Renal Evolve Question

Pass CCRN Evolve Questions - Renal-1
1. A 48-year-old man is admitted with an acute myocardial infarction. Assessment reveals

the following:
Vital Signs
Blood pressure 70/40 mm Hg
Heart rate 122 beats/min and irregular
Respiratory rate 26 breaths/min
Urine output 20 mL over the past 2 hours
Hemodynamics
Pulmonary artery pressure 34/24 mm Hg
(PAP)
Pulmonary artery occlusive 25 mm Hg
pressure (PAOP)
Right atrial pressure (RAP) 10 mm Hg
Cardiac index (CI) 1.8 L/min/m2
Which of the following would be of primary concern in evaluating the patient's renal status?
a. PAP
b. PAOP
c. RAP
d. CI
Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Correct answer: d
Rationale: Of primary concern is the CI, which evaluates the cardiac output in regard to the
body surface area. The kidneys receive 20% to 25% of the cardiac output, which is
approximately 1200 mL/min. Without sufficient cardiac output, the kidneys cannot be
perfused properly, and filtration cannot be effective.
Test-Taking Strategy: If you immediately thought of mean arterial pressure but could not
find it, remember that MAP = CO × SVR, where CO is cardiac output and SVR is systemic
vascular resistance. Cardiac output is the pump behind glomerular filtration rate. Choose
option d.
<System> Renal
<Section> Renal Physiology
<Level> Application/Analysis

2. A 48-year-old man is admitted with an acute myocardial infarction. Assessment reveals

the following:
Vital Signs
Blood pressure 70/40 mm Hg
Heart rate 122 beats/min and irregular
Respiratory rate 26 breaths/min
Urine output 20 mL over the past 2 hours
Hemodynamics
Pulmonary artery pressure 34/24 mm Hg
Pulmonary artery occlusive 25 mm Hg
pressure
Right atrial pressure 10 mm Hg
Cardiac index 1.8 L/min/m2
What would be the best laboratory test to evaluate this patient’s glomerular filtration rate
(GFR)?
a. Blood urea nitrogen
b. Serum creatinine
c. Urine creatinine clearance
d. Serum amylase

Correct answer: c
Rationale: Normal GFR is 125 mL/min or about 180 L/day. The creatinine clearance rate
reflects the GFR. It evaluates the ability of the kidneys to filter a waste product (creatinine)
that is neither reabsorbed nor secreted.
Test-Taking Strategy: Notice that options a, b, and d are serum values, but option c is a
comparison between the creatinine in the blood and the creatinine excreted in the urine. It is
logical to believe that the comparison value would be better.
<System> Renal
<Section> Renal Assessment
<Level> Knowledge/Comprehension

3. A 29-year-old woman has been a patient in the critical care unit for 2 weeks with acute
tubular necrosis (ATN) as a result of crush injuries experienced in a motor vehicle collision.
She was normotensive on admission.
What would be the most common explanation for her ATN?
a. Rhabdomyolysis
b. Hemorrhage
c. Creatinine release
d. Cardiac dysrhythmias

Correct answer: a
Rationale: The most common cause for ATN in a normotensive patient who has
experienced crush injuries is rhabdomyolysis with resultant myoglobinuria.
Rhabdomyolysis is acute muscle destruction and is associated with myoglobinuria.
Myoglobin released from muscle cells may cause acute kidney injury by having a direct
toxic effect on tubule epithelial cells or inducing intratubular cast formation.
Test-Taking Strategy: The key points in this question are that she had a crush injury and
that she was not hypotensive. Hemorrhage or dysrhythmias significant enough to cause
ATN certainly would cause hypotension, so eliminate options b and d. Creatinine is a
normal waste product that normal kidneys easily excrete, so eliminate option c.
Rhabdomyolysis causes myoglobin release, which is toxic to the renal tubules, especially in
large amounts as would occur in a crush injury. Choose option a.
<System> Renal
<Section> Acute Kidney Injury

4.
<case study> A 29-year-old woman has been a patient in the critical care unit for 2 weeks
with acute tubular necrosis (ATN) as a result of crush injuries experienced in a motor
vehicle collision. She was normotensive on admission. Which electrolyte imbalances are
likely to result from ATN?
a. Hypomagnesemia, hypocalcemia, hypokalemia
b. Hypomagnesemia, hypercalcemia, hypokalemia
c. Hypermagnesemia, hypercalcemia, hyperkalemia
d. Hypermagnesemia, hypocalcemia, hyperkalemia

Correct answer: d
Rationale: Hypermagnesemia and hyperkalemia result from the inability of the kidneys to
excrete these electrolytes. Hypocalcemia is the result of the inability of the kidneys to
produce the active component of vitamin D, 1,25-dihydroxycholecalciferol and the change
in calcium as a result of the hyperphosphatemia that is seen in ATN.
Test-Taking Strategy: In a question with multiple answers in each option like this, start
with what you know. You know that hyperkalemia is a potentially life-threatening
complication of acute kidney injury. Options c and d have hyperkalemia. Both options c and
d have hypermagnesemia, so that is decided for you. You may be tempted to choose option
c because all three imbalances are “hyper.” You need to know that hypocalcemia (and its
reciprocal hyperphosphatemia) are electrolyte imbalances seen in acute renal injury and
chronic kidney disease. Choose option d.
<System> Renal

5. Magnesium is being administered to a patient admitted with acute myocardial infarction.

Which of the following would not be an indication that magnesium levels are too high?
a. Diminished deep tendon reflexes
b. Hypotension
c. Tetany
d. Muscle weakness

