Points Awarded 30.00 Points Missed 5.00 Percentage 85.7% Etiology End-stage renal disease (ESRD) is the last stage in the progressive clinical syndrome called chronic kidney disease (CKD). 1. What is the best description of CKD? A) There are frequent exacerbations since half of all nephrons are damaged. INCORRECT Half of all nephrons are often damaged in acute renal failure. In CKD, about 90% of nephrons are typically involved. B) Condition has a rapid onset with frequent remissions. INCORRECT Acute renal failure has a rapid onset, but chronic kidney disease has a gradual onset, occurring over months or years. Neither form of renal failure has frequent periods of remission. C) It is a fatal disorder unless renal replacement therapy is received. CORRECT CKD is fatal unless some form of renal replacement therapy (dialysis or organ transplant) is done, whereas acute renal failure has a good prognosis for the return of kidney function if appropriate supportive care is provided during the acute period. D) Symptoms are reversible with life long medication. INCORRECT Chronic kidney disease is progressive, irreversible kidney injury. Acute renal failure may be reversible with adequate supportive care during the acute episode. CKD is a disorder with a complex etiology involving many interrelated factors. Diabetes mellitus is a known risk factor for renal failure. 2. What additional information in Louellen's history may be related to the onset of ESRD?
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Points Awarded 30.00
Points Missed 5.00
Percentage 85.7%
Etiology
End-stage renal disease (ESRD) is the last stage in the progressive clinical syndrome called
chronic kidney disease (CKD).
1.
What is the best description of CKD?
A) There are frequent exacerbations since half of all nephrons are damaged.
INCORRECT
Half of all nephrons are often damaged in acute renal failure. In CKD, about 90% of nephrons
are typically involved.
B) Condition has a rapid onset with frequent remissions.
INCORRECT
Acute renal failure has a rapid onset, but chronic kidney disease has a gradual onset, occurring
over months or years. Neither form of renal failure has frequent periods of remission.
C) It is a fatal disorder unless renal replacement therapy is received.
CORRECT
CKD is fatal unless some form of renal replacement therapy (dialysis or organ transplant) is
done, whereas acute renal failure has a good prognosis for the return of kidney function if
appropriate supportive care is provided during the acute period.
D) Symptoms are reversible with life long medication.
INCORRECT
Chronic kidney disease is progressive, irreversible kidney injury. Acute renal failure may be
reversible with adequate supportive care during the acute episode.
CKD is a disorder with a complex etiology involving many interrelated factors. Diabetes mellitus
is a known risk factor for renal failure.
2.
What additional information in Louellen's history may be related to the onset of ESRD?
A) Hysterectomy at age 35.
INCORRECT
This is not a risk factor for CKD.
B) Hypertension.
CORRECT
Hypertension is one of the primary causes of CKD. The vast majority of clients with CKD have
hypertension, which may be either the cause or the result of CKD.
C) Female gender.
INCORRECT
CKD does not seem to be more common in either gender.
D) Use of diuretics.
INCORRECT
Use of diuretics is not a cause of CKD, but obtaining a medication history is important since
many medications are nephrotoxic.
Diagnostic Evaluation
The following diagnostic tests were performed:
Hemoglobin.
Serum creatinine and BUN.
Serum calcium.
Arterial blood gases.
Serum potassium.
Serum phosphorus.
Urinary creatinine clearance.
3.
Which lab value is likely to be decreased in a client with chronic kidney disease?
A) Serum creatinine and BUN.
INCORRECT
Serum creatinine and BUN are tests which evaluate the removal of nitrogenous wastes by the
kidney. Both are increased in chronic kidney disease, although BUN levels are directly impacted
by protein intake, hydration status, and other factors.
B) Serum calcium.
CORRECT
Serum calcium is decreased in CKD in response to an increase in serum
phosphorous.
C) Serum phosphorous.
INCORRECT
Serum phosphorous is increased as less phosphorous is excreted by the kidney.
D) Serum potassium.
INCORRECT
Serum potassium levels are increased in CKD as the kidney loses the ability to remove
potassium from the body. Clients with CKD should be assessed carefully for symptoms of
hyperkalemia.
The nurse notes that Louellen's Hemoglobin level is 7.8.
4.
What is the underlying pathology causing this abnormal lab value?
A) Fewer red blood cells are being formed.
