Question 1

The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT).In doing so,the nurse should:

Accepted Answer

The critical care nurse is responsible for monitoring the patient receiving CRRT.The hemofilter is assessed every 2 to 4 hours for clotting (as evidenced by dark fibers or a rapid decrease in the amount of ultrafiltration without a change in the patient's hemodynamic status).The CRRT system is frequently assessed to ensure filter and lines are visible at all times,kinks are avoided,and the blood tubing is warm to the touch.The ultrafiltrate is assessed for blood (pink-tinged to frank blood),which is indicative of membrane rupture.Sterile technique is performed during vascular access dressing changes.

Question 2

The patient has just returned from having an arteriovenous fistula placed.The patient asks,"When will they be able to use this and take this other catheter out?" The nurse should reply,

Accepted Answer

An arteriovenous fistula is an internal,surgically created communication between an artery and a vein.This method produces a vessel that is easy to cannulate but requires 4 to 6 weeks before it is mature enough to use.

Question 3

The patient is diagnosed with acute kidney injury and has been getting dialysis 3 days per week.The patient complains of general malaise and is tachypneic.An arterial blood gas is ordered and shows that the patient's pH is 7.19,with a PCO₂ of 30 mm Hg and a bicarbonate level of 13 mEq/L.The nurse prepares to:

Accepted Answer

Metabolic acidosis is the primary acid-base imbalance seen in acute kidney injury.Treatment of metabolic acidosis depends on its severity.Patients with a serum bicarbonate level of less than 15 mEq/L and a pH of less than 7.20 are usually treated with intravenous sodium bicarbonate.The goal of treatment is to raise the pH to a value greater than 7.20.Rapid correction of the acidosis should be avoided,because tetany may occur as a result of hypocalcemia.Renal replacement therapies also may correct metabolic acidosis because it removes excess hydrogen ions and bicarbonate is added to the dialysate and replacement solutions; therefore,dialysis would not be cancelled.The tachypnea is a compensatory mechanism for the metabolic acidosis,and treatments to decrease the respiratory rate are not indicated.Treatment is aimed at correcting the metabolic acidosis,and this scenario does not provide data to support the need for intubation.

Question 4

Continuous venovenous hemodialysis is used to:

Accepted Answer

Continuous venovenous hemodialysis (CVVHD)is similar to CVVH in that ultrafiltration removes plasma water.It differs in that dialysate solution is added around the hemofilter membranes to facilitate solute removal by the process of diffusion.Continuous venovenous hemofiltration (CVVH)is used to remove fluids and solutes through the process of convection.Slow continuous ultrafiltration (SCUF)is also known as isolated ultrafiltration and is used to remove plasma water in cases of volume overload.Continuous venovenous hemodiafiltration (CVVHDF)combines ultrafiltration,convection and dialysis to maximize fluid and solute removal.

Question 5

The removal of plasma water and some low-molecular weight particles by using a pressure or osmotic gradient is known as:

Accepted Answer

Ultrafiltration is the removal of plasma water and some low-molecular weight particles by using a pressure or osmotic gradient.Ultrafiltration is primarily aimed at controlling fluid volume,whereas dialysis is aimed at decreasing waste products and treating fluid and electrolyte imbalances.Diffusion (or clearance)is the movement of solutes such as urea from the patient's blood to the dialysate cleansing fluid,across a semipermeable membrane (the hemofilter).

Question 6

The patient is in need of immediate hemodialysis,but has no vascular access.The nurse prepares the patient for insertion of:

Accepted Answer

Temporary percutaneous catheters are commonly used in patients with acute kidney injury because they can be used immediately.Occasionally a percutaneous tunneled catheter is placed if the patient needs ongoing hemodialysis; however,these catheters are usually inserted in the operating room.An arteriovenous fistula is an internal,surgically created communication between an artery and a vein.This method produces a vessel that is easy to cannulate but requires 4 to 6 weeks before it is mature enough to use.Arteriovenous grafts are created by using different types of prosthetic material,most commonly polytetrafluoroethylene and Teflon.Grafts are placed under the skin and are surgically anastomosed between an artery and a vein.The graft site usually heals within 2 to 4 weeks.

