Case Studies and Practice Questions

1 A. Acute CareGladys Howe, a 67-year-old female in congestiveheart failure, was admitted to the hospital ICU. Inci -dence data indicate that hospitalized elderly patientsare susceptible to developing acute kidney injury(AKI). 1. The percentage of all hospitalized patients whomay develop AKI 8% 12% 18% 25%2. Approximately 20 60% of hospitalized patientswho develop AKI require dialysis. Scoringsystems are used to predict patient outcomes. The system that classifies patients based on theirglomerular filtration rate (GFR) and/or urineoutput in mL/kg/hr is The diagnosis of acute tubular necrosis (ATN), atype of ischemic intrarenal acute kidney injury,has been discussed with Ms. Howe and herfamily. ATN is usually associated with and concentrated and inability to concentrate and sodium and sodium is determined that Ms. Howe will require kidneyreplacement therapy (KRT), also known as renalreplacement therapy (RRT). The patient and familyhave decided on hemodialysis.

2 A dual lumen dialysiscatheter has been placed. During the hospitalization,she develops a vancomycin-resis tant enterococci(VRE) In preparing the acute dialysis station for , the nurse notices she is now in contactisolation for VRE. This will include performingwhich of the following? standard precautions and contactprecautions if the wound or bodily excretionsare not for a dedicated blood pressure cuffand the patient at a station with as fewadjacent stations as all of the While Ms. Howe has been receiving dialysis inthe acute unit, the staff has been following theCenters for Disease Control and Prevention(CDC) guidelines. These guidelines her dialysis catheter and fistuladressings at the same gloves when caring for the patientOR touching the patient s a mask and face shield to avoid airborneVRE all tasks before washing The nurse knows that the overuse of vancomycin(Vancocin) has been reported as a risk factor forpatients developing VRE. Which is the bestindication for using this drug?

3 Surgical positive blood cultures for coagulase-negative of methicillin-resistantStaphylococcus aureuscolonization (MRSA). due to beta-lactam-resistant gram-positive Nursing Certification Review Guide Fifth Edition7 The case Studies and Questions have been written by content experts. They have beenreviewed by practicing nurses in each specific specialty, and they reflect areas of practicethat may be addressed in the actual examination. Patients described in the case Studies arefictional and in no way reflect any persons living or deceased. Section 4 (page 32) contains an answer sheet that can be used to note your responses tothe Practice Questions , while page 33 contains all the answers. Then in Section 5, startingon page 35, you will find each correct answer written out, with a rationale explaining thereason for the answer. If there is evidence, then the reference is included. If there is noevidence cited, then the answer is based on expert opinion.

4 There are additional suggested readings at the end of the study guide (Section 6). Case Studies and Practice QuestionsSECTION3 Layout of CRG 1 2/1/16 3:36 PM Page 77. Currently the staff is following routine standardprecautions with Ms. Howe. However, during theassessment, Ms. Howe complains of havinguncontrolled diarrhea. Ms. Howe s plan of carewill have treatment set up in a separate roomor use the automated blood pressure wear gloves while in the cleansed with 1:1000 dilutedbleach. William Day, a 65-year-old retired laborer, wasdiagnosed with proteinuria 10 years ago. He has along history of hypertension, congestive heart failure,and decreasing GFR. He takes furosemide (Lasix) 80mg daily. He is admitted to the emergency room inacute fluid overload. 8. When doing a physical assessment of Mr. Day,one clinical sign the nurse may find dry oral Mr. Day has declining kidney function due tohypertension. The nurse knows the physiologicprinciple causing hypertension is believed to beincreased production hormone (ADH).

5 Naturiuretic hormone (ANP). During his hospital stay, Mr. Day is started oncaptopril (Capoten) mg 3 times a day. Whatclass of antihypertensive medication is this drug? enzyme (ACE) channel vasodilating adrenergic Day is discharged from the hospital and started onLopressor (metroprolol tartrate) 50 mg PO bid. 11. Discharge teaching for a patient on Lopressorwould include discussion of which of thefollowing side effects? hands and of the After educating Mr. Day regarding his medication,he states, Because I take blood pressure pills, do Ineed to learn how to take my blood pressure? The nurse s response is based on the ability increases with is processed in discrete concepts enhances feedback fosters Murray, a 44-year-old male, is admitted to theMedical ICU with a diagnosis of malignant hyper -tension and kidney failure. He weighs 80 kg and isbeing treated with a sodium nitroprusside (Nipride)drip of 50 mg/250 mL D5W. The drip is being titrated tomaintain his systolic blood pres sure at 120 mmHg.

