Department 12 · 25 scenarios

Renal & Dialysis

See the risk. Understand the response.
Practise the reasoning you will carry to the bedside.

Plain English Primary sources Students & tutors

From routine safety to critical change

Learn the reasoning. Follow your local clinical pathway. These are fictional teaching cases, not patient-specific treatment instructions. Adult, pregnancy, pediatric and neonatal responses differ. Use the population-specific pathway and verified weight where required. Use current facility protocols, authorized orders and your scope of practice. Students work under supervision. In a real emergency, activate clinical help rather than consult this page.

How to use these cases Read the cues before opening the actions. Name your first priority, then compare your reasoning. The difficulty describes learning complexity; even an introductory case can involve a serious risk.

5 introductory5 intermediate5 difficult10 extremely difficult

Find or jump to a scenario

Learning complexity

25 of 25 scenarios

Open a scenario to explore its actions25 original cases

Dialysis circuit & access safety

The access arm is being used for routine measurements

Introductory

The situation

A patient with a functioning fistula arrives for care. Their documented access-protection plan is overlooked while routine blood sampling and pressure measurement are prepared.

What should catch your attention

Fistula arm
Plan overlooked
Preventable access risk

Your immediate priority

Follow the verified access-protection plan and select an appropriate alternative with the renal team.

01Fistula arm
02Follow the verified access-protection plan and select an appropriate alternative with the renal team.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Follow the verified access-protection plan and select an appropriate alternative with the renal team. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
2
Assess patient and circuit
Check consciousness, breathing, pressure and the visible access/circuit with trained dialysis staff. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
3
Use the emergency protocol
Call the dialysis lead and carry out the device-specific stop, clamp or isolation actions appropriate to the identified problem within competency. [1]
Why it matters Returning blood or manipulating a circuit may be unsafe for some emergencies.
4
Continue clinical review
Maintain emergency support, document the event and arrange ordered tests, treatment and access assessment. [1]
Why it matters A corrected machine problem can leave blood loss, infection or metabolic instability requiring care.

What to look for next

Confirm the plan is visible. Monitor circulation, access condition and prescribed laboratory trends after the event; verify any restart is authorized.

Avoid this shortcut

Do not assume every available arm is equivalent. Do not bypass a safety alarm or automatically return circuit blood when contamination, air or hemolysis is suspected.

A clear way to hand it over

“I am calling about this new concern: the access arm is being used for routine measurements. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English The extracorporeal circuit carries blood outside the body through the dialysis system.

Sources behind the actions 1 primary references

MHRA / UK Kidney Patient Safety Committee · Dialysis and continuous renal replacement safety guidance
Access/circuit safety, needle dislodgement and trained device-specific emergency response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

© 2026 RN Clarity · Lumiere Labs. All rights reserved. Original scenarios and diagrams are for personal learning. Do not copy, screenshot, print, repost, sell or reproduce them without written permission, except where applicable law permits. Cited guidance belongs to its respective owners.

Dialysis circuit & access safety

The weight does not match the dialysis record

Introductory

The situation

A patient is weighed in different clothing on another scale and the apparent change would substantially alter the proposed fluid removal.

What should catch your attention

Inconsistent measurement
Fluid-removal decision
Dialysis preparation

Your immediate priority

Obtain a reliable weight and ask the trained team to reconcile it with symptoms and the prescribed target.

01Inconsistent measurement
02Obtain a reliable weight and ask the trained team to reconcile it with symptoms and the prescribed target.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Obtain a reliable weight and ask the trained team to reconcile it with symptoms and the prescribed target. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
2
Assess patient and circuit
Check consciousness, breathing, pressure and the visible access/circuit with trained dialysis staff. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
3
Use the emergency protocol
Call the dialysis lead and carry out the device-specific stop, clamp or isolation actions appropriate to the identified problem within competency. [1]
Why it matters Returning blood or manipulating a circuit may be unsafe for some emergencies.
4
Continue clinical review
Maintain emergency support, document the event and arrange ordered tests, treatment and access assessment. [1]
Why it matters A corrected machine problem can leave blood loss, infection or metabolic instability requiring care.

What to look for next

Verify the authorized removal plan. Monitor circulation, access condition and prescribed laboratory trends after the event; verify any restart is authorized.

Avoid this shortcut

Do not independently change ultrafiltration from one inconsistent reading. Do not bypass a safety alarm or automatically return circuit blood when contamination, air or hemolysis is suspected.

A clear way to hand it over

“I am calling about this new concern: the weight does not match the dialysis record. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English The extracorporeal circuit carries blood outside the body through the dialysis system.

Sources behind the actions 1 primary references

MHRA / UK Kidney Patient Safety Committee · Dialysis and continuous renal replacement safety guidance
Access/circuit safety, needle dislodgement and trained device-specific emergency response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Communication & discharge

The patient misunderstands a fluid allowance

Introductory

The situation

A dialysis patient counts water but excludes tea, soup and ice from their prescribed allowance. They are embarrassed about a recent weight increase.

What should catch your attention

Incomplete understanding
Multiple fluid sources
Sensitive teaching

Your immediate priority

Use the individual plan and teach-back to explain which intake counts, without blame.

01Incomplete understanding
02Use the individual plan and teach-back to explain which intake counts, without blame.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Use the individual plan and teach-back to explain which intake counts, without blame. [1]
Why it matters Agreement or a smile does not demonstrate understanding of a treatment plan.
2
Make the explanation accessible
Ask the person’s preferred language and communication needs. Use a qualified interpreter for clinical decisions when needed. [1]
Why it matters Agreement or a smile does not demonstrate understanding of a treatment plan.
3
Use a small teach-back
Explain one important step in plain language and ask the person to show or describe it in their own words. [1]
Why it matters This tests how clearly we explained the task without making the person feel examined.
4
Repair the gap
Rephrase, demonstrate and repeat the check. Provide an accessible written plan and a named contact for problems. [1]
Why it matters A usable plan supports safer decisions after the nurse is no longer beside the patient.

