Harding: Lewis’s Medical-Surgical Nursing, 11th Edition
NGN Case Study
Title: Acute Pyelonephritis, Acute Kidney Injury
Scenario: A 75-year-old female with a history of asthma and type 2 diabetes mellitus
began to experience burning upon urination, lower abdominal pain, and frequent
urination a few days ago. After trying to manage her symptoms by increasing fluids,
she arrived at the emergency department with her daughter with complaints of right
flank pain, fever, and malaise. Her daughter said that the patient who is normally alert
and oriented is now experiencing some confusion. Urinalysis results show bacteriuria,
hematuria, and white blood cell casts. The nurse documents the following findings:
____ Temperature 102.2◦F (39◦C)
____ Heart rate = 94 bpm
____ Blood pressure = 138/76 mmHg
____ Respirations = 20 breaths per minute
____ Right sided costovertebral angle tenderness
____ Patient reports malaise
____ Reports 1 pack per day cigarette use
____ Patient not oriented to place and time
____ Patient reports nausea
1. NGN Item Type: Extended Multiple Response
Place a check mark next to the assessment findings that require follow-up by the
nurse.
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NGN Case Study
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Answers:
___
Temperature 102.2◦ F (39◦C)
____
Heart rate = 94 bpm
____
Blood pressure = 138/76 mm Hg
____ Respirations = 20 breaths per minute
___
Right sided costovertebral angle tenderness
___
Patient reports malaise
____ Reports 1 pack per day cigarette use
___
Patient not oriented to place and time
____ Patient reports nausea
Cognitive Skill: Recognize Cues
Reference: Harding et al., 11th ed., 2020, Ch. 45, pp. 1025, 1028, 1029.
2. NGN Item Type: Cloze
Choose the most likely options for the information missing from the statement
below by selectin from the list of options provided.
Based on the patient’s assessment data, the nurse determines that the patient is
currently at risk for complications, including _______, _______, and _______.
Options

Acute kidney injury

Lower urinary tract infection

Fluid overload

Urosepsis
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NGN Case Study
17-3

