Certified Nephrology Nurse-Nurse Practitioner Practice Test

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Format: Computer-based testing (CBT) at PSI Testing Centers or paper-and-pencil testing (if requested).
Number of Questions: 175 multiple-choice questions.
Duration: 4 hours.
Passing Score: A standard score of 95, achieved by correctly answering at least 70% of the questions (approximately 123 questions)

1. Concepts of Kidney Disease (Approximately 10–14% of the Exam)
This section assesses foundational knowledge of renal anatomy, physiology, and pathophysiology, as well as the management of kidney disease.

Renal Anatomy and Physiology:
Structure and function of the kidneys (e.g., nephron, filtration, reabsorption, secretion)
Regulation of fluid, electrolyte, and acid-base balance
Hormonal functions of the kidney (e.g., erythropoietin, renin, vitamin D activation)
Pathophysiology of Kidney Diseases:
Acute冰: Acute kidney injury (AKI), chronic kidney disease (CKD), end-stage renal disease (ESRD)
Glomerular diseases (e.g., glomerulonephritis, nephrotic syndrome)
Tubulointerstitial diseases
Genetic disorders (e.g., polycystic kidney disease)
Secondary causes of kidney disease (e.g., diabetes, hypertension, autoimmune disorders)
Assessment and Diagnosis:
Clinical presentation of kidney diseases
Diagnostic tools (e.g., urinalysis, serum creatinine, glomerular filtration rate (GFR) estimation, imaging, biopsy)
Staging and classification of kidney disease (e.g., CKD stages 1–5)
Management Principles:
Non-dialytic management of CKD (e.g., dietary modifications, blood pressure control, glycemic control)
Patient education on disease progression and lifestyle modifications

2. Hemodialysis (Approximately 25–30% of the Exam)
This section focuses on the principles and management of hemodialysis, a common kidney replacement therapy.
Principles of Hemodialysis:
Dialysis process (e.g., diffusion, ultrafiltration)
Vascular access types (e.g., arteriovenous fistula, graft, catheter)
Dialyzer types and characteristics
Patient Management:
Pre-dialysis assessment (e.g., weight, vital signs, access evaluation)
Monitoring during dialysis (e.g., blood pressure, fluid removal, complications like hypotension or cramping)
Post-dialysis evaluation and follow-up
Complications and Interventions:
Access-related complications (e.g., infection, thrombosis, stenosis)
Dialysis-related complications (e.g., disequilibrium syndrome, amyloidosis)
Medication management (e.g., anticoagulants, erythropoiesis-stimulating agents)
Pharmacology:
Medications commonly used in hemodialysis patients (e.g., phosphate binders, calcimimetics, iron supplements)
Drug dosing adjustments for reduced renal function

3. Peritoneal Dialysis (Approximately 15–20% of the Exam)
This section covers the management of patients undergoing peritoneal dialysis, an alternative to hemodialysis.
Principles of Peritoneal Dialysis:
Types (e.g., continuous ambulatory peritoneal dialysis (CAPD), automated peritoneal dialysis (APD))
Peritoneal membrane characteristics and transport rates
Dialysate composition and dwell times
Patient Management:
Catheter placement and care
Training patients for home dialysis
Monitoring for adequacy (e.g., Kt/V, peritoneal equilibration test)
Complications and Interventions:
Infectious complications (e.g., peritonitis, exit-site infections)
Non-infectious complications (e.g., hernias, membrane failure)
Fluid and electrolyte imbalances
Pharmacology:
Antibiotics for peritonitis
Adjustments for peritoneal dialysis patients

4. Kidney Transplantation (Approximately 10–15% of the Exam)
This section evaluates knowledge of kidney transplantation processes and post-transplant care.
Pre-Transplant Evaluation:
Candidate selection and workup
Donor evaluation (living vs. deceased donors)
Immunologic considerations (e.g., HLA matching, crossmatching)
Transplant Procedure:
Surgical considerations
Immunosuppressive therapy initiation
Post-Transplant Management:
Monitoring for rejection (acute and chronic)
Immunosuppressive regimens (e.g., calcineurin inhibitors, corticosteroids, antimetabolites)
Complications (e.g., infection, malignancy, cardiovascular disease)
Long-term follow-up and graft survival
Pharmacology:
Immunosuppressants (e.g., tacrolimus, mycophenolate, prednisone)
Prophylactic medications (e.g., antivirals, antifungals)

