NCLEX Renal & Urinary questions
The PrepScore bank has 71 Renal & Urinary questions, each with a rationale and two tags: the Client Needs category from the test plan and the clinical judgment step it tests. In this topic the items lean on Take action and Generate solutions, which is worth knowing before you practise it. Three worked samples are below, answers behind a reveal.
CKD stages, hemodialysis + AV fistula, peritoneal dialysis + peritonitis, kidney transplant, nephrolithiasis, BPH retention, complicated UTI, glomerulonephritis, urostomy care, multi-patient priority.
Three worked questions
Q1. A patient with AKI has the following labs. The nurse identifies the MOST concerning finding. Which is MOST concerning?
- A. BUN 50 (elevated, expected in AKI)
- B. K 7.0 + ECG peaked T waves (life-threatening hyperkalemia — HIGHEST priority; URGENT: calcium gluconate IV for ECG protection + insulin/D50 + albuterol + K binder + dialysis if refractory)
- C. Cr 3.5 (elevated, expected)
- D. HCO3 18 (mild acidosis)
Show answer and rationale
Answer: K 7.0 + ECG peaked T waves (life-threatening hyperkalemia — HIGHEST priority; URGENT: calcium gluconate IV for ECG protection + insulin/D50 + albuterol + K binder + dialysis if refractory)
K 7.0 + ECG changes = life-threatening hyperkalemia. HIGHEST priority. URGENT Ca gluconate + insulin/D50 + albuterol + binder + dialysis if refractory.
Q2. A patient develops acute hyperkalemia (K 7.0) + ECG changes (peaked T waves). The nurse activates emergency management. Which interventions are INDICATED? Select all that apply.
- A. Calcium gluconate IV 1-2 g (10% solution) — STABILIZES CARDIAC MEMBRANE within minutes (NOT K-lowering); repeat if ECG changes persist
- B. Regular INSULIN 10 units IV + D50 25 g IV (shifts K intracellularly; onset 15-30 min, duration 4-6 h)
- C. Albuterol nebulized 10-20 mg (shifts K intracellularly; onset 30 min)
- D. K BINDER (sodium zirconium cyclosilicate / patiromer / sodium polystyrene sulfonate) — removes K from body
- E. Loop diuretic (furosemide) if not anuric; HEMODIALYSIS if severe + refractory + uremic
- F. Give IV potassium (UNSAFE — already hyperkalemic)
Show answer and rationale
Answer: Calcium gluconate IV 1-2 g (10% solution) — STABILIZES CARDIAC MEMBRANE within minutes (NOT K-lowering); repeat if ECG changes persistRegular INSULIN 10 units IV + D50 25 g IV (shifts K intracellularly; onset 15-30 min, duration 4-6 h)Albuterol nebulized 10-20 mg (shifts K intracellularly; onset 30 min)K BINDER (sodium zirconium cyclosilicate / patiromer / sodium polystyrene sulfonate) — removes K from bodyLoop diuretic (furosemide) if not anuric; HEMODIALYSIS if severe + refractory + uremic
Acute hyperkalemia bundle: Ca gluconate (stabilize) + insulin/D50 + albuterol (shift) + K binder (remove) + loop diuretic if not anuric + HD if severe/refractory.
Q3. A patient with stage 4 CKD (eGFR 22) is being counseled on diet. Which modifications are APPROPRIATE? Select all that apply.
