Medical-Surgical Nursing Assessment and Management of Clinical Problems 9e Chapter 47

Chapter 47: Nursing Management: Acute Kidney Injury and Chronic Kidney Disease
Test Bank
MULTIPLE CHOICE
1. After the insertion of an arteriovenous graft (AVG) in the right forearm, a 54-year-old patient
complains of pain and coldness of the right fingers. Which action should the nurse take?
a.Teach the patient about normal AVG function.
b.Remind the patient to take a daily low-dose aspirin tablet.
c.Report the patients symptoms to the health care provider.
d.Elevate the patients arm on pillows to above the heart level.
ANS: C
The patients complaints suggest the development of distal ischemia (steal syndrome) and
may require revision of the AVG. Elevation of the arm above the heart will further decrease
perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to
maintain grafts.
DIF: Cognitive Level: Apply (application) REF: 1120

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
2. When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will
expect an assessment finding of
a. persistent skin tenting
b. rapid, deep respirations.
c. bounding peripheral pulses.
d. hot, flushed face and neck.
ANS: B
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.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse is planning care for a patient with severe heart failure who has developed elevated
blood urea nitrogen (BUN) and creatinine levels. The primary collaborative treatment goal in
the plan will be
a. augmenting fluid volume.
b. maintaining cardiac output.
c. diluting nephrotoxic substances.
d. preventing systemic hypertension.
ANS: B
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 patients 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.
DIF: Cognitive Level: Apply (application) REF: 1102 | 1105
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
4. A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which

information will the nurse monitor to evaluate the effectiveness of the prescribed calcium
gluconate IV?
a. Urine volume
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.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
5. A 48-year-old patient with stage 2 chronic kidney disease (CKD) is scheduled for an
intravenous pyelogram (IVP). Which order for the patient will the nurse question?
a. NPO for 6 hours before procedure
b. Ibuprofen (Advil) 400 mg PO PRN for pain
c. Dulcolax suppository 4 hours before procedure
d. Normal saline 500 mL IV infused before procedure
ANS: B
The contrast dye used in IVPs is potentially nephrotoxic, and concurrent use of other
nephrotoxic medications such as the nonsteroidal anti-inflammatory drugs (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.

6. Which statement by a 62-year-old patient with stage 5 chronic kidney disease (CKD) indicates
that the nurses teaching about management of CKD has been effective?
a. I need to get most of my protein from low-fat dairy products.
b. I will increase my intake of fruits and vegetables to 5 per day.
c. I will measure my urinary output each day to help calculate the amount I can
drink.
d. I need to take erythropoietin to boost my immune system and help prevent
infection.
ANS: C
The patient with end-stage kidney 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.
7. Which information will the nurse monitor in order to determine the effectiveness of 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.

8. Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before
administering the medication, the nurse should assess the
a. bowel sounds.
b. blood glucose.
c. blood urea nitrogen (BUN).
d. level of consciousness (LOC).
ANS: A
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 nurses decision to give the
medication.

9. Which menu choice by the patient who is receiving hemodialysis indicates that the nurses
teaching has been successful?
a. Split-pea soup, English muffin, and nonfat milk
b. Oatmeal with cream, half a banana, and herbal tea
c. Poached eggs, whole-wheat toast, and apple juice
d. Cheese sandwich, tomato soup, and cranberry juice
ANS: C
Poached 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.
DIF: Cognitive Level: Apply (application) REF: 1114-1115

10. Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease
(CKD), the nurse should check laboratory results for
a.potassium level.
b.total cholesterol.
c.serum phosphate.
d.serum creatinine.
ANS: C
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.

11. A 37-year-old female patient is hospitalized with acute kidney injury (AKI). Which
information will be most useful to the nurse in evaluating improvement in kidney function?
a. Urine volume
b. Creatinine level
c. Glomerular filtration rate (GFR)
d. Blood urea nitrogen (BUN) level
ANS: C
GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based
on factors such as fluid volume status and protein intake. 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.

12. A patient will need vascular access for hemodialysis. Which statement by the nurse accurately
describes an advantage of a fistula over a graft?
a. A fistula is much less likely to clot.
b. A fistula increases patient mobility.
c. A fistula can accommodate larger needles.
d. A fistula can be used sooner after surgery.
ANS: A
Arteriovenous (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.
DIF: Cognitive Level: Understand (comprehension) REF: 1120

13. 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. Auscultate for a bruit at the fistula site.
b. Assess the 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.

