ANSWERS AND 5.

Answer D
Concentration gradient is the term used
RATIONALE: when the concentration of a certain
particle is higher on one side of a
TEST I. membrane than on the other side.
Transmembrane pressure (TMP) refers to
1. Answer A the difference in hydrostatic pressure
Although many elderly patients may also between the blood and the dialysate
suffer from chronic obstructive pulmonary solution. Diffusive, or conductive
disease it is not considered a direct cause transport, refers to the movement of
of CKD. Diabetes mellitus (both type 1 and solute particles from the side of higher
type 2), systemic lupus, and hypertension concentration to the side of lower
are all diseases that contribute to the concentration through the dialysis
development of CKD. membrane. Mass transfer rate, or solute
2. Answer D flux, refers to the rate of movement
Some of the negatives associated with through a membrane.
peritoneal dialysis (PD) include protein
malnutrition and inadequate dialysis. The
protein malnutrition results from the loss
of amino acids and protein in the TEST II.
dialysate. The appetite is decreased
because of the glucose load absorbed 1 B 16 C 31 A
from the dialysis. This frequently results in 2 A 17 C 32 D
hyper triglyceridemia, which causes 3 C 18 ACD 33 A
weight gain from the caloric increase (not 4 A 19 C 34 B
from a high-carbohydrate diet). 5 A 20 C 35 A
3. Answer B 6 B 21 A 36 A
Since aluminum is usually stored in the 7 D 22 B 37 B
brain or the bones, behavioral changes, 8 B 23 D 38 D
memory loss, slurred speech, lack of 9 D 24 A 39 C
energy, dementia, and bone disease are 10 A 25 B 40 C
symptoms of aluminum toxicity. Anemia, 11 C 26 B 41 C
constipation, and loss of appetite are also 12 B 27 D 42 A
related to an excessive amount of 13 A 28 A 43 BDE
aluminum in the body. Nausea, vomiting, 14 C 29 A 44 A
diarrhea, fever, chills, upper respiratory 15 A 30 C 45 D
tract infection, elevated WBC, and
headache could be symptoms of influenza
or multiple other infectious processes. 46 B 61 B 76 D
Joint pain and redness, gangrene, back 47 B 62 B 77 A
pain, fractures, and itching are classic 48 C 63 B 78 C
symptoms of osteodystrophy. Nausea, 49 B 64 D 79 C
vomiting, metallic taste, fetid breath, GI 50 A 65 A 80 C
bleeding, diarrhea, and functional 51 D 66 C 81 D
constipation are the GI effects of uremia. 52 A 67 D 82 A
4. Answer C 53 B 68 A 83 A
The lower the molecular weight of the 54 A 69 C 84 B
solutes, the greater the amount of solutes 55 B 70 C 85 A
that will be removed. The higher the 56 B 71 B 86 C
temperature, the greater the amount of 57 D 72 D
solutes removed, the faster the flow rate 58 B 73 B
of the dialysate, the greater the removal 59 A 74 A
of solutes, and the faster the blood flow, 60 C 75 C
the greater the amount of solutes
removed.
 protectors. The drip chamber also traps
any air that gets into the line and prevents
blood clots in the extracorporeal
circulation from entering the patient by
use of a fine wire mesh on the venous side
before the patient’s venous access. The
TEST III. arterial blood is propelled from the drip
chamber into the dialyzer by a blood
1. Answer C pump in which the pliable and slightly
Molecular weights of a chemical larger-in-diameter arterial tubing is
compound represent the sum of the threaded through the pump rollers
atomic weights of the atoms that make up 4. Answer D
the molecule. Each dialyzer membrane Postdialyzer or venous pressure is that in
has a molecular weight cutoff (in daltons) the tubing returning blood from the
that determines the size of the molecules dialyzer to the patient’s venous access. A
that can pass through it. These may range low-pressure alarm may be set off by a
from 3000 to 15,000 daltons. Small separation of the blood tubing from the
molecules (e.g., sodium, potassium, venous needle or catheter, a fall in the
phosphate, urea, water) pass through the blood flow rate, a blockage in the tubing
filter easily, while large molecules, such as before the venous monitor, or a major clot
proteins (e.g., albumin with a molecular in the dialyzer. The high-pressure venous
weight of 66,000 daltons) cannot. alarm may be set off by a blockage of the
Choosing the appropriate molecular cutoff blood tubing between the monitoring site
for a membrane helps to determine what and the patient’s venous access, poor
size molecule may be removed from the positioning or infiltration of the venous
blood. This is particularly important for needle, a poorly working central venous
drug overdoses and toxins. catheter, or a clot in the venous access.
2. Answer C
Bicarbonate buffer is used for the 5. Answer B
dialysate since the acetate previously High-output cardiac failure may be seen in
used caused vasodilation and patients with anemia, hyperthyroidism, or
hypotension. Immunologic reactions and arteriovenous shunts. The latter increases
fluctuations in the white blood cell count the venous return to the heart (by 20% or
are less common since the membranes more), increasing the cardiac workload
used are more biocompatible. Pyrogenic and decreasing the arterial resistance.
reactions in high-flux dialysis are common, Tachycardia and hypotension may occur.
causing fever and discomfort for the Symptoms of heart failure, such as
patient, and sometimes require dyspnea (shortness of breath) and
hospitalization for observation. This may peripheral edema, will ensue. Often
be because the high-flux membranes have patients with end stage renal disease are
larger pores that allow fragments of anemic or have coexisting heart disease,
bacterial particles to pass into the blood. which worsens the problem. Treating
Such pyrogens have been found in the anemia to hemoglobin levels above 10–11
dialysate. Generally, patients experience g/dL and perhaps use of inotropic (heart
less postdialysis fatigue and may in fact contraction stimulants) drugs may help.
