ABFM KSA - Care of Hospitalized Patients
Test Questions and Correct Answers
Question 1
A nurse calls you about a patient who was admitted to the hospital yesterday
morning for a heart failure exacerbation. The patient's baseline creatinine level
averages 1.6 mg/dL (N 0.6-1.1) and his creatinine level on admission was 1.7 mg/dL.
The nurse is concerned about the patient's renal function.Criteria for confirming that
the patient is experiencing acute kidney injury include which one of the following?
A history of a potential cause of kidney injury
A history of symptoms consistent with acute kidney injury, such as pulmonary edema
or swelling of the extremities
Urine output ≤0.5 mL/kg/hr over the previous 6-12 hours
A rising serum creatinine level of 1.8 mg/dL today
Correct Answer
C
The term acute renal failure has historically been difficult to define, and this was
made more difficult by an implication that the kidneys were permanently damaged.
To reflect a more complete spectrum of renal injury, the currently accepted term has
been changed to acute kidney injury. Approximately 7% of all hospitalized patients
will experience some form of this condition during their stay. Recognizing acute
kidney injury will allow for interventions to prevent the condition from worsening
and prevent multi-system failure from occurring (SOR C).Guidelines from Kidney
Disease Improving Global Guidelines (KDIGO) divide acute kidney injury into three
stages:Stage 1—An increase in serum creatinine of 0.3 over the last 48 hours and/or
reduced urine output of 0.5 mL/kg/hr over the last 6 hoursStage 2—An increase in
serum creatinine to 2–3 times the baseline level and/or reduced urine output of 0.5
mL/kg/hr over the last 12 hoursStage 3—An increase in serum creatinine to over 3
times the baseline level and/or reduced urine output of 0.3 mL/kg/hr over last 24
hours or anuria for greater than 12 hoursA patient may be asymptomatic in the
early stages of acute kidney injury, as even small changes in serum creatinine levels
predict poorer clinical outcomes (SOR C). Checking for potential causes of renal
impairment may help determine the cause of renal injury but will not determine
whether it is present (SOR C).
Page 1 of 67
,Question 2
A 52-year-old male is admitted to the hospital for an acute exacerbation of COPD
after several days of worsening dyspnea, cough, and purulent sputum production.
This is his fourth exacerbation in the past year. Home oxygen has been prescribed but
he only uses it sporadically and he continues to smoke.On examination the patient
has a temperature of 37.0°C (98.6°F), a pulse rate of 100 beats/min, a respiratory rate
of 32/min, and a blood pressure of 148/90 mm Hg. His oxygen saturation is 88% on
room air, and diffuse bilateral wheezes are noted. A chest radiograph shows
hyperinflation with no distinct infiltrates.Which one of the following is true regarding
the use of antibiotics at this time?
Antibiotics should not be given until the infecting organisms are identified on a
sputum or blood culture
Penicillins with antipseudomonal activity are the initial treatment of choice
Intravenous antibiotics are superior to oral treatment in hospitalized patients
Antibiotics should be administered for a total of 14 days
Antibiotics can reduce his risk of death
Correct Answer
E
In patients with moderate to severe COPD, antibiotic treatment reduces the rate of
treatment failure and death (SOR B). Such patients often have mixed bacterial
growth from the lower respiratory tract, including Streptococcus pneumoniae,
Moraxella, Mycoplasma, and Haemophilus species, so broad coverage is indicated
based on local microbial resistance patterns, prior antibiotic use, and the degree of
the patient’s symptoms. Cultures should be obtained before antibiotics are started,
but treatment should not be delayed until results are available.Pseudomonas species
are not common etiologic agents in COPD exacerbations (SOR B). In patients who
are able to take oral medications and have a functioning alimentary tract,
intravenous antibiotics are no better than oral treatment (SOR B). Shorter courses of
antibiotics, even <5 days, showed no difference in cure rates compared to longer
courses of treatment in one meta-analysis (SOR B). The optimal duration of
antibiotic therapy has not been determined (SOR C).
Page 2 of 67
,Question 3
A 69-year-old female with a history of type 2 diabetes, hypertension, COPD, and stage
4 chronic kidney disease is admitted to the hospital with abdominal pain and fever.
Examination of the abdomen reveals moderate diffuse tenderness that is localized to
the left lower quadrant. Noncontrast CT is indeterminate, and it is recommended that
she undergo either contrast-enhanced CT or contrast-enhanced MRI for further
evaluation. Laboratory testing is remarkable for a WBC count of 16,000/mm3 (N
4300-10,800) with a left shift, a serum creatinine level of 2.5 mg/dL (N 0.6-1.5), and a
glomerular filtration rate of 28 mL/min/1.73 m2.Which one of the following is true
regarding the diagnosis and management of this patient?