Correct answer: c
Rationale: High levels of magnesium cause smooth muscle relaxation, resulting in
hypotension, diminished deep tendon reflexes, and muscle weakness, potentially resulting in
respiratory muscle paralysis and respiratory arrest. Tetany occurs with hypomagnesemia.
Test-Taking Strategy: Notice that options a, b, and d indicate a relaxant effect or weakness.
Option c is an increase in irritability. Choose option c because the question asks what would
not be an indication of high magnesium.
<System> Renal
<Section> Electrolytes

6. The psychiatric unit nurse telephones the critical care unit nurses with a report of a 27-
year-old man with a diagnosis of "coma, undetermined cause." It is reported that he has
consumed approximately 10 L of water over the past 24 hours. On admission, he is difficult
to arouse, moaning occasionally, but moving all extremities purposefully and equally. Lab
data reveal the following:
Na 110 mEq/L
Cl 80 mEq/L
K 3.5 mEq/L
HCO3 20 mEq/L
Blood urea nitrogen 20 mg/dL
(BUN)
Creatinine 2 mg/dL
Hematocrit 22%
Which of these lab abnormalities probably is causing the neurologic symptoms?

a. BUN
b. Sodium
c. Creatinine
d. Potassium

Correct answer: b
Rationale: Hyponatremia in this case (psychogenic polydipsia) is due to an excess of water
relative to total solute. This often is called hyposmolar hyponatremia. Neurologic
manifestations are the hallmark of hyponatremia. Swelling of brain cells results from the
intracellular movement of water. Lethargy, confusion, and even coma may be present in the
hyponatremic patient.
Test-Taking Strategy: Although the potassium is at low normal, only the sodium level is
abnormal. Choose option b.
<System> Renal
<Level> Synthesis/Evaluation

7. The psychiatric unit nurse telephones the critical care unit nurses with a report of a 27-
year-old man with a diagnosis of "coma, undetermined cause." It is reported that he has
consumed approximately 10 L of water over the past 24 hours. On admission, he is difficult
to arouse, moaning occasionally, but moving all extremities purposefully and equally. Lab
data reveal the following:
Na 110 mEq/L
Cl 80 mEq/L
K 3.5 mEq/L
HCO3 20 mEq/L
Blood urea nitrogen 20 mg/dL
Creatinine 2 mg/dL
Hematocrit 22%
What would be the most appropriate treatment for this patient?

a. Administer hypertonic (3%) saline.
b. Restrict fluids.
c. Administer diuretics.
d. Institute hemodialysis.

Correct answer: a
Rationale: Although fluid restriction and diuretics will be needed to restore normal fluid and
sodium balance, the neurologic symptoms and the sodium level (less than 120 mEq/L) are
indications that hypertonic saline should be used. Renal function is normal and therefore can
be relied on to eliminate the water if given time, so hemodialysis is not indicated.
Test-Taking Strategy: This sodium level is critical. Choose an option that will increase the
sodium level quickly. Restricting fluids would be the slowest. Diuretics would be somewhat
quicker. Administration of hypertonic saline would be the quickest, most direct way to
elevate the sodium in this critical situation. Choose option a. Hemodialysis or continuous
arteriovenous hemofiltration might be used if the patient did not have adequate renal
function to achieve elimination of the extra fluid.
<System> Renal

8. The action of furosemide (Lasix) is to do which of the following?

a. Act as an osmotic agent, pulling fluid into the renal tubule
b. Act at the ascending limb of the loop of Henle to decrease sodium and water reabsorption
c. Act as an antidiuretic hormone (ADH) antagonist
d. Act as an aldosterone antagonist

Correct answer: b
Rationale: Loop diuretics are the most potent diuretics available. They work by blocking the
reabsorption of sodium chloride at the thick segment of the medullary ascending loop of
Henle. This results in a large diuresis of isotonic urine. Option a describes osmotic diuretics
(e.g., mannitol). Option d describes aldosterone antagonists (e.g., spironolactone
[Aldactone]). Option d ADH antagonists are not used as diuretics, but they may be used to
treat syndrome of inappropriate antidiuretic hormone.
Test-Taking Strategy: Because you know that furosemide is a loop diuretic, look for the
answer with loop in it. Choose option b.
<System> Renal
<Section> Pharmacology

9. After an intravenous pyelogram (IVP), which of the following is an important nursing

intervention?
a. Ensure adequate fluid intake.
b. Maintain fluid restriction.
c. Provide extra doses of sodium.
d. Administer antibiotics.

Correct answer: a
Rationale: Dehydration increases the risk of contrast-induced nephropathy, which is a rare
but serious complication of IVP.
Test-Taking Strategy: Remember that IVP dye is potentially nephrotoxic. Consider that
when nephrotoxic agents go through the renal tubule in a concentrated form, they are more
likely to cause damage to the renal tubes (acute tubular necrosis). Diluting dye by increasing
fluid intake makes it less toxic. These dyes also cause osmotic diuresis, and fluids need to be
replaced. Choose option a.
<System> Renal
<Section> Renal Assessment

10. A 24-year-old man has been diagnosed with acute kidney injury as a result of severe
hemorrhaging after a motor vehicle collision. How would his acute kidney injury be
categorized?
a. Prerenal
b. Intrarenal
c. Postrenal
d. Tubular

Correct answer: a
Rationale: Prerenal failure is the result of inadequate perfusion of a normal kidney. In this
situation, the severe hemorrhaging led to hypovolemia, which resulted in hypoperfusion.
Test-Taking Strategy: Pre- means before and relates to perfusion of the kidney. Intrarenal
or intrinsic relates to problems within, changes to, and injury of the nephron. Post- means
after and relates to obstructive processes. Hemorrhage would be pre- because it is related to
perfusion of the kidney. Choose option a.
<System> Renal