5. Acute Therapies (Approximately 5–10% of the Exam)
This section addresses acute kidney injury and therapies used in critical care settings.
Acute Kidney Injury (AKI):
Causes (e.g., prerenal, intrinsic, postrenal)
Diagnostic evaluation (e.g., fractional excretion of sodium, ultrasound)
Management (e.g., fluid resuscitation, avoidance of nephrotoxins)
Continuous Renal Replacement Therapies (CRRT):
Modalities (e.g., continuous venovenous hemofiltration (CVVH), hemodiafiltration (CVVHDF))
Indications (e.g., AKI in critically ill patients, sepsis)
Anticoagulation strategies
Other Acute Therapies:
Plasmapheresis for renal-related conditions (e.g., glomerulonephritis, transplant rejection)
Management of electrolyte emergencies (e.g., hyperkalemia, hyponatremia)

6. Pharmacology (Integrated Across All Sections, Approximately 10–15%)
Pharmacology is a cross-cutting topic, with questions integrated into the above sections. Key areas include:
Medications for Kidney Disease:
Antihypertensives (e.g., ACE inhibitors, ARBs)
Diuretics
Phosphate binders, vitamin D analogs, and calcimimetics for mineral and bone disorders
Erythropoiesis-stimulating agents and iron therapy for anemia
Dosing Adjustments:
Adjustments for reduced renal clearance
Dialyzability of medications
Adverse Effects and Interactions:
Nephrotoxicity of drugs (e.g., NSAIDs, aminoglycosides)
Drug-drug interactions in patients with comorbidities

7. Professional Practice and Patient Education (Approximately 5–10%)
This section covers the nurse practitioner’s role in patient care and professional responsibilities.
Patient Education:
Teaching patients about disease processes, treatment options, and lifestyle modifications
Supporting adherence to dialysis schedules and medications
Providing resources for transplant preparation and follow-up
Ethical and Legal Considerations:
Informed consent for procedures
End-of-life care and advance directives in ESRD
Scope of practice for nephrology nurse practitioners
Collaboration:
Working with interdisciplinary teams (e.g., nephrologists, dietitians, social workers)
Referrals to certified (e.g., vascular surgeons, transplant coordinators)

