Renal failure NCLEX-RN Practice Questions

Renal failure NCLEX-RN Practice Questions

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Renal failure NCLEX-RN Practice Questions help you master high-yield clinical reasoning for acute kidney injury (AKI) and chronic kidney disease (CKD) within the NCLEX-RN framework under the Physiological Adaptation domain. In this set, you’ll analyze fluid and electrolyte imbalances, interpret renal labs, and prioritize care for life-threatening complications such as hyperkalemia, metabolic acidosis, and uremic manifestations. You’ll also refine judgment on dialysis indications, vascular access care, medication dose adjustments, and evidence-based nutrition for CKD. Each question aligns with NCLEX-style clinical scenarios to build confidence in triage, interventions, and patient education. Use these 30 practice questions to sharpen your ability to synthesize data and choose safe, effective nursing actions for patients with renal failure.

Q1. Which set of findings most strongly suggests prerenal azotemia as the cause of acute kidney injury?

  • BUN:Creatinine ratio 10:1, urine sodium 60 mEq/L, FeNa 3%
  • BUN:Creatinine ratio 25:1, urine sodium 10 mEq/L, FeNa 0.5%
  • BUN:Creatinine ratio 15:1, urine sodium 40 mEq/L, FeNa 2%
  • BUN:Creatinine ratio 12:1, urine osmolality 200 mOsm/kg, granular casts present

Correct Answer: BUN:Creatinine ratio 25:1, urine sodium 10 mEq/L, FeNa 0.5%

Q2. A patient with CKD presents with K+ 7.2 mEq/L and ECG showing tall peaked T waves. What is the nurse’s priority action?

  • Administer IV calcium gluconate
  • Give sodium polystyrene sulfonate PO
  • Start loop diuretic infusion
  • Encourage oral fluids

Correct Answer: Administer IV calcium gluconate

Q3. A 70-kg postoperative patient with suspected AKI has had 140 mL urine output over the last 8 hours. Which interpretation is most accurate?

  • Urine output is adequate and expected postoperatively
  • Oliguria is present and requires prompt evaluation
  • Anuria is present and requires emergent dialysis
  • Polyuria is present and suggests recovery phase

Correct Answer: Oliguria is present and requires prompt evaluation

Q4. A dehydrated patient with vomiting and hypotension develops AKI. Which order should the nurse implement first to address the likely cause?

  • Infuse 0.9% normal saline bolus
  • Start D5W at 125 mL/hr
  • Administer 0.45% normal saline
  • Give IV furosemide

Correct Answer: Infuse 0.9% normal saline bolus

Q5. A patient with stage 4 CKD has Hgb 9.0 g/dL, ferritin 200 ng/mL, TSAT 25%, BP controlled. Which finding supports starting epoetin alfa?

  • Hgb 11.5 g/dL, ferritin 90 ng/mL
  • Hgb 9.0 g/dL, ferritin 200 ng/mL
  • Hgb 8.6 g/dL, TSAT 12%
  • Hgb 10.8 g/dL, uncontrolled hypertension

Correct Answer: Hgb 9.0 g/dL, ferritin 200 ng/mL

Q6. A patient with ESRD reports chest pain and has a pericardial friction rub and asterixis. Which action is the priority?

  • Administer PRN morphine for pain control
  • Prepare the patient for urgent dialysis
  • Apply oxygen at 2 L/min via nasal cannula
  • Obtain a stat troponin level

Correct Answer: Prepare the patient for urgent dialysis

Q7. Which snack is most appropriate for a non-dialysis CKD patient on a low-potassium, low-phosphorus diet?

  • Banana with peanut butter
  • Orange juice and yogurt
  • Apple slices with rice cakes
  • Baked potato with skin

Correct Answer: Apple slices with rice cakes

Q8. The nurse reviews medications for a patient with ESRD. Which medication should be questioned?

  • Magnesium hydroxide for constipation
  • Calcium carbonate with meals
  • Sevelamer with meals
  • Famotidine for GERD

Correct Answer: Magnesium hydroxide for constipation

Q9. A patient with CKD needs iodinated contrast for a CT scan. Which order aligns best with renal-protective practice?

  • Hold all fluids NPO for 12 hours pre-procedure
  • Administer isotonic IV fluids before and after contrast
  • Start high-dose loop diuretic before contrast
  • Give high-protein supplements before the scan

Correct Answer: Administer isotonic IV fluids before and after contrast

Q10. A peritoneal dialysis patient has abdominal pain and cloudy effluent. What is the priority nursing action?

  • Warm the dialysate to body temperature
  • Collect effluent for cell count, Gram stain, and culture
  • Increase dextrose concentration of dialysate
  • Clamp the catheter and notify surgery

Correct Answer: Collect effluent for cell count, Gram stain, and culture

Q11. Which teaching indicates correct care of an arteriovenous (AV) fistula?

  • “I will allow blood draws from my fistula to preserve other veins.”
  • “I should check for a thrill and bruit over the fistula every day.”
  • “I can wear tight sleeves to protect the access from bumps.”
  • “It’s safe to measure blood pressure on my fistula arm.”

Correct Answer: “I should check for a thrill and bruit over the fistula every day.”

Q12. A CKD patient has phosphorus 6.0 mg/dL and calcium 8.0 mg/dL. Which prescription is appropriate?

  • Administer sevelamer with meals
  • Give calcium channel blocker before meals
  • Start magnesium oxide supplementation
  • Stop all vitamin D therapies

Correct Answer: Administer sevelamer with meals

Q13. A patient with AKI has crackles, 3+ edema, BP 168/92, and urine output 30 mL/hr. Which order is most appropriate initially?