11. A 24-year-old man has been diagnosed with acute kidney injury as a result of severe
hemorrhaging after a motor vehicle collision. Which of the following would be expected
laboratory values for this patient?
a. Low urinary osmolality, high urinary sodium concentration
b. High urinary osmolality, high urinary sodium concentration
c. Low urinary osmolality, low urinary sodium concentration
d. High urinary osmolality, low urinary sodium concentration

Correct answer: d
Rationale: A high urinary osmolality (usually greater than 900 mOsm/kg) and a low urinary
sodium concentration (usually less than 20 mEq/L) are normal physiologic responses to
hypoperfusion in patients with normal kidneys.
Test-Taking Strategy: Consider that the kidney would want to conserve sodium and water
with blood loss. If the kidney is holding onto sodium, little is excreted into the urine, so
urinary sodium is low. If the kidney is holding onto water, little is excreted into the urine, so
it is concentrated and osmolality is increased. Choose option d.
<System> Renal

12. A patient with acute kidney injury has the following arterial blood gas results:
pH 7.32
PaCO2 35 mm Hg
HCO3 18 mEq/L
This acid/base imbalance is the result of the inability of the kidney to:
a. excrete acid by-products of metabolism.
b. excrete carbon dioxide.
c. excrete bicarbonate ions.
d. excrete calcium ions.

Correct answer: a
Rationale: The patient has a metabolic acidosis because the kidneys are unable to excrete
the acid by-products of cellular metabolism.
Test-Taking Strategy: Because the pH is acidotic, look for an option that would cause
acidosis. Inability to excrete bicarbonate ions would cause an alkalotic process, so eliminate
option c. Calcium imbalances are caused by acid-base imbalances (e.g., ionized calcium
decreases in alkalosis) but will not cause imbalance, so eliminate option d. Inability to
excrete carbon dioxide (as carbonic acid) is the responsibility of the lungs, not the kidneys,
so eliminate option b. The kidney is responsible for eliminating the acid by-products of
metabolism. Choose option a.
<System> Renal

13. Peritoneal dialysis has been initiated on a patient with acute kidney injury. On the
second exchange, the nurse notices that the dialysate outflow is amber colored. Which of the
following should be suspected?
a. Infection in the peritoneal cavity
b. Bleeding in the peritoneal cavity
c. Bladder perforation
d. Bowel perforation

Correct answer: c
Rationale: Normal dialysate outflow is clear or pale yellow. If the outflow has an amber
color, the bladder could have been perforated accidentally during catheter insertion.
Test-Taking Strategy: Infection causes the dialysate return to be cloudy, so eliminate option
a. Bleeding causes the dialysate return to be pink or red depending on the severity of the
bleeding, so eliminate option b. Bowel perforation would cause the dialysate return to be
brownish, so eliminate option d. Bladder perforation would cause any urine that is in the
bladder to leak into the peritoneal cavity, discoloring the dialysate return. Choose option c.
This question is as easy as color matching.
<System> Renal
<Section> Renal Replacement Therapies

14. Continuous venovenous hemofiltration (CVVH) is started on a 44-year-old patient for

acute oliguric kidney injury. The patient has a history of cardiomyopathy and chronic heart
failure. Although CAVH is continuing, the patient’s blood pressure drops from 120/70 mm
Hg to 90/60 mm Hg. You observe a drop in the plasma in the drainage bag. One immediate
action would be to:
a. increase the infusion rate.
b. decrease the infusion rate.
c. raise the filter above the level of the patient's heart.
d. lower the filter below the level of the patient's heart.

Correct answer: d
Rationale: Placing the filter below the level of the patient's heart allows the force of gravity
to help move the ultrafiltrate. When the patient is hypotensive, the force that pushes the
blood through the circuit is decreased, which decreases the amount of ultrafiltrate.
Test-Taking Strategy: Increasing the infusion rate might increase the plasma in the drainage
bag, which might perpetuate the hypotension. A more “gentle” way of increasing the return
would be to lower the drainage bag. Choose option d.
<System> Renal

15. Continuous venovenous hemofiltration (CVVH) is started on a 44-year-old patient for

acute oliguric kidney injury. The patient has a history of cardiomyopathy and chronic heart
failure. The patient experiences a cardiopulmonary arrest. During the code, lab work reveals
a serum potassium of 8.8 mEq/L. What would be the most appropriate intervention at this
time?
a. Sodium polystyrene sulfonate (Kayexalate) enema
b. Glucose and insulin intravenously
c. Sorbitol via a nasogastric tube
d. Hemodialysis

Correct answer: b
Rationale: The most immediate action would be to give glucose and insulin intravenously to
drive the potassium temporarily into the cells. This immediate treatment must be followed
by some other measure to lower serum potassium, such as Kayexalate and sorbitol and/or
hemodialysis.
Test-Taking Strategy: This patient is in cardiac arrest, and the chosen action must have
immediate effect. Options a, c, and d will take too long. Choose option b.
<System> Renal

16. A patient admitted with Goodpasture's syndrome has developed acute tubular necrosis.
The patient’s phosphorus level is 6.5 mg/dL. Control of the phosphorus is important to
avoid complications from which of the following?
a. Hyponatremia
b. Hypocalcemia
c. Hypernatremia
d. Hypercalcemia