feel better because of the more efficient Because the kidneys are not functional,
removal and shorter dialysis times. diuretics are not useful. Reducing fluid
3. Answer D gain between dialyses and removing more
The extracorporeal circuit refers to the fluid by longer or more frequent dialyses
system of tubes, drip chambers, pressure may also be beneficial.
gauges, and pump that connect the 6. Answer C
arterial and venous accesses to the Removal of too much fluid during the
dialyzer. The drip chambers have gauges dialysis procedure may induce muscle
to measure arterial and venous pressures cramps, especially in the hands, arms, and
by monitoring lines with transducer feet. Dehydration leads to electrolyte
imbalance, especially hypernatremia that to less disequilibrium. Dietary restrictions
results in severe muscular cramping. Low- may be lessened in PD. Fluid buildup is
potassium levels (hypokalemia) may also less of a problem in PD because it is within
result in muscle cramps. Low-calcium the abdomen and frequently exchanged.
levels are more likely to cause myalgias The biggest problem with PD is clogging or
and muscle spasms than hypercalcemia. infection related to the intraperitoneal
Hypotension may also be a cause of catheter. If an infection ensues,
muscle cramps. Preventive measures replacement may be required, and the
include obtaining the patient’s correct patient must be maintained on HD in the
weight, calculating the correct volume of interim.
fluid to be removed, checking and using 9. Answer B
the prescribed dialysate concentrate, and Erythropoietin is a glycoprotein hormone
reviewing the salt and fluid dietary limits released by the kidney in response to
with the patient. hypoxic stimuli. It stimulates the red cell
precursors in the bone marrow to increase
the rate of erythropoiesis to raise the red
7. Answer B blood cell number (increases the
Anaphylactic reactions are severe allergic hemoglobin concentration). The blood
reactions that may be caused by residual level of the hormone is elevated in
germicide in the dialysis tubing (e.g., polycythemia and low in chronic kidney
ethylene oxide) or drugs, such as heparin, disease (CKD). Several different
iron dextran, or certain antibiotics. The commercial formulations are available for
pattern is one of dyspnea, often due to CKD patients on hemodialysis. It may be
laryngeal spasm; hives; itching; and given subcutaneously or intravenously,
hypotension. This is a medical emergency preferably the latter into the venous line
and requires immediate treatment with at the end of a dialysis session. Iron
epinephrine, steroids, and antihistamine should also be given if the ferritin (iron
plus vascular support. An air embolus from storage protein) level is low. Current
a broken connection in the extracorporeal recommendations are to give the hormone
circuit or empty intravenous bag may to obtain a hemoglobin level of 10–12
cause chest pain, dyspnea, and cyanosis g/dL. Higher levels may predispose to
but not itching or hives. Angina is also a thrombosis. If the hemoglobin level does
potential cause of dyspnea and chest pain, not respond by 1 g/dL in 4 weeks, the dose
as many patients have a history of may be increased by 25%.
coronary artery disease with episodes of 10. Answer D
angina; however, hives and itching are Renal osteodystrophy refers to the bone
unusual; Sublingual nitroglycerin spray or demineralization seen in chronic kidney
tablets may be used. Disequilibrium disease. It may be divided into high- or
syndrome is characterized by neurologic low-bone turnover types. Symptoms may
symptoms in reaction to rapid removal of be bone or joint pain, fractures, or bone
urea from the blood, resulting in water deformation. Blood tests usually show a
entry into the brain. low-calcium and high-phosphate levels
8. Answer D since the diseased kidney is unable to
One advantage of peritoneal dialysis (PD) excrete phosphate. Calcitriol, the active
is that there is more or less constant fluid form of vitamin D, is low, which
in the abdomen; thus, the patient is contributes to poor absorption of calcium.
exposed to more or less constant dialysis. The parathyroid hormone is elevated due
It usually requires four or five exchanges to low-calcium levels that stimulate the
of dialysate daily with so-called continuous parathyroid glands so that this disorder is
ambulatory PD; however, a cycler that associated with secondary
allows the process to be done at night hyperparathyroidism. Calcium and vitamin
during sleep (continuous cycling PD) is D supplements, phosphate binders, and
also quite popular. Since fluid is constantly hemodialysis are all indicated. Renal
in the abdomen, the dialysis duration is transplantation may be curative.
longer than in hemodialysis (HD), leading
 restricted, but the first interventions
should be aimed at the immediate
treatment of hypoxia. The foot of the bed
TEST IV. may be elevated to reduce edema, but
this isn’t the priority.
5. Answer 4
1. Answer A
Assessment of the AV fistula for bruit and
Osmosis allows for the removal of fluid
thrill is important because, if not present,
from the blood by allowing it to pass
it indicates a non-functioning fistula. No
through the semipermeable membrane to
blood pressures or venipunctures should
an area of high concentrate (dialysate),
be taken in the arm with the AV fistula.
and diffusion allows for passage of
When not being dialyzed, the AV fistula
particles (electrolytes, urea, and
site may get wet. Immediately after a
creatinine) from an area of higher
dialysis treatment, the access site is
concentration to an area of lower
covered with adhesive bandages.
concentration. Fluid passes to an area with
a higher solute concentration. The pores 6. Answer 4
of a semipermeable membrane are small, Although clients with renal failure can
thus preventing the flow of blood cells and develop stress ulcers, the nausea is
protein molecules through it. usually related to the poisons of metabolic
wastes that accumulate when the kidneys
2. Answer 2
are unable to eliminate them. The client
To prevent life-threatening complications,
has electrolyte imbalances and oliguria,
the client must follow the dialysis
but these don’t directly cause nausea.
