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Certified Nephrology Nurse Practice Test

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Exam Code: CNN
Exam Name: Certified Nephrology Nurse
Exam Type: Computer-based- multiple-choice questions.
Number of Questions: 150 scored questions + 25 unscored pretest questions.
Time Allotted: 3 hours (180 minutes).
Passing Score: Scaled score of 70 (on a 0-100 scale).

The Certified Nephrology Nurse (CNN) exam- administered by the Nephrology Nursing Certification Commission (NNCC)- assesses a registered nurse’s expertise in nephrology nursing across multiple domains. The test consists of 150 questions- covering five key content areas- each with a specific percentage of the total test. Below is a detailed breakdown of the domains- their associated topics- and relevant terminologies based on the most current information available from the NNCC and other reliable sources.

1. Concepts of Kidney Disease (35%)

- Normal Kidney Function:
- Anatomy and physiology of the kidneys (e.g.- nephron structure- glomerular filtration- tubular reabsorption- and secretion).
- Regulation of fluid- electrolyte- and acid-base balance.
- Role of kidneys in blood pressure regulation (renin-angiotensin-aldosterone system- RAAS).

- Pathological Conditions and Complications:
- Chronic kidney disease (CKD): stages (1–5)- etiology (e.g.- diabetes- hypertension- glomerulonephritis)- and complications (e.g.- anemia- bone disease- cardiovascular issues).
- Acute kidney injury (AKI): causes (prerenal- intrarenal- postrenal)- diagnostic criteria (e.g.- RIFLE- AKIN)- and management.
- End-stage renal disease (ESRD): progression from CKD- symptoms- and preparation for renal replacement therapy.
- Diabetic nephropathy: pathophysiology- risk factors- and management.
- Polycystic kidney disease (PKD) and other genetic disorders.

- Monitoring Disease Progression:
- Laboratory values: glomerular filtration rate (GFR)- serum creatinine- blood urea nitrogen (BUN)- urine albumin-to-creatinine ratio.
- Diagnostic tests: renal ultrasound- kidney biopsy- and imaging studies.
- Residual kidney function preservation strategies (e.g.- dietary management- medication adjustments).

- Patient Management:
- Medication side effects: nephrotoxic drugs (e.g.- NSAIDs- aminoglycosides)- antihypertensive agents- and phosphate binders.
- Lifestyle interventions: dietary restrictions (e.g.- sodium- potassium- phosphorus)- fluid management- and smoking cessation.
- Patient education: self-management- symptom recognition- and adherence to treatment plans.

- Nephron
- glomerulus
- tubular reabsorption
- GFR
- RAAS
- CKD
- AKI
- ESRD
- azotemia
- uremia
- proteinuria
- hematuria
- oliguria
- anuria
- nephrotoxins
- hyperkalemia
- metabolic acidosis
- anemia of CKD
- mineral bone disorder (MBD)
- estimated GFR (eGFR).

2. Hemodialysis (30%)
This domain evaluates the nurse’s knowledge of hemodialysis principles- technical aspects- and patient care- including home dialysis and infection control.

- Physiological and Technical Principles:
- Principles of dialysis: diffusion- osmosis- ultrafiltration- and convection.
- Dialysis adequacy: Kt/V- urea reduction ratio (URR)- and target clearance goals.
- Dialyzer types: high-flux vs. low-flux- biocompatibility- and membrane characteristics.

- Water Treatment:
- Components of water treatment systems: reverse osmosis- deionization- and carbon filtration.
- Water quality standards: AAMI (Association for the Advancement of Medical Instrumentation) guidelines.
- Complications: endotoxemia- pyrogenic reactions- and chloramine exposure.

- Vascular Access:
- Types: arteriovenous fistula (AVF)- arteriovenous graft (AVG)- central venous catheter (CVC).
- Access care: cannulation techniques- monitoring for complications (e.g.- stenosis- thrombosis- infection).
- Maturation and assessment: bruit- thrill- and Doppler studies.

- Infection Control:
- Protocols for preventing bloodstream infections and hepatitis transmission.
- Sterilization and disinfection of dialysis equipment.
- Isolation procedures for patients with infectious diseases (e.g.- MRSA- hepatitis B/C).

