Chapter 15 My Nursing Test Banks

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e
Chapter 15

Question 1

Type: MCSA

Of the following patients in an intensive care unit, the nurse identifies which patient as being at highest risk for the development of acute kidney injury with a prerenal cause? A patient who is:

1. Experiencing acute status asthmaticus

2. Being treated for hypertension following a cerebral vascular accident

3. In skeletal traction following a motor vehicle accident

4. Post-operative from a ruptured abdominal aortic aneurysm

Correct Answer: 4

Rationale 1: Status asthmaticus is a severe airway obstruction that results in respiratory acidosis. There is not an associated reduction in cardiac output linked with this problem.

Rationale 2: Hypertension is associated with the development of chronic renal failure and end stage renal disease.

Rationale 3: Long bone fractures can result in blood loss but the amount of blood lost is less than what would be considered as a prerenal cause for acute kidney injury.

Rationale 4: Prerenal failure commonly results from a pronounced reduction in cardiac output due to severe hypotension, hypovolemia, or severe vasoconstriction. The patient who has experienced significant blood loss as in a ruptured aortic aneurysm would be at greatest risk for the development of acute kidney injury with a prerenal cause.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-1: Differentiate between prerenal, intrinsic renal, and postrenal causes of acute kidney injury.

Question 2

Type: MCMA

While reviewing a patients medication record, the critical care nurse would be concerned about which drugs that have been implicated in the development of renal failure?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Cyclosporine

2. Contrast media

3. Aminoglycosides

4. Antiseizure medications

5. Nonsteroidal anti-inflammatory drugs (NSAIDs)

Correct Answer: 1,2,3,5

Rationale 1: Cyclosporine has been implicated in the development of renal failure.

Rationale 2: Contrast media been implicated in the development of renal failure.

Rationale 3: Aminoglycosides have been implicated in the development of renal failure.

Rationale 4: Antiseizure medications are not nephrotoxic.

Rationale 5: NSAIDs have been implicated in the development of renal failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-1: Differentiate between prerenal, intrinsic renal, and postrenal causes of acute kidney injury.

Question 3

Type: MCMA

The nurse will review a critically ill patients history for which causes of intrinsic renal failure?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Contrast media given intravenously during diagnostic imaging

2. Prescribed levothyroxine (Synthroid) following thyroidectomy

3. Acyclovir (Zovorax) prescribed for treatment of genital herpes

4. Receiving prophylactic chemotherapy after surgery for cancer

5. History of using high-dose NSAIDs for rheumatoid arthritis

Correct Answer: 1,3,5

Rationale 1: Drugs that have been implicated in the development of renal failure include contrast media.

Rationale 2: Levothyroxine (Synthroid) does not have any nephrotoxic side effects.

Rationale 3: Drugs that have been implicated in the development of renal failure include acyclovir.

Rationale 4: Chemotherapeutic agents have other systemic side effects such as bone marrow suppression and alopecia.

Rationale 5: Drugs that have been implicated in the development of renal failure include nonsteroidal anti-inflammatory drugs (NSAIDs).

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-1: Differentiate between prerenal, intrinsic renal, and postrenal causes of acute kidney injury.

Question 4

Type: MCSA

A patient in the intensive care unit is reported to be in the oliguric phase of intrinsic renal failure, which is reflected by:

1. Urine output of less then 400 mL/day

2. BUN and creatinine that may begin to increase slightly

3. Urinary output of up to 5 liters of urine each day

4. Abnormal laboratory values that can last from 6 months to a year in duration

Correct Answer: 1

Rationale 1: The oliguric phase may last 10 to 14 days during which the patient excretes less then 400 mL of urine/day.

Rationale 2: The onset phase immediately follows the renal injury and lasts 24 days. The urine output is reduced by 20% and the BUN and creatinine may begin to increase slightly.

Rationale 3: As a patient begins to regain renal function, the diuretic phase of intrinsic renal failure begins and urine output often increases up to 5 liters of urine each day.

Rationale 4: The final phase of intrinsic renal failure is the recovery phase that typically lasts from 6 months to a year. During this phase, most patients renal function and lab values slowly return to normal.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-1: Differentiate between prerenal, intrinsic renal, and postrenal causes of acute kidney injury.

Question 5

Type: MCSA

The nurse believes a patient is experiencing prerenal dysfunction and not intrinsic renal failure because of which laboratory finding?