CORRECT
Hemoglobin is decreased as the kidneys become less able to produce erythropoietin necessary
for the formation of red blood cells.
B) Renal waste products destroy red blood cells.
INCORRECT
This does not occur.
C) Hematuria results in blood loss.
INCORRECT
CKD does not result in hematuria.
D) Dehydration causes dilutional anemia.
INCORRECT
If dehydration occurred, it would be more likely to result in a high hemoglobin level rather than a
low level.
Louellen's arterial blood gas (ABG) results are:
pH 7.35.
PO2 96.00 mmHg.
PCO2 30.00 mmHg.
HCO3 18.00 mEq/L.
5.
What is the correct interpretation of these ABGs?
A) Metabolic acidosis (compensated).
CORRECT
As excessive bicarbonate is excreted, the HCO3 level decreases, causing metabolic acidosis
(decreased pH). Compensation occurs when an increased rate and depth of respirations reduce
the CO2 levels, returning the pH to low normal.
B) Respiratory alkalosis (compensated).
INCORRECT
Alkalosis would be indicated by an increased pH rather than decreased pH.
C) Respiratory acidosis (compensated).
INCORRECT
This is a compensated acidosis, but if it were respiratory in nature, the CO2 would be elevated
rather than decreased.
D) Metabolic alkalosis (compensated).
INCORRECT
Alkalosis would be indicated by an increased pH rather than decreased pH.
Clinical Manifestations
Louellen's diagnostic tests confirm the medical diagnosis of end-stage renal disease. In addition
to Louellen's complaints of fatigue, anorexia, dyspnea, and nocturia, the nurse's assessment
findings include: +1 pedal edema, basilar crackles in both lungs, and clear, pale urine. Louellen's
VS are: T 98.8° F, P 86, R 28, and BP 178/92.
6.
Which additional assessment finding is consistent with ESRD?
A) Yellow-gray pallor.
CORRECT
The client with ESRD often exhibits a yellow-gray pallor as the result of anemia and uremia. In
addition, the client with ESRD may exhibit other skin manifestations such as bruising and
uremic frost (a very late manifestation).
B) Clay-colored stool.
INCORRECT
This is not a manifestation seen in ESRD.
C) Fingernail clubbing.
INCORRECT
This finding is typical in clients with chronic lung disorders, but not in ESRD.
D) Stridor.
INCORRECT
Stridor is a crowing respiratory noise due to bronchoconstriction. It is not an expected finding in
ESRD.
The nurse notes that Louellen's blood pressure is elevated.
7.
Which explanation best describes the pathology resulting in her hypertension?
A) Activation of the renin-angiotensin cycle and excretion of aldosterone causes
hypertension.
CORRECT
The renin-angiotensin cycle causes vasoconstriction of the periphery which increases the blood
pressure. In addition, the excretion of aldosterone causes the retention of sodium and water,
further increasing the fluid volume which increases the blood pressure.
B) Irritation of the pericardial lining of the heart due to uremic toxins increases blood
pressure.
INCORRECT
This explains the cause of pericarditis.
C) An increase in the excretion of sodium and water from the kidneys causes hypertension.
INCORRECT
Hypertension would be caused by an increase in the retention of sodium and water rather than an
increase in the excretion of sodium and water.
D) The increase of uremic waste products in the blood stream increases the blood pressure.
INCORRECT
This is the probable cause for gastrointestinal manifestations such as anorexia, nausea, and
vomiting.
Pharmacologic Management
Louellen receives prescriptions for the following medications:
Calcium acetate (Phoslo) 2 gelcaps (667 mg each) PO with each meal.
Ferrous sulfate (Feosol) 1 tablet PO (65 mg) daily.
Epoetin alfa (Epogen) 3900 units subcutaneously 3 times per week (dosed at 75 U/kg
three times a week).
Glipizide (Glucotrol) 10 mg PO daily - take 30 minutes before breakfast.
Furosemide (Lasix) 40 mg PO twice daily.
Captopril (Capoten) 25 mg PO twice daily.
Potassium chloride (Kay Ciel) elixir 40 mEq PO three times daily.
8.
Which assessment finding indicates to the nurse that the desired outcome of the calcium acetate
(Phoslo) has been achieved?
A) Serum phosphorous of 4.0 mg/dl.
