Chapter 047

Lewis: Medical-Surgical Nursing, 8th Edition
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 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.
ANS: B
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 decrease
perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not
used to maintain grafts.
DIF: Cognitive Level: Application REF: 1184-1185

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
2. 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.
DIF: Cognitive Level: Application REF: 1167

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. 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
Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.
Test Bank 47-2
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: Application REF: 1165 TOP: Nursing Process:

Planning
MSC: NCLEX: Physiological Integrity
4. 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.
DIF: Cognitive Level: Application REF: 1168 TOP: Nursing Process:

Evaluation
5. 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.

6. 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
Test Bank 47-3
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.
DIF: Cognitive Level: Application REF: 1177-1178 TOP: Nursing Process:

Evaluation
7. 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.

8. 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).
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 nurses decision
to give the medication.

Test Bank 47-4
9. 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.

Evaluation
10. 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.

11. 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.

Evaluation
Test Bank 47-5
12. 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.
DIF: Cognitive Level: Comprehension REF: 1184-1185

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. 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.
DIF: Cognitive Level: Comprehension REF: 1184-1185 TOP: Nursing Process:

Planning
14. 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
Test Bank 47-6
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 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.

Evaluation
16. 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.
DIF: Cognitive Level: Comprehension REF: 1189-1190

17. 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
Test Bank 47-7
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.

Evaluation
18. 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 patients 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.

19. 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.

20. 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
patients
a. glucose.
b. potassium.
c. creatinine.
d. phosphate.
Test Bank 47-8
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.

21. 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 patients
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.
DIF: Cognitive Level: Application REF: 1165 | 1166 TOP: Nursing Process:
Evaluation
22. 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.

23. 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?
Test Bank 47-9
a. Place the patient on bed rest.

b. Start continuous pulse oximetry.
c. Discontinue the retention catheter.
d. Restrict the patients 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.

Planning
24. 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/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.

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
25. 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 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
Test Bank 47-10
26. 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.
DIF: Cognitive Level: Application REF: 1167-1168 | 1170

27. 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 patients health care provider.
c.Look at the patients 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 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 also is appropriate, but
interventions to decrease the potassium level are needed to prevent life-threatening
bradycardia.

28. 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.
Test Bank 47-11
DIF: Cognitive Level: Application REF: 1168 | 1175-1176

29. 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.

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
30. 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 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. 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.
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.
Test Bank 47-12

32. 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 patients 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.

33. 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 patients measured output plus 600
mL/day for insensible losses.

OBJ: Special Questions: Alternate Item Format TOP: Nursing Process:
Planning
34. 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 patients blood pressure.
d. Give prescribed PRN antiemetic drugs.
ANS: C
Test Bank 47-13
The patients 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.

35. 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.

36. 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.
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.


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Lewis: Medical-Surgical Nursing, 8th Edition

DIF: Cognitive Level: Application REF: 1184-1185

DIF: Cognitive Level: Application REF: 1167

DIF: Cognitive Level: Application REF: 1165 TOP: Nursing Process:

DIF: Cognitive Level: Application REF: 1168 TOP: Nursing Process:

DIF: Cognitive Level: Application REF: 1169-1170

DIF: Cognitive Level: Application REF: 1177-1178 TOP: Nursing Process:

DIF: Cognitive Level: Application REF: 1176-1177

8. Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with

DIF: Cognitive Level: Application REF: 1168

DIF: Cognitive Level: Application REF: 1177-1178 TOP: Nursing Process:

DIF: Cognitive Level: Application REF: 1176

DIF: Cognitive Level: Application REF: 1175-1176 TOP: Nursing Process:

MSC: NCLEX: Physiological Integrity

DIF: Cognitive Level: Comprehension REF: 1184-1185

DIF: Cognitive Level: Comprehension REF: 1184-1185 TOP: Nursing Process:

DIF: Cognitive Level: Application REF: 1177-1178

DIF: Cognitive Level: Application REF: 1182-1183 TOP: Nursing Process:

DIF: Cognitive Level: Comprehension REF: 1189-1190

DIF: Cognitive Level: Application REF: 1193-1194 TOP: Nursing Process:

DIF: Cognitive Level: Application REF: 1193-1194

DIF: Cognitive Level: Application REF: 1172-1173

DIF: Cognitive Level: Application REF: 1176

DIF: Cognitive Level: Application REF: 1176-1177

a. Place the patient on bed rest.

DIF: Cognitive Level: Application REF: 1185-1186 TOP: Nursing Process:

DIF: Cognitive Level: Application REF: 1167

DIF: Cognitive Level: Application REF: 1165-1167

DIF: Cognitive Level: Application REF: 1167-1168 | 1170

DIF: Cognitive Level: Application REF: 1167

DIF: Cognitive Level: Application REF: 1168 | 1175-1176

DIF: Cognitive Level: Application REF: 1185-1187

DIF: Cognitive Level: Application REF: 1177

DIF: Cognitive Level: Application REF: 1183-1184

DIF: Cognitive Level: Application REF: 1192-1193

DIF: Cognitive Level: Application REF: 1168

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DIF: Cognitive Level: Application REF: 1192-1193

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