Chapter 63: Concepts of Care for Patients with Acute Kidney Inju

The nurse is assessing a client with a diagnosis of prerenal acute kidney injury (AKI). Which condition would the nurse expect to

find in the patient’s recent history?

• Pyelonephritis

• Dehydration

• Bladder cancer

• Kidney stones

Answer explanation

Prerenal causes of AKI are related to a decrease in perfusion, such as in clients who have prolonged dehydration. Pyelonephritis is

an intrinsic or intrarenal cause of AKI related to kidney damage. Bladder cancer and kidney stones are postrenal causes of AKI

related to urine flow obstruction.

A marathon runner comes into the clinic and states “I have not urinated very much in the last few days.” The nurse notes a heart

rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is most appropriate?

• Give the client a bottle of water immediately.

• Start an intravenous line for fluids.

• Teach the patient to drink 2 to 3 L of water daily.

• Perform an electrocardiogram.

Answer explanation

This athlete is mildly dehydrated as evidenced by the higher heart rate and lower blood pressure. The nurse can start hydrating the

client with a bottle of water first, followed by teaching the patient to drink 2 to 3 L of water each day. An intravenous line may be

needed later, after the patient’s degree of dehydration is assessed. An electrocardiogram is not necessary at this time.

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NGSS.HS-LS1-3

A client comes into the emergency department with a serum creatinine of 2.2 mg/dL (1944 mcmol/L) and a blood urea nitrogen

(BUN) of 24 mL/dL (8.57 mmol/L). What question would the nurse ask first when taking this client’s history?

• “Have you been taking any aspirin, ibuprofen, or naproxen recently?”

• “Do you have anyone in your family with renal failure?”

• “Have you had a diet that is low in protein recently?”

• “Has a relative had a kidney transplant lately?”

Answer explanation

There are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and

naproxen. This would be a good question to initially ask the patient since both the serum creatinine and BUN are elevated,

indicating some renal problems. A diet high in protein could be a factor in an increased BUN.

A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse

regarding this patient’s care?

• Edema and pain

• Cardiac and respiratory status

• Electrolyte and fluid imbalance

• Mental health status

Answer explanation

This client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate,

causing polyuria. Electrolyte loss and fluid balance are essential. Edema and pain are not usually a problem with fluid loss. There

could be changes in the client’s cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated.

A client with acute kidney injury (AKI) has a blood pressure of 76/55 mm Hg. The primary health care provider prescribed 1000

mL of normal saline to be infused over 1 hour to maintain perfusion. The client starts to develop shortness of breath. What is the

nurse’s priority action?

• Calculate the mean arterial pressure (MAP).

• Ask for insertion of a pulmonary artery catheter.

• Take the client’s pulse.

• Decrease the rate of the IV infusion.

Answer explanation

The nurse would assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline

infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the

client’s hemodynamic status, but this would not be the initial or priority action by the nurse. Vital signs are also important after

adjusting the intravenous infusion.

A client has a serum potassium level of 6.5 mEq/L (6.5 mmol/L), a serum creatinine level of 2 mg/dL (176 mcmol/L), and a urine

output of 350 mL/day. What is the best action by the nurse?

• Place the client on a cardiac monitor immediately.

• Teach the client to limit high-potassium foods.

• Continue to monitor the client’s intake and output.

• Ask to have the laboratory redraw the blood specimen.

Answer explanation

The best action by the nurse would be to check the cardiac status with a monitor. High-potassium levels can lead to dysrhythmias.

The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.

A client with diabetes mellitus type 2 has been well controlled with metformin. The client is scheduled for magnetic resonance

imaging (MRI) scan with contrast. What priority would the nurse take at this time?

• Teach the client about the purpose of the MRI.

• Assess the client’s blood urea nitrogen and creatinine.

• Tell the client to withhold metformin for 24 hours before the MRI.

• Ask the client if he or she is taking antibiotics.

Answer explanation

Contrast media can be nephrotoxic (damaging to the kidneys). Metformin can also be nephrotoxic and the client should not be

exposed to two agents. Clients who have diabetes are already at risk for renal damage.

A client is started on continuous venovenous hemofiltration (CVVH). Which finding would require immediate action by the

nurse?

• Potassium level of 5.5 mEq/L (5.5 mmol/L)

• Sodium level of 138 mEq/L (138 mmol/L)

• Blood pressure of 76/58 mm Hg

• Pulse rate of 88 beats/min

Answer explanation

Hypotension can be a problem with CVVH if replacement fluid does not provide enough volume to maintain blood pressure. The

nurse needs to monitor for ongoing fluid and electrolyte replacement. The sodium level is normal and the potassium level is slightly

elevated, which could be normal findings for someone with acute kidney injury. A pulse rate of 88 beats/min is within usual limits.

The nurse is caring for four clients with chronic kidney disease (CKD). Which client would the nurse assess first upon initial

rounding?

• Client with a blood pressure of 158/90 mm Hg

• Client with Kussmaul respirations

• Client with skin itching from head to toe

• Client with halitosis and stomatitis

Answer explanation

Kussmaul respirations indicate that the client has metabolic acidosis which is a complication of CKD. The client is increasing the

rate and depth of breathing to excrete carbon dioxide through the lungs to lower serum pH. Hypertension is common in most

patients with CKD, and skin itching increases with calcium–phosphate imbalances and elevations of nitrogenous wastes, another

common finding in CKD. Uremia from CKD causes ammonia to be formed, resulting in the common findings of halitosis and

stomatitis.

The nurse is teaching assistive personnel (AP) about fluid restriction for a client who has acute kidney injury (AKI). The client’s

24-hour urinary output is 120 mL. How much fluid would the client be allowed to have over the next 24 hours?

• 380 mL

• 500 mL

• 620 mL

• 750 mL

Answer explanation

The general principle for fluid restriction for clients is that they may have a daily fluid intake of 500 mL plus the amount of their

urinary output. In this case, 120 mL urinary output plus 500 mL equals 620 mL fluid allowance.