schedule. Alcohol would further dry the
client’s skin more than it already is. The 7. Answer 4
client should follow a low-potassium diet Clients with diabetes are prone to renal
because potassium levels increase in insufficiency and renal failure. The
chronic renal failure. The client should contrast used for heart catherization must
know hemodialysis is time-consuming and be eliminated by the kidneys, which
will definitely cause a change in current further stresses them and may produce
lifestyle. acute renal failure. A teenager who has an
appendectomy and a pregnant woman
3. Answer 3
with a fractured femur isn’t at increased
The first intervention should be to check
risk for renal failure. A dialysis client
for kinks and obstructions because that
already has end-stage renal disease and
could be preventing drainage. After
wouldn’t develop acute renal failure.
checking for kinks, have the client change
position to promote drainage. Don’t give 8. Answer 4
the next scheduled exchange until the In renal failure, calcium absorption from
dialysate is drained because abdominal the intestine declines, leading to increased
distention will occur, unless the output is smooth muscle contractions, causing
within parameters set by the physician. If diarrhea. CNS changes in renal failure
unable to get more output despite rarely include headache. A serum calcium
checking for kinks and changing the level of 5 mEq/L indicates hypercalcemia.
client’s position, the nurse should then call As renal failure progresses, bleeding
the physician to determine the proper tendencies increase.
intervention. 9. Answer 2
4. Answer 1 The nurse assesses the patency of the
Airway and oxygenation are always the fistula by palpating for the presence of a
first priority. Because the client is thrill or auscultating for a bruit. The
complaining of shortness of breath and his presence of a thrill and bruit indicate
oxygen saturation is only 89%, the nurse patency of the fistula. Although the
needs to try to increase his levels by presence of a radial pulse in the left wrist
administering oxygen. The client is in and capillary refill time less than 3
pulmonary edema from fluid overload and seconds in the nail beds of the fingers on
will need to be dialyzed and have his fluids the left hand are normal findings, they do
not assess fistula patency.
10. Answer 2 anuria are not early signs, and polydipsia
Phosphate binding agents that contain is unrelated to chronic renal failure.
aluminum include Alu-caps, Basaljel, and 15. Answer 4
Amphojel. These products are made from The client may have an elevated
aluminum hydroxide. Tums are made from temperature following dialysis because the
calcium carbonate and also bind dialysis machine warms the blood slightly.
phosphorus. Tums are prescribed to avoid If the temperature is elevated excessively
the occurrence of dementia related to high and remains elevated, sepsis would be
intake of aluminum. Phosphate binding suspected and a blood sample would be
agents are needed by the client in renal obtained as prescribed for culture and
failure because the kidneys cannot sensitivity purposes.
eliminate phosphorus. 16. Answer 1
11. Answer 4 Disequilibrium syndrome may be due to
Disequilibrium syndrome is characterized the rapid decrease in BUN levels during
by headache, mental confusion, dialysis. These changes can cause
decreasing level of consciousness, nausea, cerebral edema that leads to increased
and vomiting, twitching, and possible intracranial pressure. The client is
seizure activity. Disequilibrium syndrome exhibiting early signs of disequilibrium
is caused by rapid removal of solutes from syndrome and appropriate treatments
the body during hemodialysis. At the same with anticonvulsant medications and
time, the blood-brain barrier interferes barbituates may be necessary to prevent
with the efficient removal of wastes from a life-threatening situation. The physician
brain tissue. As a result, water goes into must be notified.
cerebral cells because of the osmotic 17. Answer 1
gradient, causing brain swelling and onset Cantaloupe (1/4 small), spinach (1/2
of symptoms. The syndrome most often cooked) and strawberries (1 ¼ cups) are
occurs in clients who are new to dialysis high potassium foods and average 7 mEq
and is prevented by dialyzing for shorter per serving. Lima beans (1/3 c) averages 3
times or at reduced blood flow rates. mEq per serving.
12. Answer 4 18. Answer 4
Following dialysis, the client’s vital signs Increasing the glucose concentration
are monitored to determine whether the makes the solution increasingly more
client is remaining hemodynamically hypertonic. The more hypertonic the
stable. Weight is measured and compared solution, the greater the osmotic pressure
with the client’s predialysis weight to for ultrafiltration and thus the greater
determine effectiveness of fluid extraction. amount of fluid removed from the client
Laboratory studies are done as per during an exchange.
protocol but are not necessarily done after 19. Answer 2
the hemodialysis treatment has ended. The major complication of peritoneal
13. Answer 2 dialysis is peritonitis. Strict aseptic
Steal syndrome results from vascular technique is required in caring for the
insufficiency after creation of a fistula. The client receiving this treatment. Although
client exhibits pallor and a diminished option 4 may assist in preventing
pulse distal to the fistula. The client also infection, this option relates to an external
complains of pain distal to the fistula, site.
which is due to tissue ischemia. Warmth, 20. Answer 3
redness, and pain more likely would Pain during the inflow of dialysate is
characterize a problem with infection. common during the first few exchanges
14. Answer 1 because of peritoneal irritation; however,
Polyuria occurs early in chronic renal the pain usually disappears after 1 to 2
failure and if untreated can cause severe weeks of treatment. The infusion amount
dehydration. Polyuria progresses to should not be decreased, and the infusion
anuria, and the client loses all normal should not be slowed or stopped.
functions of the kidney. Oliguria and 21. Answer 2
An extended dwell time increases the risk The client on hemodialysis should monitor
of hyperglycemia in the client with fluid status between hemodialysis
diabetes mellitus as a result of absorption treatments by recording intake and output
of glucose from the dialysate and and measuring weight daily. Ideally, the
electrolyte changes. Diabetic clients may hemodialysis client should not gain more
require extra insulin when receiving than 0.5 kg of weight per day.