14. A 64-year-old male patient who has had progressive chronic kidney disease (CKD) for several
years has just begun regular 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 because retained fluid is removed during dialysis.
c. More protein is allowed because urea and creatinine are removed by dialysis.
d. Dietary potassium is not restricted because the level is 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.

15. Which action by a 70-year-old patient who is using peritoneal dialysis (PD) indicates that the
nurse should provide more teaching about PD?
a. The patient leaves the catheter exit site without a dressing.
b. The patient plans 30 to 60 minutes for a dialysate exchange.
c. The patient cleans the catheter while taking a bath each day.
d. The patient slows the inflow rate when experiencing abdominal pain.
ANS: C
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.

16. Which information in a patients history indicates to the nurse that the patient is not an
appropriate candidate for kidney transplantation?
a. The patient has type 1 diabetes.
b. The patient has metastatic lung cancer.
c. The patient has a history of chronic hepatitis C infection.
d. The patient is infected with the human immunodeficiency virus.
ANS: B
Disseminated malignancies are a contraindication to transplantation. The conditions of the
other patients are not contraindications for kidney transplant.

17. Which assessment finding may indicate that a patient is experiencing adverse effects to a
corticosteroid prescribed after kidney transplantation?
a. Postural hypotension
b. Recurrent tachycardia
c. Knee and hip joint pain
d. Increased serum creatinine
ANS: C
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.

18. A 38-year-old patient who had a kidney transplant 8 years ago is receiving the
immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone
(Deltasone). Which assessment data will be of most concern to the nurse?
a. The blood glucose is 144 mg/dL.
b. There is a nontender axillary lump.
c. The patients skin is thin and fragile.
d. The patients blood pressure is 150/92.
ANS: B
A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result
of chronic immunosuppressive therapy. The elevated glucose, skin change, 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.

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
19. The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic
kidney disease (CKD). Which medication reported by the patient indicates that patient
teaching is required?
a. Multivitamin with iron
b. Magnesium hydroxide
c. Acetaminophen (Tylenol)
d. Calcium phosphate (PhosLo)
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.
DIF: Cognitive Level: Apply (application) REF: 1113 | 1115-1116
20. Before administration of captopril (Capoten) to a patient with stage 2 chronic kidney disease
(CKD), the nurse will check the patients
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 would also be monitored in patients with CKD but would not
affect whether the captopril was given or not.

21. A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin
(Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by
evaluating the patients
a. blood glucose.
b. urine osmolality.
c. serum creatinine.
d. serum potassium.
ANS: C
When a patient at risk for chronic kidney disease (CKD) receives a potentially nephrotoxic
medication, it is important to monitor renal function with BUN and creatinine levels. The
other laboratory values would not be useful in assessing for the adverse effects of the
gentamicin.

22. A 55-year-old patient with end-stage kidney disease (ESKD) is scheduled to receive a
prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the
health care provider before giving the medication?
a. Creatinine 1.6 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 erythropoietin (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.

23. Which intervention will be included in the plan of care for a male patient with acute kidney
injury (AKI) who has a temporary vascular access catheter in the left femoral vein?
a. Start continuous pulse oximetry.
b. Restrict physical activity to bed rest.
c. Restrict the patients oral protein intake.
d. Discontinue the urethral retention catheter.
ANS: B
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.

24. A 25-year-old male patient 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/L
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.

25. A 72-year-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with
acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which
prescribed therapy should the nurse implement first?
a. Insert urethral catheter.
b. Obtain renal ultrasound.
c. Draw a complete blood count.
d. Infuse normal saline at 50 mL/hour.
ANS: A
The patients 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.

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
26. A 62-year-old female patient has been hospitalized for 8 days with acute kidney injury (AKI)
caused by dehydration. Which information will be most important for the nurse to report to
the health care provider?
a. The creatinine level is 3.0 mg/dL.
b. Urine output over an 8-hour period is 2500 mL.
c. The blood urea nitrogen (BUN) level is 67 mg/dL.
d. The glomerular filtration rate is <30 mL/min/1.73m2.
ANS: B
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.

27. A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram
(ECG) than were noted on the previous shift. Which action should the nurse take first?
a. Notify the patients health care provider.
b. Document the QRS interval measurement.
c. Check the medical record for most recent potassium level.
d. Check the chart for the patients current creatinine level.
ANS: C
The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the
most recent potassium and then notify the patients 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 is also appropriate, but
interventions to decrease the potassium level are needed to prevent life-threatening
dysrhythmias.

