Acute kidney injury and its electrolyte consequences are core med-surg content on the CMSRN. Drill the prerenal/intrarenal/postrenal, creatinine, and dialysis scenarios below with full rationales.
Question 1
A diabetic patient with heart failure is transferred from ICU to med-surg. The ICU medication list includes sliding-scale insulin and metformin 1000mg BID. The admitting nurse notes serum creatinine rose from 1.2 to 2.1 mg/dL during ICU stay. Which reconciliation action is essential?
- A) A) Continuing metformin with renal function monitoring
- B) B) Holding metformin until nephrology consultation✓
- C) C) Requesting sitagliptin as a substitute therapy
- D) D) Reducing metformin dose by 50% immediately
Show rationale
Metformin is contraindicated in acute kidney injury (creatinine ≥1.5 mg/dL for males) due to lactic acidosis risk per FDA guidelines. Option A ignores the absolute contraindication. Option C is premature without prescriber input. Option D is unsafe since no dose adjustment eliminates AKI risks. Option B prioritizes safety by withholding metformin until renal function stabilizes and specialist input is obtained, consistent with American Diabetes Association recommendations.
Question 2
A nurse reviews a prescription for intravenous vancomycin every 12 hours in a 60-year-old with cellulitis, normal renal function, and no MRSA risk factors. Initial cultures grew MSSA. Which nursing action upholds stewardship principles?
- A) A) Administer vancomycin as ordered and monitor troughs
- B) B) Consult pharmacy for IV-to-oral step-down therapy options
- C) C) Contact the provider to suggest switching to cefazolin✓
- D) D) Delay administration pending infectious disease consultation
Show rationale
Stewardship requires using narrowest-spectrum effective agents. Cefazolin is preferred for MSSA as it’s less nephrotoxic and reduces vancomycin overuse. Administering vancomycin (A) perpetuates inappropriate broad-spectrum use. Step-down therapy (B) is premature since IV beta-lactams outperform oral alternatives for cellulitis. Infectious disease consult (D) delays necessary intervention. CDC Core Elements state nurses should advocate for guideline-concordant therapy; MSSA infections warrant beta-lactams over vancomycin.
Question 3
A patient with end-stage renal disease receives hemodialysis three times weekly while managing poorly controlled hypertension. They miss appointments due to transportation barriers. Which model most effectively coordinates community resources and treatment adherence?
- A) A) Chronic Care Model optimizing clinic-based systems
- B) B) Community-Based Care Coordination linking to transportation services✓
- C) C) Telehealth with remote blood pressure monitoring
- D) D) Transitional Care Model with post-hospitalization follow-up
Show rationale
This model directly addresses transportation barriers through community partnerships, ensuring consistent dialysis attendance. The Chronic Care Model (A) improves clinic processes but doesn't resolve external barriers. Telehealth (C) monitors hypertension but not transportation gaps. Transitional Care (D) targets post-hospitalization periods, not chronic treatment adherence.
Question 4
A family demands continued dialysis for a brain-dead patient, insisting recovery is possible despite two confirmatory tests. The nurse notes the patient’s advance directive designates the sibling (not present) as surrogate. What should the nurse advocate for?
- A) A) Continue dialysis until the sibling arrives
- B) B) Cease treatment based on brain death criteria✓
- C) C) Obtain a court order to override the family
- D) D) Transfer care to avoid ethical conflict
Show rationale
Brain death constitutes legal death, making treatment ethically and legally unnecessary. Option B prevents non-beneficial interventions while conserving resources. Option A disregards established death criteria. Option C is premature without involving the designated surrogate. Option D abandons ethical responsibility. AMSN guidelines recognize brain death as irreversible; nurses must advocate to discontinue interventions, regardless of family objections, once legal death criteria are met.
Question 5
A 68-year-old patient with Crohn's disease and new-onset atrial fibrillation is receiving TPN. Current labs show potassium 5.8 mEq/L, glucose 220 mg/dL, and creatinine 1.9 mg/dL. The nurse notes the TPN solution contains 40 mEq/L potassium and 250 g dextrose. Which component adjustment is most urgently needed?
- A) A) Reduce dextrose concentration to 150 g/L and maintain current potassium
- B) B) Discontinue potassium additives and increase dextrose to 300 g/L
- C) C) Eliminate potassium from TPN and reduce dextrose to 200 g/L✓
- D) D) Halve potassium concentration and add sliding-scale insulin coverage
Show rationale
Hyperkalemia (K⁺ 5.8 mEq/L) and acute kidney injury (creatinine 1.9 mg/dL) contraindicate potassium administration. Concurrent hyperglycemia (220 mg/dL) with renal impairment necessitates dextrose reduction to prevent osmotic diuresis. Option A ignores hyperkalemia. Option B worsens hyperglycemia. Option D inadequately addresses hyperkalemia (halving potassium remains unsafe) and adds unnecessary insulin complexity. TPN safety standards require immediate electrolyte correction and glycemic control to prevent cardiac arrhythmias.