What to look for next

Confirm practical understanding. Confirm the person can identify the next step and warning signs. Resolve missing equipment, support or follow-up before an unsafe discharge proceeds.

Avoid this shortcut

Do not impose a generic allowance for every patient. Do not rely on children to interpret or label a person noncompliant because of a language barrier.

A clear way to hand it over

“I am calling about this new concern: the patient misunderstands a fluid allowance. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Teach-back asks the person to explain the plan so staff can check their explanation.

Sources behind the actions 2 primary references

AHRQ · Teach-back: patient and family engagement
Check the clarity of an explanation by asking patients to describe the plan in their own words.
US HHS Office of Minority Health · National CLAS Standards: communication and language assistance
Competent language assistance; avoid using untrained people or children as interpreters.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Urinary drainage

The catheter dressing is wet after bathing

Introductory

The situation

A patient with a dialysis catheter has a wet dressing after washing. The site needs prompt assessment and device-specific care.

What should catch your attention

Wet barrier
Vascular access
Infection risk

Your immediate priority

Arrange trained aseptic dressing/site review and reinforce the prescribed bathing protection plan.

01Wet barrier
02Arrange trained aseptic dressing/site review and reinforce the prescribed bathing protection plan.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Arrange trained aseptic dressing/site review and reinforce the prescribed bathing protection plan. [1]
Why it matters Poor flow can be caused by tubing position, but low output can also reflect serious illness.
2
Check simple causes
Assess pain and bladder symptoms, tubing kinks, bag position and recent urine output; keep drainage unobstructed below bladder level. [1]
Why it matters Poor flow can be caused by tubing position, but low output can also reflect serious illness.
3
Escalate persistent problems
Follow the trained catheter assessment pathway for suspected obstruction, leakage, trauma or retention; obtain a clinical plan. [1]
Why it matters Repeated manipulation or unplanned irrigation can injure tissue and introduce infection.
4
Review the indication
Document output and catheter findings, provide appropriate hygiene and ask whether the catheter is still needed. [1]
Why it matters Removing unnecessary catheters reduces infection risk and supports mobility.

What to look for next

Check for redness, pain or systemic symptoms. Check relief of bladder symptoms and restored drainage. Fever, bleeding, severe pain or continued low output needs prompt review.

Avoid this shortcut

Do not simply place another dressing over the wet one. Do not disconnect the system to improve flow, routinely irrigate or treat cloudy urine alone as infection.

A clear way to hand it over

“I am calling about this new concern: the catheter dressing is wet after bathing. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English A closed system keeps the catheter connected to its drainage equipment.

Sources behind the actions 1 primary references

CDC · CAUTI prevention: summary of recommendations
Closed, unobstructed catheter drainage, appropriate indication and avoidance of routine bladder irrigation.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Medication safety

A medicine list misses an over-the-counter painkiller

Introductory

The situation

A patient with kidney disease takes an OTC painkiller daily but did not list it as a medicine. The renal prescriber needs the complete exposure history.

What should catch your attention

OTC omission
Kidney disease
Reconciliation incomplete

Your immediate priority

Record the actual ingredient and use and ask pharmacy/prescriber to review renal safety.

01OTC omission
02Record the actual ingredient and use and ask pharmacy/prescriber to review renal safety.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Record the actual ingredient and use and ask pharmacy/prescriber to review renal safety. [1]
Why it matters A familiar-looking package or copied list cannot establish the right medicine for this person.
2
Pause and verify
Check two approved identifiers, the current order, allergy history, formulation, last dose and the actual medicine supplied. [1]
Why it matters A familiar-looking package or copied list cannot establish the right medicine for this person.
3
Clarify with the team
Contact the prescriber and pharmacist about the discrepancy. Explain urgent omitted-dose risks and obtain a documented safe plan. [1]
Why it matters Both giving the wrong medicine and delaying a time-critical medicine can harm the patient.
4
Close the loop
Record the resolved order, administration decision and monitoring plan; tell the receiving team about any remaining uncertainty. [1]
Why it matters A corrected chart must reach the bedside and the next handover to prevent repetition.

What to look for next

Confirm a verified ongoing plan. Watch for adverse effects or effects of a delayed dose according to the medicine. Escalate any deterioration rather than wait for routine pharmacy review.

Avoid this shortcut

Do not independently substitute another drug. Do not guess a dose, crush an unsuitable formulation or silently copy conflicting medication lists.

A clear way to hand it over

“I am calling about this new concern: a medicine list misses an over-the-counter painkiller. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Reconciliation means comparing medicine lists and resolving differences.

Sources behind the actions 2 primary references

NICE · NG5: Medicines optimisation
Reconciliation, medicine safety, communication and individual review.
NICE · CG183: Drug allergy—recommendations
Confirm and document allergy history before drug administration; distinguish allergy from other adverse reactions.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Dialysis circuit & access safety

Cramping with falling pressure during dialysis

Intermediate

The situation

During fluid removal, a patient develops cramps, dizziness and falling pressure. The prescribed session target has not yet been reached.

What should catch your attention

Symptomatic pressure fall
Active ultrafiltration
Target not yet reached

Your immediate priority

Notify the dialysis lead and apply the authorized intradialytic-hypotension response with patient assessment.

01Symptomatic pressure fall
02Notify the dialysis lead and apply the authorized intradialytic-hypotension response with patient assessment.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Notify the dialysis lead and apply the authorized intradialytic-hypotension response with patient assessment. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
2
Assess patient and circuit
Check consciousness, breathing, pressure and the visible access/circuit with trained dialysis staff. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
3
Use the emergency protocol
Call the dialysis lead and carry out the device-specific stop, clamp or isolation actions appropriate to the identified problem within competency. [1]
Why it matters Returning blood or manipulating a circuit may be unsafe for some emergencies.
4
Continue clinical review
Maintain emergency support, document the event and arrange ordered tests, treatment and access assessment. [1]
Why it matters A corrected machine problem can leave blood loss, infection or metabolic instability requiring care.