28. A 42-year-old patient admitted with acute kidney injury due to dehydration has oliguria,
anemia, and hyperkalemia. Which 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
Because 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.

29. A patient has arrived for a scheduled hemodialysis session. Which nursing action is most
appropriate for the registered nurse (RN) to delegate to a dialysis technician?
a. Teach the patient about fluid restrictions.
b. Check blood pressure before starting dialysis.
c. Assess for causes of an 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.

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
30. A licensed practical/vocational nurse (LPN/LVN) is caring for a patient with stage 2 chronic
kidney disease. Which observation by the RN requires an intervention?
a. The LPN/LVN administers the erythropoietin subcutaneously.
b. The LPN/LVN assists the patient to ambulate out in the hallway.
c. The LPN/LVN administers the iron supplement and phosphate binder with lunch.
d. The LPN/LVN carries a tray containing low-protein foods into the patients 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.

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
31. A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2 L
inflows. Which information should the nurse report 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 patients abdomen appears 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.

32. The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most
important to communicate to the health care provider?
a. The urine output is 900 to 1100 mL/hr.
b. The patients central venous pressure (CVP) is decreased.
c. The patient has a level 7 (0 to 10 point scale) incisional pain.
d. The blood urea nitrogen (BUN) and creatinine levels are elevated.
ANS: B
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.

33. During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness.
Which action should the nurse take first?
a. Slow down the rate of dialysis.
b. Check patients blood pressure (BP).
c. Review the hematocrit (Hct) level.
d. Give prescribed PRN antiemetic drugs.
ANS: B
The patients complaints of nausea and dizziness suggest hypotension, so the initial action
should be to check the BP. The other actions may also be appropriate based on the blood
pressure obtained.

34. The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney
transplantation. Which parameter will be most important for the nurse to consider?
a. Heart rate
b. Urine output
c. Creatinine clearance
d. Blood urea nitrogen (BUN) level
ANS: B
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.
35. A patient complains of leg cramps during hemodialysis. The nurse should first
a. massage the patients legs.
b. reposition the patient supine.
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.

36. A 74-year-old who is progressing to stage 5 chronic kidney disease asks the nurse, Do you
think I should go on dialysis? Which initial response by the nurse is best?
a. It depends on which type of dialysis you are considering.
b. Tell me more about what you are thinking regarding dialysis.
c. You are the only one who can make the decision about dialysis.
d. Many people your age use dialysis and have a good quality of life.
ANS: B
The nurse should initially clarify the patients concerns and questions about dialysis. The
patient is the one responsible for the decision and many people using dialysis do have good
quality of life, but these responses block further assessment of the patients concerns.
Referring to which type of dialysis the patient might use only indirectly responds to the
patients question.

MSC: NCLEX: Psychosocial Integrity
37. After receiving change-of-shift report, which patient should the nurse assess first?
a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange
b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level
c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4
mEq/L
d. Patient who has just returned from having hemodialysis and has a heart rate of
124/min
ANS: D
The patient who is tachycardic after hemodialysis may be bleeding or excessively
hypovolemic and should be assessed immediately for these complications. The other patients
also need assessments or interventions but are not at risk for life-threatening complications.
DIF: Cognitive Level: Analyze (analysis) REF: 1129

OBJ: Special Questions: Prioritization; Multiple Patients
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. Which information will be included when the nurse is teaching self-management to a patient
who is receiving peritoneal dialysis (select all that apply)?
a. Avoid commercial salt substitutes.
b. Drink 1500 to 2000 mL of fluids daily.
c. Take phosphate-binders with each meal.
d. Choose high-protein foods for most meals.
e. Have several servings of dairy products daily.
ANS: A, C, D
Patients who are receiving peritoneal dialysis should have a high-protein diet. Phosphate
binders are taken with meals to help control serum phosphate and calcium levels. Commercial
salt substitutes are high in potassium and should be avoided. Fluid intake is limited in patients
requiring dialysis. Dairy products are high in phosphate and usually are limited.

SHORT ANSWER
1. A patient in the oliguric phase after an acute kidney injury has had a 250 mL urine output and
an emesis of 100 mL in the past 24 hours. What is the patients fluid restriction for the next 24
hours?
ANS:
950 mL
The general rule for calculating fluid restrictions is to add all fluid losses for the previous 24
hours, plus 600 mL for insensible losses: (250 + 100 + 600 = 950 mL).


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Chapter 47: Nursing Management: Acute Kidney Injury and Chronic Kidney Disease

DIF: Cognitive Level: Apply (application) REF: 1120

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4. A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which

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