Pathophysiology
A 22 y.o. patient with diabetic nephropathy says, “I have two kidneys and I’m still young. If I stick to my insulin schedule, I don’t have to worry about kidney damage, right?” Which of the following statements is the best response?
A. “You have little to worry about as long as your kidneys keep making urine.”
B. “You should talk to your doctor because statistics show that you’re being unrealistic.”
C. “You would be correct if your diabetes could be managed with insulin.”
D. “Even with insulin, kidney damage is still a concern.”
D. “Even with insulin, kidney damage is still a concern.”
Kidney damage is still a concern. Microavascular changes occur in both of the patient’s kidneys as a complication of the diabetes. Diabetic nephropathy is the leading cause of end-stage renal disease. The kidneys continue to produce urine until the end stage. Nephropathy occurs even with insulin management.
Your patient had surgery to form an arteriovenous fistula for hemodialysis. Which information is important for providing care for the patient?
A. The patient shouldn’t feel pain during initiation of dialysis
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
D. Taking a blood pressure reading on the affected arm can cause clotting of the fistula
Pressure on the fistula or the extremity can decrease blood flow and precipitate clotting, so avoid taking blood pressure on the affected arm.
The most common early sign of kidney disease is:
A. Sodium retention
B. Elevated BUN level
C. Development of metabolic acidosis
D. Inability to dilute or concentrate urine
B. Elevated BUN level
Increased BUN is usually an early indicator of decreased renal function.
A 30 y.o. female patient is undergoing hemodialysis with an internal arteriovenous fistula in place. What do you do to prevent complications associated with this device?
A. Insert I.V. lines above the fistula.
B. Avoid taking blood pressures in the arm with the fistula.
C. Palpate pulses above the fistula.
D. Report a bruit or thrill over the fistula to the doctor.
B. Avoid taking blood pressures in the arm with the fistula.
Don’t take blood pressure readings in the arm with the fistula because the compression could damage the fistula. IV lines shouldn’t be inserted in the arm used for hemodialysis. Palpate pulses below the fistula. Lack of bruit or thrill should be reported to the doctor.
While assessing morning labs on your patient with CKD. You note the patient’s phosphate level is 6.2 mg/dL. As the nurse, you expect to find the calcium level to be?
A. Elevated
B. Low
C. Normal
D. Same as the phosphate level
B. Low
The answer is B. A normal phosphate level is 2.7-4.5 mg/dL. This patient is experiencing HYPERphosphatemia. When hyperphosphatemia presents the calcium level DECREASES because phosphate and calcium bind to each. When there is too much phosphate in the blood it takes too much calcium with it and it decreases the calcium in the blood. Therefore, the nurse would expect to find the calcium level decreased.
Your patient with chronic renal failure reports pruritus. Which instruction should you include in this patient’s teaching plan?
A. Rub the skin vigorously with a towel
B. Take frequent baths
C. Apply alcohol-based emollients to the skin
D. Keep fingernails short and clean
D. Keep fingernails short and clean
Calcium-phosphate deposits in the skin may cause pruritus. Scratching leads to excoriation and breaks in the skin that increase the patient’s risk of infection. Keeping fingernails short and clean helps reduce the risk of infection.
A patient with ESRD has an arteriovenous fistula in the left arm for hemodialysis. Which intervention do you include in his plan of care?
A. Apply pressure to the needle site upon discontinuing hemodialysis
B. Keep the head of the bed elevated 45 degrees
C. Place the left arm on an arm board for at least 30 minutes
D. Keep the left arm dry
A. Apply pressure to the needle site upon discontinuing hemodialysis
Apply pressure when discontinuing hemodialysis and after removing the venipuncture needle until all the bleeding has stopped. Bleeding may continue for 10 minutes in some patients.
You expect a patient in the oliguric phase of renal failure to have a 24 hour urine output less than:
A. 200ml
B. 400ml
C. 800ml
D. 1000ml
B. 400ml
Oliguria is defined as urine output of less than 400ml/24hours.
What is the appropriate infusion time for the dialysate in your 38 y.o. patient with chronic renal failure?
A. 15 minutes
B. 30 minutes
C. 1 hour
D. 2 to 3 hours
A. 15 minutes
Dialysate should be infused quickly. The dialysate should be infused over 15 minutes or less when performing peritoneal dialysis. The fluid exchange takes place over a period ranging from 30 minutes to several hours.