1. Urine osmolality of 200 mOsm/L

2. Urine osmolality of 550 mOsm/L

3. Urine sodium greater than 40 mmol/L

4. Presence of granular casts and sediment

Correct Answer: 2

Rationale 1: This laboratory value indicates intrinsic renal failure because the osmolality is less than 350 mOsm/L.

Rationale 2: In prerenal dysfunction, the urinalysis typically shows a concentrated urine with a high osmolality (500 mOsm/L) and a decreased urine sodium (<20 mmol/L).

Rationale 3: This laboratory value indicates instrinsic renal failure because the urine sodium is greater than 40 mmol/L.

Rationale 4: A fractional excretion of sodium (FENa) greater than 1% with granular casts and sediment is seen in intrinsic renal failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-2: Explain the lab tests that may be used to differentiate between prerenal failure and intrinsic renal failure.

Question 6

Type: MCMA

A patient is experiencing prerenal failure secondary to hypovolemia. The nurse reviewing the patients laboratory work and vascular pressures would expect to see which results?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Creatinine clearance of 50 mL/min/1.73m2

2. Low CVP or PAWP pressures

3. BUN of 65 mg/dL

4. Serum creatinine of 3 mg/dL

5. Urine with granular casts and sediment

Correct Answer: 1,2,3,4

Rationale 1: Creatinine clearance provides the most accurate estimate of glomerulo-filtration rate. Normal values range between 85 and 125 mL/min/1.73m2 for adult men and 75 to 115 mL/min/1.73m2 for adult women. Values below normal indicate at least a 50% reduction in the number of functioning nephrons.

Rationale 2: With prerenal dysfunction, the nurse assesses the patient for manifestations of hypovolemia, including low CVP or PAWP values.

Rationale 3: When the urine flow rate is reduced, more urea is absorbed. Thus, in prerenal failure, the rise in BUN may be out of proportion to the renal dysfunction.

Rationale 4: A doubling of serum creatinine normally indicates a 50% reduction in glomerular filtration rates. Normal levels in adults are 0.5 to 1.5 mg/dL.

Rationale 5: There are rarely more then a few casts and/or a little sediment present in the urine. The urine appears dark and concentrated but it is clear.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-2: Explain the lab tests that may be used to differentiate between prerenal failure and intrinsic renal failure.

Question 7

Type: MCSA

A nurse plans to administer to a patient a fluid challenge for the purpose of establishing normal renal perfusion. What does this treatment involve?

1. Infusing 250 mL of 0.9% sodium chloride over 1 hour

2. Administering albumin intravenously, followed by furosemide

3. Infusing 500 mL of normal saline over a 30-minute period

4. Giving twice the amount of IV fluid each hour compared to urinary output

Correct Answer: 3

Rationale 1: This is too slow of a rate and too little volume.

Rationale 2: The use of albumin and furosemide are not used as an initial fluid challenge. This therapy is done later to possibly stimulate the nephrons.

Rationale 3: A fluid challenge is the infusion of a bolus of 250 to 500 mL of normal saline rapidly. Although definitions of rapid administration vary depending on the circumstances, a fluid challenge of 500 mL may be administered over half an hour.

Rationale 4: Basing the amount of IV fluid to give on urinary output would be inappropriate. A fluid challenge is a large bolus that is administered quickly to rapidly hydrate the patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-3: Discuss ways to restore renal perfusion in prerenal dysfunction.

Question 8

Type: MCSA

What would the critical care nurse expect to find if administering a fluid challenge to an 80-year-old patient had the intended effect?

1. A systolic blood pressure of 120 mm Hg or less

2. Heart rate remaining steady at 60 to 70 beats per minute

3. Skin turgor showing improvement within 24 hours

4. A MAP of 70 mm Hg or higher

Correct Answer: 4

Rationale 1: The blood pressure would likely be higher following a fluid bolus. With a rapid increase of intravascular volume, an older patients vascular system would respond with increased resistance so the blood pressure would rise.

Rationale 2: As the result of increased volume from the bolus, an older patients heart would have to pump faster to accommodate for the increase in intravascular volume.

Rationale 3: Skin turgor in an older patient is not a reliable clinical sign for improved renal perfusion.

Rationale 4: A MAP of 70 mm Hg is correct and the intended outcome for an older adult. Adults over the age of 70 may require a higher MAP, perhaps as high as 100 mm Hg, to maintain adequate renal perfusion.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 15-3: Discuss ways to restore renal perfusion in prerenal dysfunction.