- Medication Administration:
- Common medications: erythropoiesis-stimulating agents (ESAs)- iron supplements- heparin- vitamin D analogs.
- Intradialytic medications: timing- dosing- and monitoring for side effects.

- Patient Care:
- Fluid volume status: assessment of dry weight- interdialytic weight gain- and ultrafiltration goals.
- Complications: hypotension- cramping- dialyzer reactions- and air embolism.
- Home dialysis: patient training- equipment setup- and troubleshooting.

- Home Care Support:
- Caregiver education- remote monitoring- and emergency preparedness.
- Psychosocial support for patients transitioning to home dialysis.

- Hemodialysis
- Kt/V
- URR
- dialyzer
- ultrafiltration
- dry weight
- interdialytic weight gain
- AVF
- AVG
- CVC
- cannulation
- stenosis
- thrombosis
- endotoxemia
- AAMI standards
- ESAs
- heparin-induced thrombocytopenia
- dialyzer reaction
- vascular access infection
- intradialytic hypotension.

3. Peritoneal Dialysis (20%)
This domain assesses the nurse’s ability to manage and teach peritoneal dialysis (PD) therapy- including its complications and patient education.

- Principles of Peritoneal Dialysis:
- Mechanisms: diffusion and osmosis across the peritoneal membrane.
- Types: continuous ambulatory peritoneal dialysis (CAPD)- automated peritoneal dialysis (APD).
- Dialysate solutions: dextrose concentrations- calcium levels- and additives (e.g.- heparin- antibiotics).

- Catheter Management:
- PD catheter types: Tenckhoff catheter- placement techniques- and care.
- Exit-site care and infection prevention.
- Complications: catheter migration- blockage- and pericatheter leaks.

- Therapy Management:
- Dwell time- exchange schedules- and ultrafiltration goals.
- Monitoring dialysis adequacy: peritoneal equilibration test (PET)- Kt/V.
- Fluid balance: managing hypervolemia and hypovolemia.

- Complications:
- Peritonitis: diagnosis (cloudy effluent- abdominal pain)- treatment (intraperitoneal antibiotics)- and prevention.
- Other complications: hernias- encapsulating peritoneal sclerosis- and ultrafiltration failure.

- Patient Education:
- Training for CAPD/APD: sterile technique- exchange procedures- and troubleshooting.
- Lifestyle adaptations: dietary recommendations- activity restrictions- and travel planning.
- Recognizing signs of infection or complications.

- Peritoneal dialysis
- CAPD
- APD
- Tenckhoff catheter
- dwell time
- PET
- Kt/V
- peritonitis
- ultrafiltration failure
- encapsulating peritoneal sclerosis
- dialysate
- exit-site infection
- intraperitoneal antibiotics
- effluent
- hypervolemia
- hypovolemia.

4. Transplant (10%)
This domain covers the nursing care of kidney transplant recipients- including pre-transplant evaluation- post-transplant care- and immunosuppression management.

- Pre-Transplant Evaluation:
- Candidate selection: medical- psychosocial- and immunological criteria.
- Donor types: living-related- living-unrelated- deceased (brain-dead or donation after circulatory death).
- Compatibility testing: ABO blood typing- human leukocyte antigen (HLA) matching- crossmatching.

- Post-Transplant Care:
- Immediate post-operative care: monitoring for graft function- fluid balance- and surgical complications.
- Delayed graft function (DGF) and acute rejection: diagnosis and management.
- Long-term care: monitoring for chronic allograft nephropathy and cardiovascular risk.

- Immunosuppression:
- Medications: calcineurin inhibitors (e.g.- tacrolimus- cyclosporine)- antimetabolites (e.g.- mycophenolate)- corticosteroids.
- Side effects: nephrotoxicity- infection risk- and malignancy.
- Adherence strategies: patient education and monitoring drug levels.

- Complications:
- Rejection: hyperacute- acute- and chronic.
- Infections: cytomegalovirus (CMV)- BK virus- and opportunistic infections.
- Other: post-transplant diabetes- lymphoproliferative disorders- and graft loss.

- Patient Education:
- Medication adherence- infection prevention- and follow-up care.
- Lifestyle modifications: diet- exercise- and sun protection.