MRI with contrast can be safely performed
It would be reasonable to delay contrast CT until her acute condition has totally
resolved
Sodium bicarbonate administration and intravenous fluids would prevent
nephrogenic systemic fibrosis from gadolinium
Reduced doses of gadolinium would prevent nephrogenic systemic fibrosis
Correct Answer
A
Stage 4 chronic kidney disease puts a patient at risk for contrast-induced
nephropathy. The risk of acute kidney injury in patients with reduced kidney
function following exposure to intravenous iodinated contrast media has been
overstated. Intravenous hydration with normal saline is recommended for patients
with a glomerular filtration rate <30 mL/min/1.73 m2. Rare cases of nephrogenic
systemic fibrosis have been associated with the group II gadolinium-based contrast
agents which are now being used. Group I agents, which are associated with a
higher risk of nephropathy, are no longer used.There is no evidence that sodium
bicarbonate and intravenous fluids reduce the risk of nephrogenic systemic fibrosis
in patients with advanced kidney disease. Delaying imaging would potentially lead
to a failure to detect serious complications that may need surgical intervention.
Contrast MRI would generally be safer than contrast CT in this setting, with
hydration as described above. Reducing the dose of gadolinium due to renal
dysfunction will lead to a suboptimal scan.
Page 3 of 67
, Question 4
A 62-year-old female is hospitalized with a small bowel obstruction and you
determine that she will require total parenteral nutrition through a central venous
catheter.Which one of the following will decrease the likelihood of catheter-related
complications in this patient?
Placement of the catheter in the femoral vein using ultrasound guidance
Placement of the catheter in the subclavian vein using ultrasound guidance
Placement of the catheter in the internal jugular vein using ultrasound guidance
Routinely changing the catheter over a guidewire every 3-5 days
Routinely moving the catheter to a different insertion site every 3-5 days
Correct Answer
B
Subclavian vein placement using ultrasound guidance is now the recommended
location and technique for central line placement, to reduce the chance of catheter-
related infections. Placement of the catheter in the femoral vein is associated with a
higher rate of post-insertion complications (SOR A). Central line placement for renal
replacement therapy only may be accomplished using the internal jugular vein.
Routinely changing the catheter over a guidewire every 3-5 days has been shown to
increase the rate of catheter-associated infections (SOR A). Evidence has shown no
benefit from moving the catheter in terms of reducing infections, and making
multiple insertions has been shown to lead to an increase in infections (SOR A).
Page 4 of 67
Test Questions and Correct Answers
Question 1
A nurse calls you about a patient who was admitted to the hospital yesterday
morning for a heart failure exacerbation. The patient's baseline creatinine level
averages 1.6 mg/dL (N 0.6-1.1) and his creatinine level on admission was 1.7 mg/dL.
The nurse is concerned about the patient's renal function.Criteria for confirming that
the patient is experiencing acute kidney injury include which one of the following?
A history of a potential cause of kidney injury
A history of symptoms consistent with acute kidney injury, such as pulmonary edema
or swelling of the extremities
Urine output ≤0.5 mL/kg/hr over the previous 6-12 hours
A rising serum creatinine level of 1.8 mg/dL today
Correct Answer
C
The term acute renal failure has historically been difficult to define, and this was
made more difficult by an implication that the kidneys were permanently damaged.
To reflect a more complete spectrum of renal injury, the currently accepted term has
been changed to acute kidney injury. Approximately 7% of all hospitalized patients
will experience some form of this condition during their stay. Recognizing acute
kidney injury will allow for interventions to prevent the condition from worsening
and prevent multi-system failure from occurring (SOR C).Guidelines from Kidney
Disease Improving Global Guidelines (KDIGO) divide acute kidney injury into three
stages:Stage 1—An increase in serum creatinine of 0.3 over the last 48 hours and/or
reduced urine output of 0.5 mL/kg/hr over the last 6 hoursStage 2—An increase in
serum creatinine to 2–3 times the baseline level and/or reduced urine output of 0.5
mL/kg/hr over the last 12 hoursStage 3—An increase in serum creatinine to over 3
times the baseline level and/or reduced urine output of 0.3 mL/kg/hr over last 24
hours or anuria for greater than 12 hoursA patient may be asymptomatic in the
early stages of acute kidney injury, as even small changes in serum creatinine levels
predict poorer clinical outcomes (SOR C). Checking for potential causes of renal
impairment may help determine the cause of renal injury but will not determine
whether it is present (SOR C).
Page 1 of 67
,Question 2
A 52-year-old male is admitted to the hospital for an acute exacerbation of COPD
after several days of worsening dyspnea, cough, and purulent sputum production.