Correct answer: b
Rationale: Long-term elevated phosphorus levels result in low serum calcium levels. In
hyperphosphatemia, there is an impaired sensitivity of the skeleton to the bone-resorbing
action of parathyroid hormone and a reduced absorption of calcium because of its being
trapped in insoluble form as calcium phosphate complexes. This is a more common problem
in chronic kidney disease but also should be considered if hyperphosphatemia in acute
kidney injury becomes a problem.
Test-Taking Strategy: Associate phosphorus and calcium with a seesaw. When one side of
the seesaw is up, the other is down. This process is consistent with normal and abnormal
kidney function. Choose option b. You do not really need to know what Goodpasture’s
syndrome is to answer the question correctly.
<System> Renal

17. A 77-year-old woman reports explosive diarrhea for 48 hours. She is extremely
lethargic. Mucous membranes are dry and sticky, and the urine is dark amber with a specific
gravity of 1.035. Vital signs are temperature 38.2° C orally; heart rate 130 beats/min and
regular; respiratory rate 26 breaths/min and regular; and blood pressure 90/74 mm Hg.
Which of the following is of the most immediate concern?
a. Infection
b. Hypovolemia
c. Nutrition
d. Skin breakdown

Correct answer: b
Rationale: Correction of hypovolemia is of immediate concern. Sympathetic nervous
system stimulation is evidenced by the narrowed pulse pressure and tachycardia. Volume
depletion is evidenced by the temperature elevation; dry, sticky mucous membranes; and
small volumes of dark, concentrated urine. Because the major function of the large intestine
is to absorb approximately 8 L of water per day, fluid loss is critical in ongoing diarrhea. If
not corrected, it may lead to hypovolemic shock and death.
Test-Taking Strategy: If you have no idea of the correct answer, consider which option is
potentially life threatening. Hypovolemia, especially in an older adult, is the most life
threatening of the options given. Choose option b.
<System> Renal
<Section> Fluid Balance

18. A patient is diagnosed with acute kidney injury (ARF) and is placed on fluid restrictions.
The patient’s total output for yesterday was 600 mL. Which of the following fluid volumes
would be allowed for today?
a. 300 mL
b. 600 mL
c. 1100 mL
d. 1500 mL

Correct answer: c
Rationale: Fluid allowances for the patient with ARF are usually 500 mL for insensible loss
added to the previous day's urine output.
Test-Taking Strategy: Because you do not want the patient to become dehydrated, you
know you need to give at least as much as the patient lost. Eliminate option a. Now consider
that there are losses that cannot be measured, and even if you cannot remember the amount
that should be allotted for insensible losses, you can eliminate option b, which allows for no
insensible losses. Of the two options that are left, calculate that the insensible losses account
for 500 or 900 mL per day. Almost a liter probably sounds a bit high. Choose 500 mL of
insensible loss along with 600 mL of measured losses for a total of 1100 mL. Choose option
c.
<System> Renal

19. A 32-year-old woman has systemic lupus erythematosus and chronic kidney disease.
Over the past 2 weeks, she has complained of feeling fatigued and short of breath after
minimal exertion. She is receiving hemodialysis. Her hemoglobin level is 4.5 g/dL. Which
of the following is indicated?
a. Recombinant human erythropoietin (Epogen)
b. Two units of packed red blood cells
c. Nitroglycerin sublingual as needed
d. Azathioprine (Imuran)

Correct answer: a
Rationale: This patient is having symptoms of decreased tissue oxygenation. In acute
situations, this would be an indication for blood. In this patient, recombinant human
erythropoietin (Epogen) is a more appropriate treatment. Epogen is used to treat anemia
resulting from reduced renal production of erythropoietin (the hormone that promotes the
production of red blood cells).
Test-Taking Strategy: Connect the treatment with the cause. The cause of the symptoms is
the decreased amount of hemoglobin to carry oxygen. The treatment is to increase the
amount of hemoglobin by treating the cause. The cause of anemia in a patient with chronic
renal failure is decreased renal production of erythropoietin. Choose option a.
<System> Renal
<Section> Chronic Kidney Disease

20. A patient with acute kidney injury is undergoing her third hemodialysis treatment in 3
days. Which of the following is the best parameter to evaluate the effectiveness of fluid
removal during hemodialysis?
a. Blood pressure
b. Blood urea nitrogen (BUN) and creatinine levels
c. Postdialysis weight
d. Serum potassium level

Correct answer: c
Rationale: Weighing the patient is the most effective means of determining overall volume
status. One pound is equal to 500 mL.
Test-Taking Strategy: Because the question says fluid, eliminate potassium, option d. BUN
is affected by fluid status, but creatinine is not, so eliminate option b. Blood pressure is
affected by sympathetic tone, hormones, and other local factors along with fluid status, so
eliminate option a. Choose weight as the most specific indicator of fluid removal. Choose
option c.
<System> Renal
<Section> Fluid Balance; Acute Kidney Injury

21. Which of the following is a cause of acute tubular necrosis (ATN)?

a. Nephrotoxic drugs
b. Bladder carcinoma
c. Glomerulonephritis
d. Hypovolemia

Correct answer: a
Rationale: Acute tubular necrosis refers to death of renal tubule tissue. ATN is the result of
ischemia that is caused by a prolonged period of hypoperfusion or nephrotoxic injury,
specifically drugs or toxins.
Test-Taking Strategy: Think of ATN as necrosis of the tubules caused by ischemia or
nephrotoxins. Choose option a.
<System> Renal

22. A 54-year-old man had surgery 3 days ago for repair of an abdominal aortic aneurysm.
Acute kidney injury has developed. Lab values reveal the following:
Na 140 mEq/L
K 4.5 mEq/L
Cl 100 mEq/L
HCO3 24 mEq/L
The anion gap would be:

a. 5 mEq/L.
b. 10 mEq/L.
c. 15 mEq/L.
d. 20 mEq/L.