You are providing education to a patient with CKD about calcium acetate. Which statement by the patient demonstrates they understood your teaching about this medication? Select-all-that-apply:
A. “This medication will help keep my calcium level normal.”
B. “I will take this medication with meals or immediately after.”
C. “It is important I consume high amounts of oatmeal, poultry, fish, and dairy products while taking this medication.”
D. “This medication will help prevent my phosphate level from increasing.”
B. “I will take this medication with meals or immediately after.”
D. “This medication will help prevent my phosphate level from increasing.”
The answers are B and D. Calcium acetate (also known as PhosLo) is a phosphate binder, which will help keep the patient’s phosphate level from becoming too high. It helps excrete the phosphate taken in the food by excreting it out of the stool. Therefore, it should be taken with meals or immediately after. Option C is wrong because the patient should AVOID these types of foods high in phosphate.
You have a patient that might have a urinary tract infection (UTI). Which statement by the patient suggests that a UTI is likely?
A. “I pee a lot.”
B. “It burns when I pee.”
C. “I go hours without the urge to pee.”
D. “My pee smells sweet.”
B. “It burns when I pee.”
A common symptom of a UTI is dysuria. A patient with a UTI often reports frequent voiding of small amounts and the urgency to void. Urine that smells sweet is often associated with diabetic ketoacidosis.
What is the priority nursing diagnosis with your patient diagnosed with end-stage renal disease?
A. Activity intolerance
B. Fluid volume excess
C. Knowledge deficit
D. Pain
B. Fluid volume excess
Fluid volume excess because the kidneys aren’t removing fluid and wastes. The other diagnoses may apply, but they don’t take priority.
An 18 y.o. student is admitted with dark urine, fever, and flank pain and is diagnosed with acute glomerulonephritis. Which would most likely be in this student’s health history?
A. Renal calculi
B. Renal trauma
C. Recent sore throat
D. Family history of acute glomerulonephritis
C. Recent sore throat
The most common form of acute glomerulonephritis is caused by goup A beta-hemolytic streptococcal infection elsewhere in the body.
You have a patient that is receiving peritoneal dialysis. What should you do when you notice the return fluid is slowly draining?
A. Check for kinks in the outflow tubing.
B. Raise the drainage bag above the level of the abdomen.
C. Place the patient in a reverse Trendelenburg position.
D. Ask the patient to cough.
A. Check for kinks in the outflow tubing.
Tubing problems are a common cause of outflow difficulties, check the tubing for kinks and ensure that all clamps are open. Other measures include having the patient change positions (moving side to side or sitting up), applying gentle pressure over the abdomen, or having a bowel movement.
Your patient with chronic kidney disease is scheduled for dialysis in the morning. While examining the patient’s telemetry strip, you note tall peaked T-waves. You notify the physician who orders a STAT basic metabolic panel (BMP). What result from the BMP confirms the EKG abnormality?
A. Phosphate 3.2 mg/dL
B. Calcium 9.3 mg/dL
C. Magnesium 2.2 mg/dL
D. Potassium 7.1 mEq/L
D. Potassium 7.1 mEq/L
The answer is D. The patient’s potassium level is extremely elevated. A normal potassium level is 3.5-5.1 mEq/L. This patient is experiencing hyperkalemia, which can cause tall peak T-waves. Remember in CKD (especially prior to dialysis), the patient will experience electrolyte imbalances, especially hyperkalemia.
The kidneys are responsible for performing all the following functions EXCEPT?
A. Activating Vitamin D
B. Secreting Renin
C. Secreting Erythropoietin
D. Maintaining cortisol production
D. Maintaining cortisol production
The answer is D. The adrenal glands are responsible for maintaining cortisol production not the kidneys.
Your patient is complaining of muscle cramps while undergoing hemodialysis. Which intervention is effective in relieving muscle cramps?
A. Increase the rate of dialysis
B. Infuse normal saline solution
C. Administer a 5% dextrose solution
D. Encourage active ROM exercises
B. Infuse normal saline solution
Treatment includes administering normal saline or hypertonic normal saline solution because muscle cramps can occur when the sodium and water are removed to quickly during dialysis. Reducing the rate of dialysis, not increasing it, may alleviate muscle cramps.