Chronic kidney failure

Allergic reaction

Hypoglycemia

Septic shock
Cognitive Skill: Analyze Cues
Reference: Harding et al., 11th ed., 2020, Ch. 45, pp. 1026, 1028, 1029; Ch. 46, p.
1061; Ch. 48, pp. 1132, 1133.
Scenario: The patient is transferred to a medical unit 2 hours after arriving at the
emergency department with an admitting diagnosis of pyelonephritis. She has a history
of asthma and type 2 diabetes mellitus. The admitting nurse is assessing the patient and
reviewing orders and diagnostic studies to develop a plan of care. The patient is awake,
alert, and pleasant but is not oriented to place and time. She reorients easily with
frequent reminding. She is complaining of pain but is not able to use the pain intensity
scale. Ibuprofen is prescribed for pain every 6 hours as needed. Vital signs are
temperature 101.4◦ F, pulse 100 bpm, respirations 22 breaths per minute, blood
pressure 138/74 mm Hg. The patient is receiving intravenous normal saline at 100
mL/hour. A urine specimen was sent to the lab for culture and sensitivity. She is
tolerating her clear liquid diet well. The nurse began an infusion of an extended
spectrum cephalosporin as soon as the urine specimen was obtained and sent to the lab.
The patient is voiding frequently and although instructed to do so, does not ask for
assistance to ambulate to the bathroom.
1. NGN Item Type: Extended Response
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NGN Case Study
17-4
Based on the patient’s current treatment plan, the patient’s priority needs will be to
prevent which of the following? Select all that apply.
A. ____Patient injury
B. ____Pain
C. ____Aspiration
D. ____Constipation
E. ____Hyperglycemia
F. ____Urosepsis
G. ____Skin breakdown
Cognitive Skill: Prioritize Hypotheses
Reference: Harding et al., 11th ed., 2020, Ch. 45, pp. 1026, 1028, 1029, Ch. 48, pp.
1132, 1133.
2. NGN Item Type: Extended Drag and Drop
Indicate which nursing response listed in the far-left column is appropriate for
each client question. Note that not all responses will be used.
Nurse’s Responses
Patient Questions
1. “You may walk in the hallway as
long as you are not feeling weak or
dizzy.”
2. “We can remove your IV needle as
soon as you begin to feel better.”
3. “The medications given to you
through your IV are rapidly
absorbed and will begin to kill the
bacteria sooner than oral
medications would.”
4. “We are giving you a lot of fluids
so that you do not become
“How much longer will I have this
pain in the side of my back?”
“Why do I have to pass my water so
frequently?”
“When will this needle be removed
from my arm?”
“Will I be able to walk around in my
room today?”
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Appropriate Response
for each Question
NGN Case Study
5.
6.
7.
8.
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dehydrated and also to dilute your
urine to help flush out the bacteria
that is in your urinary system. The
extra fluids cause you to pass your
water frequently.”
“The IV needle will need to remain
in your arm as long as you need to
receive medications and fluids to
treat your kidney infection.”
“You may only walk in your room
with the assistance of one of our
healthcare team members.”
“The pain in the side of your back
should go away as soon as the
infection subsides.”
“I can give you some pain
medication, which would provide
you with pain relief. Please notify
me if you continue to have pain and
I will ask your healthcare provider
to increase or change your pain
medication.”
“Can I take this medicine as a pill
instead of through the needle in my
arm?”
Cognitive Skill: Generate Solutions
Reference: Harding et al., 11th ed., 2020, Ch. 5, pp. 70–71, Ch. 45, p. 1029.
Scenario: The patient has now been on the medical unit for 3 days. She was diagnosed
with pyelonephritis on admission. Vital signs this morning: Temperature 98.8 (37.1◦C),
blood pressure 100/50 mm Hg, pulse 110 bpm, respirations 24 breaths per minute. The
patient is oriented to self only but is awake and alert. Her daughter is at her bedside.
The urine culture results showed enterococci, and therefore the broad-spectrum
antibiotic the patient was receiving was replaced with sensitivity-guided antibiotic
therapy. Abnormal serum laboratory results are as follows: WBC = 14500/mm3
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NGN Case Study
17-6
(normal=5000-10000/mm3), BUN = 27 mg/dL (normal = 7-20 mg/dL), creatinine 2.0
mg/dL (normal = 0.5-1.1 mg/dL). She’s now been diagnosed with acute kidney injury.
NGN Item Type: Matrix
Use an X for the nursing actions listed below that are Indicated (appropriate or
necessary), Contraindicated (could be harmful), or Nonessential (makes no
difference or not necessary) for the patient’s care at this time. Only one selection
can be made for each nursing action.
Nursing Action
Indicated
Contraindicated
Nonessential
Consult with dietician to provide a
low caloric diet.
Obtain daily weights.
Medicate with ibuprofen every 6
hours as needed for complaint of
pain.
Focus on providing holistic
nursing care to patient.
Carefully consider the type,
frequency, and dosage of the
patient’s prescribed antibiotic
therapy.
Assess for the presence of bowel
sounds every 4 hours.
Cognitive Skill: Take Action
Reference: Harding et al., 11th ed., 2020, Ch. 44, p. 1012, Ch. 46, pp. 1060, 1064–
1065.
Scenario: A 75-year-old female was admitted to the hospital 3 weeks ago with a
history of a urinary tract infection at home and was diagnosed with pyelonephritis
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17-7
upon admission. Despite treatment, her kidney infection progressed, and she developed
acute kidney injury. After her antibiotic therapy was adjusted she recovered well
enough to be discharged to her daughter’s home. The patient and her daughter were
given discharge instructions to manage her prescriptions and health maintenance at
home. She is now at the urology clinic for a 1-week follow-up appointment. Urine and
blood samples were analyzed prior to her appointment. The nurse evaluates the
effectiveness of actions.
NGN Item Type: Extended Multiple Response
Which of the following findings indicate effectiveness? Select all that apply.
_____ 1.
The patient reports that she wipes front to back after urinating
_____ 2.
The urinalysis report shows WBC >5/hpf (high), RBCs >4/hpf (high)
_____ 3.
The patient reports that she drinks 4-5 glasses of fluid per day.
_____ 4.
The patient voids approximately 3 times a day.
____ 5.
The patient reports that she has stopped taking her antibiotic medication
since she is now feeling “fine.”
_____ 6.
The patient reports no flank pain.
_____ 7.
Serum creatinine level is 1.0 mg/dL.
_____ 8.
The patient states that she rests frequently.
Cognitive Skill: Evaluate Outcomes
Reference: Harding et al., 11th ed., 2020, Ch. 44, p. 1017, Ch. 45, pp. 1028, 1030, Ch.
46, pp. 1049, 1065.
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