Correct answer: d
Rationale: The anion gap = (Na + K) − (Cl + HCO3). A normal anion gap is less than 15
mEq/L. An anion gap of greater than 15 mEq/L indicates that there are unmeasured acids
(e.g., lactic acidosis, ketoacidosis, certain toxins, and accumulation of fixed acids resulting
from renal failure).
Test-Taking Strategy: An anion gap means that there are fewer anions than there should be.
So add up the main cations and subtract the main anions. Choose option d. If you cannot
remember the formula but you know that increased acids increase the anion gap and you
know the normal value, option d is the only abnormal value.
<System> Renal

23. A 23-year-old woman is beginning her second hemodialysis treatment for acute kidney
injury. Suddenly she complains of headache and nausea. She is agitated and confused, and
you notice twitching in her right hand. Which of the following is causing these findings?
a. Uremia
b. Dialysis disequilibrium syndrome
c. Intracerebral hemorrhage
d. Fluid overload

Correct answer: b
Rationale: Dialysis disequilibrium syndrome occurs when urea is removed from the blood
at a rate faster than it is removed from the brain tissue. The greater amount of urea in the
brain causes a fluid shift resulting in cerebral edema.
Test-Taking Strategy: None
<System> Renal

24. A 23-year-old woman is beginning her second hemodialysis treatment for acute kidney
injury. Suddenly she complains of headache and nausea. She is agitated and confused, and
you notice twitching in her right hand. Dialysis disequilibrium syndrome is diagnosed. What
is the most effective prevention for dialysis disequilibrium syndrome?
a. Using a lidocaine drip
b. Using more heparin in the line
c. Increasing the blood flow rate
d. Slowing the blood flow rate

Correct answer: d
Rationale: You can prevent the syndrome by slowing the blood flow rate to a speed about
100 mL/min, which will help slow the rate at which the solute is removed from the vascular
space.
Test-Taking Strategy: Eliminate the “increasing” and “more” options (c and b) because
the adverse effects probably result from something that has occurred too rapidly.
<System> Renal

25. A patient is admitted to the critical care unit 1 year after renal transplant. The patient’s
serum sodium is 160 mEq/L. Which of the following would be the most likely cause of this
patient’s elevated sodium level?
a. Excessive oral ingestion of sodium
b. Heart failure
c. Rejection of the kidney
d. Corticosteroid therapy

Correct answer: d
Rationale: Rejection would cause the blood urea nitrogen and creatinine to go up, but the
sodium would be normal or decreased because of water retention. Heart failure would
stimulate aldosterone and retention of sodium and water, so the sodium would be normal but
the patient would be fluid overloaded. Nothing is in the case presentation to make you
believe that she has been consuming abnormal amounts of sodium. Knowing that
posttransplant patients are taking immunosuppressive agents, including corticosteroids,
leads you to option d.
<System> Renal
<Section> Renal Replacement Therapies; Electrolytes; Pharmacology

26. Angiotensin-converting enzyme (ACE) inhibitors may cause which of the following
electrolyte imbalances?
a. Hypernatremia
b. Hypomagnesemia
c. Hyperkalemia
d. Hypocalcemia

Correct answer: c
Rationale: ACE inhibitors block the conversion of angiotensin I to angiotensin II.
Angiotensin II causes vasoconstriction and blocks aldosterone. The primary effects of
aldosterone are to cause the retention of sodium and water and the excretion of potassium.
By blocking this effect, ACE inhibitors cause the excretion of sodium and water and the
retention of potassium. Hyperkalemia is an adverse effect of ACE inhibitors. Discourage the
use of potassium chloride salt substitute.
<System> Renal
<Section> Electrolytes; Pharmacology

27. Which of the following would you expect to see in a patient with serum potassium of
7 mEq/L?
a. Premature ventricular contractions and paralytic ileus
b. Hypotension and respiratory muscle paralysis
c. Stridor and paresthesias
d. Flaccid paralysis and diarrhea

Correct answer: d
Rationale: Hyperkalemia increases gastric motility, causing diarrhea. Hyperkalemia also
causes flaccid paralysis by partially depolarizing the muscle cell membrane, preventing
further depolarization.
Test-Taking Strategy: Option a is seen in hypokalemia, option b is seen in
hypermagnesemia, and option c is seen in hypocalcemia.
<System> Renal

28. Provision of adequate nutrition in a malnourished patient may cause severe deficiency
of which of the following electrolytes?
a. Potassium
b. Magnesium
c. Calcium
d. Phosphate

Correct answer: d
Rationale: This often is called refeeding syndrome. Nutritional support allows the cells to
begin making more adenosine triphosphate (ATP), and phosphate supplies are depleted. The
same thing happens in diabetic ketoacidosis with treatment when insulin allows glucose to
move into the cell increasing production of ATP and depletion of phosphate.
<System> Renal

29. Pigment-related acute tubular necrosis (ATN) occurs primarily in patients with which
of the following?
a. Abdominal trauma
b. Knife wounds
c. Crush injuries
d. Thoracic trauma

Correct answer: c
Rationale: Crush injuries cause muscle destruction and rhabdomyolysis, which liberates
myoglobin into the blood. This heavy pigment potentially causes tubular occlusion and
ATN. Myoglobinuria also may occur in electrical burns, status epilepticus, muscle ischemia,
and statins.
<System> Renal