Question 9

Type: MCSA

For which order would the nurse seek clarification regarding a patient with decreased renal perfusion and lowered glomerular filtration rate?

1. Administer acetylcysteine prior to an intravenous pyelogram procedure.

2. Infuse vancomycin 1,500 mg IV every 12 hours.

3. Check a peak and trough level with every third dose of IV clindamycin.

4. Give furosemide 10 mg by mouth daily.

Correct Answer: 2

Rationale 1: If contrast dye must be administered, it is given sparingly, or the physician may prescribe acetylcysteine for its renal protective effects.

Rationale 2: This order should be questioned. During the period of decreased renal perfusion and lowered glomerular filtration rate that occurs in prerenal failure, the kidneys are vulnerable to insults from other sources such as medications, contrast dyes, and toxins. The nurse should avoid administering nephrotoxic agents if possible.

Rationale 3: This is an appropriate order. The nurse monitors the peak and trough blood levels of medications that are known to be damaging to the kidney such as clindamycin.

Rationale 4: This is an appropriate order. Drugs that are known to be excreted by the kidneys and that are potentially harmful to the kidneys are given in reduced doses based on the patients creatinine clearance. Furosemide (Lasix) 10 mg is a reduced dose and is appropriate for this patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-4: Explain measures the critical care nurse may use to prevent further renal injury to the patient in renal failure.

Question 10

Type: MCSA

A patient has been placed on a 1,000-mL fluid restriction over 24 hours. Choose the plan that reflects how the critical care nurse would divide this amount of fluid.

1. 350 mL for dayshift, 325 mL for evening shift, and 325 mL for nightshift

2. 400 mL for dayshift, 400 mL for evening shift, and 200 mL for nightshift

3. 500 mL for dayshift, 325 mL for evening shift, and 125 mL for nightshift

4. 600 mL for dayshift, 200 mL for evening shift, and 200 mL for nightshift

Correct Answer: 3

Rationale 1: This is a division of 35%, 35%, and 32.5%.

Rationale 2: This is a division of 40%, 40%, and 20%.

Rationale 3: 500 mL for dayshift, 325 mL for evening shift, and 125 mL for nightshift is correct and demonstrates a common example of dividing a restricted fluid allotment over a 24-hour period. For 1,000 cc, one half (50%) of calculated fluid may be allotted to days (500 mL), one third (33%) for evenings (325 mL), and the balance of one sixth (17%) for night (125 mL).

Rationale 4: This is a division of 60%, 20% and 20%.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-6: Describe fluid volume management in acute kidney injury.

Question 11

Type: MCSA

The intensive care nurse explains to a patient with acute kidney injury that the most effective method for reducing hyperkalemia is the use of:

1. Insulin plus glucose

2. Inhaled beta agonists

3. Sodium bicarbonate

4. Hemodialysis

Correct Answer: 4

Rationale 1: Insulin plus glucose lowers the total body concentration of potassium but temporarily shifts the potassium into the cells, allowing time to institute other interventions that will decrease the total body concentration of potassium.

Rationale 2: Inhaled beta agonists lower the total body concentration of potassium, but temporarily shift the potassium into the cells, allowing time to institute other interventions that will decrease the total body concentration of potassium.

Rationale 3: Sodium bicarbonate lowers the total body concentration of potassium, but temporarily shifts the potassium into the cells, allowing time to institute other interventions that will decrease the total body concentration of potassium.

Rationale 4: Hemodialysis is the most effective method of adequately treating severe hyperkalemia. This method lowers the total body concentration of potassium.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-5: Discuss collaborative management of the electrolyte imbalances commonly seen in acute kidney injury.

Question 12

Type: MCSA

To test for a positive Trousseaus sign indicating hypocalcemia, the nurse would need which piece of equipment?

1. Percussion hammer

2. Penlight

3. Blood pressure cuff

4. Doppler

Correct Answer: 3

Rationale 1: A percussion hammer is used to elicit deep tendon reflexes. The hyperactive reflexes associated with hypocalcemia need very little stimulation to elicit a response.

Rationale 2: Motor reflexes are not stimulated by light. The penlight is used to assess papillary reflex and to illuminate areas for assessment.

Rationale 3: Manifestations of hypocalcemia may develop as soon as 48 hours after the onset of the oliguric phase of acute kidney injury because renal tubule disorders often result in excessive loss of calcium. Spasm of the hand and wrist, called Trousseaus sign, may become apparent when a blood pressure cuff placed on an arm is inflated to 20 mm Hg above the systolic pressure for at least 3 minutes.