peritoneal dialysis. 27. Answer 4
22. Answer 3 An AV shunt is a less common form of
The client with hyperkalemia is at risk for access site but carries a risk for bleeding
developing cardiac dysrhythmias and when it is used because two ends of an
cardiac arrest. Because of this the client external cannula are tunneled
should be placed on a cardiac monitor. subcutaneously into an artery and a vein,
Fluid intake is not increased because it and the ends of the cannula are joined. If
contributes to fluid overload and would not accidental connection occurs, the client
affect the serum potassium level could lose blood rapidly. For this reason,
significantly. Vegetables are a natural small clamps are attached to the dressing
source of potassium in the diet, and their that covers the insertion site to use if
use would not be increased. The nurse needed. The shunt site should be assessed
may also assess the sodium level because at least every four hours.
sodium is another electrolyte commonly 28. Answer 1,2,4,5
measured with the potassium level. If outflow drainage is inadequate, the
However, this is not a priority action at nurse attempts to stimulate outflow by
this time. changing the client’s position. Turning the
23. Answer 3 client to the other side or making sure that
Antihypertensive medications such as the client is in good body alignment may
enalapril are given to the client following assist with outflow drainage. The drainage
hemodialysis. This prevents the client bag needs to be lower than the client’s
from becoming hypotensive during dialysis abdomen to enhance gravity drainage.
and also from having the medication The connecting tubing and the peritoneal
removed from the bloodstream by dialysis. dialysis system is also checked for kinks or
No rationale exists for waiting a full day to twisting and the clamps on the system are
resume the medication. This would lead to checked to ensure that they are open.
ineffective control of the blood pressure. There is no reason to contact the
24. Answer 2 physician.
Clients with peritoneal dialysis catheters 29. Answer 1
are at high risk for infection. A dressing Crackles in the lungs, weight gain, and
that is wet is a conduit for bacteria for elevated blood pressure are indicators of
bacteria to reach the catheter insertion excess fluid volume, a common
site. The nurse assures that the dressing is complication in chronic renal failure. The
kept dry at all times. Reinforcing the client’s fluid status should be monitored
dressing is not a safe practice to prevent carefully for imbalances on an ongoing
infection in this circumstance. Flushing the basis.
catheter is not indicated. Scrubbing the 30. Answer 1, 2, 3
catheter with povidone-iodine is done at Appropriate nursing diagnoses for clients
the time of connection or disconnecting of with chronic renal failure include excess
peritoneal dialysis. fluid volume related to fluid and sodium
retention; imbalanced nutrition, less than
25. Answer 2 body requirements related to anorexia,
If the client experiences air embolus nausea, and vomiting; and activity
during hemodialysis, the nurse should intolerance related to fatigue. The nursing
terminate dialysis immediately, notify the diagnoses of impaired gas exchange and
physician, and administer oxygen as pain are not commonly related to chronic
needed renal failure.
26. Answer 2 31. Answer 3
The disadvantages of peritoneal dialysis in must be given with or immediately after
long-term management of chronic renal meals and snacks. There is no need for the
failure is that is requires large blocks of client to take it on a 24-hour schedule. It is
time. The risk of hemorrhage or hepatitis not administered to treat hyperacidity in
is not high with PD. PD is effective in clients with CRF and therefore is not
maintaining a client’s fluid and electrolyte prescribed between meals.
balance. 37. Answer 1
32. Answer 1 Magnesium is normally excreted by the
The main reason for warming the kidneys. When the kidneys fail,
peritoneal dialysis solution is that the magnesium can accumulate and cause
warm solution helps dilate peritoneal severe neurologic problems. MOM is
vessels, which increases urea clearance. harsher than Metamucil, but magnesium
Warmed dialyzing solution also contributes toxicity is a more serious problem. A client
to client comfort by preventing chilly may find both MOM and Metamucil
sensations, but this is a secondary reason unpalatable. MOM is not high in sodium.
for warming the solution. The warmed 38. Answer 2
solution does not force potassium into the Uremia can cause decreased alertness, so
cells or promote abdominal muscle the nurse needs to validate the client’s
relaxation. comprehension frequently. Because the
33. Answer 2 client’s ability to concentrate is limited,
Because the client has a permanent short lesions are most effective. If family
catheter in place, blood tinged drainage members are present at the sessions, they
should not occur. Persistent blood tinged can reinforce the material. Written
drainage could indicate damage to the materials that the client can review are
abdominal vessels, and the physician superior to videotapes, because the clients
should be notified. The bleeding is may not be able to maintain alertness
originating in the peritoneal cavity, not the during the viewing of the videotape.
kidneys. Too rapid infusion of the dialysate 39. Answer 3
can cause pain. Dietary management for clients with
34. Answer 2 chronic renal failure is usually designed to
Because hypotension is a complication of restrict protein, sodium, and potassium
peritoneal dialysis, the nurse records intake. Protein intake is reduced because
intake and output, monitors VS, and the kidney can no longer excrete the
observes the client’s behavior. The nurse byproducts of protein metabolism. The
also encourages visiting and other degree of dietary restriction depends on
diversional activities. A client on PD does the degree of renal impairment. The client
not need to be placed in bed with padded should also receive a high carbohydrate
side rails or kept NPO. diet along with appropriate vitamin and
35. Answer 3 mineral supplements. Calcium
A client in renal failure develops requirements remain 1,000 to 2,000
hyperphosphatemia that causes a mg/day.
corresponding excretion of the body’s 40. Answer 2
calcium stores, leading to renal The major benefit of CAPD is that it frees
osteodystrophy. To decrease this loss, the client from daily dependence on
aluminum hydroxide gel is prescribed to dialysis centers, home health care
bind phosphates in the intestine and personnel, and machines for life-
facilitate their excretion. Gastric sustaining treatment. The independence is
hyperacidity is not necessarily a problem a valuable outcome for some people.
associated with chronic renal failure. CAPD is costly and must be done daily.