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Question: 609
A 57-year-old male on hemodialysis presents with a phosphorus level of 8.2 mg/dL despite taking lanthanum carbonate 1000 mg three times daily. His calcium is 9.0 mg/dL, and iPTH is 600 pg/mL. What is the most appropriate next step?
1. Increase lanthanum carbonate to 1500 mg three times daily
2. Add cinacalcet 30 mg daily
3. Initiate paricalcitol 2 mcg three times weekly
4. Switch to calcium acetate 667 mg three times daily
Answer: B
Explanation: Persistent hyperphosphatemia and elevated iPTH suggest uncontrolled secondary hyperparathyroidism. Cinacalcet lowers iPTH and may indirectly Improve phosphate control by reducing bone turnover. Increasing lanthanum carbonate may help but does not address iPTH. Paricalcitol risks hypercalcemia. Calcium acetate is contraindicated due to potential hypercalcemia.
Question: 610
A 57-year-old male with ESRD on hemodialysis presents with a hemoglobin of 8.5 g/dL and transferrin saturation (TSAT) of 15%. His ferritin is 100 ng/mL. He is on erythropoietin 6000 units weekly. What is the most appropriate next step?
1. Continue current erythropoietin dose
2. Start IV iron sucrose 200 mg weekly
3. Increase erythropoietin to 8000 units weekly
4. Switch to darbepoetin alfa 60 mcg weekly
Answer: B
Explanation: Low TSAT (15%) and ferritin (100 ng/mL) indicate iron deficiency anemia in this hemodialysis patient. IV iron sucrose 200 mg weekly is the most appropriate step to correct iron stores and Improve erythropoietin response, per KDIGO guidelines. Continuing or increasing erythropoietin without addressing iron deficiency is ineffective. Switching to darbepoetin is not indicated without optimizing iron.
Question: 611
A 71-year-old male with ESRD on hemodialysis presents with a serum albumin of 2.8 g/dL and a normalized protein catabolic rate (nPCR) of 0.6 g/kg/day. His dry weight is 65 kg. The NP suspects protein-energy wasting. What is the most appropriate intervention?
1. Administer IV albumin 25 g post-dialysis
2. Start enteral tube feeding with 2,000 kcal/day
3. Increase dietary protein intake to 1.2 g/kg/day
4. Initiate testosterone 100 mg IM weekly
Answer: C
Explanation: Protein-energy wasting is indicated by low serum albumin and nPCR (<0.8 g/kg/day). Increasing dietary protein intake to 1.2 g/kg/day, per KDOQI guidelines, is the first-line intervention to Improve nutritional status in hemodialysis patients. Enteral feeding is reserved for severe malnutrition. IV albumin does not address underlying nutritional deficits. Testosterone is not standard for protein-energy wasting in ESRD.
Question: 612
A 57-year-old male with CKD Stage 5 has a serum iPTH of 800 pg/mL, calcium 9.5 mg/dL, and phosphorus 6.8 mg/dL. He is on calcitriol 0.5 �g daily. What is the most appropriate next step?
1. Increase calcitriol to 1 �g daily
2. Switch to sevelamer 1600 mg three times daily
3. Add paricalcitol 5 �g three times weekly
4. Start cinacalcet 30 mg daily
Answer: D
Explanation: Severe secondary hyperparathyroidism (iPTH 800 pg/mL) with elevated phosphorus requires cinacalcet to lower PTH by reducing parathyroid gland activity. Increasing calcitriol or adding paricalcitol risks hypercalcemia, and sevelamer addresses phosphorus but not PTH directly.
Question: 613
A 59-year-old male with ESRD on hemodialysis presents with a serum calcium of 10.8 mg/dL, phosphorus 5.5 mg/dL, and PTH 450 pg/mL. He is on sevelamer 800 mg TID and calcitriol 0.5 mcg IV thrice weekly. The NP calculates his calcium-phosphorus product as 59.4 mg�/dL�. What is the most appropriate management?
1. Increase calcitriol to 1 mcg IV thrice weekly
2. Start cinacalcet 30 mg daily and stop calcitriol
3. Switch sevelamer to calcium acetate 667 mg TID
4. Continue current regimen and monitor labs
Answer: B
Explanation: The patient has hypercalcemia (calcium 10.8 mg/dL) and an elevated calcium-phosphorus product (>55 mg�/dL�), increasing the risk of vascular calcification. Stopping calcitriol (which increases calcium) and starting cinacalcet (to lower PTH and calcium) is appropriate. Increasing calcitriol worsens hypercalcemia. Switching to calcium acetate risks further calcium elevation. Continuing the current regimen does not address the hypercalcemia.