Which of the following symptoms do you expect to see in a patient diagnosed with acute pyelonephritis?
A. Jaundice and flank pain
B. Costovertebral angle tenderness and chills
C. Burning sensation on urination
D. Polyuria and nocturia
B. Costovertebral angle tenderness and chills
Costovertebral angle tenderness, flank pain, and chills are symptoms of acute pyelonephritis. Jaundice indicates gallbladder or liver obstruction. A burning sensation on urination is a sign of lower urinary tract infection.
A patient with stage 4 chronic kidney disease asks what type of diet they should follow. You explain the patient should follow a:
A. Low protein, low sodium, low potassium, low phosphate diet
B. High protein, low sodium, low potassium, high phosphate diet
C. Low protein, high sodium, high potassium, high phosphate diet
D. Low protein, low sodium, low potassium, high phosphate diet
A. Low protein, low sodium, low potassium, low phosphate diet
The answer is A. The patient should follow this type of diet because protein breaks down into urea (remember patient will have increased urea levels), low sodium to prevent fluid excess, low potassium to prevent hyperkalemia (remember glomerulus isn’t filtering out potassium/phosphate as it should), and low phosphate to prevent hyperphosphatemia.
A patient with Stage 5 CKD is experiencing extreme pruritus and has several areas of crystallized white deposits on the skin. As the nurse, you know this is due to excessive amounts of what substance found in the blood?
A. Calcium
B. Urea
C. Phosphate
D. Erythropoietin
B. Urea
The answer is B. This patient is experiencing uremic frost that occurs in severe chronic kidney disease. This is due to high amounts of urea in the blood being secreted via the sweat glands onto the skin, which will appear as white deposits on the skin. The patient will experience itching with this.
Which patient below is NOT at risk for developing chronic kidney disease?
A. A 58 year old female with uncontrolled hypertension.
B. A 69 year old female with diabetes mellitus.
C. A 45 year old male with polycystic ovarian disease.
D. A 78 year old female with an intrarenal injury.
C. A 45 year old male with polycystic ovarian disease.
The answer is C. Options A, B, and D are all at risk for developing CKD. However, option C is not at risk for CKD.
Your patient becomes restless and tells you she has a headache and feels nauseous during hemodialysis. Which complication do you suspect?
A. Infection
B. Disequilibrium syndrome
C. Air embolus
D. Acute hemolysis
B. Disequilibrium syndrome
Disequilibrium syndrome is caused by a rapid reduction in urea, sodium, and other solutes from the blood. This can lead to cerebral edema and increased intracranial pressure (ICP). Signs and symptoms include headache, nausea, restlessness, vomiting, confusion, twitching, and seizures.
A 55 year old male patient is diagnosed with chronic kidney disease. The patient’s recent GFR was 25 mL/min. What stage of chronic kidney disease is this known as?
A. Stage 1
B. Stage 3
C. Stage 4
D. Stage 5
C. Stage 4
Stage 4: Severe loss renal function GFR 15-29 mL/min
A 65 year old male patient has a glomerular filtration rate of 55 mL/min. The patient has a history of uncontrolled hypertension and coronary artery disease. You’re assessing the new medication orders received for this patient. Which medication ordered by the physician will help treat the patient’s hypertension along with providing a protective mechanism to the kidneys?
A. Lisinopril
B. Metoprolol
C. Amlodipine
D. Verapamil
A. Lisinopril
The answer is A. There are two types of drugs that can be used to treat hypertension and protect the kidneys in patients with CKD. These drugs include angiotensin converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs). The only drug listed here that is correct is Lisinopril. This drug is known as an ACE inhibitor. Metoprolol is a BETA BLOCKER. Amlodipine and Verapamil are calcium channel blockers.
A patient with CKD has a low erythropoietin (EPO) level. The patient is at risk for?
A. Hypercalcemia
B. Anemia
C. Blood clots
D. Hyperkalemia
B. Anemia
The answer is B. EPO (erythropoietin) helps create red blood cells in the bone marrow. The kidneys produce EPO and when the kidneys are damaged in CKD they can decrease in the production of EPO. Therefore, the patient is at risk for anemia.