This is his fourth exacerbation in the past year. Home oxygen has been prescribed but
he only uses it sporadically and he continues to smoke.On examination the patient
has a temperature of 37.0°C (98.6°F), a pulse rate of 100 beats/min, a respiratory rate
of 32/min, and a blood pressure of 148/90 mm Hg. His oxygen saturation is 88% on
room air, and diffuse bilateral wheezes are noted. A chest radiograph shows
hyperinflation with no distinct infiltrates.Which one of the following is true regarding
the use of antibiotics at this time?
Antibiotics should not be given until the infecting organisms are identified on a
sputum or blood culture
Penicillins with antipseudomonal activity are the initial treatment of choice
Intravenous antibiotics are superior to oral treatment in hospitalized patients
Antibiotics should be administered for a total of 14 days
Antibiotics can reduce his risk of death
Correct Answer
E
In patients with moderate to severe COPD, antibiotic treatment reduces the rate of
treatment failure and death (SOR B). Such patients often have mixed bacterial
growth from the lower respiratory tract, including Streptococcus pneumoniae,
Moraxella, Mycoplasma, and Haemophilus species, so broad coverage is indicated
based on local microbial resistance patterns, prior antibiotic use, and the degree of
the patient’s symptoms. Cultures should be obtained before antibiotics are started,
but treatment should not be delayed until results are available.Pseudomonas species
are not common etiologic agents in COPD exacerbations (SOR B). In patients who
are able to take oral medications and have a functioning alimentary tract,
intravenous antibiotics are no better than oral treatment (SOR B). Shorter courses of
antibiotics, even <5 days, showed no difference in cure rates compared to longer
courses of treatment in one meta-analysis (SOR B). The optimal duration of
antibiotic therapy has not been determined (SOR C).
Page 2 of 67
,Question 3
A 69-year-old female with a history of type 2 diabetes, hypertension, COPD, and stage
4 chronic kidney disease is admitted to the hospital with abdominal pain and fever.
Examination of the abdomen reveals moderate diffuse tenderness that is localized to
the left lower quadrant. Noncontrast CT is indeterminate, and it is recommended that
she undergo either contrast-enhanced CT or contrast-enhanced MRI for further
evaluation. Laboratory testing is remarkable for a WBC count of 16,000/mm3 (N
4300-10,800) with a left shift, a serum creatinine level of 2.5 mg/dL (N 0.6-1.5), and a
glomerular filtration rate of 28 mL/min/1.73 m2.Which one of the following is true
regarding the diagnosis and management of this patient?
MRI with contrast can be safely performed
It would be reasonable to delay contrast CT until her acute condition has totally
resolved
Sodium bicarbonate administration and intravenous fluids would prevent
nephrogenic systemic fibrosis from gadolinium
Reduced doses of gadolinium would prevent nephrogenic systemic fibrosis
Correct Answer
A
Stage 4 chronic kidney disease puts a patient at risk for contrast-induced
nephropathy. The risk of acute kidney injury in patients with reduced kidney
function following exposure to intravenous iodinated contrast media has been
overstated. Intravenous hydration with normal saline is recommended for patients
with a glomerular filtration rate <30 mL/min/1.73 m2. Rare cases of nephrogenic
systemic fibrosis have been associated with the group II gadolinium-based contrast
agents which are now being used. Group I agents, which are associated with a
higher risk of nephropathy, are no longer used.There is no evidence that sodium
bicarbonate and intravenous fluids reduce the risk of nephrogenic systemic fibrosis
in patients with advanced kidney disease. Delaying imaging would potentially lead
to a failure to detect serious complications that may need surgical intervention.
Contrast MRI would generally be safer than contrast CT in this setting, with
hydration as described above. Reducing the dose of gadolinium due to renal
dysfunction will lead to a suboptimal scan.
Page 3 of 67
, Question 4
A 62-year-old female is hospitalized with a small bowel obstruction and you
determine that she will require total parenteral nutrition through a central venous
catheter.Which one of the following will decrease the likelihood of catheter-related
complications in this patient?
Placement of the catheter in the femoral vein using ultrasound guidance
Placement of the catheter in the subclavian vein using ultrasound guidance
Placement of the catheter in the internal jugular vein using ultrasound guidance
Routinely changing the catheter over a guidewire every 3-5 days
Routinely moving the catheter to a different insertion site every 3-5 days
Correct Answer
B
Subclavian vein placement using ultrasound guidance is now the recommended
location and technique for central line placement, to reduce the chance of catheter-
related infections. Placement of the catheter in the femoral vein is associated with a
higher rate of post-insertion complications (SOR A). Central line placement for renal
replacement therapy only may be accomplished using the internal jugular vein.
Routinely changing the catheter over a guidewire every 3-5 days has been shown to
increase the rate of catheter-associated infections (SOR A). Evidence has shown no
benefit from moving the catheter in terms of reducing infections, and making
multiple insertions has been shown to lead to an increase in infections (SOR A).
Page 4 of 67