- Kidney transplant
- HLA matching
- crossmatching
- DGF
- acute rejection
- chronic allograft nephropathy
- calcineurin inhibitors
- immunosuppression
- CMV
- BK virus
- post-transplant diabetes
- graft survival
- living donor
- deceased donor
- ABO incompatibility.

5. Acute Therapies (5%)
This domain focuses on acute renal replacement therapies and apheresis- typically used in critical care or inpatient settings.

- Continuous Renal Replacement Therapy (CRRT):
- Modalities: continuous venovenous hemofiltration (CVVH)- hemodiafiltration (CVVHDF)- hemodialysis (CVVHD).
- Indications: AKI in critically ill patients- fluid overload- and severe electrolyte imbalances.
- Technical aspects: vascular access- anticoagulation (e.g.- citrate- heparin)- and circuit monitoring.
- Complications: bleeding- filter clotting- and hemodynamic instability.

- Sustained Low-Efficiency Dialysis (SLED):
- Hybrid therapy combining features of CRRT and intermittent hemodialysis.
- Indications and patient selection.
- Monitoring and troubleshooting.

- Apheresis:
- Types: plasmapheresis- therapeutic plasma exchange (TPE)- and leukapheresis.
- Indications: autoimmune disorders (e.g.- Goodpasture’s syndrome- myasthenia gravis)- transplant rejection- and thrombotic microangiopathies.
- Procedure: vascular access- replacement fluids- and monitoring for complications (e.g.- hypocalcemia- allergic reactions).

- Patient Care:
- Monitoring: vital signs- fluid balance- and laboratory values during therapy.
- Patient and family education: explaining procedures and expected outcomes.
- Psychosocial support: addressing anxiety and critical illness.

- CRRT
- CVVH
- CVVHDF
- CVVHD
- SLED
- apheresis
- plasmapheresis
- TPE
- citrate anticoagulation
- filter clotting
- hemodynamic instability
- thrombotic microangiopathy
- hypocalcemia
- replacement fluid