6 Adual lumen catheter is placed for hemo dialysis. Serum blood values include blood urea nitrogen(BUN) 200 mg/dL, creatinine mg/dL, mEq/L, and carbon dioxide (CO2) 12 With a BUN of 200 mg/dL, the nurse wouldexpect Mr. Murray s neural examination to show of of upper and slowly reactive and Since Mr. Murray has hyperkalemia, the nursewill monitor closely for potential Noting Mr. Murray s laboratory values anddiagnosis, the nurse will provide patient all treatment modalities before dialysis since the process of dialysiscan be Mr. Murray starts to ask questionsindicating that he is ready to a standardized teaching format For Mr. Murray s initial hemodialysis, the nursemight be asked to decrease the blood flow rate,use a dialyzer with a lower coefficient, ordecrease dialysate flow. What is the bestrationale for this process? will minimize complications associated witha Nipride will minimize complications associated withmalignant will reduce trauma at the dual lumencatheter insertion will decrease diffusion of urea across theblood-brain barrier, reducing the possibility ofcerebral 3.

7 Case Studies and Practice Questions Acute Care8 Nephrology Nursing Certification Review Guide Fifth Edition Layout of CRG 1 2/1/16 3:36 PM Page 8A. Acute 13-18%. AKI develops in 13 18% of allhospitalized patients. One in 5 adults and 1 in 3children experience AKI during ahospitalization. Fallone, S., & Cotton, (2015). Acute kidney injury. In (Ed.), Core curriculum for nephrology nursing: Module4. Acute kidney injury(6th ed., p. 22). Pitman, NJ: AmericanNephrology Nurses , Injury, Failure, Loss, and End-stage kidney failure. Patients are classifiedbased on estimated GFR ranges and/or urineoutput. May be helpful in deciding when toinitiate , S., & Cotton, (2015). Acute kidney injury. In (Ed.), Core curriculum for nephrology nursing: Module4. Acute kidney injury(6th ed., p. 23). Pitman, NJ: AmericanNephrology Nurses oliguria and inability to usually associated with oliguriabecause of the extensive nephron , S., & Cotton, (2015). Acute kidney injury.

8 In (Ed.), Core curriculum for nephrology nursing: Module4. Acute kidney injury(6th ed., p. 31). Pitman, NJ: AmericanNephrology Nurses Perform all of the above. A to C are allpart of CDC guidelines for preventing the trans -missionof infections among chronic , , Counts, , German, S., Holloway, K.,Howard, L., & Wiseman, K. (2015). Foundations in infectionprevention, control, and clinical applications in nephrologynursing. In Counts (Ed.), Core curriculum for nephrologynursing: Module 2. Physiologic and psychosocial basis fornephrology nursing Practice (6th ed., p. 345). Pitman, NJ:American Nephrology Nurses wearing gloves when caring for thepatient OR touching the patient gloves is an importantpart of the CDC guidelines. The nurse shouldalso remember to sanitize hands after removinggloves and before moving to the next patient. Peacock, , Counts, German, S., Holloway, K., Howard,L., & Wiseman, K. (2015). Foundations in infectionprevention, control, and clinical applications in nephrologynursing.

9 In Counts (Ed.), Core curriculum for nephrologynursing: Module 2. Physiologic and psychosocial basis fornephrology nursing Practice (6th ed., p. 387). Pitman, NJ:American Nephrology Nurses Infections due to beta-lactam-resistantgram-positive useand overuse of antibiotics play a large role in thedevelopment of antibiotic-resistant antibiotics such as Ancef (cefazolin) arereasonable substitutes in many situations. Thisreduces the use of vancomycin and the risk forVRE. Peacock, , Counts, , German, S., Holloway, K.,Howard, L., & Wiseman, K. (2015). Foundations in infectionprevention, control, and clinical applications in nephrologynursing. In Counts (Ed.), Core curriculum for nephrologynursing: Module 2. Physiologic and psychosocial basis fornephrology nursing Practice (6th ed., p. 341). Pitman, NJ:American Nephrology Nurses dialysis treatment set up in a separateroom or CDC guidelines, separatingMs. Howe from the other patients as much aspossible will help prevent the transmission , , Counts, German, S.

10 , Holloway, K., Howard,L., & Wiseman, K. (2015). Foundations in infectionprevention, control, and clinical applications in nephrologynursing. In Counts (Ed.), Core curriculum for nephrologynursing: Module 2. Physiologic and psychosocial basis fornephrology nursing Practice (6th ed., p. 343). Pitman, NJ:American Nephrology Nurses liver congestion. Pulmonary edemaincreases pressure in the right atrium. Thepressure can then back up into the liver causingcongestion and swelling. Greco, K., & Mahon, (2015). The kidney in health anddisease: Genetics and genomics. In Counts (Ed.), Corecurriculum for nephrology nursing: Module 2. Physiologic andpsychosocial basis for nephrology nursing Practice (6th ed., p. 98). Pitman, NJ: American Nephrology Nurses , B. (2015), Hemodialysis in the acute setting:Prehemodialysis patient assessment. In Counts (Ed.), Core curriculum for nephrology nursing: Module 4. Acutekidney injury(6th ed., p. 65, Table ). Pitman, NJ:American Nephrology Nurses renin.