreased calcium levels -c. The calcium-phosphorus imbalances that occur inCKD result in hypocalcemia, from a deficiency of activevitamin D and increased phosphorus levels. This leads toan increased rate of bone remodeling with a weakenedbone matrix. Aluminum accumulation is also believed tocontribute to the osteomalacia. Osteitis fibrosa involves

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replacement of calcium in the bone with fibrous tissueand is primarily a result of elevated levels of parathyToidhormone resulting from hypocalcemia.Priority Decision: What is the most appropriate snack for the nurse to offer a patient withstage 4 CKD?a. Raisinsb. Ice creamc. Dill picklesd.Hard candy -d. A patient with CKD may have unlimited intake of sugarsand starches (unless the patient is diabetic) and hard candy is ar. appropriate snack and mayhelp 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 fl’_rid_ Pickled foodshave high sodium content.Lewis, Sharon L.; Dirksen, Shannon Ruff; Bucher. Linda (2014-03-14). Stud}7Guide forMedical-Surgical Nursing: Assessment and Management of Clinical Problems (Study Guidefor Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 413).Elsevier Health Sciences. Kindle Edition.Which complication of chronic kidney disease is treated with erythropoietin (EPO)?a. Anemiab. Hypertensionc. Hyperkalemiad.Mineral and bone disorder -a. Erythropoietin is used to treat anemia, as it stimulates thebone marrow to produce red blood cells.The patient with CKD asks why she is receiving nifedipine (Procardia) and furosemide(Lasix). Tne nurseunderstands that these drugs are being used to treat the patient'sa. anemia.b. hypertension.c. hyperkalemia.d. mineral and bone disorder. -b. Nifedipine (Procardia) is a calcium channel blocker andfurosemide (Lasix) is a loop diuretic. Both are used to treathypertension.Which drugs will be used to treat the patient with CKD for mineral and bone disorder (selectall that apply)?a. Cinacalcet (Sensipar)b. Se -elamer (Renagel)c. IV glucose and insulind.Calcium acetate (PhosLo)e.IV 10%calcium gluconate -a, b, d. Cinacalcet (Sensipar), a calcimimetic agentto control secondary7hy’perparathyToidism; sevelamer(Renagel), a noncalcium phosphate binder; and calcium

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acetate (PhosLo), a calcium-based phosphate binder ateused to treat mineral ar.d bone disorder in CKD. IV glucoseand insulin and IV 10% calcium gluconate along withsodium polystyrene sulfonate (Kayexalate) are used to treatthe 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 isdialyzable is iron.b. The s 'ndrome that includes all of the signs ar.d symptoms seen in rhe various bodysystems in CKD is azotemia.c. The use of morphine is contraindicated in the patient with CKD because accumulation ofits metabolites maycause seizures.d. The use of calcium-based phosphate binders in the patient with CKD is contraindicatedwhen serum calcium levels are increased. -d. In rhe patient with CKD, when serum calcium levelsare increased, calcium-based phosphate binders are not used. The nutrient supplemented forpatients on dialysis is folic acid. The various body system manifestations occur with uremia,which includes azotemia. Meperidine is contraindicated in patients with CKD related topossibleseizures.During the nursing assessment of ±e patient with renal insufficiency, the nurse asks thepatient specifically about ahistory ofa. angina.b. asthma.c. hypertension.d. rheumatoid arthritis. -c. The most common causes of CKD in the United Statesare diabetes mellitus and hj pertension. The nurse should obtain information on long-termhealth problems that are related to kidney disease. The other disorders are not closelyassociated 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 thatapply)?a. Less protein lossb. Rapid fluid removalc. Less cardiovascular stressd. Decreased hyperlipidemiae. Requires fewer dietar,' restrictions -c, e. Peritoneal dialysis is less stressful for thecardiovascular system and requires fewer dietaryrestrictions. Peritoneal dialysis actually contributes to mote protein loss and increasedh 'perlipidemia. The fluid ar.d creatinine removal are slower with peritoneal dialysis thanhemodialysis.What does the dialysate for PD routinely contain?

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