Antacids will not prevent Curling’s stress Side effects and complications are similar
ulcers and do not affect metabolic to those of standard peritoneal dialysis.
acidosis. 41. Answer 3
36. Answer 3 Dietary restrictions with CAPD are fewer
Aluminum hydroxide gel is administered to than those with standard peritoneal
bind the phosphates in ingested foods and dialysis because dialysis is constant, not
intermittent. The constant slow diffusion of vaginal Lactobacilli bacteria, which protect
CAPD helps prevent accumulation of against infection. Angina, asthma and
toxins and allows for a more liberal diet. fractures don’t increase the risk of UTI.
CAPD does not work more quickly, but 5. Answer A
more consistently. Both types of Tubing problems are a common cause of
peritoneal dialysis are effective. outflow difficulties, check the tubing for
42. Answer 1 kinks and ensure that all clamps are open.
Cloudy drainage indicates bacterial Other measures include having the patient
activity in the peritoneum. Other signs and change positions (moving side to side or
symptoms of infection are fever, sitting up), applying gentle pressure over
hyperactive bowel sounds, and abdominal the abdomen, or having a bowel
pain. Swollen legs may be indicative of movement
congestive heart failure. Poor drainage of
dialysate fluid is probably the result of a
kinked catheter. Redness at the insertion 6. Answer A
site indicates local infection, not Dialysate should be infused quickly. The
peritonitis. However, a local infection that dialysate should be infused over 15
is left untreated can progress to the minutes or less when performing
peritoneum peritoneal dialysis. The fluid exchange
takes place over a period ranging from 30
minutes to several hours.
7. Answer B
Don’t take blood pressure readings in the
TEST V. arm with the fistula because the
compression could damage the fistula. IV
1. Answer B lines shouldn’t be inserted in the arm used
Costovertebral angle tenderness, flank for hemodialysis. Palpate pulses below the
pain, and chills are symptoms of acute fistula. Lack of bruit or thrill should be
pyelonephritis. Jaundice indicates reported to the doctor.
gallbladder or liver obstruction. A burning 8. Answer B
sensation on urination is a sign of lower Disequilibrium syndrome is caused by a
urinary tract infection. rapid reduction in urea, sodium, and other
2. Answer B solutes from the blood. This can lead to
A common symptom of a UTI is dysuria. A cerebral edema and increased intracranial
patient with a UTI often reports frequent pressure (ICP). Signs and symptoms
voiding of small amounts and the urgency include headache, nausea, restlessness,
to void. Urine that smells sweet is often vomiting, confusion, twitching, and
associated with diabetic ketoacidosis seizures.
3. Answer D 9. Answer 2
Pyridium is taken to relieve dysuria Treatment includes administering normal
because is provides an analgesic and saline or hypertonic normal saline solution
anesthetic effect on the urinary tract because muscle cramps can occur when
mucosa. The patient can stop taking it the sodium and water are removed to
after the dysuria is relieved. The urine quickly during dialysis. Reducing the rate
may temporarily turn red or orange due to of dialysis, not increasing it, may alleviate
the dye in the drug. The drug isn’t taken muscle cramps.
before voiding, and is usually taken 3 10. Answer 4
times a day for 2 days. Calcium-phosphate deposits in the skin
may cause pruritus. Scratching leads to
4. Answer C excoriation and breaks in the skin that
Women are more prone to UTI’s after increase the patient’s risk of infection.
menopause due to reduced estrogen Keeping fingernails short and clean helps
levels. Reduced estrogen levels lead to reduce the risk of infection.
reduced levels of 11. Answer 4
All urine should be strained through gauze An elevated prostate-specific antigen level
or a urine strainer to catch stones that are indicates prostate cancer, but it can be
passed. The stones are then analyzed for falsely elevated if done after the prostate
composition. Ambulation may help the gland is manipulated. A digital rectal
movement of the stone down the urinary examination should be done as part of the
tract. Encourage fluid to help flush the yearly screening, and then the antigen
stones out. test is done if the digital exam suggests
12. Answer 3 cancer. MRI is used in staging the cancer.
The most common form of acute 21. Answer 4
glomerulonephritis is caused by group A Kidney damage is still a concern.
beta-hemolytic streptococcal infection Microavascular changes occur in both of
elsewhere in the body. the patient’s kidneys as a complication of
13. Answer 1 the diabetes. Diabetic nephropathy is the
Narcotic analgesics are usually needed to leading cause of end-stage renal disease.
relieve the severe pain of renal calculi. The kidneys continue to produce urine
Muscle relaxants are typically used to until the end stage. Nephropathy occurs
treat skeletal muscle spasms. NSAIDS and even with insulin management.
salicylates are used for their anti-
inflammatory and antipyretic properties
and to treat less severe pain.
14. Answer 3 22. Answer 4
Invasive procedures such as Drinking 2-3L of water daily inhibits
catheterization can introduce bacteria into bacterial growth in the bladder and helps
the urinary tract. A lack of fluid intake flush the bacteria from the bladder. The
could cause concentration of urine, but patient should be instructed to void after
wouldn’t necessarily cause infection. sexual activity.