Question 7

The patient gets hemodialysis 3 days a week.He is 74 inches tall and weighs 100 kg.In planning the care for this patient,the nurse recommends:

Accepted Answer

Nutritional recommendations include the following: caloric intake of 25 to 35 kcal/kg of ideal body weight per day (2500-3500 kcal)and protein intake of no less than 0.8 g/kg body weight.Patients who are extremely catabolic should receive 1.5 to 2 g/kg of ideal body weight per day,75% to 80% of which contains all the required essential amino acids; sodium intake of 0.5 to 1.0 g/day; potassium intake of 20 to 50 mEq/day; calcium intake of 800 to 1200 mg/day; fluid intake equal to the volume of the patient's urine output plus an additional 600 to 1000 mL/day.

Question 8

The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury.The catheter has been in place for 5 days.The nurse should:

Accepted Answer

Routine replacement of hemodialysis catheters to prevent infection is not recommended.The decision to remove or replace the catheter is based on clinical need and/or signs and symptoms of infection.The typical catheter has a single or double lumen and is designed only for short-term renal replacement therapy during acute situations.The catheter is not used for fluid and medication administration.

Question 9

Slow continuous ultrafiltration is also known as isolated ultrafiltration and is used to:

Accepted Answer

Slow continuous ultrafiltration (SCUF)is also known as isolated ultrafiltration and is used to remove plasma water in cases of volume overload.Continuous venovenous hemofiltration (CVVH)is used to remove fluids and solutes through the process of convection.Continuous venovenous hemodialysis (CVVHD)is similar to CVVH in that ultrafiltration removes plasma water.It differs in that dialysate solution is added around the hemofilter membranes to facilitate solute removal by the process of diffusion.Continuous venovenous hemodiafiltration (CVVHDF)combines ultrafiltration,convection,and dialysis to maximize fluid and solute removal.

Question 10

The patient's potassium level is 7.0 mEq/L.Besides dialysis,which of the following actually reduces plasma potassium levels and total body potassium content safely in a patient with renal dysfunction?

Accepted Answer

Only dialysis and administration of cation exchange resins (sodium polystyrene sulfonate [Kayexalate])actually reduce plasma potassium levels and total body potassium content in a patient with renal dysfunction.In the past,sorbitol has been combined with sodium polystyrene sulfonate powder (Kayexalate)for administration.The concomitant use of sorbitol with Kayexalate has been implicated in cases of colonic intestinal necrosis; therefore,this combination is not recommended.Other treatments,such as administration of regular insulin and calcium gluconate only "protect" the patient for a short time until dialysis or cation exchange resins can be instituted.

Question 11

Continuous venovenous hemofiltration is used to:

Accepted Answer

Continuous venovenous hemofiltration (CVVH)is used to remove fluids and solutes through the process of convection.Slow continuous ultrafiltration (SCUF)is used to remove plasma water in cases of volume overload.Continuous venovenous hemodialysis (CVVHD)is similar to CVVH in that ultrafiltration removes plasma water.It differs in that dialysate solution is added around the hemofilter membranes to facilitate solute removal by the process of diffusion.Continuous venovenous hemodiafiltration (CVVHDF)combines ultrafiltration,convection,and dialysis to maximize fluid and solute removal.

Question 12

Peritoneal dialysis is different from hemodialysis in that peritoneal dialysis:

Accepted Answer

Peritoneal dialysis is the removal of solutes and fluid by diffusion through a patient's own semipermeable membrane (the peritoneal membrane)with a dialysate solution that has been instilled into the peritoneal cavity.This renal replacement therapy is not commonly used for the treatment of acute kidney injury because of its comparatively slow ability to alter biochemical imbalances.Clinical indications for peritoneal dialysis include acute and chronic kidney injury,severe water intoxication,electrolyte disorders,and drug overdose.

Question 13

The patient is in progressive care unit following arteriovenous fistula implantation in his left upper arm,and is due to have blood drawn with his next set of vital signs and assessment.When the nurse assesses the patient,the nurse should:

Accepted Answer

An arteriovenous fistula should be auscultated for a bruit and palpated for the presence of a thrill or buzz every 8 hours.The extremity that has a fistula or graft must never be used for drawing blood specimens,obtaining blood pressure measurements,administering intravenous therapy,or giving intramuscular injections.Such activities produce pressure changes within the altered vessels that could result in clotting or rupture.