What to look for next

Reassess perfusion and the revised session plan. Monitor circulation, access condition and prescribed laboratory trends after the event; verify any restart is authorized.

Avoid this shortcut

Do not continue unchanged solely to reach the target. Do not bypass a safety alarm or automatically return circuit blood when contamination, air or hemolysis is suspected.

A clear way to hand it over

“I am calling about this new concern: cramping with falling pressure during dialysis. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English The extracorporeal circuit carries blood outside the body through the dialysis system.

Sources behind the actions 1 primary references

MHRA / UK Kidney Patient Safety Committee · Dialysis and continuous renal replacement safety guidance
Access/circuit safety, needle dislodgement and trained device-specific emergency response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Dialysis circuit & access safety

A fistula loses its usual palpable vibration

Intermediate

The situation

Before a session, the patient says the fistula feels different. The usual vibration is not detected by the trained assessment.

What should catch your attention

Access change
Possible dysfunction
Before cannulation

Your immediate priority

Seek urgent renal/access assessment and do not proceed with unverified use.

01Access change
02Seek urgent renal/access assessment and do not proceed with unverified use.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Seek urgent renal/access assessment and do not proceed with unverified use. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
2
Assess patient and circuit
Check consciousness, breathing, pressure and the visible access/circuit with trained dialysis staff. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
3
Use the emergency protocol
Call the dialysis lead and carry out the device-specific stop, clamp or isolation actions appropriate to the identified problem within competency. [1]
Why it matters Returning blood or manipulating a circuit may be unsafe for some emergencies.
4
Continue clinical review
Maintain emergency support, document the event and arrange ordered tests, treatment and access assessment. [1]
Why it matters A corrected machine problem can leave blood loss, infection or metabolic instability requiring care.

What to look for next

Follow the documented alternative access/session plan. Monitor circulation, access condition and prescribed laboratory trends after the event; verify any restart is authorized.

Avoid this shortcut

Do not repeatedly probe or cannulate to test the access. Do not bypass a safety alarm or automatically return circuit blood when contamination, air or hemolysis is suspected.

A clear way to hand it over

“I am calling about this new concern: a fistula loses its usual palpable vibration. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English The extracorporeal circuit carries blood outside the body through the dialysis system.

Sources behind the actions 1 primary references

MHRA / UK Kidney Patient Safety Committee · Dialysis and continuous renal replacement safety guidance
Access/circuit safety, needle dislodgement and trained device-specific emergency response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Glucose safety

Low glucose during dialysis

Intermediate

The situation

A patient with diabetes becomes sweaty and confused during dialysis. Their measured glucose is low and safe swallowing needs assessment.

What should catch your attention

Confirmed low glucose
Active dialysis
Route safety

Your immediate priority

Use the authorized hypoglycemia pathway and involve the dialysis team in session and medicine review.

01Confirmed low glucose
02Use the authorized hypoglycemia pathway and involve the dialysis team in session and medicine review.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Use the authorized hypoglycemia pathway and involve the dialysis team in session and medicine review. [1]
Why it matters The brain needs glucose; giving food to an unconscious person risks aspiration.
2
Assess and act
Check glucose and consciousness. If the person can swallow safely, give the protocol’s rapid carbohydrate; if not, call urgent help and use the authorized non-oral rescue pathway. [1]
Why it matters The brain needs glucose; giving food to an unconscious person risks aspiration.
3
Check the response
Recheck glucose at the protocol interval, commonly 15 minutes after oral treatment, and repeat or escalate as directed. [1]
Why it matters A single treatment can fail, and symptoms alone do not show that glucose has recovered.
4
Prevent recurrence
Review meal interruption, insulin or other medicines, kidney function and the next nutrition plan with the team. [1]
Why it matters Correction without addressing the cause can lead to another episode soon afterwards.

What to look for next

Monitor recurrence. Continue prescribed glucose checks and observe alertness, swallowing and food intake. Some medicines can cause prolonged or recurrent hypoglycemia.

Avoid this shortcut

Do not assume symptoms are only low blood pressure. Do not give oral glucose to someone unable to swallow or change insulin orders independently.

A clear way to hand it over

“I am calling about this new concern: low glucose during dialysis. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Hypoglycemia means blood glucose is too low for safe body function.

Sources behind the actions 2 primary references

NIDDK · Low blood glucose (hypoglycemia)
Rapid carbohydrate for a person who can swallow; reassessment after 15 minutes; severe episodes require emergency help.
American Diabetes Association · Diabetes Care in the Hospital: Standards of Care—2026
Nurse-initiated hospital hypoglycemia protocols, documentation, medication/meal review and prevention of recurrence.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Infection control

Catheter-site redness with chills

Intermediate

The situation

A dialysis patient has new catheter-site tenderness and rigors during treatment. Their temperature is not dramatically elevated.

What should catch your attention

Access concern
Rigors
Possible bloodstream infection

Your immediate priority

Call the renal/medical team promptly, assess for deterioration and prepare prescribed cultures/treatment.

01Access concern
02Call the renal/medical team promptly, assess for deterioration and prepare prescribed cultures/treatment.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Call the renal/medical team promptly, assess for deterioration and prepare prescribed cultures/treatment. [1]
Why it matters Different infections spread in different ways; one isolation label does not fit all illnesses.
2
Apply the right precautions
Use standard precautions plus the indicated contact, droplet or airborne precautions; follow the facility’s placement and PPE pathway. [1]
Why it matters Different infections spread in different ways; one isolation label does not fit all illnesses.
3
Assess clinical severity
Check breathing, alertness, vital signs and hydration, and request diagnostic review when indicated. [1]
Why it matters Infection control cannot replace clinical treatment of a deteriorating patient.
4
Protect shared care
Use dedicated or cleaned equipment, appropriate hand hygiene and environmental cleaning; communicate precautions during transfer. [1]
Why it matters Organisms can spread through staff hands, equipment and unclear handovers.