- A. RESTRICT sodium to < 2 g/day (BP control, fluid management)
- B. RESTRICT potassium if elevated (< 2-3 g/day individualized; avoid: bananas, citrus, potatoes, tomatoes, dried fruits, salt substitutes)
- C. RESTRICT phosphate (< 800-1000 mg/day; avoid processed foods, dairy, cola, nuts, beans); take phosphate binders with meals
- D. MODERATE protein restriction (0.6-0.8 g/kg/day for stage 4 non-dialysis; once on dialysis adequate protein 1.0-1.2 g/kg/day)
- E. Fluid management individualized (no strict restriction unless edema/hyponatremia/dialysis)
- F. High-potassium high-phosphate diet (CONTRAINDICATED for stage 4 CKD)
Show answer and rationale
Answer: RESTRICT sodium to < 2 g/day (BP control, fluid management)RESTRICT potassium if elevated (< 2-3 g/day individualized; avoid: bananas, citrus, potatoes, tomatoes, dried fruits, salt substitutes)RESTRICT phosphate (< 800-1000 mg/day; avoid processed foods, dairy, cola, nuts, beans); take phosphate binders with mealsMODERATE protein restriction (0.6-0.8 g/kg/day for stage 4 non-dialysis; once on dialysis adequate protein 1.0-1.2 g/kg/day)Fluid management individualized (no strict restriction unless edema/hyponatremia/dialysis)
Stage 4 CKD diet: low Na, individualized K + P restriction, moderate protein, individualized fluid.
The rules that decide these questions
From the pack's rule cards — the reasoning shortcuts a wrong answer usually means you were missing.
Stage 1: eGFR ≥ 90 with kidney damage. Stage 2: 60-89. Stage 3a: 45-59. Stage 3b: 30-44. Stage 4: 15-29 — refer to nephrology, prep for RRT (vascular access, modality choice, transplant evaluation). Stage 5: < 15 — RRT typically initiated. Diet: protein restriction in advanced stages, potassium + phosphorus restriction, fluid as ordered.
Auscultate bruit + palpate thrill q shift = patency. NO BP, IV access, venipuncture, lab draws, or restrictive clothing/jewelry on the fistula arm. Avoid sleeping on it. Watch for steal syndrome (cold + numb + pale distal hand). Patient teaches: don't carry heavy bags on that arm; report numbness, coolness, no thrill.
Cloudy effluent ± abdominal pain + fever = PD peritonitis. Send effluent for cell count + gram stain + culture. Start empiric intraperitoneal antibiotics per protocol (covers gram + / gram -). Do NOT discontinue PD — IP antibiotics need PD route to work. Reinforce sterile technique + connectology training to prevent recurrence.
Acute rejection presents with fever, graft tenderness, rising creatinine, decreased UO, HTN, weight gain. Workup: tacrolimus level, BUN/Cr, UA, ultrasound (rule out obstruction), and renal biopsy (gold standard). Treatment: pulse steroids for cellular; anti-thymocyte globulin or plasmapheresis for antibody-mediated. NEVER stop immunosuppression unilaterally — adjust under guidance.
Severe colicky flank → groin pain + hematuria. NSAIDs (e.g., ketorolac) first-line for pain (reduce ureteral spasm). Tamsulosin for 5-10 mm distal ureteral stones (medical expulsive therapy). Strain urine + send stone for analysis. For calcium oxalate: maintain dietary calcium (binds oxalate in gut), reduce oxalate (spinach, beets, nuts, chocolate, tea), low sodium, hydrate to 2-3 L/day urine.
Bladder scan to confirm. For volumes > 800-1000 mL, drain 500-1000 mL initially then clamp + pause 15-30 min before continuing (rapid drainage = mucosal hemorrhage + vasovagal hypotension). Prefer straight cath for one-time; Foley if recurrent. Monitor for post-obstructive diuresis (UO > 200 mL/hr) — replace fluids + monitor electrolytes.
Practise the whole pack, tagged and explained
Every item carries its Client Needs category and clinical judgment step, so a wrong answer names the step that failed.
Frequently asked questions
How many Renal & Urinary questions does the bank have?
71 multiple-choice items, plus 10 unfolding cases in the Renal & Urinary pack, each with a rationale.
Are the samples real bank items?
Yes — the three questions above are drawn from the live bank, with their real rationales and tags.
Which clinical judgment steps does this topic train?
Most items in this topic test Take action and Generate solutions, though every step appears.
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