15. Answer 3 23. Answer 1
Hematuria and proteinuria indicate acute The drug turns the urine orange. It may be
glomerulonephritis. These finding result prescribed for longer than 7 days and is
from increased permeability of the usually ordered three times a day after
glomerular membrane due to the antigen- meals. Phenazopyridine is an azo
antibody reaction. Generalized edema is (nitrogenous) analgesic; not an antibiotic.
seen most often in nephrosis. 24. Answer 3
16. Answer 2 Mild to moderate HTN may result from
Oliguria is defined as urine output of less sodium or water retention and
than 400ml/24hours. inappropriate rennin release from the
17. Answer 2 kidneys. Oliguria and fatigue also may be
Increased BUN is usually an early indicator seen. Other signs are proteinuria and
of decreased renal function. azotemia.
18. Answer 3 25. Answer 2
Stress incontinence is an involuntary loss Fluid volume excess because the kidneys
of a small amount of urine due to sudden aren’t removing fluid and wastes. The
increased intra-abdominal pressuer, such other diagnoses may apply, but they don’t
as with coughing or sneezing. take priority.
19. Answer 2 26. Answer 1
Hemorrhage is a potential complication. Apply pressure when discontinuing
Urine retention isn’t a problem soon after hemodialysis and after removing the
surgery because a catheter is in place. venipuncture needle until all the bleeding
Pneumonia may occur if the patient has stopped. Bleeding may continue for 10
doesn’t cough and deep breathe. minutes in some patients.
Thrombosis may occur later if the patient 27. Answer 2
doesn’t ambulate 28. Answer 1
20. Answer 4 Daily doubling of the urine output
indicates that the nephrons are healing.
This means the patient is passing into the The patient with ESRD may develop
second phase (dieresis) of acute renal arrhythmias caused by hypokalemi. Call
failure. the doctor after checking the patient’s
29. Answer 4 potassium values. Lidocaine may be
Pressure on the fistula or the extremity ordered if the PVCs are frequent and the
can decrease blood flow and precipitate patient is symptomatic.
clotting, so avoid taking blood pressure on 38. Answer 1
the affected arm. Cyclosporine suppresses the immune
30. Answer 2 response to prevent rejection of the
The patient should follow a low-protein transplanted kidney. The use of
diet with a prescribed amount of water. cyclosporine places the patient at risk for
The patient requires some protein to meet tumors.
metabolic needs. Salt substitutes 39. Answer 1
shouldn’t be used without a doctor’s order The immunosuppressive activity of
because it may contain potassium, which cyclosporine places the patient at risk for
could make the patient hyperkalemic. infection, and steroids can mask the signs
Fluid and protein restrictions are needed. of infection. The patient may not be able
31. Answer 1 to resume normal fluid intake or return to
Disequilibrium occurs when excess solutes work for an extended period of time and
are cleared from the blood more rapidly the patient may need cyclosporine
than they can diffuse from the body’s cells therapy for life.
into the vascular system. 40. Answer 3
Symptoms of rejection include fever, rapid
weight gain, hypertension, pain over the
32. Answer 2 graft site, peripheral edema, and
Instruct the patient with neurogenic diminished urine output.
bladder to write down his voiding pattern
and empty the bladder at the same times
each day. 41. Answer 3
33. Answer 3 Urine output less than 50ml in 24 hours
Because of damage to the nephrons, the signifies oliguria, an early sign of renal
kidney can’t excrete all the metabolic failure. Anuria is uncommon except in
wastes of protein, so this patient’s protein obstructive renal disorders.
intake must be restricted. A higher intake 42. Answer 2
of carbs, fats, and vitamin supplements is Acute renal failure causes hypervolemia as
needed to ensure the growth and a result of overexpansion of extracellular
maintenance of the patient’s tissues. fluid and plasma volume with the
34. Answer 4 hypersecretion of rennin. Therefore,
The vibration or thrill felt during palpation hypervolemia causes hypertension.
ensures that the fistula has the desired 43. Answer 2
turbulent blood flow. Pinching the fistula A total UO of 120ml is too low. Assess the
could cause damage. Aspirating blood is a patient’s circulation and hemodynamic
needless invasive procedure. stability for signs of hypovolemia. A fluid
35. Answer 1 bolus may be required, but only after
Bones lose calcium when a patient can no further nursing assessment and a doctor’s
longer bear weight. The calcium lost from order.
bones form calculi, a concentration of 44. Answer 4
mineral salts also known as a stone, in the Bleeding at the urethral meatus is
renal system. evidence that the urethra is injured.
36. Answer 2 Because catheterization can cause further
Kidneys are unable to rid the body of harm, consult with the doctor.
excess fluids which results in fluid volume 45. Answer 1
excess during ESRD. With nephrotic syndrome, the glomerular
37. Answer 4 basement membrane of the kidney
becomes more porous, leading to loss of Since hemodialysis must be carried out
protein in the urine. As the patient repetitively, usually three times a week for
recovers, less protein is found in the urine. 4 hours, repeated vascular access is
46. Answer 3 required. Arterial blood is sent to the
Prerenal failure is caused by such dialyzer and returned to the patient by an
conditions as hypovolemia that impairs arm vein. Arteriovenous shunts connect
kidney perfusion; giving isotonic fluids the artery and vein by an external tube,
improves urine output. Vasoactive which has a connecting port so that blood
substances can increase blood pressure in may be sent to the dialysis machine from
both conditions. the artery and returned to the vein. These
47. Answer 1 shunts are subject to infection and clotting
Hemodynamic stability must be so that surgically implanted arteriovenous
established before continuous peritoneal fistulas were developed, which connect
dialysis can be started. artery and vein entirely within the arm.
