Acute Kidney Injury (Acute Renal Failure)

1. ______________ is solely filtered from the bloodstream via the glomerulus and is NOT reabsorbed
back into the bloodstream but is excreted through the urine.

A. Urea

B. Creatinine

C. Potassium

D. Magnesium

The answer is B. Creatinine is a waste product from muscle breakdown and is removed from the
bloodstream via the glomerulus of the nephron. It is the only substance that is solely filtered out of the
blood but NOT reabsorbed back into the system. It is excreted out through the urine. This is why a
creatinine clearance test is used as an indicator for determining renal function and for calculating the
glomerular filtration rate.

2. A patient with acute renal injury has a GFR (glomerular filtration rate) of 40 mL/min. Which signs and
symptoms below may this patient present with? Select all that apply:

A. Hypervolemia

B. Hypokalemia

C. Increased BUN level

D. Decreased Creatinine level

The answers are A and C. The glomerular filtration rate indicates how well the glomerulus is filtering the
blood. A normal GFR tends to be 90 mL/min or higher. A GFR of 40 mL/min indicates that the kidney’s
ability to filter the blood is decreased. Therefore, the kidneys will be unable to remove waste and
excessive water from the blood…hence hypervolemia and an increased BUN level will present in this
patient. The patient will experience HYPERkalemia (not hypo) because the kidneys are unable to remove
potassium from the blood. In addition, an INCREASED creatinine level (not decreased) will present
because the kidneys cannot remove excessive waste products, such as creatinine.

3. You’re assessing morning lab values on a female patient who is recovering from a myocardial
infraction. Which lab value below requires you to notify the physician?

A. Potassium level 4.2 mEq/L

B. Creatinine clearance 35 mL/min

C. BUN 20 mg/dL

D. Blood pH 7.40

The answer is B. A normal creatinine clearance level in a female should be 85-125 mL/min (95-140
mL/min males). A creatinine clearance level indicates the amount of blood the kidneys can make per
minute that contain no amounts of creatinine in it. Remember creatinine is a waste product of muscle
breakdown. Therefore, the kidneys should be able to remove excessive amounts of it from the
bloodstream. A patient who has experienced a myocardial infraction is at risk for pre-renal acute injury
due to decreased cardiac output to the kidneys from a damaged heart muscle (the heart isn’t able to pump
as efficiently because of ischemia). All the other labs values are normal.

4. A 55 year old male patient is admitted with a massive GI bleed. The patient is at risk for what type of
acute kidney injury?

A. Post-renal

B. Intra-renal

C. Pre-renal

D. Intrinsic renal

The answer is C. Pre-renal injury is due to decreased perfusion to the kidneys secondary to a cause
(massive GI bleeding…patient is losing blood volume). This leads to a major decrease in kidney function
because the kidneys are deprived of nutrients to function and the amount of blood it can filter. Pre-renal
injury can eventually lead to intrarenal damage where the nephrons become damaged.

5. Select all the patients below that are at risk for acute intra-renal injury?

A. A 45 year old male with a renal calculus.

B. A 65 year old male with benign prostatic hyperplasia.

C. A 25 year old female receiving chemotherapy.

D. A 36 year old female with renal artery stenosis.

E. A 6 year old male with acute glomerulonephritis.

F. An 87 year old male who is taking an aminoglycoside medication for an infection.

The answers are: C, E, and F. These patients are at risk for an intra-renal injury, which is where there is
damage to the nephrons of kidney. The patients in options A and B are at risk for POST-RENAL injury
because there is an obstruction that can cause back flow of urine into the kidney, which can lead to
decreased function of the kidney. The patient in option D is at risk for PRE-RENAL injury because there
is an issue with perfusion to the kidney.

6. A patient with acute kidney injury has the following labs: GFR 92 mL/min, BUN 17 mg/dL, potassium
4.9 mEq/L, and creatinine 1 mg/dL. The patient’s 24 hour urinary output is 1.75 Liters. Based on these
findings, what stage of AKI is this patient in?

A. Initiation

B. Diuresis

C. Oliguric

D. Recovery

The answer is D. This patient is in the recovery stage of AKI. The patient’s labs and urinary output
indicate the renal function has returned to normal. Remember the recovery stages starts when the GFR
(glomerular filtration rate) has returned to normal (normal GFR 90 mL/min or higher), which will allow
waste levels and electrolyte levels to be maintained.

7. A 36 year old male patient is diagnosed with acute kidney injury. The patient is voiding 4 L/day of
urine. What complication can arise based on the stage of AKI this patient is in? Select all that apply:

A. Water intoxication

B. Hypotension

C. Low urine specific gravity

D. Hypokalemia

E. Normal GFR

The answers are: B, C, and D. This patient is in the DIURESIS stage of AKI. The nephrons are now
starting to filter out waste but cannot concentrate the urine. There is now a high amount of urea in the
filtrate (because the nephrons can filter the urea out of the blood) and this causes osmotic diuresis.
Urinary output will be excessive (3 to 6 L/day). Therefore, the patient is at risk for hypotension, diluted
urine (low urine specific gravity), and hypokalemia (waste potassium in the urine). The patient is not at
risk for water intoxication and will not have a normal GFR until the recovery stage.
8. True or False: All patients with acute renal injury will progress through the oliguric stage of AKI but
not all patients will progress through the diuresis stage.

The answer is FALSE. Some patients will skip the oliguric stage of AKI and progress to the diuresis
stage.

9. Which patient below with acute kidney injury is in the oliguric stage of AKI:

A. A 56 year old male who has metabolic acidosis, decreased GFR, increased BUN/Creatinine,
hyperkalemia, edema, and urinary output 350 mL/day.

B. A 45 year old female with metabolic alkalosis, hypokalemia, normal GFR, increased BUN/creatinine,
edema, and urinary output 600 mL/day.

C. A 39 year old male with metabolic acidosis, hyperkalemia, improving GFR, resolving edema, and
urinary output 4 L/day.

D. A 78 year old female with respiratory acidosis, increased GFR, decreased BUN/creatinine,
hypokalemia, and urinary output 550 mL/day.

The answer is A. During the oliguric stage of AKI the patient will have a urinary output of 400 mL/day or
LESS. This is due to a decreased GRF (glomerular filtration rate), which will lead to increased amounts
of waste in the blood (increased BUN/Creatinine), metabolic acidosis (decreased excretion of hydrogen
ions), hyperkalemia, hypervolemia (edema/hypertension), and urinary output of <400 mL/day.

10. You’re developing a nursing care plan for a patient in the diuresis stage of AKI. What nursing
diagnosis would you include in the care plan?

A. Excess fluid volume

B. Risk for electrolyte imbalance

C. Urinary retention

D. Acute pain

The answer is B. During the diuresis stage of AKI, the patient will be losing an excessive amount of urine
(3-6 Liters/day) and is at risk for fluid volume deficient and electrolyte imbalance. The nurse must
monitor the patient’s electrolyte levels, especially potassium (hypokalemia).

11. While educating a group of nursing students about the stages of acute kidney injury, a student asks
how long the oliguric stage lasts. You explain to the student this stage can last?

A. 1-2 weeks
B. 1-3 days

C. Few hours to 2 weeks

D. 12 months

The answer is A. The oliguric stage can last 1-2 weeks. Regarding the other stages of AKI: Initiation: few
hours to several days, diuresis: 1-3 weeks, and recovery: 12 months or more.

12. A patient with AKI has a urinary output of 350 mL/day. In addition, morning labs showed an
increased BUN and creatinine level along with potassium level of 6 mEq/L. What type of diet ordered by
the physician is most appropriate for this patient?

A. Low-sodium, high-protein, and low-potassium

B. High-protein, low-potassium, and low-sodium

C. Low-protein, low-potassium, and low-sodium

D. High-protein and high-potassium

The answer is C. The patient with AKI, especially in the oliguric stage of AKI, should eat a low-protein,
low-potassium, and low-sodium diet. This is because the kidneys are unable to filter out waste products,
excessive water, and maintain electrolyte balance. The patient will have a buildup of waste (BUN and
creatinine). Remember these waste products are the byproduct of protein (urea) and muscle breakdown
(creatinine). So the patient should avoid high-protein foods. In addition, the patient is at risk for
hyperkalemia and fluid overload (needs low-potassium and sodium foods).

Chronic Kidney Disease (End Stage Renal Failure)

1. A 55 year old male patient is diagnosed with chronic kidney disease. The patient’s recent GFR was 25
mL/min. What stage of chronic kidney disease is this known as?

A. Stage 1

B. Stage 3

C. Stage 4

D. Stage 5

The answer is C. This is known as Stage 4 of CKD because the GFR (glomerular filtration rate) for this
stage is 15-29 mL/min (patient’s GFR is 25 mL/min). The other stage’s criteria are as follows:
Stage 1: Kidney damage with normal renal function GFR >90 ml/min but with proteinuria (3 months or
more);

Stage 2: Kidney damage with mild loss of renal function GFR 60-89 ml/min with proteinuria (3 months
or more);

Stage 3: Mild-to-severe loss of renal function GFR 30-59 mL/min;

Stage 4: Severe loss renal function GFR 15-29 mL/min;

Stage 5: End stage renal disease GRF less 15 mL/min

2. A patient with CKD has a low erythropoietin (EPO) level. The patient is at risk for?

A. Hypercalcemia

B. Anemia

C. Blood clots

D. Hyperkalemia

The answer is B. EPO (erythropoietin) helps create red blood cells in the bone marrow. The kidneys
produce EPO and when the kidneys are damaged in CKD they can decrease in the production of EPO.
Therefore, the patient is at risk for anemia.

3. A 65 year old male patient has a glomerular filtration rate of 55 mL/min. The patient has a history of
uncontrolled hypertension and coronary artery disease. You’re assessing the new medication orders
received for this patient. Which medication ordered by the physician will help treat the patient’s
hypertension along with providing a protective mechanism to the kidneys?

A. Lisinopril

B. Metoprolol

C. Amlodipine

D. Verapamil

The answer is A. There are two types of drugs that can be used to treat hypertension and protect the
kidneys in patients with CKD. These drugs include angiotensin converting enzyme inhibitors (ACE
inhibitors) and angiotensin receptor blockers (ARBs). The only drug listed here that is correct is
Lisinopril. This drug is known as an ACE inhibitor. Metoprolol is a BETA BLOCKER. Amlodipine and
Verapamil are calcium channel blockers.

4. Which patient below is NOT at risk for developing chronic kidney disease?

A. A 58 year old female with uncontrolled hypertension.

B. A 69 year old male with diabetes mellitus.

C. A 45 year old female with polycystic ovarian disease.

D. A 78 year old female with an intrarenal injury.

The answer is C. Options A, B, and D are all at risk for developing CKD. However, option C is not at risk
for CKD.

5. A patient with Stage 5 CKD is experiencing extreme pruritus and has several areas of crystallized white
deposits on the skin. As the nurse, you know this is due to excessive amounts of what substance found in
the blood?

A. Calcium

B. Urea

C. Phosphate

D. Erythropoietin

The answer is B. This patient is experiencing uremic frost that occurs in severe chronic kidney disease.
This is due to high amounts of urea in the blood being secreted via the sweat glands onto the skin, which
will appear as white deposits on the skin. The patient will experience itching with this.

6. Your patient with chronic kidney disease is scheduled for dialysis in the morning. While examining the
patient’s telemetry strip, you note tall peaked T-waves. You notify the physician who orders a STAT
basic metabolic panel (BMP). What result from the BMP confirms the EKG abnormality?

A. Phosphate 3.2 mg/dL

B. Calcium 9.3 mg/dL

C. Magnesium 2.2 mg/dL

D. Potassium 7.1 mEq/L

The answer is D. The patient’s potassium level is extremely elevated. A normal potassium level is 3.5-
5.1 mEq/L. This patient is experiencing hyperkalemia, which can cause tall peak T-waves. Remember in
CKD (especially prior to dialysis), the patient will experience electrolyte imbalances, especially
hyperkalemia.

7. You are providing education to a patient with CKD about calcium acetate. Which statement by the
patient demonstrates they understood your teaching about this medication? Select-all-that-apply:

A. “This medication will help keep my calcium level normal.”

B. “I will take this medication with meals or immediately after.”

C. “It is important I consume high amounts of oatmeal, poultry, fish, and dairy products while taking this
medication.”

D. “This medication will help prevent my phosphate level from increasing.”

The answers are B and D. Calcium acetate (also known as PhosLo) is a phosphate binder, which will help
keep the patient’s phosphate level from becoming too high. It helps excrete the phosphate taken in the
food by excreting it out of the stool. Therefore, it should be taken with meals or immediately after. Option
C is wrong because the patient should AVOID these types of foods high in phosphate.

8. While assessing morning labs on your patient with CKD. You note the patient’s phosphate level is 6.2
mg/dL. As the nurse, you expect to find the calcium level to be?

A. Elevated

B. Low

C. Normal

D. Same as the phosphate level

The answer is B. A normal phosphate level is 2.7-4.5 mg/dL. This patient is experiencing
HYPERphosphatemia. When hyperphosphatemia presents the calcium level DECREASES because
phosphate and calcium bind to each. When there is too much phosphate in the blood it takes too much
calcium with it and it decreases the calcium in the blood. Therefore, the nurse would expect to find the
calcium level decreased.

9. A patient with stage 4 chronic kidney disease asks what type of diet they should follow. You explain
the patient should follow a:

A. Low protein, low sodium, low potassium, low phosphate diet

B. High protein, low sodium, low potassium, high phosphate diet

C. Low protein, high sodium, high potassium, high phosphate diet

D. Low protein, low sodium, low potassium, high phosphate diet

The answer is A. The patient should follow this type of diet because protein breaks down into urea
(remember patient will have increased urea levels), low sodium to prevent fluid excess, low potassium to
prevent hyperkalemia (remember glomerulus isn’t filtering out potassium/phosphate as it should), and
low phosphate to prevent hyperphosphatemia.

10. The kidneys are responsible for performing all the following functions EXCEPT?

A. Activating Vitamin D

B. Secreting Renin

C. Secreting Erythropoietin

D. Maintaining cortisol production