Rationale 4: A Doppler is used to assess arterial flow such as hard-to-feel peripheral pulses.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-5: Discuss collaborative management of the electrolyte imbalances commonly seen in acute kidney injury.

Question 13

Type: MCSA

The typical dietary plan for a patient with acute kidney injury would focus on provision of:

1. High fat, low protein

2. High carbohydrate, low protein

3. High protein, low sodium

4. High calorie, low carbohydrate

Correct Answer: 2

Rationale 1: A high-fat diet is not healthy for any patient population. A low-protein diet is not appropriate as this would cause the body to break down lean muscle mass for metabolic function.

Rationale 2: Goals for nutritional intervention in the patient with acute kidney injury include preserving lean body mass, preventing metabolic alterations, and enhancing renal recovery by limiting uremic toxicity. Protein is allowed but limited because its catabolism may result in accumulation of toxic waste products (urea, phosphate, and potassium). Protein requirements can be calculated roughly based on the rise in the patients BUN in 24 hours, and the amount of protein in the patients diet can be based on this calculation. The remainder of the calories the patient requires is supplied as carbohydrates or lipids.

Rationale 3: A high-protein diet is not appropriate as this would cause a lethal amount of toxic waste to accumulate in a renal failure patient. A low-sodium diet would be appropriate as this would aid in reducing fluid retention.

Rationale 4: A high-caloric diet is not appropriate for this would contribute to unnecessary weight gain. Carbohydrates are needed for energy so restriction would be detrimental.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15-4: Explain measures the critical care nurse may use to prevent further renal injury to the patient in renal failure.

Question 14

Type: MCSA

What would the best nutritional goal for the patient with acute kidney injury?

1. Weight will increase by 3 pounds in a month

2. Patient eats over 50% of all meals

3. Albumin level will rise from 2.6 g/dL

4. Total protein level will increase to 10 g/dL

Correct Answer: 3

Rationale 1: Maintenance of body weight (with no evidence of excessive fluid intake or output) is important. The weight gain could be excess fluid, which, therefore, is not desirable.

Rationale 2: Eating over 50% of meals does not indicate the specific foods ingested. In order to accomplish nutritional goals, 100% of the diet should be consumed.

Rationale 3: The nurse assesses the patient for indications that he is being adequately nourished. These include albumin level of 3.5 to 4.0 g/dL; increase of this level shows improvement.

Rationale 4: The protein level is too high. The normal range is 6 to 8 g/dL.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 15-4: Explain measures the critical care nurse may use to prevent further renal injury to the patient in renal failure.

Question 15

Type: MCSA

A patient with acute kidney injury is disappointed that hemodialysis, instead of peritoneal dialysis, is planned for treatment. After teaching about the two types of dialysis, the nurse determines that further instruction is needed when the patient makes which statement about the disadvantages of peritoneal dialysis?

1. Its not speedy enough to remove the wastes.

2. It may worsen my breathing problems.

3. It cannot be used for older patients like me.

4. Its not nearly as efficient as hemodialysis.

Correct Answer: 3

Rationale 1: This is a correct statement that does not require further teaching. Peritoneal dialysis is often not speedy enough to adequately remove the midsized wastes such as urea that accumulate rapidly in catabolic patients with acute kidney injury.

Rationale 2: This is a correct statement that does not require further teaching. The volume of fluid that is placed in the peritoneum in PD tends to have a negative impact on respiratory function.

Rationale 3: This is not a correct statement. Age is not a primary determining factor in use of peritoneal dialysis. It is rarely used in acute kidney injury because there are a variety of disadvantages; for example, several studies have demonstrated poorer outcomes for patients who received PD rather than other modalities of treatment for acute kidney injury.

Rationale 4: This is a correct statement that does not require further teaching. Peritoneal dialysis is not speedy enough to remove wastes and fluid for those patients experiencing acute kidney injury.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 15-7: Explain why peritoneal dialysis is of limited use in patients with acute kidney injury.

Question 16

Type: MCSA

Which patient situation would increase the risk for developing dialysis disequilibrium syndrome?