48. Answer 3 These are still standard for most dialysis
In renal failure, patients become patients.
hyperkalemic because they can’t excrete 3. Answer D
potassium in the urine. Polystyrene Dialysis machines have evolved since their
sulfonate acts to excrete potassium by initial frequent use in the 1960s. The initial
pulling potassium into the bowels and type, the so-called Kiil, consisted of 70 lb
exchanging it for sodium. flat plates covered by sheets of
49. Answer 4 cellophane. They required cleaning and
Patients with renal calculi commonly have storage after each use, and membranes
blood in the urine caused by the stone’s had to be replaced. The coil dialyzer was
passage through the urinary tract. The supported by a mesh screen coiled around
urine appears dark, tests positive for a central core. It required complete
blood, and is typically scant. sterilization with a large amount of blood
50. Answer 1 in a canister that was bathed in the
For life. dialysate. The Gambro flat plate dialyzer
used a new membrane type named
cuprophane. These early machines were
replaced by the so-called hollow fiber
TEST VI. dialyzer, which is the type in use today. In
this model, the blood flows through tiny
1. Answer C hollow tubes (fibers) while the dialysate
Hemodialysis requires vascular access flows around the outside of these fibers.
since the blood flows out of the patient, Biocompatible membranes, sophisticated
through the dialysis machine's alarms, and automatic functions
semipermeable membrane, and then back characterize the modern dialyzer.
into the patient. The membrane keeps 4. Answer A
certain waste products or excess water The kidney is a fist-sized bilateral organ
from returning to the patient, while with a tough outer capsule. The most
electrolytes and blood cells are returned. external portion of the organ is called the
Peritoneal dialysis is performed with an cortex. The renal medulla or interior
intra-abdominal catheter without blood portion of the kidney contains sections
ever leaving the body. Vascular access is called pyramids with points referred to as
not required. The blood vessels of the papillae. Each papilla delivers urine into a
abdominal cavity act as a filter similar to receptacle-like calyx, which then transmits
the semipermeable membrane used in urine into the renal pelvis. The pelvis
hemodialysis. Peritoneal dialysis may be connects to the ureter and delivers urine
performed at home with a cycler machine for excretion. The functional unit of the
to exchange fresh sterile dialysate, often kidney is the nephron, present in the
overnight 7 days a week. Manual cortex and extending into the medulla.
exchange of dialysate may also be done. The nephron is composed of a glomerulus,
2. Answer B a tangled bunch of capillaries, which
produces the glomerular filtrate, and a plate dialyzers and the circular cross
renal tubule, which acts on the filtrate to section found in hollow fiber dialyzers.
reabsorb water and exchange electrolytes. Synthetic and cellulose are descriptions of
Blood is conducted to the glomerulus via the materials used to produce the
an afferent arteriole and is filtered by the membranes used in dialysis.
glomerular capillaries, which retain blood 3. Answer C
cells and large molecules, such as The advantage of cellulose membrane
proteins. The blood is then returned by usage is low cost; the disadvantage is that
way of an efferent arteriole. all cellulose membranes have some
5. Answer C bioincompatibility with blood. Synthetic
The normal adult has a glomerular membranes are reusable and
filtration rate (GFR) of about 125 mL/min, biocompatible. The disadvantages of
although there is some variability due to synthetic membranes include their
age and sex. Clinically, this value is often expense in comparison to cellulose
expressed as GFR/m2 body surface area. It membranes, their high-water permeability
is usually measured by the so-called that results in the need for ultrafiltration,
creatinine clearance in which blood and the absorption of protein to the membrane
urine creatinine concentrations and the surface, and the risk of backfiltration from
urine volume are measured, and the GFR dialysate to blood. There is no major
calculated. Little creatinine is reabsorbed disadvantage resulting from waste
by the renal tubules, thus making it a disposal problems.
valuable standard for estimating 4. Answer D
glomerular function. In end stage renal One of the possible complications of
disease, the GFR is often below 15 peritoneal dialyses is an infection of the
mL/min/1.73 m2, and dialysis is required. peritoneum (peritonitis). The usual cause
Many drugs are excreted by the kidneys, is a break in the closed system, allowing
and dosage adjustments based on GFR are the entrance of microorganisms into the
often necessary. peritoneal cavity. Signs and symptoms of
this type of infection include: cloudy
effluent; abdominal pain; nausea and
vomiting; peritoneal cell count greater
TEST VII. than 100 white blood cells, more than 50%
of which are neutrophils; and culture
results, such as Gram +, Gram-, multiple
1. Answer A
organisms, and fungi. Treatment involves
Ultrafiltration occurs when hydrostatic
prompt diagnosis, peritoneal flushes with
pressure or an osmotic pressure forces
1.5% dialysate, and intraperitoneal
water through the semipermeable
antibiotics with added heparin to prevent
membrane. The water carries solutes, at
fibrin and adhesion formation,
or near their original concentration, in a
(appropriate antibiotic based on culture
process called "solvent drag." Larger
results). A stool culture may be applicable
molecules remain, with the membrane
if the diagnosis of peritoneal infection is
acting as a filter, or sieve. When the
eliminated
concentration of a certain type of particle
is higher on one side of a membrane than
on the other side, a concentration gradient
exists. In this situation, particles in high
concentration flow through the membrane 5. Answer E
to the low concentration side. Solutes and Transplant researchers have identified two
catabolic waste products transfer from the main antigen systems: blood groups (ABO)
blood where a high concentration exists and human leukocyte antigen. The ABO
into the lower dialysate concentration. blood groups are the first consideration
2. Answer B when determining organ compatibility with
There are two blood flow geometries, the the recipient, with potential recipients
rectangular cross section seen in parallel divided by blood type. Rh (Rhesus) factor
does not affect solid organ high blood pressure, and elevated
transplantation. cholesterol levels are at highest risk. This
disease process involves an increase in
the blood flow to the kidney, caused by
hyperglycemia. This results in an elevation
TEST VIII. of blood pressure, increasing the workload
of the glomeruli. The glomeruli thicken
and allow serum albumin to pass into the
1. Answer E urine (albuminuria). This sign is detectable
Symptoms and signs of diabetic only by medical testing and begins several
nephropathy include edema around the years before symptoms are apparent. At
eyes upon awakening, progressing to this stage, kidney biopsy confirms the
general swelling of the legs and body, diagnosis. Nephrosclerosis is the
weight gain, frothy urine, malaise, fatigue, hardening of the arterioles of the kidneys
nausea and vomiting, headache, caused by uncontrolled high blood
hiccoughs, and pruritus. Serum creatinine pressure. Polycystic kidney disease is a
and blood urea nitrogen levels elevate at genetic disorder in which fluid-filled cysts
this stage. The additional diagnosis of replace normal healthy kidney tissue.