30. Which of the following is indicated in acute tubular necrosis (ATN) when the blood
urea nitrogen (BUN) is greater than 100 mg/dL?
a. Aggressive rehydration
b. Diuretics
c. Dialysis
d. Nephrectomy

Correct answer: c
Rationale: Dialysis usually is indicated when the BUN is greater than 100 mg/dL.
Aggressive rehydration is indicated long before the BUN is greater than 100 mg/dL.
Diuretics may be used early but are not used if the patient is dehydrated or anuric.
Nephrectomy is not indicated for ATN.
<System> Renal

31. A patient has urine specific gravity of 1.035, urinary sodium of 5 mEq/L, blood urea
nitrogen (BUN) of 40 mg/dL, and creatinine of 1.2 mg/dL. Urinalysis reveals no
proteinuria. These findings indicate which type of acute kidney injury?
a. Prerenal
b. Intrarenal—cortical
c. Intrarenal—medullary
d. Postrenal

Correct answer: a
Rationale: These findings indicate that the body is holding onto sodium and water. The
BUN/creatinine ratio of greater than 10:1 is seen in dehydration (prerenal) or catabolism.
Test-Taking Strategy: The increase in urine specific gravity is indicative of dehydration,
and dehydration is the most significant cause of prerenal acute kidney injury.
<System> Renal

32. A patient develops carpopedal spasm and neuromuscular irritability manifested by

Chvostek’s and Trousseau’s signs. Which electrolyte imbalance should you suspect?
a. Hyperkalemia
b. Hypercalcemia
c. Hypermagnesemia
d. Hyperphosphatemia

Correct answer: d
Rationale: The patient’s signs/symptoms are associated with hypocalcemia and its
reciprocal condition, hyperphosphatemia. The same signs/symptoms also are seen in
hypomagnesemia.
Test-Taking Strategy: You probably immediately looked for hypocalcemia but could not
find it among the options. To answer this question correctly, you need to remember the
reciprocal relationship between calcium and phosphorus.
<System> Renal

33. The electrolyte imbalance that is a frequent cause of postoperative paralytic ileus is
which of the following?
a. Hypocalcemia
b. Hypokalemia
c. Hypomagnesemia
d. Hyponatremia

Correct answer: b
Rationale: Hypokalemia decreases gastric motility and often occurs after surgery, primarily
because of the action of aldosterone. Nasogastric suctioning, vomiting, and diuresis also
may contribute to perioperative potassium loss.
Test-Taking Strategy: If you just identified hypokalemia as a common postoperative
electrolyte imbalance, you would correctly choose option b.
<System> Renal

34. Magnesium sulfate is being given for refractory ventricular tachycardia in a patient
with an acute myocardial infarction. The patient becomes hypotensive with respiratory
depression and hyporeflexia. What should be done?
a. Call a code.
b. Give calcium chloride intravenously.
c. Administer furosemide (Lasix).
d. Prepare for dialysis of the patient.

Correct answer: b
Rationale: Diuretics will increase excretion of magnesium, but they will not be fast enough
to avert respiratory arrest. Dialysis is the treatment in a patient with renal failure, but if the
patient does not already have a vascular access, initiating dialysis will take too long. The
patient has not arrested yet, so attempt to prevent it with the administration of calcium.
Calcium is an antagonist to hypermagnesemia.
<System> Renal

35. Which of the following would not be restricted during the oliguric phase of acute
kidney injury?
a. Protein
b. Sodium
c. Potassium
d. Carbohydrates

Correct answer: d
Rationale: There are two issues here. First, restrict what the kidney will have difficulty
eliminating (i.e., sodium, water, potassium, magnesium, phosphorus). Second, reduce
nitrogenous wastes. While protein restriction seems obvious because protein metabolism
will increase BUN, the carbohydrate issue is less obvious. Inadequate carbohydrate
intake will cause catabolism (i.e., protein metabolism).
<System> Renal
<Section> Acute Kidney injury

36. Which of the following would not be a risk factor for developing acute kidney injury
after cardiac surgery?
a. Cardiogenic shock
b. Duration of cardiopulmonary bypass
c. Antibiotic therapy
d. Dobutamine therapy

Correct answer: d
Rationale: Any cause of hypoperfusion, such as cardiogenic shock or the duration of
cardiopulmonary bypass, is a risk factor for acute kidney injury. Antibiotic therapy,
especially aminoglycosides, is also a risk factor for kidney injury. Dobutamine would
actually increase renal perfusion, and current studies indicate that dobutamine increases
renal perfusion more than low-dose dopamine. Low-dose dopamine is no longer indicated to
improve renal perfusion.
<System> Renal

37. A 54-year-old man is admitted to the critical care unit with acute kidney injury resulting
from a bladder tumor. This would be classified as which type of acute kidney injury?
a. Prerenal
b. Intrarenal—medullary
c. Intrarenal—cortical
d. Postrenal

Correct answer: d
Rationale: Postrenal failure is defined as an obstructive process that occurs distal to the
kidney. Prerenal failure is caused by a decreased glomerular filtration rate resulting from
decreased volume or pressure. Intrarenal failure is due to injury within the kidney.
Intrarenal—cortical is caused by an infectious or inflammatory process within the kidney.
Intrarenal—medullary is caused by prolonged ischemic injury or a nephrotoxin. Pre- means
before, and post- means after. Postrenal renal failure logically would be renal failure caused
by some problem after the kidney, such as tumor or stone.
Test-Taking Strategy: Consider the anatomy of the renal system. The bladder is after (i.e.,
post) the kidney.
<System> Renal