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Question: 1532
A patient on APD reports fever and chills. The nurse observes redness at the catheter exit site and obtains
an exit-site culture. Which finding confirms an exit-site infection?
A. Culture positive for Escherichia coli
B. Serum C-reactive protein 10 mg/L
C. Effluent cell count 50/�L, 40% neutrophils
D. Culture positive for Staphylococcus aureus
Answer: D
Explanation: Staphylococcus aureus is the most common cause of exit-site infections in PD patients,
presenting with redness and fever. Escherichia coli is less likely, effluent cell count suggests peritonitis,
and C-reactive protein is nonspecific.
Question: 1533
A Tenckhoff catheter exit site shows erythema and slight crusting. Which prophylactic measure is most
effective in preventing progression to infection?
A. Apply gentamicin cream daily
B. Cleanse with alcohol swabs
C. Use mupirocin cream daily
D. Cover with occlusive dressing
Answer: C
Explanation: Daily mupirocin application at the Tenckhoff catheter exit site is effective in preventing
infections, particularly by Staphylococcus aureus. Gentamicin is less effective against common
organisms, alcohol swabs may irritate the site, and occlusive dressings increase infection risk.
Question: 1534
A patient with TMA on TPE has a pre-TPE LDH of 1200 U/L and haptoglobin <10 mg/dL. After 1.5
plasma volume exchanges with FFP, the LDH is 900 U/L. What is the most likely haptoglobin level
post-TPE?
A. <10 mg/dL
B. 50�100 mg/dL
C. 20�40 mg/dL
D. >150 mg/dL
Answer: C
Explanation: TMA causes hemolysis, reducing haptoglobin (<10 mg/dL) and elevating LDH. TPE with
FFP replaces haptoglobin and removes hemolysis mediators. A 1.5 plasma volume exchange removes
~78% of plasma constituents, replacing them with FFP (haptoglobin ~50�200 mg/dL). Post-TPE,
haptoglobin rises modestly (20�40 mg/dL), reflecting partial restoration, while LDH decreases (1200 to
900 U/L), indicating reduced hemolysis.
Question: 1535
A 50-year-old female with AKI due to rhabdomyolysis has a serum creatine kinase of 25,000 U/L.
Which electrolyte abnormality is most likely to occur acutely?
A. Hyperkalemia
B. Hypercalcemia
C. Hypomagnesemia
D. Hyponatremia
Answer: A
Explanation: Rhabdomyolysis causes muscle breakdown, releasing potassium into the bloodstream,
leading to hyperkalemia, especially in AKI where renal potassium excretion is impaired. This can be life-
threatening. Hypercalcemia is rare acutely but may occur in recovery. Hypomagnesemia is not typical,
and hyponatremia is less likely unless significant fluid overload or dilution occurs.
Question: 1536
What is the primary advantage of CVVH over CVVHD in managing cytokine storm in sepsis?
A. Higher convective clearance
B. Better clearance of small solutes
C. Lower anticoagulation needs
D. Reduced filter clotting
Answer: A
Explanation: CVVH uses convection, which is more effective for clearing middle-molecular-weight
molecules like cytokines in sepsis. CVVHD relies on diffusion, better for small solutes. Anticoagulation
needs and filter clotting risks are similar between modalities.
Question: 1537
A 60-year-old patient with CKD-MBD has a serum phosphate of 6.5 mg/dL and calcium of 8.0 mg/dL.
The nephrologist prescribes calcium acetate. When should the patient take this medication?
A. At bedtime
B. With meals
C. Only when needed
D. First thing in the morning
Answer: B
Explanation: Calcium acetate, a phosphate binder, should be taken with meals to bind dietary phosphate
in the gut, reducing absorption. Timing at bedtime, morning, or as needed is less effective.
Question: 1538
A patient on APD with 5 cycles (2 L, 2.5% dextrose, 2-hour dwells) and a daytime icodextrin dwell has a
PET indicating high transport status. Ultrafiltration is 500 mL/day, and the patient has edema and a 4 kg
weight gain. What is the most appropriate intervention?
A. Increase cycles to 6 with 1.5% dextrose
B. Replace icodextrin with 2.5% dextrose
C. Reduce cycle time to 1.5 hours
D. Switch to 4.25% dextrose for all cycles
Answer: D
Explanation: High transporters lose the glucose gradient quickly, reducing ultrafiltration. Switching to
4.25% dextrose increases the osmotic gradient, improving fluid removal to address edema and weight
gain. Increasing cycles with 1.5% dextrose is less effective, reducing cycle time may not sufficiently
enhance ultrafiltration, and replacing icodextrin with 2.5% dextrose for the long dwell risks reabsorption.
Question: 1539
In CVVH, a patient�s effluent rate is 28 mL/kg/h for a 60 kg patient. What is the total effluent volume
over 24 hours?
A. 1680 mL
B. 6720 mL
C. 5040 mL
D. 40320 mL
Answer: D
Explanation: For a 60 kg patient, an effluent rate of 28 mL/kg/h equals 28 � 60 = 1680 mL/h. Over 24