What to look for next

Trend circulation and symptoms. Watch for new cases, ongoing symptoms and deterioration. Recheck that precautions remain appropriate as the diagnosis or test results change.

Avoid this shortcut

Do not routinely remove the access independently. Do not delay emergency care while seeking a perfect room or assume gloves replace hand hygiene.

A clear way to hand it over

“I am calling about this new concern: catheter-site redness with chills. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Transmission-based precautions add measures to routine infection prevention.

Sources behind the actions 2 primary references

CDC · Clinical safety: hand hygiene for healthcare workers
Gown/gloves and hand hygiene; soap and water when visibly soiled and as an additional precaution in C. diff outbreaks. Alcohol rub access should remain available.
CDC · Transmission-based precautions
Organism-specific isolation, respiratory protection and safe transport precautions.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Kidney function & fluids

Urine output falls after dehydration

Intermediate

The situation

A kidney-disease patient has diarrhea, poor intake and reduced urine. They also take medicines that may affect renal perfusion.

What should catch your attention

Volume loss
Reduced urine
Medicine factors

Your immediate priority

Seek assessment of fluid status, renal trends and medicine exposure.

01Volume loss
02Seek assessment of fluid status, renal trends and medicine exposure.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Seek assessment of fluid status, renal trends and medicine exposure. [1]
Why it matters A low urine total may reflect measurement error, obstruction or impaired kidney perfusion.
2
Check the trend
Compare measured urine, creatinine and vital signs with baseline; check collection accuracy and obstruction clues. [1]
Why it matters A low urine total may reflect measurement error, obstruction or impaired kidney perfusion.
3
Assess fluid status
Check intake, losses, weight, edema and breathing, and seek a clinician’s fluid and medication review. [1]
Why it matters Someone may be swollen yet poorly perfused; a reflex fluid bolus or diuretic can be unsafe.
4
Monitor the authorized plan
Track prescribed fluid balance, electrolytes and medicine changes, and escalate urgent complications such as hyperkalemia or pulmonary edema. [1]
Why it matters AKI can rapidly affect drug clearance, cardiac rhythm and fluid tolerance.

What to look for next

Follow individualized fluid and laboratory review. Look for improving perfusion and urine trends, stable electrolytes and no respiratory overload. Escalate worsening symptoms or urgent laboratory results.

Avoid this shortcut

Do not give unrestricted fluid without assessing overload risk. Do not diagnose dehydration from urine alone or routinely treat AKI with loop diuretics.

A clear way to hand it over

“I am calling about this new concern: urine output falls after dehydration. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English AKI means an acute decrease in kidney function.

Sources behind the actions 2 primary references

NICE · NG148: Acute kidney injury—recommendations
Recognize low urine output, compare creatinine with baseline, investigate causes and do not routinely treat AKI with loop diuretics.
NICE · CG174: Intravenous fluid therapy in adults
Individual fluid assessment and repeated review of response and comorbid risks.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Heart failure & fluid balance

New breathlessness before a missed dialysis session

Difficult

The situation

A patient missed dialysis and now has worsening dyspnea, edema and reduced urine. Pressure is high and respiratory effort is increasing.

What should catch your attention

Missed treatment
Congestion
Respiratory decline

Your immediate priority

Request urgent renal/respiratory assessment and support prescribed oxygen/ventilation and definitive fluid-removal planning.

01Missed treatment
02Request urgent renal/respiratory assessment and support prescribed oxygen/ventilation and definitive fluid-removal planning.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Request urgent renal/respiratory assessment and support prescribed oxygen/ventilation and definitive fluid-removal planning. [1]
Why it matters Congestion and impaired circulation can coexist, so one measurement cannot determine treatment.
2
Recognize the pattern
Compare breathlessness, oxygen need, edema, weight, pressure and urine with baseline and assess medication or fluid changes. [1]
Why it matters Congestion and impaired circulation can coexist, so one measurement cannot determine treatment.
3
Escalate the change
Seek urgent clinical review for respiratory distress, hypotension or poor perfusion and prepare the prescribed cardiac investigations. [1]
Why it matters Acute heart failure requires diagnosis and treatment matched to the current physiology.
4
Deliver and review the plan
Give ordered diuretics or respiratory support with the required kidney, electrolyte and output monitoring. [1]
Why it matters Treatment can improve congestion while also changing pressure, kidney function and electrolytes.

What to look for next

Track breathing and perfusion. Track work of breathing, perfusion, urine and laboratory trends after treatment; report deterioration rather than chasing urine volume alone.

Avoid this shortcut

Do not treat this only as a routine scheduling problem. Do not give a routine fluid bolus for low urine or a diuretic for every swollen patient without assessment and authorization.

A clear way to hand it over

“I am calling about this new concern: new breathlessness before a missed dialysis session. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Congestion means fluid accumulation; perfusion means blood reaching organs.

Sources behind the actions 3 primary references

NICE · CG187: Acute heart failure—recommendations
Specialist assessment, ordered IV diuretics with renal/urine monitoring and ventilatory support for selected severe respiratory failure.
NICE · NG148: Acute kidney injury—recommendations
Recognize low urine output, compare creatinine with baseline, investigate causes and do not routinely treat AKI with loop diuretics.
British Thoracic Society · Oxygen use in adults in healthcare and emergency settings
Targeted oxygen therapy, urgent blood gases for hypercapnia risk and oxygen during critical illness without unsafe withholding.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Bleeding & circulation

Persistent bleeding after needle removal

Difficult

The situation

An access puncture continues bleeding despite the trained initial hemostasis method. The patient is on antithrombotic treatment and feels faint.

What should catch your attention

Persistent access bleeding
Antithrombotic exposure
Symptoms

Your immediate priority

Call urgent dialysis/medical help and use the approved hemostasis method while assessing circulation.