  • Strict NPO status
  • IV furosemide bolus
  • Hypertonic saline infusion
  • Immediate hemodialysis

Correct Answer: IV furosemide bolus

Q14. A trauma patient with myoglobinuria (tea-colored urine) and CK 22,000 U/L is at high risk for AKI. What is the priority intervention?

  • Restrict fluids to prevent edema
  • Administer aggressive isotonic IV fluids
  • Start potassium-sparing diuretic
  • Begin protein supplementation

Correct Answer: Administer aggressive isotonic IV fluids

Q15. An older adult with BPH presents with lower abdominal distension and anuria. What is the priority action?

  • Administer IV diuretics
  • Insert a Foley catheter after bladder scan confirms retention
  • Encourage ambulation to stimulate urination
  • Administer desmopressin

Correct Answer: Insert a Foley catheter after bladder scan confirms retention

Q16. Which order should the nurse question for a patient with AKI?

  • Gentamicin IV every 8 hours
  • Acetaminophen PO as needed
  • Pantoprazole IV daily
  • Sliding-scale insulin PRN

Correct Answer: Gentamicin IV every 8 hours

Q17. A patient with CKD has Ca 7.6 mg/dL, phosphorus 6.2 mg/dL, and markedly elevated PTH. Which medication best addresses secondary hyperparathyroidism?

  • Furosemide
  • Epoetin alfa
  • Calcitriol
  • Sodium bicarbonate

Correct Answer: Calcitriol

Q18. A patient with AKI has persistent metabolic acidosis despite bicarbonate therapy: pH 7.05, HCO3– 10 mEq/L, K+ 6.5 mEq/L with weakness. What is the next priority?

  • Prepare for emergent dialysis
  • Start oral sodium bicarbonate
  • Restrict dietary potassium
  • Encourage deep breathing exercises

Correct Answer: Prepare for emergent dialysis

Q19. A patient with hyperkalemia (K+ 6.3 mEq/L), ileus, and CKD is admitted. Which order should the nurse question?

  • Insulin with dextrose IV
  • Albuterol nebulization
  • Sodium polystyrene sulfonate PO
  • Calcium gluconate IV

Correct Answer: Sodium polystyrene sulfonate PO

Q20. A patient with CKD starts lisinopril. Which laboratory result requires notifying the provider immediately?

  • Serum potassium 5.9 mEq/L
  • Creatinine increase from 1.8 to 2.2 mg/dL
  • BUN 28 mg/dL
  • Sodium 134 mEq/L

Correct Answer: Serum potassium 5.9 mEq/L

Q21. During the first hemodialysis session, the patient develops headache, nausea, and agitation. What is the priority action?

  • Slow or stop dialysis and notify the provider
  • Increase ultrafiltration rate to remove more fluid
  • Administer oral antiemetics and continue dialysis
  • Offer warm blankets and reassurance

Correct Answer: Slow or stop dialysis and notify the provider

Q22. A septic patient with AKI is hypotensive on vasopressors. Which renal replacement modality is most appropriate?

  • Intermittent hemodialysis (IHD)
  • Peritoneal dialysis in the ward
  • Continuous renal replacement therapy (CRRT)
  • Oral sodium bicarbonate only

Correct Answer: Continuous renal replacement therapy (CRRT)

Q23. A patient with ischemic AKI has FeNa 3% and urine microscopy showing muddy brown granular casts. What is the most likely diagnosis?

  • Prerenal azotemia
  • Acute tubular necrosis
  • Acute interstitial nephritis
  • Postrenal obstruction

Correct Answer: Acute tubular necrosis

Q24. A peritoneal dialysis patient has poor outflow during an exchange. What is the best initial nursing action?

  • Reposition the patient and ensure tubing is not kinked
  • Increase dialysate dextrose concentration
  • Add heparin to the dialysate
  • Instill an additional 1 liter of dialysate

Correct Answer: Reposition the patient and ensure tubing is not kinked

Q25. Which medication requires dose adjustment in stage 4 CKD to prevent neurotoxicity?

  • Gabapentin
  • Amlodipine
  • Atorvastatin
  • Metoprolol tartrate

Correct Answer: Gabapentin

Q26. A patient with tumor lysis syndrome has rising uric acid and creatinine. Which order best prevents AKI progression?

  • Start rasburicase and aggressive IV hydration
  • Restrict fluids to 1 liter/day
  • Begin potassium supplementation
  • Administer magnesium hydroxide

Correct Answer: Start rasburicase and aggressive IV hydration

Q27. Which meal selection is best for a nondialysis CKD patient on a low-sodium, low-potassium, low-phosphorus diet?

  • Cheese pizza, tomato sauce, and orange slices
  • Grilled chicken, white rice, green beans, and apple
  • Baked salmon, spinach salad, and banana
  • Yogurt parfait with granola and raisins

Correct Answer: Grilled chicken, white rice, green beans, and apple

Q28. Which medication should typically be held before hemodialysis to reduce the risk of intradialytic hypotension?

  • Lisinopril
  • Sevelamer
  • Insulin glargine
  • Acetaminophen

Correct Answer: Lisinopril

Q29. A patient with suspected glomerulonephritis has edema and hematuria. Which urine microscopy finding supports this diagnosis?

  • Muddy brown granular casts
  • Hyaline casts
  • Red blood cell casts
  • Eosinophils

Correct Answer: Red blood cell casts

Q30. A patient just returned from hemodialysis via AV graft. Which post-dialysis action is appropriate?

  • Avoid invasive procedures for several hours due to heparinization
  • Apply a BP cuff on the access arm to trend pressures
  • Use the graft for IV antibiotics
  • Place tourniquet above graft for venipuncture

Correct Answer: Avoid invasive procedures for several hours due to heparinization

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