hours, 1680 � 24 = 40,320 mL (40.32 L).
Question: 1540
A 50-year-old female, 5 years post-deceased donor renal transplant, has a serum creatinine of 1.8 mg/dL
(baseline 1.3 mg/dL). Biopsy shows chronic allograft nephropathy (Banff grade II). Her
immunosuppression includes tacrolimus, MMF, and prednisone. Which factor is most strongly associated
with reduced graft survival in this scenario?
A. Chronic calcineurin inhibitor toxicity
B. History of acute rejection
C. Donor age >60 years
D. Recipient BMI >35 kg/m�
Answer: B
Explanation: A history of acute rejection is a strong predictor of reduced graft survival, as it contributes
to cumulative immune-mediated damage, accelerating chronic allograft nephropathy. While calcineurin
inhibitor toxicity, older donor age, and high BMI are risk factors, prior acute rejection has a more
significant impact due to its direct effect on long-term graft function.
Question: 1541
A dialysis facility�s RO system operates at 150 psi with a permeate flow of 60 L/min and a concentrate
flow of 20 L/min. What is the recovery rate?
A. 75%
B. 60%
C. 80%
D. 85%
Answer: A
Explanation: Recovery rate = [Permeate flow / (Permeate flow + Concentrate flow)] � 100 = [60 / (60 +
20)] � 100 = 75%, indicating efficient water use per AAMI RD62:2014 guidelines.
Question: 1542
A 47-year-old patient on CAPD reports a bulge near the PD catheter site, exacerbated by coughing. The
bulge is tender and irreducible. What is the most likely complication, and what is the immediate
management?
A. Encapsulating peritoneal sclerosis; start corticosteroids
B. Peritoneal leak; reduce dwell volume
C. Incisional hernia; urgent surgical consultation
D. Tunnel infection; initiate antibiotics
Answer: C
Explanation: A tender, irreducible bulge near the PD catheter site, worsened by coughing, suggests an
incarcerated incisional hernia, a serious complication requiring urgent surgical consultation to prevent
strangulation. EPS involves systemic symptoms and fibrosis, not a localized bulge. Peritoneal leaks cause
diffuse or scrotal edema, and tunnel infections present with erythema or discharge, not an irreducible
mass.
Question: 1543
Which component of the RAAS is most directly responsible for increasing sodium reabsorption in the
distal nephron, contributing to blood pressure regulation?
A. Angiotensin II
B. Aldosterone
C. Renin
D. Vasopressin
Answer: B
Explanation: Aldosterone, a RAAS hormone, acts on the distal tubule and collecting duct to increase
sodium reabsorption via epithelial sodium channels (ENaC), promoting water retention and elevating
blood pressure. Angiotensin II stimulates aldosterone release, renin initiates the cascade, and vasopressin
regulates water reabsorption.
Question: 1544
A 55-year-old patient with thrombotic microangiopathy is undergoing daily TPE. The nurse calculates
the patient�s plasma volume using the formula: Plasma Volume (L) = [0.065 � weight (kg)] � (1 �
hematocrit). If the patient weighs 80 kg and has a hematocrit of 40%, what is the plasma volume?
A. 2.88 L
B. 3.84 L
C. 3.36 L
D. 3.12 L
Answer: D
Explanation: Plasma volume = [0.065 � 80] � (1 � 0.4) = 5.2 � 0.6 = 3.12 L. This calculation accounts
for the patient�s weight and hematocrit to determine the plasma volume for TPE planning.
Question: 1545
A patient with CKD has a hemoglobin of 9 g/dL. What is the primary renal mechanism contributing to
this anemia?
A. Increased hemolysis in glomeruli
B. Reduced erythropoietin production
C. Decreased iron reabsorption
D. Enhanced cytokine production
Answer: B
Explanation: CKD reduces erythropoietin production by peritubular interstitial fibroblasts, impairing red
blood cell production and causing anemia. Hemolysis, iron reabsorption, and cytokines are secondary or
unrelated.
Question: 1546
A 39-year-old female kidney transplant recipient is on cyclosporine with a trough level of 200 ng/mL.
She develops gingival hyperplasia and hirsutism. Which modification to her calcineurin inhibitor regimen
is most appropriate?
A. Continue cyclosporine and treat symptoms
B. Switch to tacrolimus
C. Reduce cyclosporine dose to target 100�150 ng/mL
D. Increase cyclosporine to target 250 ng/mL
Answer: B
Explanation: Gingival hyperplasia and hirsutism are common side effects of cyclosporine. Switching to
tacrolimus, which has a lower incidence of these side effects, is appropriate while maintaining effective
immunosuppression. Reducing the dose may compromise efficacy, and continuing cyclosporine does not
address the adverse effects.
Question: 1547
A home HD patient�s caregiver reports a temperature of 38.5�C and chills during a session. The patient�s
WBC count is 14,000/�L. What should the caregiver do first?
A. Administer oral acetaminophen 500 mg
B. Collect blood cultures
C. Stop dialysis and notify the center