Question 6
A home-bound patient with severe heart failure takes spironolactone, bumetanide, and digoxin. Their BP is 88/50 mmHg, and they report dizziness when standing. Recent labs show K+ 5.6 mEq/L and Cr 2.1 mg/dL. Which medication action is most urgent?
- A) A) Hold spironolactone and notify the cardiologist today✓
- B) B) Skip the next bumetanide dose and recheck weight tomorrow
- C) C) Administer all medications with increased fluid intake
- D) D) Reduce digoxin dose and repeat labs next week
Show rationale
Hyperkalemia (K+ 5.6) with AKI (Cr 2.1) and hypotension requires immediate spironolactone hold—it worsens all three risks. Holding bumetanide (B) could precipitate fluid overload in heart failure. Increasing fluids (C) exacerbates hyponatremia and hypertension. Digoxin reduction (D) doesn't address the emergent electrolyte imbalance. AMSN protocols prioritize potassium management in renal impairment for patients on aldosterone antagonists.
Question 7
Post-MH crisis, the patient has elevated CK levels. Which finding warrants immediate action?
- A) A) CK 15,000 IU/L with clear urine output
- B) B) CK 20,000 IU/L with urine pH 5.0
- C) C) CK 8,000 IU/L with fractional excretion of sodium 2%
- D) D) CK 25,000 IU/L with urine myoglobin >10,000 ng/mL✓
Show rationale
High myoglobinuria with elevated CK indicates severe rhabdomyolysis requiring urgent hydration/alkalinization to prevent renal failure per nephrology guidelines. Isolated CK elevation (A,C) may be monitored. Acidic urine (B) exacerbates myoglobin toxicity but myoglobin level is the critical discriminator for tubular injury risk.
Question 8
In an ICU patient with MRSA bacteremia on vancomycin, troughs are consistently 18-20 mcg/mL. After 72 hours, repeat cultures are negative, but creatinine rises from 1.0 to 1.8 mg/dL. Which adjustment supports stewardship?
- A) A) Continue vancomycin and add gentamicin for synergistic effect
- B) B) Switch to daptomycin and monitor CPK levels twice weekly
- C) C) Reduce vancomycin dose to target troughs of 10-15 mcg/mL✓
- D) D) Discontinue vancomycin and initiate linezolid orally
Show rationale
Stewardship optimizes dosing to minimize toxicity while maintaining efficacy. High vancomycin troughs increase nephrotoxicity risk without proven benefit in uncomplicated bacteremia. Dose reduction balances efficacy and safety. Adding gentamicin (A) exacerbates nephrotoxicity unnecessarily. Daptomycin (B) or linezolid (D) are costly alternatives without clear superiority for resolving infection. IDSA MRSA guidelines recommend troughs of 15-20 mcg/mL only for complex infections, with lower targets if toxicity occurs.
Question 9
A nurse is reconciling home medications for a 68-year-old patient admitted for heart failure exacerbation. The patient has chronic kidney disease (Stage 3) and reports taking ibuprofen 400mg TID for arthritis. The EHR medication reconciliation module flags ibuprofen. What is the nurse's most appropriate EHR action?
- A) A) Document the patient's self-report and proceed to the next medication.
- B) B) Override the alert, noting the patient's long-term use without issues.
- C) C) Initiate an EHR alert for the provider regarding potential renal risk.✓
- D) D) Discontinue ibuprofen immediately in the EHR medication list.
Show rationale
The alert flags a known nephrotoxin (ibuprofen) in a patient with renal impairment (CKD Stage 3), requiring provider notification for review and potential alternative therapy (discriminating cues: comorbidity, medication class). Option A neglects the safety alert. Option B inappropriately overrides a clinically significant alert. Option D exceeds nursing scope; medication changes require provider order.
Question 10
A medical-surgical nurse receives an alert for a critical potassium result of 2.8 mEq/L in a 72-year-old diabetic patient with heart failure who is prescribed IV furosemide. When documenting the intervention, which action best demonstrates data integrity according to nursing informatics principles?
- A) A) Documenting Critical lab result addressed per protocol in the progress notes within one hour
- B) B) Recording the potassium value, timestamp of notification, and specific actions taken in the EHR flowsheet immediately✓
- C) C) Adding a comment in the medication administration record about holding the next furosemide dose
- D) D) Notifying the charge nurse verbally and noting the conversation in the shift handoff report
Show rationale
Data integrity requires accurate, complete, and timely documentation. Option B captures objective data (value), timing, and interventions, creating an auditable trail per informatics standards. Option A lacks specificity, violating completeness principles. Option C focuses only on medication changes without documenting the critical result notification, omitting key data. Option D relies on verbal communication and delayed documentation in shift report, risking data loss. The elderly patient's comorbidities (diabetes, heart failure) and nephrotoxic medication (furosemide) heighten urgency for precise documentation to prevent adverse outcomes.