Question: 614
A 53-year-old female with CKD Stage 4 has a serum bicarbonate of 16 mEq/L, eGFR 25 mL/min/1.73 m�, and normal anion gap. What is the most appropriate treatment?
1. Start sodium bicarbonate 1300 mg twice daily
2. Initiate furosemide 80 mg daily
3. Administer IV sodium bicarbonate 50 mEq
4. Begin ammonium chloride 500 mg daily
Answer: A
Explanation: Metabolic acidosis (bicarbonate 16 mEq/L) in CKD is treated with oral sodium bicarbonate to maintain levels =22 mEq/L, slowing CKD progression. IV bicarbonate is for acute severe acidosis, furosemide does not correct acidosis, and ammonium chloride worsens acidosis.
Question: 615
A 60-year-old male on hemodialysis presents with a pre-dialysis plasma osmolality of 320 mOsm/kg (normal: 275�295 mOsm/kg) and a serum sodium of 145 mEq/L. The NP suspects hyperosmolar state. What is the most likely cause?
1. Dehydration
2. Excessive dialysate sodium
3. Uremia
4. Hyperglycemia
Answer: D
Explanation: Hyperosmolarity with elevated sodium in hemodialysis patients is often due to hyperglycemia, which increases plasma osmolality (calculated as 2 � Na + glucose/18 + BUN/2.8). Dehydration is less likely with controlled dialysis. Excessive dialysate sodium affects post-dialysis sodium, not pre-dialysis. Uremia is chronic in ESRD.
Question: 616
A 38-year-old female with CKD Stage 4 presents with a serum creatinine of 3.8 mg/dL, eGFR 18 mL/min/1.73 m�, and hemoglobin of 9.2 g/dL. Her iron studies show: ferritin 150 ng/mL, TSAT 18%. What is the next step in managing her anemia?
1. Initiate darbepoetin alfa 60 �g weekly
2. Transfuse 2 units of packed red blood cells
3. Start oral iron sulfate 325 mg three times daily
4. Administer IV iron sucrose 200 mg weekly
Answer: D
Explanation: The patient has anemia of CKD with low TSAT (18%), indicating iron deficiency, despite adequate ferritin. IV iron sucrose is preferred to replete iron stores and Improve erythropoiesis before starting erythropoiesis-stimulating agents (ESAs) like darbepoetin alfa. Oral iron is poorly absorbed in CKD, and transfusion is reserved for severe symptomatic anemia or acute blood loss, not indicated here.
Question: 617
A 46-year-old male with CKD stage 4 has an eGFR of 20 mL/min/1.73 m� and a serum uric acid of 9.5 mg/dL. He has no history of gout. What is the most appropriate management?
1. Initiate allopurinol 100 mg daily
2. Start febuxostat 40 mg daily
3. No intervention
4. Increase fluid intake to 3 L/day
Answer: C
Explanation: Asymptomatic hyperuricemia (uric acid 9.5 mg/dL) in CKD stage 4 does not require treatment in the absence of gout or urate nephropathy. No intervention is the most appropriate management. Allopurinol and febuxostat are indicated for symptomatic hyperuricemia or specific complications, not routinely in CKD. Increasing fluid intake is not targeted for hyperuricemia management.
Question: 618
A 69-year-old female with CKD stage 5 on hemodialysis presents with a phosphorus level of 7.8 mg/dL. She is non-compliant with her phosphate binder. Which binder is most appropriate to Improve compliance?
1. Calcium acetate 667 mg with meals
2. Sucroferric oxyhydroxide 500 mg daily
3. Sevelamer carbonate 800 mg three times daily
4. Lanthanum carbonate 1,000 mg with meals
Answer: B
Explanation: Sucroferric oxyhydroxide 500 mg daily is the most appropriate phosphate binder to Improve compliance, as it requires fewer pills and has a lower pill burden. Calcium acetate risks hypercalcemia. Lanthanum and sevelamer require multiple daily doses, which may reduce adherence in a non-compliant patient.
Question: 619
A 67-year-old male with CKD stage 4 (eGFR 22 mL/min/1.73 m�) presents with metabolic acidosis (serum bicarbonate 16 mEq/L). His medications include lisinopril 20 mg daily and furosemide 40 mg daily. His arterial blood gas shows pH 7.30, pCO2 32 mmHg, and HCO3? 15 mEq/L. What is the most appropriate initial treatment?