38. A patient has gained 1 kg since yesterday. How much fluid does this weight gain
represent?
a. 250 mL
b. 500 mL
c. 1000 mL
d. 2000 mL

Correct answer: c
Rationale: One pound is equal to approximately 500 mL. One kilogram (2.2 lb) is equal
to approximately 1 L.
<System> Renal

39. A 30-year-old man was electrocuted with 440 volts of electrical current. An entry
wound was noted in his left hand, and a large exit wound was noted on the sole of his right
foot. Eight hours after admission into the critical care unit, the nurse observes that the urine
is brownish. A specimen is sent to the laboratory. What intervention is anticipated?
a. Rapid fluid administration and dopamine at 2 mcg/kg/min
b. Furosemide (Lasix) 10 mg IV and dopamine at 2 mcg/kg/min
c. Rapid fluid administration and 25 g of 20% mannitol
d. Insertion of a double-lumen vascular catheter and hemodialysis

Correct answer: c
Rationale: Myoglobin is muscle protein that is seen in the urine after extensive muscle
injury such as electrical burns, status epilepticus, and crush injuries. Myoglobin may cause
acute tubular necrosis. To prevent damage to the tubules, forced diuresis with fluids and
osmotic diuretics usually is initiated. Alkalinization of the urine through intravenous
administration of sodium bicarbonate also may be initiated.
Test-Taking Strategy: The single most important intervention when any renal toxin (e.g.,
nephrotoxic antibiotics, nephrotoxic dyes, and myoglobin) is present is to flush the toxins
through the renal tubules with lots of fluids. Because options a and c include rapid fluid
administration, narrow your choices to these options. Next, consider that all that fluid may
be a problem and that a diuretic likely is appropriate to help eliminate the excess fluid. Also,
low-dose dopamine no longer is recommended to increase renal flow. Choose option c.
<System> Renal

40. A patient receiving an angiotensin-converting enzyme (ACE) inhibitor and

spironolactone (Aldosterone) for heart failure is at risk for which electrolyte imbalance?
a. Hypernatremia
b. Hyperkalemia
c. Hypocalcemia
d. Hypophosphatemia

Correct answer: b
<Rationale>Because ACE inhibitors block the release of aldosterone, and spironolactone
is an aldosterone antagonist, the action of aldosterone is diminished. Because aldosterone
causes the retention of sodium and water and the excretion of potassium, the patient is at
risk for hyperkalemia.
Test-Taking Strategy: Remember that spironolactone traditionally has been called a
potassium-sparing diuretic. Thus it would cause the retention of potassium.
<System> Renal
<Section> Electrolyte Imbalance; Pharmacology

41. A 42-year-old woman with chronic kidney disease is admitted to the emergency
department with tachycardia, hypotension, dyspnea, S3, crackles, and frothy hemoptysis.
Oxygen is being administered at 4 L/min via nasal cannula. Immediate management
would include which of the following?
a. Initiate dialysis.
b. Administer digoxin.
c. Administer diuretics.
d. Administer venous vasodilators.

Correct answer: a
Rationale: The cause of this acute left ventricular failure with pulmonary edema is fluid
overload related to renal failure. The appropriate immediate management is to dialyze the
patient as soon as possible.
Test-Taking Strategy: If you are not sure of the answer, notice that three of the choices are
drugs, and one of these drugs performs the function of the kidney in eliminating the excess
fluid. Read the question slowly and carefully to note chronic kidney disease. Diuretics
would eliminate excess fluid in most patients, but not in a patient with renal failure. Choose
option a.
<System> Renal
<Section> Chronic Renal Failure

42. A patient with an electrical burn develops brown urine. The urinalysis confirms
myoglobinuria. Which of the following interventions would you anticipate to prevent the
development of acute tubular necrosis and kidney injury in this patient?
a. Saline, mannitol, and bicarbonate
b. Colloids, furosemide, and dopamine
c. Blood, furosemide, and dobutamine
d. Lactated Ringer’s solution, hydrochlorothiazide, and dopamine

Correct answer: a
Rationale: The destruction of muscle by the electricity has caused myoglobin to appear in
the urine. Myoglobin is a heavy pigment that can cause acute tubular necrosis and kidney
injury. The treatment for myoglobinuria is to flush the pigments through with fluids,
usually saline, and diuretics, usually mannitol. Alkalinization of the urine using sodium
bicarbonate intravenously also may be prescribed to increase the excretion of the
myoglobin.
<System> Renal

43. A patient with diabetic ketoacidosis was admitted to the critical care unit from the
emergency department. His initial laboratory results included serum glucose 660 mg/dL,
pH 7.0, and serum potassium of 5 mEq/L. As the pH is corrected with insulin and fluids,
what would be the anticipated change in his potassium?
a. The potassium would decrease to approximately 3 mEq/L
b. The potassium would decrease to approximately 4 mEq/L
c. The potassium would remain at approximately 5 mEq/L
d. The potassium would increase to approximately 6 mEq/L

Correct answer: a
Rationale: Changes in pH causes potassium to move either into or out of the cell.
Acidosis causes potassium to leave the cell and increases serum potassium levels, whereas
alkalosis causes potassium to enter the cell and decreases serum potassium. For every
change in pH of 0.1, the potassium moves 0.5 mEq/L in the opposite direction. In this
patient the pH has changed 4 x 0.1 from the midline normal pH of 7.4 so the serum
potassium is expected to decrease by 2 mEq/L (0.5 x 4) when the pH is corrected. So 5
minus 2 mEq/L is 3 and this is what the potassium would be expected to fall to with
correction of the pH. Potassium replacement is indicated now even though his potassium is
currently at a high normal level. The potassium level will plummet as insulin and fluids
correct the blood glucose and pH.
Test-Taking Strategy: If you remember that there is a change in serum potassium level
with pH changes, you eliminate option c. If you remember that the change in pH and the
change in serum potassium is inverse, you eliminate option d. To choose between options
a and b, you need to know how significant a change is expected.
<System> Renal