Question 11
A 68-year-old patient with osteoarthritis, hypertension controlled with lisinopril, and stage 3 chronic kidney disease (eGFR 45 mL/min) reports worsening knee pain. Which analgesic is safest for short-term use?
- A) A) Ibuprofen 400 mg every 6 hours as needed
- B) B) Naproxen 500 mg twice daily as needed
- C) C) Celecoxib 200 mg daily as needed
- D) D) Acetaminophen 1000 mg every 6 hours as needed✓
Show rationale
Acetaminophen is safest here due to minimal renal impact, unlike NSAIDs (A, B, C) which reduce renal perfusion and worsen CKD. The patient's CKD (eGFR 45) and hypertension amplify NSAID risks like acute kidney injury. Celecoxib (C) avoids antiplatelet effects but still harms renal function. Ibuprofen (A) and naproxen (B) pose additional cardiovascular risks in hypertension. Guidelines (e.g., American Geriatrics Society) prioritize acetaminophen for mild-moderate pain in CKD. Distractors ignore renal cues; only D aligns with both renal protection and pain control needs.
Question 12
A provider verbally orders "metformin 1000 mg now" for a diabetic patient with cellulitis. The nurse notes the patient's creatinine is 2.2 mg/dL and blood glucose is 250 mg/dL. Which action aligns with safe practice?
- A) A) Administer metformin and encourage increased oral fluid intake
- B) B) Withhold metformin and recheck creatinine in 6 hours before giving
- C) C) Question the order due to renal impairment contraindication✓
- D) D) Administer half the dose and monitor for gastrointestinal side effects
Show rationale
Metformin is contraindicated when creatinine >1.5 mg/dL (male) due to lactic acidosis risk. Option A ignores this hazard. Option B delays necessary hyperglycemia management. Option D doesn't mitigate acidosis risk as reduced dosing remains unsafe. Option C correctly questions the order per FDA black box warnings requiring metformin avoidance in renal impairment.
Question 13
A nurse triages earthquake survivors in a school gym. A 50-year-old with crush injuries to both legs develops oliguria and ECG showing peaked T-waves. Community labs report disrupted creatinine testing. Which resource is essential?
- A) A) Coordinate helicopter transport to a trauma center with dialysis.✓
- B) B) Administer kayexalate from the shelter's renal emergency kit.
- C) C) Mobilize physical therapy volunteers for compartment syndrome checks.
- D) D) Request point-of-care electrolyte analyzers from FEMA supplies.
Show rationale
Oliguria and hyperkalemia (peaked T-waves) suggest rhabdomyolysis requiring emergent dialysis. Option A enables life-saving intervention. Option B (kayexalate) is slower and less effective. Option C misses renal implications. Option D (testing) delays treatment for diagnosis.
Question 14
A non-English-speaking patient repeatedly misses dialysis appointments. The nurse learns transportation is unreliable and he fears losing his job. Which intervention respects both rights and responsibilities?
- A) A) Schedule all appointments at his workplace for convenience
- B) B) Explain that non-adherence voids his insurance coverage
- C) C) Arrange evening sessions and confirm ride assistance programs✓
- D) D) Transfer care to a closer facility without his input
Show rationale
Patients have a responsibility to attend treatment but a right to reasonable accommodations. Option C addresses barriers collaboratively. Option A assumes employer flexibility without consent. Option B threatens inappropriately. Option D violates autonomy in care decisions. The CMS Hospital Conditions of Participation require addressing access barriers, including language and transport.
Question 15
A 72-year-old with stage 3 CKD and heart failure develops new confusion and reduced urine output 48 hours after starting ibuprofen for arthritis pain. Which finding most strongly suggests an adverse drug reaction?
- A) A) Blood pressure increase from 130/80 to 150/90 mmHg
- B) B) Serum creatinine rising from 1.2 to 2.0 mg/dL in 24 hours✓
- C) C) New-onset bilateral ankle edema and crackles in lung bases
- D) D) Potassium level of 5.0 mEq/L on routine electrolyte panel
Show rationale
NSAIDs like ibuprofen cause acute kidney injury in CKD patients by reducing renal perfusion. A rapid creatinine rise with oliguria directly indicates nephrotoxicity, aligning with drug initiation timing. Option A reflects hypertension, which NSAIDs can exacerbate but isn't specific to kidney injury. Option C suggests heart failure exacerbation, which NSAIDs may worsen but isn't a direct ADR. Option D shows mild hyperkalemia, which could be multifactorial and lacks specificity to NSAID toxicity.