01Persistent access bleeding
02Call urgent dialysis/medical help and use the approved hemostasis method while assessing circulation.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Call urgent dialysis/medical help and use the approved hemostasis method while assessing circulation. [1]
Why it matters External loss can underestimate bleeding, and a normal early blood count cannot rule out shock.
2
Call and assess
Activate the local bleeding response for instability; assess airway, breathing, pulse, pressure, alertness and visible loss. [1]
Why it matters External loss can underestimate bleeding, and a normal early blood count cannot rule out shock.
3
Prepare safe resuscitation
Maintain or obtain suitable access within competence; prepare ordered fluids, blood tests and blood products using identification and compatibility checks. [1]
Why it matters Resuscitation supports circulation while the team seeks the bleeding source.
4
Track treatment and source control
Report procedure history, anticoagulants and last doses; help arrange urgent specialist review and prescribed monitoring. [1]
Why it matters Replacement alone cannot stop every source of bleeding or resolve medication-related risk.

What to look for next

Monitor blood loss and access perfusion. Trend observations and loss after interventions. Escalate ongoing shock, respiratory change or a suspected transfusion reaction immediately.

Avoid this shortcut

Do not apply unapproved pressure that occludes the whole access. Do not wait for a laboratory result before responding to shock or independently select reversal drugs.

A clear way to hand it over

“I am calling about this new concern: persistent bleeding after needle removal. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Hemodynamic instability means circulation is not adequately supporting the body.

Sources behind the actions 2 primary references

NICE · NG24: Blood transfusion (updated February 2026)
General blood-product decisions, compatibility and patient monitoring; major bleeding follows a separate emergency pathway.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Dialysis circuit & access safety

Confusion develops during a first intensive dialysis session

Difficult

The situation

During an early dialysis session, a patient develops headache, nausea and increasing confusion. Glucose and circulation also need checking.

What should catch your attention

New neurological symptoms
Dialysis timing
Several possible causes

Your immediate priority

Call the dialysis lead urgently and use the session-complication pathway while evaluating ABCs and reversible causes.

01New neurological symptoms
02Call the dialysis lead urgently and use the session-complication pathway while evaluating ABCs and reversible causes.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Call the dialysis lead urgently and use the session-complication pathway while evaluating ABCs and reversible causes. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
2
Assess patient and circuit
Check consciousness, breathing, pressure and the visible access/circuit with trained dialysis staff. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
3
Use the emergency protocol
Call the dialysis lead and carry out the device-specific stop, clamp or isolation actions appropriate to the identified problem within competency. [1]
Why it matters Returning blood or manipulating a circuit may be unsafe for some emergencies.
4
Continue clinical review
Maintain emergency support, document the event and arrange ordered tests, treatment and access assessment. [1]
Why it matters A corrected machine problem can leave blood loss, infection or metabolic instability requiring care.

What to look for next

Trend neurological and physiological findings. Monitor circulation, access condition and prescribed laboratory trends after the event; verify any restart is authorized.

Avoid this shortcut

Do not assume a single mechanism or continue without review. Do not bypass a safety alarm or automatically return circuit blood when contamination, air or hemolysis is suspected.

A clear way to hand it over

“I am calling about this new concern: confusion develops during a first intensive dialysis session. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English The extracorporeal circuit carries blood outside the body through the dialysis system.

Sources behind the actions 1 primary references

MHRA / UK Kidney Patient Safety Committee · Dialysis and continuous renal replacement safety guidance
Access/circuit safety, needle dislodgement and trained device-specific emergency response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Peritoneal dialysis infection

Peritoneal dialysate becomes cloudy with abdominal pain

Difficult

The situation

A patient receiving peritoneal dialysis has new abdominal pain and cloudy drained fluid. The previous exchanges were clear.

What should catch your attention

Cloudy effluent
Abdominal pain
Peritonitis concern

Your immediate priority

Contact the renal team urgently and obtain prescribed effluent sampling and treatment through the aseptic pathway.

01Cloudy effluent
02Contact the renal team urgently and obtain prescribed effluent sampling and treatment through the aseptic pathway.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Contact the renal team urgently and obtain prescribed effluent sampling and treatment through the aseptic pathway. [1]
Why it matters Pain or cloudy effluent warrants prompt assessment for peritonitis.
2
Recognize and report
Report abdominal pain, cloudy effluent, exchange findings and systemic symptoms. [1]
Why it matters Pain or cloudy effluent warrants prompt assessment for peritonitis.
3
Obtain the prescribed samples
Use trained aseptic collection and prepare ordered effluent testing and timely treatment. [1]
Why it matters Samples help identify the cause without replacing prompt clinical care.
4
Monitor and escalate
Follow the renal treatment/exchange plan and activate resuscitation for shock or respiratory decline. [1]
Why it matters A localized concern can progress to systemic illness.

What to look for next

Monitor systemic deterioration and exchange findings. Track perfusion, pain, effluent and treatment response and arrange urgent reassessment for worsening.

Avoid this shortcut

Do not discard all diagnostic effluent before sampling instructions. Do not delay urgent treatment for a routine appointment or independently choose catheter removal.

A clear way to hand it over

“I am calling about this new concern: peritoneal dialysate becomes cloudy with abdominal pain. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Peritonitis is inflammation or infection of the lining inside the abdomen.

Sources behind the actions 1 primary references

ISPD · Peritonitis recommendations: 2022 update
Cloudy effluent/abdominal symptoms, aseptic sampling and prompt renal-directed treatment.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Urinary drainage

The catheter will not drain and the patient has discomfort

Difficult

The situation

A renal patient has sudden absent catheter output and lower-abdominal discomfort. The tubing is kinked but kidney deterioration is also possible.

What should catch your attention

Possible retention
Mechanical obstruction
Low output

Your immediate priority

Check and correct the external kink within policy and reassess drainage, bladder symptoms and renal status.