1. Peritoneal dialysis provided in a home environment

2. Patient who received an ACE inhibitor prior to hemodialysis

3. A known history of long-term substance abuse

4. Patient undergoing first hemodialysis treatment

Correct Answer: 4

Rationale 1: Peritoneal dialysis is a much slower process than HD because the solute and fluid removal is slower. This allows for equilibrium of cells, especially those in the brain, to adjust to the change in fluid and solutes.

Rationale 2: The use of an ACE inhibitor before HD is not contraindicated and does not contribute to disequilibrium syndrome.

Rationale 3: A history of substance abuse does not contribute to the development of disequilibrium syndrome because this disorder does not affect osmotic or pressure gradients.

Rationale 4: Dialysis disequilibrium syndrome is especially common in patients undergoing their first or second dialysis treatment who experience sudden, large decreases in their BUN. The most likely explanation for this syndrome is that the levels of urea do not drop as rapidly in the brain as the plasma because of the blood-brain barrier. The higher levels of urea in the brain result in an osmotic concentration gradient between the brain cells and the plasma. Fluid enters the brain cells by osmosis until the concentration levels equal that of the extracellular fluid, resulting in cerebral edema and the dialysis disequilibrium syndrome.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 15-9: Describe nursing actions for the patient requiring hemodialysis or continuous renal replacement therapy.

Question 17

Type: MCSA

What will the nurse do when caring for a patient with an atrioventricular fistula in the forearm for hemodialysis?

1. Percuss the fistula for presence of a bruit each shift

2. Take the blood pressure in the unaffected arm

3. Position the patient so there is pressure on the access area

4. Flush the fistula with heparin every shift

Correct Answer: 2

Rationale 1: It is recommended to palpate for the thrill and auscultate, not percuss, the bruit over the access every 8 hours to assess for patency.

Rationale 2: This is the appropriate nursing care. Taking the blood pressure in the arm with fistula is contraindicated. When caring for a patient with an AV fistula or graft, the nurse assesses and maintains the patency of the access by avoiding any obstruction of blood flow in that extremity, such as blood pressure measurement, IV placement, phlebotomy, or positioning the patient so there is pressure on the access.

Rationale 3: No pressure should be placed on the arm with the fistula as this could cause the fistula to become clotted.

Rationale 4: Around-the-clock heparin flushes would not be utilized because the fistula is not an IV access but is part of the general circulation. Flushing would also increase the potential for infection. Access needs to be limited by HD personnel only.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-9: Describe nursing actions for the patient requiring hemodialysis or continuous renal replacement therapy.

Question 18

Type: MCSA

The nurse monitors the patient undergoing intermittent hemodialysis (IHD) for the most common complication of the procedure, which is:

1. Hypotension

2. Infection

3. Hyperglycemia

4. Hypokalemia

Correct Answer: 1

Rationale 1: Up to 30% of patients with acute kidney injury who undergo IHD experience rapid shifts in plasma volume that can result in hypotension, which is the most common complication.

Rationale 2: The nurse should also continuously monitor for the complications of infection as the hemodialysis is an invasive procedure. However, it is not the most common complication.

Rationale 3: Hyperglycemia would be the expected complication with peritoneal dialysis related to glucose in the dialysate.

Rationale 4: Hypokalemia is not a common complication associated with IHD as the dialysate bath contains potassium. If the patients potassium is 5.5, then the dialysate bath would be 3.0. This would lower the patients potassium level to 4.0 via diffusion.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-9: Describe nursing actions for the patient requiring hemodialysis or continuous renal replacement therapy.

Question 19

Type: MCSA

The intensive care nurse is reviewing a patients chart to find the most accurate indicator of fluid volume status, which is:

1. Intake and output

2. Daily weights

3. Hematocrit level

4. Systolic blood pressure

Correct Answer: 2

Rationale 1: Although intake and output are carefully measured in most critically ill patients, they have been shown to be inaccurate. Still, the nurse attempts to maintain as accurate a record as possible.

Rationale 2: Weight is a more accurate indicator of fluid volume status than many of the other assessment parameters. The patient should be weighed daily at the same time on the same properly calibrated scale with the same amount of clothing or bed linens.

Rationale 3: Laboratory values can be used to identify hemodilution from fluid volume excess. It may be evident as a decrease in hemoglobin, hematocrit, and serum sodium values.

Rationale 4: Multiple factors can affect systolic blood pressure readings in addition to fluid excess.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-6: Describe fluid volume management in acute kidney injury.