1. Sodium bicarbonate 650 mg orally twice daily
2. Increase furosemide to 80 mg daily
3. Discontinue lisinopril
4. Administer acetazolamide 250 mg daily
Answer: A
Explanation: The patient has metabolic acidosis (pH <7.35, low HCO3?) with partial respiratory compensation (low pCO2). In CKD, alkali therapy with sodium bicarbonate is indicated for serum bicarbonate <22 mEq/L to prevent bone loss and muscle wasting. Starting sodium bicarbonate 650 mg twice daily is appropriate to correct acidosis gradually. Increasing furosemide may worsen acidosis by increasing bicarbonate loss. Discontinuing lisinopril is not indicated, as it helps slow CKD progression. Acetazolamide causes acidosis and is contraindicated.
Question: 620
A 59-year-old male with CKD stage 3 and a lipid profile of LDL-C 115 mg/dL, HDL-C 30 mg/dL, triglycerides 450 mg/dL is on atorvastatin 20 mg daily. His eGFR is 45 mL/min/1.73 m�. What is the most appropriate additional therapy?
1. Fenofibrate 145 mg daily
2. Niacin 1.5 g daily
3. Ezetimibe 10 mg daily
4. Omega-3 fatty acids 4 g daily
Answer: A
Explanation: For elevated triglycerides (450 mg/dL) in CKD stage 3, fenofibrate at 145 mg daily is appropriate to reduce triglycerides and cardiovascular risk. Niacin is less preferred due to its side effects. Ezetimibe has minimal effect on triglycerides. Omega-3 fatty acids are indicated for triglycerides =500 mg/dL. Fenofibrate is the best choice for this scenario.
Question: 621
A 58-year-old male with CKD stage 4 (eGFR 18 mL/min/1.73 m�) presents with metabolic acidosis (serum bicarbonate 16 mEq/L, pH 7.28). His serum potassium is 5.8 mEq/L, and he takes lisinopril 20 mg daily. What is the most appropriate treatment for his acidosis?
1. Discontinue lisinopril
2. Furosemide 40 mg orally daily
3. Sodium polystyrene sulfonate 15 g orally
4. Sodium bicarbonate 650 mg orally twice daily
Answer: D
Explanation: Metabolic acidosis in CKD (bicarbonate 16 mEq/L, pH 7.28) requires correction to prevent bone loss and muscle wasting. Sodium bicarbonate 650 mg twice daily is the standard treatment to raise serum bicarbonate to 22�24 mEq/L. Furosemide may worsen dehydration and acidosis. Sodium polystyrene sulfonate addresses hyperkalemia but not acidosis. Discontinuing lisinopril may help hyperkalemia but does not correct acidosis directly.
Question: 622
A 55-year-old male on PD presents with ultrafiltration failure. His 4-hour PET shows a D/P creatinine ratio of 0.9, indicating high transporter status. Which PD prescription adjustment is most appropriate?
1. Increase dwell time to 6 hours
2. Switch to icodextrin for long dwell
3. Use higher dextrose concentration (4.25%)
4. Increase fill volume to 2.5 L
Answer: B
Explanation: A high transporter (D/P creatinine 0.9) indicates rapid solute transport but poor ultrafiltration due to rapid glucose absorption. Icodextrin, a glucose polymer, provides sustained ultrafiltration for long dwells, ideal for high transporters. Increasing dwell time worsens ultrafiltration in high transporters. Higher dextrose concentrations are less effective due to rapid absorption. Increasing fill volume may cause discomfort without improving ultrafiltration.
Question: 623
A 58-year-old male on hemodialysis presents with a serum albumin of 2.8 g/dL and a 5% weight loss over 3 months. His dietary protein intake is 0.8 g/kg/day. What is the most appropriate intervention?
1. Initiate anabolic steroids
2. Administer IV albumin 25 g weekly
3. Start oral nutritional supplements
4. Increase dietary protein to 1.2 g/kg/day
Answer: D
Explanation: Hypoalbuminemia (2.8 g/dL) and weight loss suggest protein-energy wasting, common in dialysis patients. Increasing dietary protein to 1.2 g/kg/day (KDOQI recommendation) addresses nutritional deficiency. IV albumin is not indicated for chronic hypoalbuminemia. Oral supplements may help but are less specific than increasing protein intake. Anabolic steroids are not first-line for malnutrition.
Question: 624