01Possible retention
02Check and correct the external kink within policy and reassess drainage, bladder symptoms and renal status.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Check and correct the external kink within policy and reassess drainage, bladder symptoms and renal status. [1]
Why it matters Poor flow can be caused by tubing position, but low output can also reflect serious illness.
2
Check simple causes
Assess pain and bladder symptoms, tubing kinks, bag position and recent urine output; keep drainage unobstructed below bladder level. [1]
Why it matters Poor flow can be caused by tubing position, but low output can also reflect serious illness.
3
Escalate persistent problems
Follow the trained catheter assessment pathway for suspected obstruction, leakage, trauma or retention; obtain a clinical plan. [1]
Why it matters Repeated manipulation or unplanned irrigation can injure tissue and introduce infection.
4
Review the indication
Document output and catheter findings, provide appropriate hygiene and ask whether the catheter is still needed. [1]
Why it matters Removing unnecessary catheters reduces infection risk and supports mobility.

What to look for next

Record response and escalate persistent absence. Check relief of bladder symptoms and restored drainage. Fever, bleeding, severe pain or continued low output needs prompt review.

Avoid this shortcut

Do not force irrigation routinely. Do not disconnect the system to improve flow, routinely irrigate or treat cloudy urine alone as infection.

A clear way to hand it over

“I am calling about this new concern: the catheter will not drain and the patient has discomfort. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English A closed system keeps the catheter connected to its drainage equipment.

Sources behind the actions 1 primary references

CDC · CAUTI prevention: summary of recommendations
Closed, unobstructed catheter drainage, appropriate indication and avoidance of routine bladder irrigation.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Dialysis circuit & access safety

A venous dialysis needle dislodges unnoticed by the alarm

Extremely difficult

The situation

A patient's venous needle has partly come out and blood is pooling beneath the blanket. The machine has not produced the expected alarm.

What should catch your attention

Visible blood loss
Needle displaced
Alarm not reliable alone

Your immediate priority

Activate the dialysis emergency stop/clamp and bleeding-control response immediately with trained staff.

01Visible blood loss
02Activate the dialysis emergency stop/clamp and bleeding-control response immediately with trained staff.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate the dialysis emergency stop/clamp and bleeding-control response immediately with trained staff. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
2
Assess patient and circuit
Check consciousness, breathing, pressure and the visible access/circuit with trained dialysis staff. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
3
Use the emergency protocol
Call the dialysis lead and carry out the device-specific stop, clamp or isolation actions appropriate to the identified problem within competency. [1]
Why it matters Returning blood or manipulating a circuit may be unsafe for some emergencies.
4
Continue clinical review
Maintain emergency support, document the event and arrange ordered tests, treatment and access assessment. [1]
Why it matters A corrected machine problem can leave blood loss, infection or metabolic instability requiring care.

What to look for next

Monitor circulation and quantified loss. Monitor circulation, access condition and prescribed laboratory trends after the event; verify any restart is authorized.

Avoid this shortcut

Do not rely on the machine to detect every dislodgement. Do not bypass a safety alarm or automatically return circuit blood when contamination, air or hemolysis is suspected.

A clear way to hand it over

“I am calling about this new concern: a venous dialysis needle dislodges unnoticed by the alarm. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English The extracorporeal circuit carries blood outside the body through the dialysis system.

Sources behind the actions 1 primary references

MHRA / UK Kidney Patient Safety Committee · Dialysis and continuous renal replacement safety guidance
Access/circuit safety, needle dislodgement and trained device-specific emergency response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Dialysis circuit & access safety

Air is seen in the dialysis return circuit

Extremely difficult

The situation

During treatment, staff identify air in the return circuit and the patient reports acute breathlessness. The device alarm has activated.

What should catch your attention

Circuit air
Acute symptoms
Potential embolic emergency

Your immediate priority

Use the device-specific emergency isolation/stop protocol and summon resuscitation help.

01Circuit air
02Use the device-specific emergency isolation/stop protocol and summon resuscitation help.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Use the device-specific emergency isolation/stop protocol and summon resuscitation help. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
2
Assess patient and circuit
Check consciousness, breathing, pressure and the visible access/circuit with trained dialysis staff. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
3
Use the emergency protocol
Call the dialysis lead and carry out the device-specific stop, clamp or isolation actions appropriate to the identified problem within competency. [1]
Why it matters Returning blood or manipulating a circuit may be unsafe for some emergencies.
4
Continue clinical review
Maintain emergency support, document the event and arrange ordered tests, treatment and access assessment. [1]
Why it matters A corrected machine problem can leave blood loss, infection or metabolic instability requiring care.

What to look for next

Continue respiratory/circulatory monitoring. Monitor circulation, access condition and prescribed laboratory trends after the event; verify any restart is authorized.

Avoid this shortcut

Do not bypass the air alarm or return suspect circuit contents. Do not bypass a safety alarm or automatically return circuit blood when contamination, air or hemolysis is suspected.

A clear way to hand it over

“I am calling about this new concern: air is seen in the dialysis return circuit. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English The extracorporeal circuit carries blood outside the body through the dialysis system.

Sources behind the actions 1 primary references

MHRA / UK Kidney Patient Safety Committee · Dialysis and continuous renal replacement safety guidance
Access/circuit safety, needle dislodgement and trained device-specific emergency response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Dialysis circuit & access safety

Possible hemolysis during dialysis

Extremely difficult

The situation

A dialysis patient develops chest/back discomfort and abnormal-looking circuit blood. The trained team suspects hemolysis and potassium toxicity is possible.

What should catch your attention

Circuit concern
Systemic symptoms
Hyperkalemia risk

Your immediate priority

Stop treatment through the dialysis emergency protocol, call urgent help and prepare prescribed tests and rescue.