Question 20

Type: MCSA

Using evidence based practice interventions for a patient with acute kidney injury, the nurse is aware that the best approach for fluid volume excess management is:

1. A sodium-restricted diet

2. Diuretics

3. Fluid restriction

4. Plasmapheresis

Correct Answer: 3

Rationale 1: A sodium-restricted diet alone is not enough. The typical diet would also include potassium restriction and a protein intake of 4080 gms/day.

Rationale 2: Diuretics, once a mainstay of treatment, are being reconsidered as therapy because these medications, especially furosemide, are nephrotoxic.

Rationale 3: The most effective interventions for fluid volume excess in the patient with acute kidney injury are fluid restriction and renal replacement therapies.

Rationale 4: Plasmapheresis is a blood-purification procedure used to treat several autoimmune diseases, and is not used for fluid volume excess generated by acute kidney injury.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-6: Describe fluid volume management in acute kidney injury.

Question 21

Type: MCSA

The nurse preparing to administer peritoneal dialysis would have which responsibility in contrast to hemodialysis?

1. Knowing the patients dry weight prior to beginning

2. Monitoring for changes in vital signs

3. Inspecting the tunneled catheter for infection

4. Suggesting a low-Fowlers position for comfort

Correct Answer: 3

Rationale 1: Knowing the patients weight prior to beginning is appropriate for both procedures.

Rationale 2: Monitoring for changes in vital signs before, during, and after is appropriate to both procedures.

Rationale 3: Access to the peritoneum is by tunneled catheter. The catheter has several sections: the first outside the body, the next located in the subcutaneous layer and having at least one Dacron cuff or flanged collar to anchor the catheter, and a section in the peritoneal cavity with multiple lumens for rapid delivery of fluid. The nurse maintains aseptic technique when caring for the catheter and assesses the access site at least daily.

Rationale 4: Placing the patient in a low-Fowlers position would be appropriate for either type of therapy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-7: Explain why peritoneal dialysis is of limited use in patients with acute kidney injury.

Question 22

Type: MCMA

To assist with the common complication of hypotension for the patient undergoing continuous renal replacement therapies, the nurse could implement which actions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Infuse 0.9% sodium chloride boluses.

2. Administer mannitol.

3. Decrease the rate of ultrafiltration on the dialyzer.

4. Administer albumin.

5. Place the patient in a high-Fowlers position.

Correct Answer: 1,2,3,4

Rationale 1: The nurse might manage hypotension by administering normal saline boluses.

Rationale 2: The nurse might manage hypotension by providing volume expanders such as mannitol.

Rationale 3: The nurse might manage hypotension by decreasing the rate of ultrafiltration on the dialyzer.

Rationale 4: The nurse might manage hypotension by providing volume expanders such as albumin.

Rationale 5: Raising the head of the bed would lower the blood pressure even further. Lowering the head of the bed would, instead, raise the blood pressure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-8: Discuss the advantages and disadvantages of hemodialysis and continuous renal replacement therapies in acute kidney injury.

Question 23

Type: MCSA

The nurse would identify which nursing diagnosis for the patient experiencing dialysis disequilibrium syndrome?

1. Infection

2. Altered thought processes

3. Fluid volume deficit

4. Anxiety

Correct Answer: 2

Rationale 1: Disequilibrium syndrome affects the brain and is not related to exposure to pathogens.

Rationale 2: Dialysis disequilibrium syndrome is especially common in patients undergoing their first or second dialysis treatment who experience sudden, large decreases in their BUN. The most likely explanation for this syndrome is that the levels of urea do not drop as rapidly in the brain as the plasma because of the blood-brain barrier. The higher levels of urea in the brain result in an osmotic concentration gradient between the brain cells and the plasma. Fluid enters the brain cells by osmosis until the concentration levels equal that of the extracellular fluid, resulting in cerebral edema and the dialysis disequilibrium syndrome. Manifestations of the syndrome include headache and mental impairment that may progress to confusion, agitation, seizures, and nausea and vomiting.

Rationale 3: Fluid volume deficit would be manifested by physiologic signs such as hypotension and tachycardia.

Rationale 4: Anxiety is a manifestation of hypoxia and fluid volume overload.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 15-8: Discuss the advantages and disadvantages of hemodialysis and continuous renal replacement therapies in acute kidney injury.