Question 14

The patient is getting hemodialysis for the second time when he complains of a headache and nausea and,a little later,of becoming confused.The nurse realizes these are symptoms of:

Accepted Answer

Dialysis disequilibrium syndrome often occurs after the first or second dialysis treatment or in patients who have had sudden,large decreases in BUN and creatinine levels as a result of the hemodialysis.Because of the blood-brain barrier,dialysis does not deplete the concentrations of BUN,creatinine,and other uremic toxins in the brain as rapidly as it does those substances in the extracellular fluid.An osmotic concentration gradient established in the brain allows fluid to enter until the concentration levels equal those of the extracellular fluid.The extra fluid in the brain tissue creates a state of cerebral edema for the patient,which results in severe headaches,nausea and vomiting,twitching,mental confusion,and occasionally seizures.Dialyzer membrane incompatibility may cause hypotension.Hyperthermia,not hypothermia,may result if the temperature control devices on the dialysis machine malfunction.Potassium shifts may occur but would be manifested in cardiac dysrhythmias.

Question 15

Continuous renal replacement therapy (CRRT)differs from conventional intermittent hemodialysis in that:

Accepted Answer

CRRT is a continuous extracorporeal blood purification system managed by the bedside critical care nurse.It is similar to conventional intermittent hemodialysis in that a hemofilter is used to facilitate the processes of ultrafiltration and diffusion.It differs in that CRRT provides a slow removal of solutes and water as compared to the rapid removal of water and solutes that occurs with intermittent hemodialysis.

Question 16

The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place.In caring for this patient,the nurse should:

Accepted Answer

Tenderness at the insertion site,swelling,erythema or drainage should be reported to the physician.Transparent,semipermeable polyurethane dressings are recommended as they allow continuous visualization for assessment of signs of infection.Replace transparent dressings on temporary percutaneous catheters at least every 7 days and no more than once a week for tunneled percutaneous catheters unless the dressing is soiled or loose.The catheter is not used for the administration of fluids or medications or for the sampling of blood unless a specific order is obtained to do so.

Question 17

The nurse is assessing a patient with a new arteriovenous fistula,but does not hear a bruit or feel a thrill.Pulses distal to the fistula are not palpable.The nurse should:

Accepted Answer

Inadequate collateral circulation past the fistula or graft may result in loss of this pulse.The physician is notified immediately if no bruit is auscultated,no thrill is palpated,or the distal pulse is absent.Loss of bruit and thrill indicate a loss of blood flow most likely due to clotting.The patient will need to return to surgery as soon as possible for declotting.Raising the arm above the level of the heart will not help.Warm packs may or may not help.

Question 18

The patient is admitted to the unit with the diagnosis of rhabdomyolysis.The patient is started on intravenous (IV)fluids and IV mannitol.Because mannitol is an osmotic diuretic,the nurse should:

Accepted Answer

Mannitol,an osmotic diuretic often used in acute kidney injury caused by rhabdomyolysis,increases plasma volume.Patients may be at risk for the development of pulmonary edema due to the rapid expansion of intravascular volume triggered by mannitol.Hearing is assessed with administration of loop diuretics,such as furosemide,which have been associated with deafness.Aggressive fluid administration is required in rhabdomyolysis.Diuretics may increase the risk of acute kidney injury from volume depletion when they are given before procedures requiring radiological contrast agents or if the patient is hypovolemic.Adequate hydration prior to administration of diuretics is essential.

Question 19

Daily weights are being recorded for the patient.His urine output has been less than his intravenous and oral intake.His weight yesterday was 97.5 kg.This morning it is 99 kg.The nurse understands that this corresponds to a(n):

Accepted Answer

A 1-kg gain in body weight is equal to a 1000-mL fluid gain.This patient has gained 1.5 kg,or 1.5 liters of fluid.

Question 20

The patient is a new postoperative patient.She weighs 75 kg.The nurse expects the minimal acceptable urine output to be:

Accepted Answer

Normal urine output is 0.5 to 1 mL/kg of body weight each hour.

Quiz 15: Acute Kidney Injury

The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT) .In doing so,the nurse should: