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Urinary Disorders NCLEX

Challenge Exam (Quiz #1: 50
Questions)
UPDATED ON OCTOBER 17, 2023
BY MATT VERA BSN, R.N.
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1. 1. Question

1 point(s)
Which of the following symptoms do you expect to see in a
patient diagnosed with acute pyelonephritis?

o A. Jaundice and flank pain

o B. Costovertebral angle tenderness and chills
o C. Burning sensation on urination
 o D. Polyuria and nocturia
Correct
Correct Answer: B. Costovertebral angle tenderness and
chills
Costovertebral angle tenderness, flank pain, and chills are
symptoms of acute pyelonephritis. Acute pyelonephritis is a
bacterial infection causing inflammation of the kidneys.
Pyelonephritis occurs as a complication of an ascending urinary
tract infection which spreads from the bladder to the kidneys.
Symptoms usually include fever, flank pain, nausea, vomiting,
burning with urination, increased frequency, and urgency.
 Option A: Jaundice indicates gallbladder or liver
obstruction. Dysfunction in prehepatic phase results in
elevated serum levels of unconjugated bilirubin while
insult in post hepatic phase marks elevated
conjugated bilirubin. Hepatic phase impairment can
elevate both unconjugated and conjugated bilirubin.
 Option C: A burning sensation on urination is a sign of
lower urinary tract infection. Symptoms of
uncomplicated UTI are pain on urination (dysuria),
frequent urination (frequency), inability to start the
urine stream (hesitation), sudden onset of the need to
urinate (urgency), and blood in the urine (hematuria).
Usually, patients with uncomplicated UTI do not have
fever, chills, nausea, vomiting, or back pain, which are
signs of kidney involvement or upper tract
disease/pyelonephritis.
 Option D: Nocturnal polyuria as a cause of nocturia is
more prevalent in older patients, while in younger
patients, a decreased nocturnal bladder capacity is the
more common etiology. Caffeine and excessive oral
fluid intake in the evenings, as well as alcoholism, can
contribute significantly to this disorder. It is also
associated with congestive heart failure, obstructive
sleep apnea, evening use of diuretics, peripheral
edema, high dietary salt intake, and chronic venous
insufficiency of the lower extremities.
2. 2. Question

1 point(s)
You have a patient that might have a urinary tract infection (UTI).
Which statement by the patient suggests that a UTI is likely?
 o A. “I pee a lot.”
o B. “It burns when I pee.”
o C. “I go hours without the urge to pee.”
o D. “My pee smells sweet.”
Correct
Correct Answer: B. “It burns when I pee.”
A common symptom of a UTI is dysuria. A patient with a UTI often
reports frequent voiding of small amounts and the urgency to
void. Symptoms of uncomplicated UTI are pain on urination
(dysuria), frequent urination (frequency), inability to start the
urine stream (hesitation), sudden onset of the need to urinate
(urgency), and blood in the urine (hematuria). Usually, patients
with uncomplicated UTI do not have fever, chills, nausea,
vomiting, or back pain, which are signs of kidney involvement or
upper tract disease/pyelonephritis.
 Option A: High amounts of solutes within the renal
tubules cause a passive osmotic diuresis (solute
diuresis) and thus an increase in urine volume. The
classic example of this process is the glucose-induced
osmotic diuresis in uncontrolled diabetes mellitus,
when high urinary glucose levels (> 250 mg/dL [13.88
mmol/L]) exceed tubular reabsorption capacity,
leading to high glucose levels in the renal tubules;
water follows passively, resulting in glucosuria and
increased urine volume.
 Option C: Oliguria can be the result of various causes
that can be apparent or subclinical. Oliguria can arise
as a result of the normal physiological response of the
body or due to an underlying pathology affecting the
kidney or urinary tract. The most common prerenal
cause is reduced blood flow to the kidney secondary to
intravascular volume depletion, heart failure, sepsis,
or as a side effect of medication.
 Option D: Urine that smells sweet is often associated
with diabetic ketoacidosis. Commonly accepted
criteria for diabetic ketoacidosis are blood glucose
greater than 250 mg/dl, arterial pH less than 7.3,
serum bicarbonate less than 15 mEq/l, and the
presence of ketonemia or ketonuria.
3. 3. Question
1 point(s)
Which instructions do you include in the teaching care plan for a
patient with cystitis receiving phenazopyridine (Pyridium)?

o A. If the urine turns orange-red, call the doctor.

o B. Take phenazopyridine just before urination to relieve
pain.
o C. Once painful urination is relieved, discontinue prescribed
antibiotics.
o D. After painful urination is relieved, stop taking
phenazopyridine.
Incorrect
Correct Answer: D. After painful urination is relieved, stop
taking phenazopyridine.
Pyridium is taken to relieve dysuria because it provides an
analgesic and anesthetic effect on the urinary tract mucosa. The
patient can stop taking it after the dysuria is relieved.
Symptomatic treatment with analgesics may be used in patients
who present with severe dysuria. Phenazopyridine is a urinary
analgesic used in short-term treatment of urinary dysuria or
discomfort.
 Option A: The urine may temporarily turn red or
orange due to the dye in the drug. Patients should be
informed that Phenazopyridine HCl produces a
reddish-orange discoloration of the urine and may
stain fabric. Staining of contact lenses has been
reported.
 Option B: The drug isn’t taken before voiding, and is
usually taken 3 times a day for 2 days. Treatment of a
urinary tract infection with Phenazopyridine HCl should
not exceed two days because there is a lack of
evidence that the combined administration of
Phenazopyridine HCl and an antibacterial provides
greater benefit than administration of the antibacterial
alone after two days.
 Option C: Antibiotics should not be discontinued
without indication from the physician. The analgesic
action may reduce or eliminate the need for systemic
analgesics or narcotics. It is, however, compatible with
antibacterial therapy and can help to relieve pain and
 discomfort during the interval before antibacterial
therapy controls the infection.
4. 4. Question

1 point(s)
Which patient is at greatest risk for developing a urinary tract
infection (UTI)?

o A. A 35 y.o. woman with a fractured wrist

o B. A 20 y.o. woman with asthma
o C. A 50 y.o. postmenopausal woman
o D. A 28 y.o. with angina
Incorrect
Correct Answer: C. A 50 y.o. postmenopausal woman
Women are more prone to UTIs after menopause due to reduced
estrogen levels. Reduced estrogen levels lead to reduced levels
of vaginal Lactobacilli bacteria, which protect against infection.
Premenopausal women have large concentrations of lactobacilli
in the vagina and prevent the colonization of uropathogens.
However, the use of antibiotics can erase this protective effect.
 Option A: An uncomplicated UTI usually only involves
the bladder. When the bacteria invade the bladder
mucosal wall, cystitis is produced. The majority of
organisms causing a UTI are enteric coliforms that
usually inhabit the periurethral vaginal introitus. These
organisms ascend into the bladder and cause a UTI.
 Option B: Sexual intercourse is a common cause of a
UTI as it promotes the migration of bacteria into the
bladder. People who frequently void and empty the
bladder have a much lower risk of a UTI. Pathogenic
bacteria ascend from the perineum, causing UTI.
Women have shorter urethras than men and therefore
are more susceptible to UTI. Very few uncomplicated
UTIs are caused by blood-borne bacteria. Escherichia
coli is the most common organism in uncomplicated
UTI by a large margin.
 Option D: A major risk factor for UTI is the use of a
catheter. In addition, manipulation of the urethra is
also a risk factor. Sexual intercourse and the use of
spermicide and diaphragm are also risk factors for UTI.
Frequent pelvic exams and the presence of anatomical
 abnormalities of the urinary tract can also predispose
one to UTI.
5. 5. Question

1 point(s)
You have a patient that is receiving peritoneal dialysis. What
should you do when you notice the return fluid is slowly draining?

o A. Check for kinks in the outflow tubing.

o B. Raise the drainage bag above the level of the abdomen.
o C. Place the patient in a reverse Trendelenburg position.
o D. Ask the patient to cough.
Correct
Correct Answer: A. Check for kinks in the outflow tubing.
Tubing problems are a common cause of outflow difficulties,
check the tubing for kinks and ensure that all clamps are open.
Other measures include having the patient change positions
(moving side to side or sitting up), applying gentle pressure over
the abdomen, or having a bowel movement. Assess the patency
of catheter, noting difficulty in draining. Note the presence of
fibrin strings and plugs. Slowing of flow rate and presence of
fibrin suggests partial catheter occlusion requiring further
evaluation and intervention.
 Option B: Check tubing for kinks; note the placement
of bottles and bags. Anchor catheter so that adequate
inflow/outflow is achieved. Improper functioning of
equipment may result in retained fluid in the abdomen
and insufficient clearance of toxins.
 Option C: Turn from side to side, elevate the head of
the bed, apply gentle pressure to the abdomen. May
enhance outflow of fluid when the catheter is
malpositioned and obstructed by the omentum.
 Option D: Monitor BP and pulse, noting hypertension,
bounding pulses, neck vein distension, peripheral
edema; measure CVP if available. Elevations indicate
hypervolemia. Assess heart and breath sounds, noting
S3 and crackles, rhonchi. Fluid overload may
potentiate HF and pulmonary edema.
6. 6. Question

1 point(s)
What is the appropriate infusion time for the dialysate in your 38
y.o. patient with chronic renal failure undergoing peritoneal
dialysis?

o A. 15 minutes
o B. 30 minutes
o C. 1 hour
o D. 2 to 3 hours
Correct
Correct Answer: A. 15 minutes
Dialysate should be infused quickly. The dialysate should be
infused over 15 minutes or less when performing peritoneal
dialysis. The fluid exchange takes place over a period ranging
from 30 minutes to several hours. Each exchange takes about 30
to 40 minutes. During an exchange, yothe client can read, talk,
watch television, or sleep. With CAPD, the client can keep the
solution in the belly for 4 to 6 hours or more. The time that the
dialysis solution is in the belly is called the dwell time. Usually,
the client changes the solution at least four times a day and sleep
with solution in the belly at night
 Option B: The client’s schedule will change as he
works his dialysis exchanges into his routine. If he
does CAPD during the day, he has some control over
when he does the exchanges. However, he’ll still need
to stop his normal activities and take about 30
minutes to perform an exchange. If he does
automated peritoneal dialysis, he’ll have to set up his
cycler every night.
 Option C: Between exchanges, the client keeps his
catheter and transfer set hidden inside his clothing. At
the beginning of an exchange, he’ll remove the
disposable cap from the transfer set and connect the
set to a tube that branches like the letter Y. One
branch of the Y-tube connects to the drain bag, while
the other connects to the bag of fresh dialysis solution.
 Option D: With automated peritoneal dialysis, a
machine called a cycler fills and empties the belly
three to five times during the night. In the morning,
the client begins the day with a fresh solution in his
belly. He may leave this solution in his belly all day or
do one exchange in the middle of the afternoon
 without the machine. People sometimes call this
treatment continuous cycler-assisted peritoneal
dialysis or CCPD.
7. 7. Question

1 point(s)
A 30 y.o. female patient is undergoing hemodialysis with an
internal arteriovenous fistula in place. What do you do to prevent
complications associated with this device?

o A. Insert I.V. lines above the fistula.

o B. Avoid taking blood pressures in the arm with the
fistula.
o C. Palpate pulses above the fistula.
o D. Report a bruit or thrill over the fistula to the doctor.
Incorrect
Correct Answer: B. Avoid taking blood pressures in the
arm with the fistula.
Don’t take blood pressure readings in the arm with the fistula
because the compression could damage the fistula. Do not let
anyone put a blood pressure cuff on the access arm. An AV fistula
causes extra pressure and extra blood to flow into the vein,
making it grow large and strong. The larger vein provides easy,
reliable access to blood vessels. Without this kind of access,
regular hemodialysis sessions would not be possible.
 Option A: IV lines shouldn’t be inserted in the arm
used for hemodialysis. Untreated veins cannot
withstand repeated needle insertions, because they
would collapse the way a straw collapses under strong
suction.
 Option C: Palpate pulses below the fistula. Ensuring
to check the access for signs of infection or problems
with blood flow before each hemodialysis treatment,
even if the patient is inserting the needles. Watch for
and report signs of infection, including redness,
tenderness, or pus.
 Option D: Lack of bruit or thrill should be reported to
the doctor. Check the thrill in the access every day.
The thrill is the rhythmic vibration a person can feel
over the vascular access. Do not wear jewelry or tight
 clothes over the access site. Do not sleep with the
access arm under the head or body.
8. 8. Question

1 point(s)
Your patient becomes restless and tells you she has a headache
and feels nauseous during hemodialysis. Which complication do
you suspect?

o A. Infection
o B. Disequilibrium syndrome
o C. Air embolism
o D. Acute hemolysis
Correct
Correct Answer: B. Disequilibrium syndrome
Disequilibrium syndrome is caused by a rapid reduction in urea,
sodium, and other solutes from the blood. This can lead to
cerebral edema and increased intracranial pressure (ICP). Signs
and symptoms include headache, nausea, restlessness, vomiting,
confusion, twitching, and seizures.
 Option A: Patients who undergo dialysis treatment
have an increased risk for getting an infection.
Hemodialysis patients are at high risk for infection
because the process of hemodialysis requires frequent
use of catheters or insertion of needles to access the
bloodstream.
 Option C: Air embolism during renal dialysis is
extremely rare because of the safeguards built into
the apparatus and procedures currently used. Air
enters the circuit through the infusion bottle, the
heparin syringe or line, or the blood pump insert.
Emergency treatment with posture, oxygen, dextran
infusion, and dexamethasone was apparently
successful in reversing some of the manifestations.
Prevention depends partly on better design of
equipment and partly on the incorporation in the
hemodialysis circuit of devices which detect air and
prevent it from reaching the patient.
 Option D: Uncommonly, patients on dialysis can have
severe (at times life-threatening) hemolysis. These
patients fit into either of two categories, depending on
 whether hemolysis involves all or the majority of the
patients being dialyzed under similar circumstances in
a given dialysis center or whether the hemolysis is
patient specific. Hemolysis in the former is often the
result of water-borne toxins, centralized dialysis
equipment failure, or blood tubing defects—whereas in
the latter it results from medication or possibly
inadequate dialytic therapy.
9. 9. Question

1 point(s)
Your patient is complaining of muscle cramps while undergoing
hemodialysis. Which intervention is effective in relieving muscle
cramps?

o A. Increase the rate of dialysis.

o B. Infuse normal saline solution.
o C. Administer a 5% dextrose solution.
o D. Encourage active ROM exercises.
Correct
Correct Answer: B. Infuse normal saline solution
Treatment includes administering normal saline or hypertonic
normal saline solution because muscle cramps can occur when
the sodium and water are removed too quickly during dialysis.
Saline and/or dextrose solutions, electrolytes, and NaHCO3 may
be infused in the venous side of continuous arteriovenous (CAV)
hemofilter when high ultrafiltration rates are used for removal of
extracellular fluid and toxic solutes. Volume expanders may be
required during or following hemodialysis if sudden or marked
hypotension occurs.
 Option A: Reducing the rate of dialysis, not increasing
it, may alleviate muscle cramps. The central role of
volume removal as the trigger for susceptible patients
seems evident from the fact that intradialytic cramps
are usually associated with hypotension and that
prompt correction of hypotension by saline
administration and discontinuation of ultrafiltration
often improve the cramping.
 Option C: Most patients surveyed (76%) reported that
fluid removal by dialysis was decreased, was stopped,
and/or fluid was given back as the main intervention
 used to alleviate their cramps. When asked about all
interventions to alleviate dialysis cramps, the most
frequent response (29%) was a combination of
decreasing fluid removal, raising the lower
extremities, and massaging the extremities.
 Option D: Avoid trauma to shunt. Handle tubing
gently, maintain cannula alignment. Limit activity of
extremity. Avoid taking BP or drawing blood samples
in shunt extremity. Instruct the patient not to sleep on
the side with shunt or carry packages, books, purse on
affected extremity.
10.10. Question

1 point(s)
Your patient with chronic renal failure reports pruritus. Which
instruction should you include in this patient’s teaching plan?

o A. Rub the skin vigorously with a towel.

o B. Take frequent baths.
o C. Apply alcohol-based emollients to the skin.
o D. Keep fingernails short and clean.
Correct
Correct Answer: D. Keep fingernails short and clean.
Calcium-phosphate deposits in the skin may cause pruritus.
Scratching leads to excoriation and breaks in the skin that
increase the patient’s risk of infection. Keeping fingernails short
and clean helps reduce the risk of infection. Although dialysis has
largely eliminated skin problems associated with uremic frost,
itching can occur because the skin is an excretory route for waste
products such as phosphate crystals (associated with
hyperparathyroidism in ESRD).
 Option A: Keep linens dry, wrinkle-free. Reduces
dermal irritation and risk of skin breakdown. Change
position frequently; move patient carefully; pad bony
prominences with sheepskin, elbow, or heel
protectors. Decreases pressure on edematous, poorly
perfused tissues to reduce ischemia.
 Option B: Recommend the patient use cool, moist
compresses to apply pressure (rather than scratch)
pruritic areas. Keep fingernails short; encourage the
 use of gloves during sleep if needed. Alleviates
discomfort and reduces the risk of dermal injury.
 Option C: Provide soothing skincare. Restrict the use
of soaps. Apply ointments or creams (lanolin,
Aquaphor). Baking soda, cornstarch baths decrease
itching and are less drying than soaps. Lotions and
ointments may be desired to relieve dry, cracked skin.
11.11. Question

1 point(s)
Which intervention do you plan to include with a patient who has
renal calculi?

o A. Maintain bed rest

o B. Increase dietary purines
o C. Restrict fluids
o D. Strain all urine
Correct
Correct Answer: D. Strain all urine
All urine should be strained through gauze or a urine strainer to
catch stones that are passed. The stones are then analyzed for
composition. Strain all urine. Document any stones expelled and
sent to the laboratory for analysis. Retrieval of calculi allows
identification of the type of stone and influences choice of
therapy.
 Option A: Ambulation may help the movement of the
stone down the urinary tract. Encourage the patient to
walk if possible to facilitate spontaneous passage.
Determine patient’s normal voiding pattern and note
variations. Calculi may cause nerve excitability, which
causes sensations of an urgent need to void. Usually,
frequency and urgency increase as calculus nears
ureterovesical junctions.
 Option B: Offer fruit juices, particularly cranberry
juice to help acidify urine. Irrigate with acid or alkaline
solutions as indicated. Changing urine pH may help
dissolve stones and prevent further stone formation.
 Option C: Encourage fluid to help flush the stones
out. Increased hydration flushes bacteria, blood, and
debris and may facilitate stone passage. Investigate
reports of bladder fullness; palpate for suprapubic
 distention. Note decreased urine output, presence of
periorbital and dependent edema. Urinary retention
may develop, causing tissue distension (bladder,
kidney), and potentiates the risk of infection, renal
failure.
12.12. Question

1 point(s)
An 18 y.o. student is admitted with dark urine, fever, and flank
pain and is diagnosed with acute glomerulonephritis. Which
would most likely be in this student’s health history?

o A. Renal calculi
o B. Renal trauma
o C. Recent sore throat
o D. Family history of acute glomerulonephritis
Incorrect
Correct Answer: C. Recent sore throat
The most common form of acute glomerulonephritis is caused by
group A beta-hemolytic streptococcal infection elsewhere in the
body. Poststreptococcal glomerulonephritis (PSGN) results from a
bacterial infection that causes rapid deterioration of the kidney
function due to an inflammatory response following streptococcal
infection. PSGN most commonly presents in children 1 to 2 weeks
after a streptococcal throat infection, or within 6 weeks following
a streptococcal skin infection.
 Option A: Nephrogenic streptococci infection
precedes PSGN, which initially affects skin or
oropharynx. More recently, PSGN is associated with
skin infections (impetigo) more frequently than throat
infections (pharyngitis). Group A Streptococcus (GAS)
has been subtyped depending on the surface M
protein and opacity factor, which are known to be
nephrogenic and can cause PSGN.
 Option B: Other causes of post-infectious
glomerulonephritis include bacterial (endocarditis,
enterocolitis, pneumonia, intraventricular shunt
infections), viral (hepatitis B and C infections, human
immunodeficiency virus, cytomegalovirus, Epstein Barr
virus, parvovirus B19), fungal (coccidioidomycosis,
 histoplasmosis), and parasitic infections (malaria,
leishmania, toxoplasmosis, and schistosomiasis).
 Option D: Genetic factors are expected to predispose
to the condition since almost 40% of patients with
PSGN gave a positive family history. There is no
specific gene found to cause PSGN. Poor hygiene,
overcrowding, and low socioeconomic status are
important risk factors for streptococci outbreaks, and
this explains the higher incidence of PSGN in
impoverished countries.
13.13. Question

1 point(s)
Which drug is indicated for pain related to acute renal calculi?

o A. Narcotic analgesics
o B. Nonsteroidal anti-inflammatory drugs (NSAIDS)
o C. Muscle relaxants
o D. Salicylates
Correct
Correct Answer: A. Narcotic analgesics
Narcotic analgesics are usually needed to relieve the severe pain
of renal calculi. Narcotic analgesics act at the central nervous
system (CNS) mu receptors and are commonly used in the
treatment of renal colic. They are inexpensive and proven
effective. Disadvantages include sedation, respiratory depression,
smooth muscle spasm, and potential for abuse and addiction.
 Option B: Nonsteroidal anti-inflammatory drugs
(NSAIDs) inhibit pain and inflammatory reactions by
decreasing the activity of cyclooxygenase, which is
responsible for prostaglandin synthesis. Both
properties are beneficial in the management of renal
(ureteral) colic.
 Option C: Muscle relaxants are typically used to treat
skeletal muscle spasms. Muscle relaxants are used to
treat muscle spasm, which may play a role in patient
discomfort. Skeletal muscle relaxant used in
conjunction with other therapies to treat pain and
discomfort associated with musculoskeletal conditions.
Reduces nerve impulse transmission from spinal cord
to skeletal muscle.
  Option D: Salicylates are used for their anti-
inflammatory and antipyretic properties and to treat
less severe pain. Aspirin is a cyclooxygenase-1 (COX-
1) inhibitor. It is a modifier of the enzymatic activity of
cyclooxygenase-2 (COX-2). Unlike other NSAIDs
(ibuprofen/naproxen), which bind reversibly to this
enzyme, aspirin binding is irreversible. It also blocks
thromboxane A2 on platelets in an irreversible fashion
preventing platelet aggregation.
14.14. Question

1 point(s)
Which of the following causes the majority of UTI’s in hospitalized
patients?

o A. Lack of fluid intake

o B. Inadequate perineal care
o C. Invasive procedures
o D. Immunosuppression
Correct
Correct Answer: C. Invasive procedures
Invasive procedures such as catheterization can introduce
bacteria into the urinary tract. A lack of fluid intake could cause
concentration of urine, but wouldn’t necessarily cause infection. A
major risk factor for UTI is the use of a catheter. In addition,
manipulation of the urethra is also a risk factor. UTI is very
common after a kidney transplant; the two triggers include the
use of immunosuppressive drugs and vesicoureteral reflux. Other
risk factors include the use of antibiotics and diabetes mellitus.
 Option A: Pathogenic bacteria ascend from the
perineum, causing UTI. Women have shorter urethras
than men and therefore are more susceptible to UTI.
Very few uncomplicated UTIs are caused by blood-
borne bacteria. Escherichia coli is the most common
organism in uncomplicated UTI by a large margin.
 Option B: Sexual intercourse and the use of
spermicide and diaphragm are also risk factors for UTI.
Frequent pelvic exams and the presence of anatomical
abnormalities of the urinary tract can also predispose
one to UTI.
  Option D: E.coli causes the majority of UTI but other
organisms of importance include proteus, klebsiella,
and enterococcus. The diagnosis of UTI is made from
the clinical history and urinalysis, but the proper
collection of the urine sample is important.
15.15. Question

1 point(s)
Clinical manifestations of acute glomerulonephritis include which
of the following?

o A. Chills and flank pain

o B. Oliguria and generalized edema
o C. Hematuria and proteinuria
o D. Dysuria and hypotension
Correct
Correct Answer: C. Hematuria and proteinuria
Hematuria and proteinuria indicate acute glomerulonephritis.
These findings result from increased permeability of the
glomerular membrane due to the antigen-antibody reaction.
Generalized edema is seen most often in nephrosis. The most
common presenting symptom is gross hematuria as it occurs in
30 to 50% of cases with acute PSGN; patients often describe their
urine as smoky, tea-colored, cola-colored, or rusty. The hematuria
can be described as postpharyngitic (hematuria seen after weeks
of infection).
 Option A: Approximately 50% of children with PSGN
are asymptomatic and are discovered accidentally
during routine urine analysis. The classic triad of
glomerulonephritis includes hematuria, edema, and
hypertension. Typically, patients give a history of a
recent streptococcal infection such as pharyngitis,
tonsillitis, or impetigo.
 Option B: The incidence of edema is seen in about
65-90% of the cases. Puffiness of the eyelids
(periorbital edema) is typical for the nephritic
syndrome. It is most prominent in the morning and
tends to resolve at the end of the day. Generalized
edema is also a common feature.
 Option D: Renal involvement is common and is
transient with recovery in 1-2 weeks. Less than half of
 the patients experience oliguria. Depending on the
severity of renal involvement, signs, and symptoms
suggestive of anuric renal failure or life-threatening
acid-base imbalance, electrolyte abnormalities
(especially hyperkalemia), and fluid overload would
require RRT. About 60-80% of the patients experience
high blood pressure which typically resolves in 10
days.
16.16. Question

1 point(s)
You expect a patient in the oliguric phase of renal failure to have
a 24 hour urine output less than:

o A. 200ml
o B. 400ml
o C. 800ml
o D. 1000ml
Incorrect
Correct Answer: B. 400ml
Oliguria is defined as urine output of less than 400ml/24hours.
Renal causes of oliguria arise as a result of tubular damage. As a
result of the tubular damage, the kidney loses its normal function
i.e., production of urine while excreting the waste metabolites. In
addition to this, direct damage to the renal tubules leads to a
back leak of filtered uremic metabolites from the tubular lumen
into the bloodstream. Hence, in these cases, decreased
production of urine leads to oliguria.
 Option A: The most common prerenal cause is
reduced blood flow to the kidney secondary to
intravascular volume depletion, heart failure, sepsis,
or as a side effect of medication. Oliguria secondary to
prerenal causes usually resolves with the restoration
of normal renal perfusion.
 Option C: As a result of the decreased renal blood
flow, various neurohormonal pathways are activated
that result in the increased production of renin,
angiotensin, aldosterone as well as catecholamines,
and prostaglandins. Activation of these pathways
leads to increased water and salt reabsorption
resulting in the production of low quantities of
 concentrated urine while maintaining adequate
glomerular filtration rate (GFR) and renal blood flow
(RBF) to meet the metabolic requirements of the
kidneys.
 Option D: Oliguria can arise as a result of the normal
physiological response of the body or due to an
underlying pathology affecting the kidney or urinary
tract. The human body has a normal physiological
mechanism of conserving fluids and electrolytes in
episodes of hypovolemia. These mechanisms are
under close neurohormonal control and are completely
reversible without any subsequent injury to the
kidneys.
17.17. Question

1 point(s)
The most common early sign of kidney disease is:

o A. Sodium retention
o B. Elevated BUN level
o C. Development of metabolic acidosis
o D. Inability to dilute or concentrate urine
Correct
Correct Answer: B. Elevated BUN level
Increased BUN is usually an early indicator of decreased renal
function. Although, immediately after a renal insult, blood urea
nitrogen (BUN) or creatinine levels may be within the normal
range. The only sign of the acute kidney injury may be a decline
in urine output. AKI can lead to the accumulation of water,
sodium, and other metabolic products. It can also result in
several electrolyte disturbances.
 Option A: Evaluation of AKI should include a thorough
search for all possible etiologies of AKI, including
prerenal, renal, and post renal disease. The timing of
the onset of AKI can be especially helpful when
dealing with hospitalized patients. For example, if a
patient’s labs are being checked every day and
creatinine suddenly starts to rise on the fourth day of
admission then an inciting factor can usually be found
in 24-48 hours preceding the onset.
  Option C: The impetus for glomerular filtration is the
difference in the pressures between the glomerulus
and the Bowman space. This pressure gradient is
affected by the renal blood flow and is under the direct
control of the combined resistances of afferent and
efferent vascular pathways. Nevertheless, whatever
the cause of AKI, renal blood flow reduction is a
common pathologic pathway for declining glomerular
filtration rate.
 Option D: The prerenal form of AKI is because of any
cause of reduced blood flow to the kidney. This may
be part of systemic hypoperfusion resulting from
hypovolemia or hypotension, or maybe due to
selective hypoperfusion to the kidneys, such as those
resulting from renal artery stenosis and aortic
dissection.
18.18. Question

1 point(s)
A patient is experiencing which type of incontinence if she
experiences leaking urine when she coughs, sneezes, or lifts
heavy objects?

o A. Overflow
o B. Reflex
o C. Stress
o D. Urge
Correct
Correct Answer: C. Stress
Stress incontinence is an involuntary loss of a small amount of
urine due to sudden increased intra-abdominal pressure, such as
with coughing or sneezing. Stress incontinence happens when
physical movement or activity — such as coughing, laughing,
sneezing, running or heavy lifting — puts pressure (stress) on the
bladder, causing to leak urine.
 Option A: Overflow incontinence occurs when the
bladder is overdistended and reaches its limit of
compliance. At this point, the intravesical pressure
exceeds the resting urethral closure pressure and
urine overflows despite the absence of detrusor
 contraction. Patients experience a sense of incomplete
emptying, slow-flowing urine, and urinary dribbling.
 Option B: Reflex incontinence is due to neurologic
impairment of the central nervous system. Common
neurologic disorders associated with reflex
incontinence include stroke, Parkinson disease, and
brain tumors. Reflex incontinence also occurs in
patients with spinal cord injuries and multiple
sclerosis. When patients with suprapontine or
suprasacral spinal cord lesions present with symptoms
of urge incontinence, this is known as detrusor
hyperreflexia.
 Option D: People who experience urge incontinence
get a strong feeling to urinate even when the bladder
isn’t full. This can occur in both men and women and
involves a strong urge to urinate, often followed by
loss of urine before reaching the toilet.
19.19. Question

1 point(s)
Immediately post-op after a prostatectomy, which complications
require priority assessment of your patient?

o A. Pneumonia
o B. Hemorrhage
o C. Urine retention
o D. Deep vein thrombosis
Correct
Correct Answer: B. Hemorrhage
Hemorrhage is a potential complication. Postoperative
hemorrhage is a rare but severe complication in LRP. Bleeding
generally originates from injured venous vessels in the
prostatectomy area, which is always self-limiting due to tissue
compression in the pelvic space. However, it is not easy for
slightly larger arteries to stop bleeding automatically.
 Option A: Pneumonia may occur if the patient doesn’t
cough and deep breathe. Postoperative pneumonia is
an important cause of morbidity and mortality and
represents an important financial burden of $10.5
billion per year. Patients undergoing surgery,
especially complex procedures, are at a greater risk
 due to intubation, post-surgical atelectasis, and long
hospital stays exposing them to hospital-acquired
pathogens. It has been estimated that approximately
one out of four deaths within six days of surgery is due
to its complications.
 Option C: Urine retention isn’t a problem soon after
surgery because a catheter is in place. Although
leaving a temporary indwelling catheter is standard
practice after radical prostatectomy to allow
anastomotic healing, urinary catheterization
represents a source of infection, significant discomfort,
and anxiety for the patient following radical
prostatectomy.
 Option D: Thrombosis may occur later if the patient
doesn’t ambulate. Historically, the reported rate of
symptomatic VTEs is low in open prostatectomy
series, as well as robot-assisted radical prostatectomy
(RARP) series. As a result, it is unclear which patients
are at the highest risk of VTEs developing and who
would benefit from medical prophylaxis, given the low
incidence of VTEs and a possible increase in
complications with the use of heparin.
20.20. Question

1 point(s)
The most indicative test for prostate cancer is:

o A. A thorough digital rectal examination

o B. Magnetic resonance imaging (MRI)
o C. Excretory urography
o D. Prostate-specific antigen
Correct
Correct Answer: D. Prostate-specific antigen
An elevated prostate-specific antigen level indicates prostate
cancer, but it can be falsely elevated if done after the prostate
gland is manipulated. Elevated Prostate Specific Antigen (PSA)
levels (usually greater than 4 ng/ml) in the blood is how 80% of
prostate cancers initially present even though elevated PSA
levels alone correctly identify prostate cancer only about 25% to
30% of the time. We recommend at least 2 abnormal PSA levels
 or the presence of a palpable nodule on DRE to justify a biopsy
and further investigation.
 Option A: A digital rectal examination should be done
as part of the yearly screening, and then the antigen
test is done if the digital exam suggests cancer. Digital
rectal examination (DRE) may detect prostate
abnormalities, asymmetry, and suspiciously hard
nodules but is not considered a definitive test for
prostate cancer by itself. An abnormal DRE initially
uncovers about 20% of all prostate cancers.
 Option B: MRI is used in staging the cancer. Prostate
MRI has much better soft tissue resolution than
ultrasound and can identify areas in the gland that are
truly “suspicious” with a high degree of accuracy and
reliability (positive predictive value greater than 90%).
Prostate MRI is also used for surgical planning in men
considering radical prostatectomy and for improved
biopsies, instead of saturation biopsies, when cancer is
strongly suspected despite a negative initial TRUS-
guided biopsy.
 Option C: An intravenous pyelogram (PIE-uh-low-
gram), also called an excretory urogram, is an X-ray
exam of the urinary tract. An intravenous pyelogram
lets the doctor view the kidneys, the bladder, and the
tubes that carry urine from the kidneys to the bladder
(ureters).
21.21. Question

1 point(s)
A 22 y.o. patient with diabetic nephropathy says, “I have two
kidneys and I’m still young. If I stick to my insulin schedule, I
don’t have to worry about kidney damage, right?” Which of the
following statements is the best response?

o A. “You have little to worry about as long as your

kidneys keep making urine.”
o B. “You should talk to your doctor because statistics show
that you’re being unrealistic.”
o C. “You would be correct if your diabetes could be
managed with insulin.”
 o D. “Even with insulin, kidney damage is still a
concern.”
Incorrect
Correct Answer: D. “Even with insulin, kidney damage is
still a concern.”
Kidney damage is still a concern. Microvascular changes occur in
both of the patient’s kidneys as a complication of the diabetes.
Diabetic nephropathy is the leading cause of end-stage renal
disease. The kidneys continue to produce urine until the end
stage. Nephropathy occurs even with insulin management.
 Option A: In T2DM, UKPDS (United Kingdom
Prospective Diabetes Study) showed that targeting an
HbA1C of 7% led to a lower risk of microvascular
complications, including nephropathy. However, blood
pressure (BP) control also led to a decrease in
cardiovascular mortality.
 Option B: The benefits of good glycemic control early
in the onset of disease carried over even after a long
time, despite glycemic control being similar in both
groups on longer follow up. This effect is “metabolic
memory,” a term coined by DCCT/EDIC investigators.
 Option C: Studies in patients with T1DM and overt
proteinuria have also shown that ACE inhibitors slow
the progress of diabetic nephropathy. The IDNT and
RENAAL studies have shown similar benefits in T2DM
patients. These studies provide clear evidence of the
benefit of RAS-blocking medication on slowing
progression of diabetic nephropathy, independent of
their effect on BP.
22.22. Question

1 point(s)
A patient diagnosed with sepsis from a UTI is being discharged.
What do you plan to include in her discharge teaching?

o A. Take cool baths.

o B. Avoid tampon use.
o C. Avoid sexual activity.
o D. Drink 8 to 10 eight-oz glasses of water daily.
Correct
 Correct Answer: D. Drink 8 to 10 eight-oz glasses of water
daily
Drinking 2-3L of water daily inhibits bacterial growth in the
bladder and helps flush the bacteria from the bladder. Encourage
increased oral fluid intake (2 to 3 liters a day if no
contraindication). Fluid intake facilitates urine production and
flushes bacteria from the urinary tract.
 Option A: Instruct the female client to wipe the area
from front to back and the avoidance of bath tubs.
Proper perineal care helps in minimizing the risk of
contamination and re-infection.
 Option B: Tampons are advised during the
menstruation rather than sanitary napkins because
they keep the bladder opening area drier, hence
limiting the growth of bacteria. Avoid wearing tight-
fitting or constricting undergarments made of non-
breathing materials.
 Option C: The patient should be instructed to void
after sexual activity. Completely emptying the bladder
prevents bladder distention and compromised blood
supply to the bladder wall. These predispose the client
to UTI.
23.23. Question

1 point(s)
You’re planning your medication teaching for your patient with a
UTI prescribed phenazopyridine (Pyridium). What do you include?

o A. “Take this drug between meals and at bedtime.”

o B. “You need to take this antibiotic for 7 days.”
o C. “Your urine might turn bright orange.”
o D. “Don’t take this drug if you’re allergic to penicillin.”
Incorrect
Correct Answer: C. “Your urine might turn bright orange.”
The drug turns the urine orange. It may be prescribed for longer
than 7 days and is usually ordered three times a day after meals.
Phenazopyridine will most likely darken the color of the urine to
an orange or red color. This is a normal effect and is not harmful.
Darkened urine may also cause stains to the underwear that may
be permanent.
  Option A: Take phenazopyridine after meals. Drink
plenty of liquids while taking phenazopyridine.
Phenazopyridine can also permanently stain soft
contact lenses; do not wear them while taking this
medicine.
 Option B: Phenazopyridine is an azo (nitrogenous)
analgesic; not an antibiotic. Phenazopyridine is used to
treat urinary symptoms such as pain or burning,
increased urination, and increased urge to urinate.
These symptoms can be caused by infection, injury,
surgery, catheter, or other conditions that irritate the
bladder.
 Option D: Phenazopyridine will treat urinary
symptoms, but this medication will not treat a urinary
tract infection. Take any antibiotic that the doctor
prescribes to treat an infection. Phenazopyridine is a
pain reliever that affects the lower part of the urinary
tract (bladder and urethra).
24.24. Question

1 point(s)
Which finding leads you to suspect acute glomerulonephritis in
your 32 y.o. patient?

o A. Dysuria, frequency, and urgency

o B. Back pain, nausea, and vomiting
o C. Hypertension, oliguria, and fatigue
o D. Fever, chills, and right upper quadrant pain
radiating to the back
Incorrect
Correct Answer: C. Hypertension, oliguria, and fatigue
Mild to moderate HTN may result from sodium or water retention
and inappropriate renin release from the kidneys. Oliguria and
fatigue also may be seen. Other signs are proteinuria and
azotemia. The term “glomerulonephritis” encompasses a subset
of renal diseases characterized by immune-mediated damage to
the basement membrane, mesangium, or the capillary
endothelium, leading to hematuria, proteinuria, and azotemia.
 Option A: As the glomerular filtration rate (GFR) is
decreased, symptoms like edema and hypertension
occur, majorly due to the subsequent salt and water
 retention caused by the activation of the renin-
angiotensin-aldosterone system.
 Option B: Acute forms of glomerulonephritis can
result from either a primary renal cause or a
secondary illness that causes renal manifestations.
Most forms of glomerulonephritis are considered
progressive disorders, which without timely therapy
progress to chronic glomerulonephritis (characterized
by progressive glomerular damage and
tubulointerstitial fibrosis leading to a reduced
glomerular filtration rate).
 Option D: Etiological classification can be made on
the basis of clinical presentation, which can range
from severe proteinuria (>3.5 g/day) and edema
qualifying for nephrotic syndrome, to a nephritic
syndrome where hematuria and hypertension are
more prominent while proteinuria is less pronounced.
25.25. Question

1 point(s)
What is the priority nursing diagnosis with your patient diagnosed
with end-stage renal disease?

o A. Activity intolerance
o B. Fluid volume excess
o C. Knowledge deficit
o D. Pain
Incorrect
Correct Answer: B. Fluid volume excess
Fluid volume excess because the kidneys aren’t removing fluid
and wastes. The other diagnoses may apply, but they don’t take
priority. Renal disorder impairs glomerular filtration that results in
fluid overload. With fluid volume excess, hydrostatic pressure is
higher than the usual pushing excess fluids into the interstitial
spaces.
 Option A: Schedule care and provide rest periods
following an activity; allow the client to set own limits
in the amount of exertion tolerated. Promotes
autonomy and control of situations as the presence of
a chronic disease may encourage independence.
  Option C: Review disease process and prognosis and
future expectations. Provides a knowledge base from
which the patient can make informed choices. If fluid
overload is present, diuretic therapy or dialysis will be
part of the regimen.
 Option D: Perform a comprehensive assessment of
pain (location, onset, characteristics, and frequency)
to be able to compare changes from previous reports
to rule out worsening of underlying
condition/developing complications.
26.26. Question

1 point(s)
A patient with ESRD has an arteriovenous fistula in the left arm
for hemodialysis. Which intervention do you include in his plan of
care?

o A. Apply pressure to the needle site upon

discontinuing hemodialysis.
o B. Keep the head of the bed elevated 45 degrees.
o C. Place the left arm on an arm board for at least 30
minutes.
o D. Keep the left arm dry.
Correct
Correct Answer: A. Apply pressure to the needle site upon
discontinuing hemodialysis.
Apply pressure when discontinuing hemodialysis and after
removing the venipuncture needle until all the bleeding has
stopped. Bleeding may continue for 10 minutes in some patients.
The AV fistula is the safest type of vascular access. It can last for
years and is least likely to get infections or blood clots. A surgeon
connects an artery (a large blood vessel that carries blood from
the heart) and a vein (a blood vessel that carries blood to the
heart) under the skin in the arm. Usually, they do the AV fistula in
the non-dominant arm.
 Option B: Remove any restrictive clothing or jewelry
from the arm. To prevent injuries, place an armband
on the patient or a sign over the bed that says no BP
measurements, venipunctures, or injections on the
affected side. When blood flow through the vascular
access is reduced, it can clot.
  Option C: Perform hand hygiene before you assess or
touch the vascular access. If it’s new vascular access
with a wound, don gloves. Position the patient’s arm
so the vascular access is easily visualized. Palpate the
vascular access to feel for a thrill or vibration that
indicates arterial and venous blood flow and patency.
 Option D: Check the patient’s circulation by palpating
his pulses distal to the vascular access; observing
capillary refill in his fingers; and assessing him for
numbness, tingling, altered sensation, coldness, and
pallor in the affected extremity.
27.27. Question

1 point(s)
Your 60 y.o. patient with pyelonephritis and possible septicemia
has had five UTIs over the past two years. She is fatigued from
lack of sleep, has lost weight, and urinates frequently even in the
night. Her labs show: sodium, 154 mEq/L; osmolarity 340
mOsm/L; glucose, 127 mg/dl; and potassium, 3.9 mEq/L. Which
nursing diagnosis is a priority?

o A. Fluid volume deficit related to osmotic diuresis induced

by hyponatremia
o B. Fluid volume deficit related to inability to
conserve water
o C. Altered nutrition: Less than body requirements related to
hypermetabolic state
o D. Altered nutrition: Less than body requirements related to
catabolic effects of insulin deficiency
Correct
Correct Answer: B. Fluid volume deficit related to inability
to conserve water
Monitor and document vital signs especially BP and HR. Decrease
in circulating blood volume can cause hypotension and
tachycardia. Alteration in HR is a compensatory mechanism to
maintain cardiac output. Usually, the pulse is weak and may be
irregular if electrolyte imbalance also occurs. Hypotension is
evident in hypovolemia.
 Option A: The serum sodium result is normal. Assess
skin turgor and oral mucous membranes for signs of
dehydration. Signs of dehydration are also detected
 through the skin. Skin of elderly patients loses
elasticity, hence skin turgor should be assessed over
the sternum or on the inner thighs. Longitudinal
furrows may be noted along the tongue.
 Option C: Identify the possible cause of the fluid
disturbance or imbalance. Establishing a database of
history aids accurate and individualized care for each
patient. Weigh daily with the same scale, and
preferably at the same time of day. Weight is the best
assessment data for possible fluid volume imbalance.
An increase of 2 lbs a week is considered normal.
 Option D: Monitor serum electrolytes and urine
osmolality, and report abnormal values. Elevated
blood urea nitrogen suggests fluid deficit. Urine
specific gravity is likewise increased. Note the
presence of nausea, vomiting, and fever. These factors
influence intake, fluid needs, and route of
replacement.
28.28. Question

1 point(s)
Which sign indicates the second phase of acute renal failure?

o A. Daily doubling of urine output (4 to 5 L/day).

o B. Urine output less than 400 ml/day.
o C. Urine output less than 100 ml/day.
o D. Stabilization of renal function.
Correct
Correct Answer: A. Daily doubling of urine output (4 to 5
L/day).
Daily doubling of the urine output indicates that the nephrons are
healing. This means the patient is passing into the second phase
(diuresis) of acute renal failure. The GFR is stable albeit at a level
determined by the severity of the initial event. This cellular repair
and reorganization phase results in slowly improving cellular
function and sets the stage for improvement in organ function.
 Option B: The initiation phase of ATN occurs when
renal blood flow (RBF) decreases to a level resulting in
severe cellular ATP depletion that in turn leads to
acute cell injury and dysfunction. Renal tubular
 epithelial cell injury is a key feature of the Initiation
Phase.
 Option C: The extension phase is ushered in by two
major events: continued hypoxia following the initial
ischemic event and an inflammatory response. It is
during this phase that renal vascular endothelial cell
damage likely plays a key role in the continued
ischemia of the renal tubular epithelium, as well as,
the inflammatory response observed with ischemic
ARF. During this phase, cells continue to undergo
injury and death with both necrosis and apoptosis
being present predominantly in the outer medulla
 Option D: During the recovery phase cellular
differentiation continues, epithelial polarity is
reestablished and normal cellular and organ function
returns. Thus, renal function can be directly related to
the cycle of cell injury and recovery.
29.29. Question

1 point(s)
Your patient had surgery to form an arteriovenous fistula for
hemodialysis. Which information is important for providing care
for the patient?

o A. The patient shouldn’t feel pain during initiation of

dialysis.
o B. The patient feels best immediately after the dialysis
treatment.
o C. Using a stethoscope for auscultating the fistula is
contraindicated.
o D. Taking a blood pressure reading on the affected
arm can cause clotting of the fistula.
Correct
Correct Answer: D. Taking a blood pressure reading on
the affected arm can cause clotting of the fistula.
Pressure on the fistula or the extremity can decrease blood flow
and precipitate clotting, so avoid taking blood pressure on the
affected arm. For the most effective hemodialysis, the patient
needs good vascular access with an arteriovenous (AV) fistula or
an AV graft that provides adequate blood flow. To prevent
injuries, place an armband on the patient or a sign over the bed
 that says no BP measurements, venipunctures, or injections on
the affected side. When blood flow through the vascular access is
reduced, it can clot.
 Option A: Check the patient’s circulation by palpating
his pulses distal to the vascular access; observing
capillary refill in his fingers; and assessing him for
numbness, tingling, altered sensation, coldness, and
pallor in the affected extremity.
 Option B: Auscultate the vascular access with a
stethoscope to detect a bruit or “swishing” sound that
indicates patency. Palpate the vascular access to feel
for a thrill or vibration that indicates arterial and
venous blood flow and patency.
 Option C: Assess the vascular access for signs and
symptoms of infection such as redness, warmth,
tenderness, purulent drainage, open sores, or
swelling. Patients with end-stage kidney disease are at
increased risk of infection.
30.30. Question

1 point(s)
A patient with diabetes mellitus and renal failure begins
hemodialysis. Which diet is best on days between dialysis
treatments?

o A. Low-protein diet with unlimited amounts of water.

o B. Low-protein diet with a prescribed amount of
water.
o C. No protein in the diet and use of a salt substitute
o D. No restrictions.
Correct
Correct Answer: B. Low-protein diet with a prescribed
amount of water
The patient should follow a low-protein diet with a prescribed
amount of water. The patient requires some protein to meet
metabolic needs. Protein can help keep healthy blood protein
levels and improve health. Protein also helps keep the muscles
strong, helps wounds heal faster, strengthens the immune
system, and helps improve overall health.
 Option A: Learn how much fluid you can safely drink
(including coffee, tea, water, and any food that is
 liquid at room temperature). Diet is an important part
of the treatment. The kidneys cannot get rid of enough
waste products and fluids from the blood and the body
now has special needs. Therefore, the client will need
to limit fluids and change the intake of certain foods in
the diet.
 Option C: Salt substitutes shouldn’t be used without a
doctor’s order because it may contain potassium,
which could make the patient hyperkalemic. Use less
salt and eat fewer salty foods: This may help to control
blood pressure. It may also help reduce fluid weight
gains between dialysis sessions since salt increases
thirst and causes the body to retain (or hold on to)
fluid.
 Option D: Fluid and protein restrictions are needed.
At first the kidney and diabetic diet appear to be very
different, but they are alike in many ways. Both diets
recommend eating 3 balanced meals, avoiding large
amounts of protein, and limiting sodium. A balanced
meal has at least 3 of the food groups (protein, grain,
vegetables, fruits, and dairy). The kidney diet limits
the amount of milk that you drink, but many people
with diabetes already limit milk to 4 ounces a day.
31.31. Question

1 point(s)
After the first hemodialysis treatment, your patient develops a
headache, hypertension, restlessness, mental confusion, nausea,
and vomiting. Which condition is indicated?

o A. Disequilibrium syndrome
o B. Respiratory distress
o C. Hypervolemia
o D. Peritonitis
Correct
Correct Answer: A. Disequilibrium syndrome
Disequilibrium occurs when excess solutes are cleared from the
blood more rapidly than they can diffuse from the body’s cells
into the vascular system. The dialysis disequilibrium syndrome is
defined as a clinical syndrome of neurologic deterioration that is
seen in patients who undergo hemodialysis. It is more likely to
 occur in patients during or immediately after their first treatment
but can occur in any patient who receives hemodialysis.
 Option B: Patients with end-stage renal failure
treated by hemodialysis have a marked increased risk
for cardiovascular death. These patients have both an
accelerated form of arteriosclerosis with calcification
in atheromatous intimal plaques and also medial
calcification due to Monckeberg’s. In extreme cases,
soft tissue calcification can lead to calciphylaxis
resulting in skin ulceration, amputation, and death.
 Option C: Having too much water in the body is called
fluid overload or hypervolemia. One of the main
functions of the kidneys is to balance fluid in the body.
If too much fluid builds up in the body, it can have
harmful effects on health, such as difficulty breathing
and swelling.
 Option D: Peritonitis is a peritoneal dialysis-related
infection caused by bacteria entering the abdomen
from outside the body and infecting the peritoneum.
Bacteria may enter the body through the open ends of
the PD catheter during exchanges.
32.32. Question

1 point(s)
Which action is most important during bladder training in a
patient with a neurogenic bladder?

o A. Encourage the use of an indwelling urinary catheter.

o B. Set up specific times to empty the bladder.
o C. Encourage Kegel exercises.
o D. Force fluids.
Correct
Correct Answer: B. Set up specific times to empty the
bladder.
Instruct the patient with a neurogenic bladder to write down his
voiding pattern and empty the bladder at the same times each
day. Offer an opportunity to void every 1 to 2 hours, even if the
urge to void is not felt. Intervals may be based on a shorter time
than exist in continent voiding.
 Option A: Initiate voiding by manual stimulation, i.e.,
apply pressure with hands over the suprapubic area or
 bend the patient over to increase intra-abdominal
pressure. During the program, the bed and clothing
may be padded to protect them from becoming wet,
avoid diapering, since this further demeans the person
and may give “permission” to be incontinent.
 Option C: Instruct patient to do vaginal and rectal
contractions to strengthen periurethral tissue (Kegel
exercises). Perform these exercises 10 times daily
over a 6 to 8 week period. Evaluation of the exercise
program is then done.
 Option D: Record time and amount of fluid intake. If
no fluid restriction, encourage daily intake of 2000-
2500 mL per day. Limit in the evening. Repeat voiding
by manual compression every 2 hours to prevent over-
distention.
33.33. Question

1 point(s)
A patient with diabetes has had many renal calculi over the past
20 years and now has chronic renal failure. Which substance
must be reduced in this patient’s diet?

o A. Carbohydrates
o B. Fats
o C. Protein
o D. Vitamin C
Correct
Correct Answer: C. Protein
Because of damage to the nephrons, the kidney can’t excrete all
the metabolic wastes of protein, so this patient’s protein intake
must be restricted. Eating animal protein may increase the
chances of developing kidney stones. Although you may need to
limit how much animal protein you eat each day, you still need to
make sure you get enough protein. Consider replacing some of
the meat and animal protein you would typically eat with beans,
dried peas, and lentils, which are plant-based foods that are high
in protein and low in oxalate.
 Option A: Eat oxalates wisely. Foods high in this
chemical may increase formation of kidney stones. If
you’ve already had kidney stones, you may wish to
reduce or eliminate oxalates from your diet
 completely. If you’re trying to avoid kidney stones,
check with your doctor to determine if limiting these
foods is enough.
 Option B: Good sources of calcium include milk,
yogurt, cottage cheese, and other types of cheeses.
Vegetarian sources of calcium include legumes,
calcium-set tofu, dark green vegetables, nuts, seeds,
and blackstrap molasses. If you don’t like the taste of
cow’s milk, or, if it doesn’t agree with you, try lactose-
free milk, fortified soy milk, or goat’s milk.
 Option D: Citrus fruit, and their juice, can help reduce
or block the formation of stones due to naturally
occurring citrate. Good sources of citrus include
lemons, oranges, and grapefruit. A higher intake of
carbs, fats, and vitamin supplements is needed to
ensure the growth and maintenance of the patient’s
tissues.
34.34. Question

1 point(s)
What is the best way to check for patency of the arteriovenous
fistula for hemodialysis?

o A. Pinch the fistula and note the speed of filling on release.

o B. Use a needle and syringe to aspirate blood from the
fistula.
o C. Check for capillary refill of the nail beds on that
extremity.
o D. Palpate the fistula throughout its length to assess
for a thrill.
Correct
Correct Answer: D. Palpate the fistula throughout its
length to assess for a thrill.
The vibration or thrill felt during palpation ensures that the fistula
has the desired turbulent blood flow. Assess for patency at least
every 8 hours. Palpate the vascular access to feel for a thrill or
vibration that indicates arterial and venous blood flow and
patency. Auscultate the vascular access with a stethoscope to
detect a bruit or “swishing” sound that indicates patency.
 Option A: Pinching the fistula could cause damage.
To prevent injuries, place an armband on the patient
 or a sign over the bed that says no BP measurements,
venipunctures, or injections on the affected side.
When blood flow through the vascular access is
reduced, it can clot.
 Option B: Aspirating blood is a needless invasive
procedure. Narrowing, also known as stenosis, of the
blood vessel is the most common problem. This results
in insufficient blood flow through the fistula or graft.
Clotting can also cause decreased flow. If you don’t
feel a thrill (vibration), the access may be clotted.
 Option C: Patients with an AVF for hemodialysis will
present with evidence of a surgical incision on the
lateral wrist, volar forearm, or upper arm. A working
AVF will have a palpable thrill and continuous bruit.
Superficial fistulas have a palpable thrill, a bruit, or
even a pulsatile mass. It may be possible to auscultate
a machinery-like murmur over the fistula.
35.35. Question

1 point(s)
You have a paraplegic patient with renal calculi. Which factor
contributes to the development of calculi?

o A. Increased calcium loss from the bones.

o B. Decreased kidney function.
o C. Decreased calcium intake.
o D. High fluid intake.
Incorrect
Correct Answer: A. Increased calcium loss from the bones.
Bones lose calcium when a patient can no longer bear weight.
The calcium lost from bones form calculi, a concentration of
mineral salts also known as a stone, in the renal system. Renal
stone disease is a common problem in patients with spinal cord
injury. The factors responsible are thought to include
hypercalciuria and chronic urinary infection. The urine of all stone
patients was oversaturated with calcium phosphate for part of
each day. Urinary calcium was elevated in 16% and plasma urate
in 30% of the paraplegics studied.
 Option B: Specific risk factors for CKD in stone
formers include recurrent urinary tract infections,
struvite and possibly uric acid stone composition,
 symptomatic stones, solitary kidney, ileal conduit,
neurogenic bladder, and hydronephrosis.
 Option C: The effect of calcium supplementation on
stone formation is currently controversial. It is likely
that large doses of supplemental calcium, especially if
taken separately from a meal, may lead to stone
formation. When necessary, stone-forming patients
should be encouraged to take their calcium
supplements with a meal and their stone disease
should be monitored.
 Option D: Increased water intake is associated with a
reduced risk of kidney stones; increased consumption
of tea and alcohol may reduce kidney stone risk. An
average daily water intake was recommended for
kidney stone prevention.
36.36. Question

1 point(s)
What is the most important nursing diagnosis for a patient in
end-stage renal disease?

o A. Risk for injury

o B. Fluid volume excess
o C. Altered nutrition: less than body requirements
o D. Activity intolerance
Incorrect
Correct Answer: B. Fluid volume excess
Kidneys are unable to rid the body of excess fluids which results
in fluid volume excess during ESRD. Renal disorder impairs
glomerular filtration that results in fluid overload. With fluid
volume excess, hydrostatic pressure is higher than the usual
pushing excess fluids into the interstitial spaces. Since fluids are
not reabsorbed at the venous end, fluid volume overloads the
lymph system and stays in the interstitial spaces.
 Option A: Assess I&O, electrolyte panel, and
creatinine; administer diuretics as ordered. Provides
an indication of renal function affecting output with
water and electrolyte retention as the disease
progresses and nephrons are destroyed.
 Option C: Due to restricted foods and prescribed
dietary regimen, an individual experiencing renal
 problems cannot maintain ideal body weight and
sufficient nutrition. At the same time, patients may
experience anemia due to decreased erythropoietic
factors that cause a decrease in the production of RBC
causing anemia and fatigue.
 Option D: Assess the extent of weakness, fatigue,
ability to participate in active and passive activities.
Provides information about the impact of activities on
fatigue and energy reserves. Schedule care and
provide rest periods following an activity; allow the
client to set their own limits in the amount of exertion
tolerated.
37.37. Question

1 point(s)
Frequent PVCs are noted on the cardiac monitor of a patient with
end-stage renal disease. The priority intervention is:

o A. Call the doctor immediately.

o B. Give the patient IV lidocaine (Xylocaine).
o C. Prepare to defibrillate the patient.
o D. Check the patient’s latest potassium level.
Correct
Correct Answer: D. Check the patient’s latest potassium
level
The patient with ESRD may develop arrhythmias caused by
hypokalemia. The incidence of PVCs, as well as complex PVCs in
patients with ESRD, was comparable to that of the patients who
had had myocardial infarction but was significantly higher than
that found in low-risk subjects. The high incidence of complex
PVCs in patients with ESRD may predispose them to increased
cardiovascular death, and further investigation of this finding is
indicated.
 Option A: Call the doctor after checking the patient’s
potassium values. The observation that two distinct
patterns of arrhythmia appearance can be identified
among arrhythmic dialysis patients was first made by
Abe et al. They showed patients having almost
constant PCV throughout the 24-h ECG recording and
patients with a marked increase during dialysis and
the early post-dialysis period.
  Option B: Lidocaine may be ordered if the PVCs are
frequent and the patient is symptomatic. In
conventional HD with constant and low potassium
(range 0–2.5 mEq/l) a large amount of potassium is
abruptly removed from the extracellular space. Most
of this potassium originates from the cells, crosses the
cell membrane, the extracellular space (the blood),
and the dialysis membrane before reaching the
dialysate. The depletion of the potassium reserves
within the cells may have important repercussions on
cardiac electrophysiology.
 Option C: Potassium fluxes during HD have been
associated with an increase in QT interval, an increase
in the dispersion of QT, and in the inhomogeneous
repolarisation revealed by the analysis of the spatial
aspects of T-wave complexity. The resulting
repolarization heterogeneity allows for the onset of
distinctive reentrant arrhythmias, and hypokalemia
may act as a triggering factor in the genesis of
premature ventricular depolarisations.
38.38. Question

1 point(s)
A patient who received a kidney transplant returns for a follow-up
visit to the outpatient clinic and reports a lump in her breast.
Transplant recipients are:

o A. At increased risk for cancer due to

immunosuppression caused by cyclosporine (Neoral).
o B. Consumed with fear after the life-threatening experience
of having a transplant.
o C. At increased risk for tumors because of the kidney
transplant.
o D. At decreased risk for cancer, so the lump is most likely
benign.
Correct
Correct Answer: A. At increased risk for cancer due to
immunosuppression caused by cyclosporine (Neoral).
Cyclosporine suppresses the immune response to prevent
rejection of the transplanted kidney. The use of cyclosporine
places the patient at risk for tumors. Cyclosporine works to
 suppress cell-mediated immune reactions. Research has detected
no effects on phagocytic function in animals, and it does not
cause bone marrow suppression in animal or human models.
 Option B: Cyclosporine is a widely used
immunosuppressive drug, especially in transplant
patients. The majority of patients on cyclosporine can
be followed as outpatients by the nurse practitioner,
primary care provider, an internist, and the specialist.
The clinical staff must monitor cyclosporine levels
regularly to prevent acute rejection, nephrotoxicity,
and predictable dose-dependent adverse reactions.
 Option C: Decreases glomerular filtration rate (GFR)
due to an increased tone of the glomerular afferent
arterioles. Serum creatinine concentration rises and
decreases creatinine clearance. The undesirable
effects correlate with the duration of treatment and
dose.
 Option D: Cyclosporine is effective due to specific
and reversible inhibition of immunocompetent
lymphocytes in the G0 and G1-phase of the cell cycle.
The T-helper cell is the primary target, although it may
also suppress T-suppressor cells.
39.39. Question

1 point(s)
You’re developing a care plan with the nursing diagnosis risk for
infection for your patient that received a kidney transplant. A
goal for this patient is to:

o A. Remain afebrile and have negative cultures.

o B. Resume normal fluid intake within 2 to 3 days.
o C. Resume the patient’s normal job within 2 to 3 weeks.
o D. Try to discontinue cyclosporine (Neoral) as quickly as
possible.
Correct
Correct Answer: A. Remain afebrile and have negative
cultures.
The immunosuppressive activity of cyclosporine places the
patient at risk for infection, and steroids can mask the signs of
infection. The patient’s BUN creatinine ratio, magnesium levels,
and blood pressure require monitoring while on therapy. Uric acid
 monitoring is debatable. Therapeutic monitoring of cyclosporine
in transplant patients is a valuable tool in adjusting drug dosage
to prevent acute rejection, nephrotoxicity, and predictable dose-
dependent adverse reactions.
 Option B: The patient may not be able to resume
normal fluid intake or return to work for an extended
period of time and the patient may need cyclosporine
therapy for life. The range between effective
cyclosporine concentrations and the concentrations
associated with serious toxicity is fairly narrow. Sub-
optimal doses or concentrations can lead to
therapeutic failure or severe toxicity.
 Option C: Patients on cyclosporine are at a slight risk
of lymphoproliferative malignancies and infections;
thus, a thorough history and physical exam are vital at
each clinic visit. Cyclosporine therapy has a much
higher opportunity for patient success with the
communication and collaboration of an
interprofessional healthcare team.
 Option D: In solid organ transplantation, it has clinical
use for the treatment of organ rejection in kidney,
liver, and heart allogeneic transplants. Cyclosporine is
subject to therapeutic monitoring based on
pharmacokinetics measures. The medication has low-
to-moderate within-subject variability.
40.40. Question

1 point(s)
You suspect kidney transplant rejection when the patient shows
which symptoms?

o A. Pain in the incision, general malaise, and hypotension.

o B. Pain in the incision, general malaise, and depression.
o C. Fever, weight gain, and diminished urine output.
o D. Diminished urine output and hypotension.
Correct
Correct Answer: C. Fever, weight gain, and diminished
urine output.
Symptoms of rejection include fever, rapid weight gain,
hypertension, pain over the graft site, peripheral edema, and
diminished urine output. Kidney transplantation is the treatment
 of choice in patients with end-stage renal disease or severe
chronic kidney disease as it improves the quality of life and has
better survival advantages compared to dialysis. Various factors
merit consideration to match the donor kidney with the recipient,
as the donor kidney acts as an alloantigen.
 Option A: In general, when transplanting tissue or
cells from a genetically different donor to the graft
recipient, the alloantigen of the donor induces an
immune response in the recipient against the graft.
This response can destroy the graft if not controlled.
The whole process is called allograft rejection.
 Option B: Most patients who have acute rejection
episodes are asymptomatic and have abnormal
allograft dysfunction evidence from the routine blood
workups; when there is a sudden rise of serum
creatinine to more than 25% of the baseline value, the
clinicians should suspect allograft rejection.
 Option D: Even when the creatinine is not trending
down as expected in the early post-transplant phase,
the possibility of rejection should be a consideration.
Any new-onset or worsening proteinuria and new-
onset or worsening hypertension should raise the
suspicion for rejection.
41.41. Question

1 point(s)
Your patient returns from the operating room after abdominal
aortic aneurysm repair. Which symptom is a sign of acute renal
failure?

o A. Anuria
o B. Diarrhea
o C. Oliguria
o D. Vomiting
Correct
Correct Answer: C. Oliguria
Urine output less than 50ml in 24 hours signifies oliguria, an early
sign of renal failure. In patients with acute oliguria, one of the
most common functional derangements that are observed is the
sudden fall in the GRF, leading to acute renal failure. It results in
rapid increment in plasma urea and creatinine levels, metabolic
 acidosis with hyperkalemia, other electrolyte abnormalities, and
volume overload.
 Option A: Anuria is uncommon except in obstructive
renal disorders. Anuria is non-passage of urine, in
practice is defined as the passage of less than 100
milliliters of urine in a day. Anuria is often caused by a
failure in the function of the kidneys. It may also occur
because of some severe obstruction like kidney stones
or tumors.
 Option B: Acute diarrhea is defined as an episode
lasting less than 2 weeks. Infection most commonly
causes acute diarrhea. Most cases are the result of a
viral infection, and the course is self-limited. Chronic
diarrhea is defined as a duration lasting longer than 4
weeks and tends to be non-infectious. Common causes
include malabsorption, inflammatory bowel disease,
and medication side effects.
 Option D: When loss of kidney function is mild or
moderately severe, the kidneys cannot absorb water
from the urine to reduce the volume of urine and
concentrate it. Later, the kidneys have less ability to
excrete the acids normally produced by the body and
the blood becomes more acidic, a condition called
acidosis.
42.42. Question

1 point(s)
Which cause of hypertension is the most common in acute renal
failure?

o A. Pulmonary edema
o B. Hypervolemia
o C. Hypovolemia
o D. Anemia
Incorrect
Correct Answer: B. Hypervolemia
Acute renal failure causes hypervolemia as a result of
overexpansion of extracellular fluid and plasma volume with the
hypersecretion of renin. Therefore, hypervolemia causes
hypertension. Fluid overload leads to endothelial dysfunction due
to inflammation and ischemia-reperfusion injury, causing damage
 to glycocalyx and capillary leakage. Capillary leakage leads to
interstitial edema and at the same time, due to significant loss of
volume to the interstitial compartment, there is reduction in
circulating intravascular volume. This may then lead to reduction
in renal perfusion pressure and subsequently to AKI.
 Option A: Interstitial edema leads to impairment in
the diffusion of oxygen and metabolites from
capillaries to tissues. Interstitial edema increases
tissue pressure and leads to obstruction of lymphatic
drainage and disturbance in cell-to-cell interaction,
which will lead to progressive organ failure. The
kidney’s ability to accommodate increasing
hydrostatic interstitial pressures is limited due to renal
capsule, and thus all these effects are more
prominently seen in the kidney.
 Option C: Fluid overload is also known to cause
distension of atria and stretching of vessel walls,
causing a release of ANP, which further leads to EGL
damage, and cascade leads to AKI. Massive fluid
resuscitation and positive fluid balance are known risk
factors for intra-abdominal hypertension (IAH)
development. Elevated IAP leads to compression of
intra-abdominal vessels causing compromised
microvascular blood flow and increased renal venous
congestion. This results in impaired renal plasma flow
and decreased glomerular filtration rate, causing AKI.
 Option D: Acute kidney injury can be classified based
on the causative factor into intrinsic renal, prerenal,
and postrenal AKI. Prerenal causes contribute to the
majority of community-acquired cases of AKI. In the
case of prerenal AKI, fluid resuscitation is the gold
standard, but if this resuscitation continues beyond
the correction of hypovolemia, then it is associated
with increased morbidity, mortality, and length of
hospital stay as well as increased risk of AKI.
43.43. Question

1 point(s)
A patient returns from surgery with an indwelling urinary catheter
in place and empty. Six hours later, the volume is 120ml. The
drainage system has no obstructions. Which intervention has
priority?
 o A. Give a 500 ml bolus of isotonic saline.
o B. Evaluate the patient’s circulation and vital signs.
o C. Flush the urinary catheter with sterile water or saline.
o D. Place the patient in the shock position and notify the
surgeon.
Correct
Correct Answer: B. Evaluate the patient’s circulation and
vital signs.
A total UO of 120ml is too low. Assess the patient’s circulation
and hemodynamic stability for signs of hypovolemia. Normal
urine output is 1-2 ml/kg/hr. To determine the urine output of
your patient, you need to know their weight, the amount of urine
produced, and the amount of time it took them to produce that
urine.
 Option A: A fluid bolus may be required, but only
after further nursing assessment and a doctor’s order.
A decrease in output (to less than 400 ml per 24
hours) may indicate acute failure, especially in high-
risk patients. Accurate monitoring of I&O is necessary
for determining renal function and fluid replacement
needs and reducing the risk of fluid overload. Do note
that hypervolemia usually occurs in the anuric phase
of ARF and may mask the symptoms.
 Option C: Accurately record intake and output (I&O)
noting to include “hidden” fluids such as IV antibiotic
additives, liquid medications, frozen treats, ice chips.
Religiously measure gastrointestinal losses and
estimate insensible losses (sweating), including wound
drainage, nasogastric outputs, and diarrhea.
 Option D: Assess skin, face, dependent areas for
edema. Evaluate the degree of edema (on a scale of
+1–+4). Edema occurs primarily in dependent tissues
of the body, (hands, feet, lumbosacral area). The
patient can gain up to 10 lb (4.5 kg) of fluid before
pitting edema is detected. Periorbital edema may be a
presenting sign of this fluid shift because these fragile
tissues are easily distended by even minimal fluid
accumulation.
44.44. Question

1 point(s)
 You’re preparing for urinary catheterization of a trauma patient
and you observe bleeding at the urethral meatus. Which action
has priority?

o A. Irrigate and clean the meatus before catheterization.

o B. Check the discharge for occult blood before
catheterization.
o C. Heavily lubricate the catheter before insertion.
o D. Delay catheterization and notify the doctor.
Correct
Correct Answer: D. Delay catheterization and notify the
doctor.
Bleeding at the urethral meatus is evidence that the urethra is
injured. Because catheterization can cause further harm, consult
with the doctor. Urethral trauma can occur due to pelvic and
perineal injuries or iatrogenic trauma to the urethra. Urethral
bleeding as one of the complications of urethral trauma is not
usually life-threatening, nevertheless it can be very
embarrassing.
 Option A: Traditionally, direct pressure on the
bleeding site is the standard way to control
hemorrhage. Putting pressure on the perineum is the
only way we can reach this goal. In the perineum,
applying a pressure dressing over a solid object which
is fixed with adhesive bands to the lower abdomen is
the conventional method.
 Option B: The second method to control traumatic or
non-traumatic urethral bleeding is to apply
intermittent penile ligation. This intervention does not
permit bleeding through the urethra, increases
pressure at the bleeding site and helps homeostasis.
 Option C: Intermittent penile and continuous perineal
compression are methods that are taught but not
mentioned in the literature directly. Sometimes these
methods are ineffective and difficult to tolerate. In
applying this method, providing direct pressure on the
distal end of the urethra and also corpus spongiosum
and urethral arteries ceases the bleeding.
45.45. Question