Question 24

Type: MCSA

The critical care nurse is providing a training session on the principles of renal replacement therapies. When discussing how solutes move across a semipermeable membrane from a higher to lower concentration, the nurse is describing:

1. Ultrafiltration

2. Diffusion

3. Active transport

4. Osmosis

Correct Answer: 2

Rationale 1: Ultrafiltration (convection) involves a pressure gradient being created between the sides of the semipermeable membrane. Solutes are carried in solution across the semipermeable membrane in response to the pressure gradient, producing an ultrafiltrate.

Rationale 2: Diffusion involves the movement of solutes across a semipermeable membrane from a solution where they are in a higher concentration (the plasma) to a solution where they are in a lower concentration (the dialysate).

Rationale 3: Active transport (sometimes called active intake because of the absorbing movement of particles) is an energy-requiring process that moves material across a cell membrane and up the concentration gradient.

Rationale 4: Osmosis occurs when solution (water) moves from an area of low-solute concentration (the plasma) to an area of higher solute concentration (the dialysate).

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 15-8: Discuss the advantages and disadvantages of hemodialysis and continuous renal replacement therapies in acute kidney injury.

Question 25

Type: MCMA

A critically ill patient is being evaluated for acute kidney injury. The nurse expects that which laboratory tests will be prescribed for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Urinalysis

2. Blood-urea-nitrogen level

3. Serum creatinine

4. Arterial blood gases

5. Hemoglobin and hematocrit levels

Correct Answer: 1,2,3

Rationale 1: This laboratory test will be used to differentiate prerenal failure from intrinsic renal failure.

Rationale 2: This blood test measures the amount of urea that is being filtered out of the blood by the kidneys.

Rationale 3: This blood test assesses kidney function and is more accurate than the blood-urea-nitrogen level.

Rationale 4: This blood test is not specific for renal function.

Rationale 5: These levels are not specific for renal function.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-2: Explain the lab tests that may be used to differentiate between prerenal failure and intrinsic renal failure.

Question 26

Type: MCMA

The nurse is preparing an infusion of norepinephrine for a patient with acute kidney injury. What are the nurses responsibilities when providing this medication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Monitor the blood pressure every 2 to 5 minutes.

2. Monitor changes in MAP.

3. Monitor heart rate and pattern.

4. Infuse through the central line.

5. Infuse through a hand vein.

Correct Answer: 1,2,3,4

Rationale 1: The nurse monitors the BP every 2 to 5 minutes after beginning a continuous infusion.

Rationale 2: The medication will be titrated up or down depending upon the patients mean arterial pressure. The goal MAP of 80 should be achieved with the lowest possible dose of medication.

Rationale 3: The nurse will continuously monitor the patients heart rate and rhythm pattern while administering this medication.

Rationale 4: Norepinephrine should be administered through a central venous catheter.

Rationale 5: The veins in the hands, arms, ankles, and legs should be avoided.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-3: Discuss ways to restore renal perfusion in prerenal dysfunction.

Question 27

Type: MCMA

The nurse is planning care for a patient with an acute kidney injury. Which interventions would prevent further injury to the patients kidneys?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Use strict aseptic technique when providing care.

2. Discuss the need for acetylcysteine with the health care provider prior to testing that uses contrast dye.

3. Measure urine output every 8 hours.

4. Prepare a fluid challenge with Dextrose 5% and water.

5. Calculate fluid restriction.

Correct Answer: 1,2

Rationale 1: The nurse is scrupulous in his use of aseptic technique to prevent the development of an infection because removal of the by-products of infection and excretion of antibiotics may impose additional burdens on the damaged kidneys.

Rationale 2: If contrast dye must be administered, it is given sparingly or the physician may prescribe it; the nurse administers acetylcysteine for its renal protective effects.

Rationale 3: The patients urine output should be measured as frequently as necessary to assess renal function. However, every 8 hours would be an excessive amount of time to make this assessment.

Rationale 4: Dextrose 5% and water is not the solution used for a fluid challenge.

Rationale 5: This might need to be done for the patient who is fluid volume overloaded. However, this intervention would not specifically prevent any further kidney injury.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15-4: Explain measures the critical care nurse may use to prevent further renal injury to the patient in renal failure.

Question 28

Type: MCMA

A patient with an acute kidney injury is prescribed intravenous calcium for a potassium level of 6.8 mEq/L. What actions will the nurse make when providing this medication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Administer the medication IV push over 2 minutes.

2. Observe for electrocardiogram rhythm changes in 1 to 3 minutes after administering the medication.

3. Monitor for ongoing effects to last 30 to 60 minutes.

4. Discontinue the medication if tachycardia occurs.

5. Observe for a urine output increase within 10 minutes after administering this medication.

Correct Answer: 1,2,3

Rationale 1: This medication should be administered IV push over 2 minutes.