retinopathy may be evident. Amyloidosis refers to a condition in which
2. Answer D proteins (amyloid proteins) have been
Steps that need to be taken include: (1) altered and become insoluble, then
use a Dextrostick to ascertain the deposit in various organs.
presence of glucose, (2) resuture the exit 5. Answer A
site, (3) discontinue peritoneal dialysis for Recombinant human erythropoietin, or
a minimum of 2 weeks to allow healing, epoetin alfa, (Epogen, Procrit) is used to
(3) if unable to stop therapy, decrease stimulate red blood cell production in
volume with automated peritoneal dialysis patients with end state renal disease.
in supine position; and (4) stabilize or Cinacalcet HCl (Senispar) is a drug used
replace the catheter. for lowering the level of parathyroid in the
3. Answer C blood. Furosemide (Lasix) and bumetanide
The main precautions that must be (Bumex) are commonly used diuretics.
followed when performing dialysis on a Sevelamer hydrochloride (Renagel) is one
recent transplant recipient are: (1) of the latest drugs used for phosphate-
Observe for hypotension as a result of the binding.
risk of internal bleeding in first 24 hours
postsurgery, and then alert the physician
if hypotension occurs. (2) Avoid
hypotension to prevent ischemia of the TEST IX.
newly transplanted kidney, even if fluid
removal during dialysis is compromised. 1 C 16 A 31 A
(3) Maintain the integrity of the surgical 2 D 17 A 32 C
incision site. (4) Use heparin-free or 3 A 18 C 33 A
minimal anticoagulation therapy for newly 4 D 19 A 34 A
postoperative patients and for those who 5 A 20 B 35 B
have had a percutaneous renal biopsy. (5) 6 D 21 C 36 A
Observe for an electrolyte imbalance, 7 C 22 A 37 D
especially hyperkalemia. 8 C 23 A 38 C
4. Answer B 9 D 24 D 39 B
Diabetic nephropathy is the most common 10 D 25 ABE 40 C
cause of chronic kidney disease in 11 D 26 B 41 C
Western countries. It affects insulin- 12 C 27 A 42 B
dependent diabetics, or type 1 diabetes, 13 B 28 A 43 B
and non-insulin dependent diabetics, or 14 B 29 C 44 A
type 2 diabetes. Those with poorly 15 D 30 D 45 C
controlled blood sugar levels, uncontrolled TEST X.
 2 A 12 C
1 C 13 B 25 B 3 C 13 B
2 B 14 A 26 A 4 B 14 B
3 D 15 D 27 B 5 B 15 B
4 D 16 B 28 A 6 C 16 A
5 B 17 D 29 B 7 B 17 A
6 C 18 A 30 B 8 D 18 C
7 A 19 D 31 C 9 D 19 C
8 C 20 D 32 B 10 D 20 D
9 A 21 C 33 B
10 B 22 C 34 D
11 C 23 A 35 C PART IV. CNN
12 A 24 A
1 A 10 C
PART I. HD and PD 2 D 11 D
3 A 12 D
1 A 10 D 19 D&B 4 B 13 A
2 B 11 C 20 A 5 B 14 B
3 D 12 D 21 B 6 A 15 B
4 C 13 A&B 22 B 7 C 16 A
5 D 14 D 23 A 8 A 17 C
6 E 15 E 24 B 9 A 18 B
7 D 16 A 25 C
8 E 17 B 26 D
9 A 18 E 27 D PART V. CNN

1 A 16 A 31 A
PART II. CNN 2 B 17 A 32 B
3 C 18 C 33 D
1 D 23 D 45 B 4 D 19 B 34 C
2 A 24 A 46 A 5 C 20 C 35 A
3 C 25 B 47 B 6 C 21 C 36 D
4 A 26 C 48 A 7 B 22 C 37 A
5 C 27 C 49 C 8 A 23 A 38 A
6 B 28 D 50 A 9 B 24 B 39 B
7 C 29 D 51 D 10 B 25 A 40 D
8 C 30 D 52 A 11 A 26 B 41 B
9 D 31 D 53 A 12 B 27 C 42 B
10 B 32 B 54 B 13 A 28 B 43 D
11 C 33 D 55 A 14 B 29 C
12 A 34 D 56 B 15 B 30 B
13 C 35 D 57 B
14 A 36 A 58 A PART VI. CNN
15 C 37 B 59 A
16 B 38 B 60 C 1 D 6 C 11 D
17 C 39 B 61 A 2 D 7 C 12 A
18 C 40 D 62 B 3 B 8 D 13 A
19 B 41 D 63 B 4 B 9 A 14 D
20 A 42 C 64 C 5 D 10 D 15 D
21 D 43 C 65 A
22 C 44 C
PART III. CNN

1 C 11 B