44. A patient with alcoholic cirrhosis has peripheral edema and ascites. Albumin has been
prescribed. Which of the following describes the rationale for albumin in this
circumstance?
a. To reduce third-spacing
b. To treat protein malnutrition
c. To treat coagulopathy
d. To reduce ammonia levels

Correct answer: a
Rationale: The liver’s inability to build plasma proteins results in hypoproteinemia in
cirrhosis. The decrease in serum albumin (the primary intravascular protein) results in
third-spacing manifested by ascites and peripheral edema. Replacing albumin will
increase intravascular colloidal oncotic pressure to hold and pull fluid into the vascular
space. Hypoproteinemia also contributes to coagulopathy; this is the result of the liver’s
inability to produce adequate amounts of fibrinogen. Intravenous administration of
albumin is not a treatment for malnutrition and it does not reduce ammonia levels.
Test-Taking Strategy: Consider the patient’s clinical presentation and choose the option
that is most directly related to the peripheral edema and ascites.
<System> Renal

45. A patient with chronic kidney disease asks why he is anemic. The explanation to this
patient should be that anemia is the result of:
a. loss of blood in the urine.
b. inadequate production of a hormone that stimulates production of red blood cells.
c. deficiency of iron needed for production of red blood cells.
d. development of a gastric ulcer and blood loss as a result of the ulcer.

Correct answer: b
Rationale: Anemia in a patient with chronic kidney disease is caused by inadequate
production of erythropoietin, a hormone that stimulates production of RBCs in the bone
marrow.
<System> Renal
<Section> Chronic Kidney Disease

46. A patient with acute pancreatitis is experiencing muscle spasm. A prolonged QT

interval is also noted on his ECG. Which of the following is a major concern with this
patient?
a. That he has hypermagnesemia and is at risk for respiratory arrest
b. That he has hyperkalemia and is at risk for asystole
c. That he has hypocalcemia and is at risk for dysrhythmias such as torsades de pointes
d. That he has hyponatremia and is at risk for seizures

Correct answer: c
Rationale: Acute pancreatitis can cause significant hypocalcemia which is manifested by
tetany and prolonged QT interval. The prolonged QT interval predisposes the patient to
torsades de pointes.
Test-Taking Strategy: The electrolyte imbalance that occurs in acute pancreatitis is
hypocalcemia and the muscle spasm and prolonged QT interval are consistent with
hypocalcemia. Even though hypermagnesemia can cause respiratory arrest, hyperkalemia
can cause asystole, and hyponatremia can cause seizures, these electrolyte imbalances are
not consistent with the history and presentation.
<System> Renal

47. An elderly man is admitted after several days of nausea, vomiting, and diarrhea.
Which of the following would be most indicative of dehydration in this patient?
a. Thirst, hypotension, bradycardia
b. Hypotension, tachycardia, oliguria
c. Thirst, tachycardia, dry mucous membranes
d. Bradycardia, dry mucous membranes, oliguria

Correct answer: b
Rationale: Tachycardia, hypotension, oliguria, dry mucous membranes, and poor skin
turgor would all be indications of dehydration. Even though thirst may be an indication of
dehydration, it is frequently not seen in elderly patients, which makes option b preferred
over option c.
Test-Taking Strategy: With questions with multiple answers such as this one, use the
True/False method with each answer in the option. So options a and d can easily be
eliminated by the bradycardia in those options. With options b and c, you need to know
how elderly patients vary in their clinical presentation of dehydration.
<System> Renal

48. A patient with a large amount of protein in the urine suggests damage to which
portion of the nephron?
a. Glomerulus
b. Bowman’s capsule
c. Proximal convoluted tubule
d. Collecting duct

Correct answer: a
Rationale: Damage to the glomerulus causes loss of protein and proteinuria. Examples
are glomerulonephritis, Goodpasture’s syndrome, and nephrotic syndrome.
Test-Taking Strategy: Consider the glomerulus a semipermeable membrane. If it is
damaged, it becomes more permeable allowing loss of protein and red blood cells.
<System> Renal

Renal Evolve Question

Загружено:

Сведения о документе

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Renal Evolve Question

Загружено:

Авторское право:

Доступные форматы

Pass CCRN Evolve Questions - Renal-1

1. A 48-year-old man is admitted with an acute myocardial infarction. Assessment reveals

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

2. A 48-year-old man is admitted with an acute myocardial infarction. Assessment reveals

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

5. Magnesium is being administered to a patient admitted with acute myocardial infarction.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Which of these lab abnormalities probably is causing the neurologic symptoms?

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

What would be the most appropriate treatment for this patient?

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

8. The action of furosemide (Lasix) is to do which of the following?

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

9. After an intravenous pyelogram (IVP), which of the following is an important nursing

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

14. Continuous venovenous hemofiltration (CVVH) is started on a 44-year-old patient for

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

15. Continuous venovenous hemofiltration (CVVH) is started on a 44-year-old patient for

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

21. Which of the following is a cause of acute tubular necrosis (ATN)?

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

The anion gap would be:

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier, Inc. All rights reserved.