D. Switch to a low-flux dialyzer
Answer: C
Explanation: Fever (38.5�C), chills, and leukocytosis (14,000/�L) during HD suggest a possible infection
(e.g., access-related). Stopping dialysis and notifying the center is critical for evaluation and treatment.
Acetaminophen treats symptoms, blood cultures require medical supervision, and changing dialyzers is
irrelevant.
Question: 1548
A patient on APD with a 2.5% dextrose dialysate achieves a weekly Kt/V of 1.6, below the target of 1.7.
The PET shows a D/P creatinine ratio of 0.55, indicating a low-average transporter. What modification to
the prescription is most likely to Strengthen Kt/V?
A. Increase cycle volume to 2.5L
B. Increase dwell time to 90 minutes per cycle
C. Reduce dextrose to 1.5%
D. Switch to CAPD with four exchanges
Answer: B
Explanation: A D/P creatinine ratio of 0.55 indicates a low-average transporter, with slower solute
clearance. Increasing dwell time to 90 minutes per cycle in APD enhances solute diffusion, improving
Kt/V. Increasing volume or switching to CAPD may not be as effective, and reducing dextrose could
compromise ultrafiltration.
Question: 1549
A 67-year-old patient with CKD undergoes a kidney biopsy showing lupus nephritis. Which laboratory
finding is most specific for this diagnosis?
A. Normal urine albumin-to-creatinine ratio
B. Normal serum complement levels
C. Negative ANA test
D. Elevated anti-dsDNA antibodies
Answer: D
Explanation: Elevated anti-dsDNA antibodies are highly specific for lupus nephritis, reflecting
autoimmune glomerular damage. Low complement levels, not normal, are typical. A negative ANA test
and normal uACR are inconsistent with active lupus nephritis.
Question: 1550
A patient on CVVH with a polysulfone filter experiences a sudden increase in venous return pressure
from 80 mmHg to 200 mmHg over 30 minutes. The ultrafiltration rate is 1.5 L/h, and heparin
anticoagulation is used (aPTT 60 seconds). What is the most appropriate next step?
A. Administer a 1000-unit heparin bolus
B. Increase ultrafiltration rate to 2 L/h
C. Switch to citrate anticoagulation
D. Rinse back the circuit and replace the filter
Answer: D
Explanation: A rapid increase in venous return pressure suggests filter clotting, as clots increase
resistance in the circuit. The aPTT (60 seconds) indicates therapeutic anticoagulation, making additional
heparin unnecessary. Increasing ultrafiltration worsens clotting by concentrating blood in the filter.
Switching to citrate may prevent future clotting but doesn�t address the current clot. Rinsing back the
blood (if not fully clotted) and replacing the filter is the standard response to circuit clotting.
Question: 1551
Which renal mechanism compensates for respiratory alkalosis?
A. Increased potassium reabsorption
B. Increased hydrogen ion secretion
C. Decreased bicarbonate reabsorption
D. Reduced ammonium excretion
Answer: C
Explanation: In respiratory alkalosis, the kidneys compensate by decreasing bicarbonate reabsorption,
primarily in the proximal tubule, to reduce plasma pH. Hydrogen ion secretion decreases, potassium
reabsorption is unrelated, and ammonium excretion is not the primary response.
Question: 1552
A 70-kg patient on SLED for AKI has a prescribed urea clearance (Kt/V) goal of 0.8 per session. The
dialysis parameters are Qb 180 mL/min, Qd 300 mL/min, and session duration of 10 hours. The dialyzer
has a urea clearance rate of 160 mL/min at these settings. Calculate the delivered Kt/V and determine if
the prescription meets the goal.
A. 0.85, meets goal
B. 0.72, does not meet goal
C. 0.90, meets goal
D. 0.76, does not meet goal
Answer: B
Explanation: Kt/V is calculated as (dialyzer clearance � time) / volume of distribution (V). Here,
clearance (K) is 160 mL/min, time (t) is 10 hours (600 min), and V is estimated as 0.6 � body weight =
0.6 � 70 kg = 42 L (42,000 mL). Kt = 160 mL/min � 600 min = 96,000 mL. Kt/V = 96,000 / 42,000 =
2.29 for the session, but since SLED targets a per-session Kt/V, we adjust for daily equivalence. For 10
hours, Kt/V � 0.72 (96,000 / (42,000 � 1.33, as 24/10 adjustment)). This is below the goal of 0.8, so it
does not meet the target.
Question: 1553
In a patient with AKI, which intervention is most critical to prevent progression to intrinsic renal damage
in the prerenal stage?
A. Correction of hypovolemia
B. Administration of loop diuretics
C. Initiation of dialysis
D. Use of nephrotoxic contrast agents
Answer: A
Explanation: Correcting hypovolemia in prerenal AKI restores renal perfusion, preventing ischemia and
progression to intrinsic damage (e.g., acute tubular necrosis). Diuretics may worsen dehydration, dialysis
is premature, and contrast agents are nephrotoxic.
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