Rationale 2: The effects of this medication occur 1 to 3 minutes after administering.

Rationale 3: The effects of this medication last 30 to 60 minutes.

Rationale 4: This medication should be discontinued if bradycardia occurs.

Rationale 5: This medication does not affect urine output.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-5: Discuss collaborative management of the electrolyte imbalances commonly seen in acute kidney failure.

Question 29

Type: FIB

The nurse is calculating the distribution restricted fluids for a patient with acute kidney injury. The patient had a urine output of 200 mL the previous day. What amount of fluid is the patient permitted during the night?

Standard Text: Record your answer rounding to the nearest whole number.

Correct Answer: 100

Rationale : To calculate the distribution of fluid in a fluid restriction, add the previous days urine output total to 400 mL as insensible fluid loss. One half of the total is to be allotted to days. One third of the total allotted to evening and one sixth of the total allotted to night. For this patient, 200 mL of the previous day urine output + 400 mL insensible loss = 600 mL. One sixth of 600 mL is 100 mL.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-6: Describe fluid volume management in acute kidney injury.

Question 30

Type: MCMA

The nurse suspects that a patient with acute kidney injury will not be prescribed peritoneal dialysis because:

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Peritoneal dialysis takes too much time to remove body wastes.

2. The excess fluid in the peritoneum can negatively impact the patients breathing.

3. There are poorer outcomes from using peritoneal dialysis.

4. The patient has hypertension.

5. The patient has a potassium level of 5.5 mEq/L.

Correct Answer: 1,2,3

Rationale 1: Peritoneal dialysis is often not speedy or efficient enough to adequately remove the midsized wastes such as urea, which accumulate rapidly in catabolic acute kidney injury patients.

Rationale 2: The volume of fluid that is placed in the peritoneum during peritoneal dialysis tends to have a negative impact on respiratory function.

Rationale 3: Several studies have demonstrated poorer outcomes for patients who received peritoneal dialysis rather than other modalities of treatment for acute kidney injury.

Rationale 4: Hypertension is not a reason why peritoneal dialysis would not be indicated for this patient.

Rationale 5: This potassium level is not a contraindication for the use of peritoneal dialysis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15-7: Explain why peritoneal dialysis is of limited use in patients with acute kidney injury.

Question 31

Type: MCMA

A patient with acute kidney injury is prescribed intermittent hemodialysis three times a week for 4 hours each session. The nurse will plan interventions to address what problems that can occur between sessions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Fluid overload

2. Waste accumulation

3. Electrolyte imbalances

4. Hypotension

5. Infection

Correct Answer: 1,2,3

Rationale 1: A disadvantage of intermittent hemodialysis is that fluid overload can develop between sessions.

Rationale 2: A disadvantage of intermittent hemodialysis is that waste accumulation can develop between sessions.

Rationale 3: A disadvantage of intermittent hemodialysis is that electrolyte imbalances can develop between sessions.

Rationale 4: Hypotension can occur after a session and not usually between sessions.

Rationale 5: The risk for infection is not higher between sessions.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15-8: Discuss the advantages and disadvantages of hemodialysis and continuous renal replacement therapies in acute kidney injury.

Question 32

Type: MCMA

The nurse is caring for a patient during continuous renal replacement therapy. What interventions would the nurse perform at this time?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Monitor vital signs every half hour.

2. Administer replacement fluid as determined by the hourly fluid balance goal.

3. Assess partial thromboplastin time every 1 to 2 hours.

4. Warm the dialysate to body temperature.

5. Inspect the dialysate return.

Correct Answer: 1,2,3

Rationale 1: The nurse will monitor the patients vital signs and hemodynamic and fluid balance status every half hour.

Rationale 2: The nurse will administer replacement fluid as determined by the hourly fluid balance goal set by the nephrologist.

Rationale 3: The nurse will review partial thromboplastin times as often as every 1 to 2 hours.

Rationale 4: This intervention would be done if the patient were receiving peritoneal dialysis.

Rationale 5: This intervention would be done if the patient were receiving peritoneal dialysis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-9: Describe nursing actions for the patient requiring hemodialysis or continuous renal replacement therapy.

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e Test Bank

Copyright 2012 by Pearson Education, Inc.

Leave a Reply