01Circuit concern
02Stop treatment through the dialysis emergency protocol, call urgent help and prepare prescribed tests and rescue.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Stop treatment through the dialysis emergency protocol, call urgent help and prepare prescribed tests and rescue. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
2
Assess patient and circuit
Check consciousness, breathing, pressure and the visible access/circuit with trained dialysis staff. [1]
Why it matters Circuit alarms do not replace patient assessment or exclude blood loss and access failure.
3
Use the emergency protocol
Call the dialysis lead and carry out the device-specific stop, clamp or isolation actions appropriate to the identified problem within competency. [1]
Why it matters Returning blood or manipulating a circuit may be unsafe for some emergencies.
4
Continue clinical review
Maintain emergency support, document the event and arrange ordered tests, treatment and access assessment. [1]
Why it matters A corrected machine problem can leave blood loss, infection or metabolic instability requiring care.

What to look for next

Monitor ECG and circulation. Monitor circulation, access condition and prescribed laboratory trends after the event; verify any restart is authorized.

Avoid this shortcut

Do not automatically return potentially hemolyzed circuit blood. Do not bypass a safety alarm or automatically return circuit blood when contamination, air or hemolysis is suspected.

A clear way to hand it over

“I am calling about this new concern: possible hemolysis during dialysis. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English The extracorporeal circuit carries blood outside the body through the dialysis system.

Sources behind the actions 1 primary references

MHRA / UK Kidney Patient Safety Committee · Dialysis and continuous renal replacement safety guidance
Access/circuit safety, needle dislodgement and trained device-specific emergency response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Electrolyte & rhythm safety

Critical hyperkalemia after missed dialysis

Extremely difficult

The situation

A patient who missed dialysis has profound weakness, new ECG changes and a critical potassium result.

What should catch your attention

Missed clearance
Critical potassium
ECG toxicity

Your immediate priority

Activate urgent hyperkalemia treatment and definitive renal removal planning.

01Missed clearance
02Activate urgent hyperkalemia treatment and definitive renal removal planning.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate urgent hyperkalemia treatment and definitive renal removal planning. [1]
Why it matters Severe potassium elevation can cause fatal rhythm changes, sometimes without dramatic symptoms.
2
Assess cardiac risk
Check symptoms, monitoring and ECG promptly; report the potassium result, kidney function and sample concerns without delaying care for an unstable patient. [1]
Why it matters Severe potassium elevation can cause fatal rhythm changes, sometimes without dramatic symptoms.
3
Support ordered stabilization
Prepare protocol-directed calcium when indicated and potassium-shifting or removal treatment; follow independent medicine checks. [1]
Why it matters Calcium protects the heart temporarily but does not remove potassium from the body.
4
Monitor treatment complications
Track repeat potassium and ECG, and glucose checks after insulin-based treatment, following the full monitoring period. [1]
Why it matters Potassium can rebound and treatment can cause delayed hypoglycemia.

What to look for next

Monitor glucose, rhythm and repeat potassium. Escalate ECG deterioration, recurrent high potassium or low glucose. Confirm the plan for potassium removal and medicine review.

Avoid this shortcut

Do not treat a temporary shift as definitive removal. Do not assume a normal ECG excludes danger or that calcium has corrected the potassium level.

A clear way to hand it over

“I am calling about this new concern: critical hyperkalemia after missed dialysis. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Hyperkalemia means potassium in blood is too high.

Sources behind the actions 1 primary references

UK Kidney Association · Management of hyperkalaemia in adults (updated July 2026)
Urgent ECG/monitoring, calcium for indicated cardiac toxicity, potassium-lowering treatment and glucose monitoring after insulin.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Infection & shock

Septic shock from suspected dialysis access infection

Extremely difficult

The situation

A dialysis patient has rigors, hypotension and confusion with an access concern. Fluid overload risk complicates resuscitation.

What should catch your attention

Shock
Possible access source
Limited fluid tolerance

Your immediate priority

Activate emergency sepsis and renal assessment and communicate the fluid/access constraints.

01Shock
02Activate emergency sepsis and renal assessment and communicate the fluid/access constraints.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate emergency sepsis and renal assessment and communicate the fluid/access constraints. [1]
Why it matters Delay can allow poor organ perfusion to worsen before the diagnosis is fully confirmed.
2
Escalate early
Assess airway, breathing, circulation and mental state; activate the local emergency or sepsis response for shock or rapid decline. [1]
Why it matters Delay can allow poor organ perfusion to worsen before the diagnosis is fully confirmed.
3
Support the prescribed bundle
Prepare cultures and lactate testing, urgent antimicrobials and individualized fluid or vasopressor treatment as ordered; do not delay urgent therapy for a difficult sample. [1]
Why it matters Identifying infection and supporting circulation address different parts of the same emergency.
4
Reassess after each step
Trend blood pressure, breathing, alertness, urine and response to treatment; report overload or persistent poor perfusion. [1]
Why it matters Fluids and medicines must be adjusted to response and comorbidity, rather than repeated automatically.

What to look for next

Reassess after each prescribed intervention. Continue close observations through transfer and handover. Persistent shock, rising support needs or reduced consciousness requires further immediate escalation.

Avoid this shortcut

Do not apply an unreviewed fixed fluid plan. Do not wait for fever, laboratory confirmation or a score threshold when clinical shock is evident.

A clear way to hand it over

“I am calling about this new concern: septic shock from suspected dialysis access infection. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Perfusion means blood flow delivering oxygen to organs.

Sources behind the actions 2 primary references

SCCM / ESICM · Surviving Sepsis Campaign adult guidelines—2026
Immediate emergency response, cultures/lactate, prompt antimicrobials in shock and individualized resuscitation with reassessment.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Severe allergic reaction

Severe reaction during dialysis

Extremely difficult

The situation

Soon after treatment begins, a patient develops wheeze, swelling and hypotension. Circuit/material or medicine exposure may be responsible.

What should catch your attention

Temporal exposure
Airway threat
Shock

Your immediate priority

Activate anaphylaxis and the dialysis-specific emergency response, with authorized epinephrine and airway support.