A 65-year-old male with ESRD on hemodialysis develops a fever of 38.7�C and erythema around his tunneled catheter exit site. Blood cultures are positive for methicillin-resistant Staphylococcus aureus (MRSA). What is the most appropriate management?
1. Administer oral clindamycin 600 mg three times daily
2. Use vancomycin lock therapy
3. Start topical mupirocin and monitor
4. Initiate IV vancomycin and remove catheter
Answer: D
Explanation: Catheter-related bloodstream infection with MRSA requires IV vancomycin and catheter removal (option B) to eliminate the infection source. Oral clindamycin (option A) is inadequate for bloodstream infections. Topical mupirocin (option C) is for localized infections, not bacteremia. Vancomycin lock (option D) is adjunctive, not primary treatment.
Question: 625
A 63-year-old male on peritoneal dialysis presents with a dialysate leak at the catheter exit site and reduced ultrafiltration. His 24-hour ultrafiltration volume is 500 mL with 2.5% dextrose. What is the most appropriate management?
1. Initiate intraperitoneal antibiotics
2. Reduce dwell volumes temporarily
3. Remove the peritoneal catheter
4. Switch to hemodialysis permanently
Answer: B
Explanation: A dialysate leak at the catheter exit site can reduce ultrafiltration by allowing fluid to escape into subcutaneous tissues. Reducing dwell volumes temporarily allows the leak to heal while maintaining peritoneal dialysis. Intraperitoneal antibiotics are not indicated without infection, catheter removal is premature, and switching to hemodialysis is unnecessary unless the leak persists.
Question: 626
A 65-year-old male patient with a kidney transplant (6 months post-transplant) presents with fever, dysuria, and a urine culture positive for Escherichia coli (sensitive to ciprofloxacin). His serum creatinine is 1.8 mg/dL (baseline 1.3 mg/dL). The NP must adjust the antibiotic dose. What is the MOST appropriate ciprofloxacin dose, assuming an eGFR of 40 mL/min/1.73 m�?
1. Ciprofloxacin 250 mg orally every 12 hours
2. Ciprofloxacin 500 mg orally every 12 hours
3. Ciprofloxacin 750 mg orally every 12 hours
4. Ciprofloxacin 500 mg orally every 24 hours
Answer: D
Explanation: Ciprofloxacin is renally cleared, requiring dose adjustment in reduced eGFR (40 mL/min/1.73 m�). For an eGFR of 30�50 mL/min/1.73 m�, the recommended dose for uncomplicated UTI is ciprofloxacin 500 mg orally every 24 hours to prevent accumulation and toxicity. Ciprofloxacin 250 mg every 12 hours is insufficient for systemic infection. Ciprofloxacin 500 mg or 750 mg every 12 hours exceeds the safe dose for this eGFR, risking toxicity (e.g., seizures, tendon rupture).
Question: 627
A 54-year-old female with a kidney transplant has a BK virus PCR of 50,000 copies/mL and a creatinine of 2.8 mg/dL (baseline 1.4 mg/dL). She takes tacrolimus and mycophenolate. What is the most appropriate management?
1. Start leflunomide 20 mg daily
2. Increase tacrolimus trough to 10 ng/mL
3. Administer cidofovir 1 mg/kg weekly
4. Reduce mycophenolate dose by 50%
Answer: D
Explanation: BK virus nephropathy requires reducing immunosuppression, typically by lowering mycophenolate dose by 50%, to allow immune clearance of the virus. Leflunomide or cidofovir is considered for refractory cases. Increasing tacrolimus worsens BK viremia.
Question: 628
A 61-year-old male with a kidney transplant presents with a CMV viral load of 10,000 copies/mL. He is asymptomatic but has a leukocyte count of 3,000/�L. His immunosuppression includes tacrolimus, mycophenolate, and prednisone. What is the most appropriate management?
1. Reduce mycophenolate dose by 50%
2. Discontinue tacrolimus
3. Start valganciclovir 900 mg twice daily
4. Administer CMV immunoglobulin
Answer: C
Explanation: Asymptomatic CMV viremia (10,000 copies/mL) with leukopenia requires preemptive treatment with valganciclovir 900 mg twice daily, adjusted for renal function, to prevent progression to CMV disease. Reducing mycophenolate may help leukopenia but doesn�t address viremia. Discontinuing tacrolimus risks rejection. CMV immunoglobulin is used for prophylaxis or severe disease, not preemptive therapy.

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