CORRECT
Calcium acetate (Phoslo) acts as a phosphate binder, reducing the high serum phosphorous levels
commonly found in the client with CKD.
B) Serum hematocrit of 32%.
INCORRECT
Hematocrit is not affected by the use of Phoslo.
C) Serum hemoglobin of 12 g/dl.
INCORRECT
Hemoglobin is not affected by the use of Phoslo.
D) Serum glucose of 90 mg/dl.
INCORRECT
This normal glucose level is managed with the client's glipizide (Glucotrol).
9.
Which assessment should the nurse perform to determine if the desired outcome of the captopril
(Capoten) has been achieved?
A) Fingerstick glucose.
INCORRECT
This would be an appropriate assessment measure for a hypoglycemic agent such as glipizide
(Glucotrol), but not for captopril.
B) Intake and output.
INCORRECT
This would be an appropriate assessment measure for a diuretic such as fuorsemide (Lasix), but
not for captopril.
C) Apical pulse.
INCORRECT
This does not provide data as to the desired outcome of the captopril.
D) Blood pressure.
CORRECT
Captopril (Capoten) is an ACE inhibitor used as an antihypertensive agent.
10.
Which assessment data indicates to the nurse that the desired outcome of the epoetin alfa
(Epogen) has been achieved?
A) Normo-active bowel sounds.
INCORRECT
This is not an indicator for the desired outcome of Epogen.
B) Ate 100% of diet.
INCORRECT
This is not the BEST indicator that the desired outcome of Epoetin has been achieved, although
an improvement in dietary intake may be a secondary benefit of a reduction in fatigue.
C) No further edema.
INCORRECT
This assessment finding is an indicator used to assess the effectiveness of a diuretic such as
fuorsemide (Lasix), but not Epogen.
D) Conjunctival sac returns to a reddish-pink color.
CORRECT
This assessment finding reflects an improvement in the client's anemia. Epogen stimulates the
production of RBCs, resulting in an increase in hematocrit. It is used to treat the anemia common
in clients with CKD.
Nursing Diagnoses and Interventions
Louellen is admitted to an acute care facility for management of her ESRD. The nurse's plan of
care includes the following nursing diagnoses:
Fluid volume excess.
Altered nutrition: less than body requirements.
Decreased cardiac output.
Fatigue.
Constipation.
Risk for injury.
11.
Based on these diagnoses, which nursing intervention should be included in Louellen's plan of
care?
A) Monitor and record daily weights.
CORRECT
Daily weights are an essential assessment of the degree of fluid volume excess. Remember, 1 kg
of weight gain equals about 1 liter of retained fluid. The cornerstones of conservative
management of CKD are fluid restriction, diet therapy, and drug therapy.
B) Encourage oral fluid intake.
INCORRECT
Fluid restrictions will be instituted.
C) Avoid any subcutaneous and intramuscular injections.
INCORRECT
Although the client with CKD is likely to bruise easily due to a reduction in platelets, avoidance
of injections is not necessary.
D) Offer frequent high-protein snacks.
INCORRECT
Protein is restricted to reduce the accumulation of waste products associated with protein
metabolism, which causes the manifestations of uremia.
Louellen asks the nurse if she can eat eggs.
12.
The nurse's response is based on what understanding?
A) Eggs are considered an incomplete protein source.
INCORRECT
Eggs are considered a complete protein.
B) Eggs are a source of high biologic value protein.
CORRECT
Since protein intake is restricted, the protein allowed should be of high biologic value, such as
eggs.
C) Eggs are a high-fat food and should be avoided.
INCORRECT
Eggs are only high in fat if cooked in fat, such as when fried in oil or bacon grease.
D) Eggs contain too much protein and are not allowed.
INCORRECT
Eggs are a good source of protein.
Louellen has a urinary output of 120 ml for the previous 24 hours. She is on fluid restriction.
13.
How much fluid will Louellen be allowed to drink during the next 24 hours?
A) 1,000 ml of fluid.
INCORRECT
This is not the correct amount for Louellen.
B) 450 ml of fluid.
INCORRECT
This is not the correct amount for Louellen.
C) 20 ml of fluid.
INCORRECT
This is not the correct amount for Louellen.
D) 720 ml of fluid.
CORRECT
Usually the fluid allowance is 500 to 600 ml more than the previous day's 24-hour urine output.