1 point(s)
 What change indicates recovery in a patient with nephrotic
syndrome?

o A. Disappearance of protein from the urine.

o B. Decrease in blood pressure to normal.
o C. Increase in serum lipid levels.
o D. Gain in body weight.
Incorrect
Correct Answer: A. Disappearance of protein from the
urine.
With nephrotic syndrome, the glomerular basement membrane of
the kidney becomes more porous, leading to loss of protein in the
urine. As the patient recovers, less protein is found in the urine.
Albumin is a protein that acts like a sponge, drawing extra fluid
from the body into the bloodstream where it remains until
removed by the kidneys. When albumin leaks into the urine, the
blood loses its capacity to absorb extra fluid from the body,
causing edema.
 Option B: Nephrotic syndrome results from a problem
with the kidneys’ filters, called glomeruli. Glomeruli
are tiny blood vessels in the kidneys that remove
wastes and excess fluids from the blood and send
them to the bladder as urine.
 Option C: As blood passes through healthy kidneys,
the glomeruli filter out the waste products and allow
the blood to retain cells and proteins the body needs.
However, proteins from the blood, such as albumin,
can leak into the urine when the glomeruli are
damaged. In nephrotic syndrome, damaged glomeruli
allow 3 grams or more of protein to leak into the urine
when measured over a 24-hour period, which is more
than 20 times the amount that healthy glomeruli
allow.
 Option D: The loss of different proteins from the body
can lead to a variety of complications in people with
nephrotic syndrome. Blood clots can form when
proteins that normally prevent them are lost through
the urine. Blood clots can block the flow of blood and
oxygen through a blood vessel.
46.46. Question
1 point(s)
Which statement correctly distinguishes renal failure from
prerenal failure?

o A. With prerenal failure, vasoactive substances such

as dopamine (Intropin) increase blood pressure.
o B. With prerenal failure, there is less response to such
diuretics as furosemide (Lasix).
o C. With prerenal failure, an IV isotonic saline
infusion increases urine output.
o D. With prerenal failure, hemodialysis reduces the BUN
level.
Incorrect
Correct Answer: C. With prerenal failure, an IV isotonic
saline infusion increases urine output.
Prerenal failure is caused by such conditions as hypovolemia that
impairs kidney perfusion; giving isotonic fluids improves urine
output. Vasoactive substances can increase blood pressure in
both conditions. The cells in the macula densa are sensitive to
the increased delivery of NaCl and activate Type 2 adenosine
receptors resulting in vasoconstriction of the glomerular
arterioles and retraction of glomerular tufts. As a consequence
urine output is decreased and urinary excretion of sodium is
reduced providing a diagnostic flag of the tubular ischemic
process.
 Option A: In other clinical scenarios, renal
hypoperfusion can be present even in the presence of
normal blood pressure. Normotensive patients are
predisposed to renal hypoperfusion when intrinsic
renal structural changes from premorbid conditions
interfere with the reserve mechanisms, or extrinsic
factors impair the compensatory mechanisms.
 Option B: Under normal circumstances, almost 80%
of the NaCl is reabsorbed by the end of the thick
ascending limb of Henle’s loop. If there is a failure in
the tubular reabsorption mechanism, more NaCl will
reach this point. Loop diuretics reduce effective
intravascular volume and impair the autoregulatory
mechanism by interfering with the reabsorption of
NaCl by the macula densa cells.
  Option D: The most important parameter to
distinguish prerenal failure secondary to volume
depletion or hypotension from ATN is the response to
the fluid expansion. The return of the renal function to
the previous baseline within 24 to 72 hours is
considered to represent prerenal disease, whereas
persistent renal failure is called ATN.
47.47. Question

1 point(s)
Which criterion is required before a patient can be considered for
continuous peritoneal dialysis?

o A. The patient must be hemodynamically stable.

o B. The vascular access must have healed.
o C. The patient must be in a home setting.
o D. Hemodialysis must have failed.
Correct
Correct Answer: A. The patient must be hemodynamically
stable.
Hemodynamic stability must be established before continuous
peritoneal dialysis can be started. Starting dialysis with a PDC is
preferable to an HDC in terms of patient morbidity, mortality, and
cost. It has also been shown in large observational retrospective
studies that there is a survival advantage for PD over HD in the
first 1 to 3 years of dialysis.
 Option B: Patients selected for PD will undergo PD
catheter placement using one of the several
techniques described above. Once the catheter has
healed, they undergo technique training at a dialysis
unit for 2 to 3 weeks, learning the proper aseptic
technique to use the catheter for dialysis.
 Option C: Peritoneal dialysis is one of the modalities
utilized for dialysis. There are several advantages of
PD versus HD. Patients using PD will not need to leave
home every other day to get dialysis, rather they
perform their treatments at home using a very simple
principle for removing toxins from their body.
 Option D: The 2013 Annual Data Report from the
United States Renal Data System also shows a
significantly improved adjusted probability of 5-year
 survival with PD compared to HD. This early survival,
for the most part, may be explained by selection bias
because healthier patients may be more likely to
choose PD as their modality. Patients with comorbid
conditions tend to start HD after an acute illness and
have high early mortality that is wrongly attributed to
their HD modality.
48.48. Question

1 point(s)
Polystyrene sulfonate (Kayexalate) is used in renal failure to:

o A. Correct acidosis.
o B. Reduce serum phosphate levels.
o C. Exchange potassium for sodium.
o D. Prevent constipation from sorbitol use.
Incorrect
Correct Answer: C. Exchange potassium for sodium.
In renal failure, patients become hyperkalemic because they
can’t excrete potassium in the urine. Polystyrene sulfonate acts
to excrete potassium by pulling potassium into the bowels and
exchanging it for sodium. Sodium polystyrene sulfonate helps by
removing extra potassium from the body. Due to its slow onset of
action, it is a second-line agent in emergent situations. Data on
the non-FDA approved use of this drug is limited. This drug can
also help to remove excess calcium, sodium from solutions in
technical applications.
 Option A: Sodium polystyrene sulfonate (SPS) is an
insoluble polymer cation-exchange resin. After
ingestion of oral formulation or application through the
rectal route, this resin exchanges sodium with
potassium ions from the intestinal cells. Then the
potassium binds with SPS, continues to move through
the gastrointestinal tract, and is finally eliminated in
the feces. But sodium polystyrene sulfonate is not
selective for potassium; it may bind with calcium and
magnesium.
 Option B: The exchange capacity of SPS is
approximately 33% or 1 mEq of potassium per 1 gram
of resin, and this number is not constant. It may be as
low as 0.4 to 0.8 mEq/gram of SPS resin. Competition
 from other cations, especially sodium, calcium, and
magnesium, contributes to this reduction of this
exchange capacity.
 Option D: Clinicians should not use SPS in patients
who have abnormal bowel functions, such as bowel
obstruction, Ileus, and postoperative patients. Using
SPS in these patients may increase the risk of bowel
ischemia, necrosis, and serious constipation.
49.49. Question

1 point(s)
Your patient has complaints of severe right-sided flank pain,
nausea, vomiting, and restlessness. He appears slightly pale and
is diaphoretic. Vital signs are BP 140/90 mmHg, Pulse 118
beats/min., respirations 33 breaths/minute, and temperature,
98.0F. Which subjective data supports a diagnosis of renal
calculi?

o A. Pain radiating to the right upper quadrant.

o B. History of mild flu symptoms last week.
o C. Dark-colored coffee-ground emesis.
o D. Dark, scanty urine output.
Incorrect
Correct Answer: A. Pain radiating to the right upper
quadrant.
Patients with renal calculi will most likely report acute, severe
flank pain that will often radiate to the abdomen and especially to
the groin, testicle, and labia. It is often sharp and severe in
nature. It may also be colicky. The pain is often associated with
nausea and vomiting which is due to the embryological origins of
the urogenital tract.
 Option B: If infected, patients may also present with
fever, chills, or other systemic signs of infection. This
condition, called pyonephrosis or obstructive
pyelonephritis, is potentially severe and life-
threatening, requiring emergency decompression
surgery.
 Option C: Patients often present with hematuria as
85% of patients demonstrate at least microscopic
hematuria on urinalysis. The physical exam may
reveal costovertebral tenderness and hypoactive
 bowel sounds. The testis and pubic area may also be
tender to touch. Fever is rarely seen in renal colic but
the presence of fever, pyuria, and leukocytosis may be
indicative of pyelonephritis.
 Option D: Patients with renal calculi commonly have
blood in the urine caused by the stone’s passage
through the urinary tract. The urine appears dark,
tests positive for blood, and is typically scant. Renal
calculi are a common cause of blood in the urine
(hematuria) and pain in the abdomen, flank, or groin.
They occur in one in 11 people at some time in their
lifetimes with men affected 2 to 1 over women.
50.50. Question

1 point(s)
Immunosuppression following kidney transplantation is
continued:

o A. For life
o B. 24 hours after transplantation
o C. A week after transplantation
o D. Until the kidney is not anymore rejected
Correct
Correct Answer: A. For life.
After an organ transplant, the client will need to take
immunosuppressant (anti-rejection) drugs. These drugs help
prevent the immune system from attacking (“rejecting”) the
donor organ. Typically, they must be taken for the lifetime of the
transplanted organ. Organ rejection is a constant threat. Keeping
the immune system from attacking the transplanted organ
requires constant vigilance. So, it’s likely that the transplant team
will make adjustments to the anti-rejection drug regimen.
 Option B: One risk of a kidney transplant is that the
body will reject (fight) the new kidney. This can
happen if the body’s immune system realizes that the
kidney is from someone else. To prevent this from
happening, the client must take medicines to weaken
the immune system. These medicines are called
immunosuppressants, or anti-rejection medicines.
 Option C: Once the client recovered from the
transplant surgery, he may be able to start a new
 exercise routine. Exercise can help improve heart and
lung health, prevent weight gain and even improve
mood. Talk to the doctor about the types of exercise
that are right, how often one should exercise, and for
how long.
 Option D: Though kidney transplants are often
successful, there are some cases when they are not. It
is possible that the body may refuse to accept the
donated kidney shortly after it is placed in the body. It
is also possible the new kidney may stop working
overtime.
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