01Temporal exposure
02Activate anaphylaxis and the dialysis-specific emergency response, with authorized epinephrine and airway support.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate anaphylaxis and the dialysis-specific emergency response, with authorized epinephrine and airway support. [1]
Why it matters A rash may be absent; life-threatening allergy is identified by organ compromise.
2
Recognize severe compromise
Stop the suspected trigger when possible; call emergency help for sudden airway, breathing or circulation problems after an exposure. [1]
Why it matters A rash may be absent; life-threatening allergy is identified by organ compromise.
3
Use the emergency protocol
Give intramuscular epinephrine/adrenaline under the authorized pathway, support airway and oxygenation, and position safely without standing the patient. [1]
Why it matters Epinephrine addresses dangerous airway and circulatory effects; antihistamines do not replace it.
4
Prepare continued care
Arrange ordered fluids, repeat treatment and observation; report the exposure, symptoms and treatment times. [1]
Why it matters Symptoms can persist or recur, requiring monitored follow-up rather than immediate reassurance.

What to look for next

Record exposures and response. Continuously review breathing, perfusion and response. Escalate ongoing compromise and arrange allergy documentation and follow-up after stabilization.

Avoid this shortcut

Do not automatically return circuit blood during a suspected severe treatment reaction. Do not wait for a rash, use antihistamines as sole emergency treatment or let a hypotensive person walk.

A clear way to hand it over

“I am calling about this new concern: severe reaction during dialysis. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Anaphylaxis is a serious systemic allergic reaction; adrenaline and epinephrine are two names for the same medicine.

Sources behind the actions 1 primary references

Resuscitation Council UK · Emergency treatment of anaphylactic reactions
IM adrenaline/epinephrine first-line, positioning, emergency support and observation; antihistamines do not treat airway or circulatory compromise.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Heart failure & fluid balance

Acute pulmonary edema while hypotensive

Extremely difficult

The situation

A renal patient is severely breathless with crackles and low pressure. They are fluid overloaded but also poorly perfused.

What should catch your attention

Congestion and shock
Renal disease
Competing management needs

Your immediate priority

Activate critical renal/cardiac assessment and prepare individualized respiratory/hemodynamic and dialysis support.

01Congestion and shock
02Activate critical renal/cardiac assessment and prepare individualized respiratory/hemodynamic and dialysis support.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate critical renal/cardiac assessment and prepare individualized respiratory/hemodynamic and dialysis support. [1]
Why it matters Congestion and impaired circulation can coexist, so one measurement cannot determine treatment.
2
Recognize the pattern
Compare breathlessness, oxygen need, edema, weight, pressure and urine with baseline and assess medication or fluid changes. [1]
Why it matters Congestion and impaired circulation can coexist, so one measurement cannot determine treatment.
3
Escalate the change
Seek urgent clinical review for respiratory distress, hypotension or poor perfusion and prepare the prescribed cardiac investigations. [1]
Why it matters Acute heart failure requires diagnosis and treatment matched to the current physiology.
4
Deliver and review the plan
Give ordered diuretics or respiratory support with the required kidney, electrolyte and output monitoring. [1]
Why it matters Treatment can improve congestion while also changing pressure, kidney function and electrolytes.

What to look for next

Track perfusion and oxygenation. Track work of breathing, perfusion, urine and laboratory trends after treatment; report deterioration rather than chasing urine volume alone.

Avoid this shortcut

Do not assume either a routine bolus or rapid fluid removal is universally safe. Do not give a routine fluid bolus for low urine or a diuretic for every swollen patient without assessment and authorization.

A clear way to hand it over

“I am calling about this new concern: acute pulmonary edema while hypotensive. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Congestion means fluid accumulation; perfusion means blood reaching organs.

Sources behind the actions 3 primary references

NICE · CG187: Acute heart failure—recommendations
Specialist assessment, ordered IV diuretics with renal/urine monitoring and ventilatory support for selected severe respiratory failure.
NICE · NG148: Acute kidney injury—recommendations
Recognize low urine output, compare creatinine with baseline, investigate causes and do not routinely treat AKI with loop diuretics.
British Thoracic Society · Oxygen use in adults in healthcare and emergency settings
Targeted oxygen therapy, urgent blood gases for hypercapnia risk and oxygen during critical illness without unsafe withholding.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Peritoneal dialysis infection

Peritoneal infection progresses to shock

Extremely difficult

The situation

Cloudy dialysate and abdominal pain are followed by hypotension, confusion and reduced perfusion. The patient is now systemically unstable.

What should catch your attention

Peritonitis concern
Shock
Rapid progression

Your immediate priority

Activate emergency sepsis/renal response and prompt prescribed antimicrobials and source assessment.

01Peritonitis concern
02Activate emergency sepsis/renal response and prompt prescribed antimicrobials and source assessment.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate emergency sepsis/renal response and prompt prescribed antimicrobials and source assessment. [1]
Why it matters Pain or cloudy effluent warrants prompt assessment for peritonitis.
2
Recognize and report
Report abdominal pain, cloudy effluent, exchange findings and systemic symptoms. [1]
Why it matters Pain or cloudy effluent warrants prompt assessment for peritonitis.
3
Obtain the prescribed samples
Use trained aseptic collection and prepare ordered effluent testing and timely treatment. [1]
Why it matters Samples help identify the cause without replacing prompt clinical care.
4
Monitor and escalate
Follow the renal treatment/exchange plan and activate resuscitation for shock or respiratory decline. [1]
Why it matters A localized concern can progress to systemic illness.

What to look for next

Trend circulation and abdominal findings. Track perfusion, pain, effluent and treatment response and arrange urgent reassessment for worsening.

Avoid this shortcut

Do not manage this as a routine outpatient exchange issue. Do not delay urgent treatment for a routine appointment or independently choose catheter removal.

A clear way to hand it over

“I am calling about this new concern: peritoneal infection progresses to shock. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Peritonitis is inflammation or infection of the lining inside the abdomen.

Sources behind the actions 1 primary references

ISPD · Peritonitis recommendations: 2022 update
Cloudy effluent/abdominal symptoms, aseptic sampling and prompt renal-directed treatment.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Bleeding & circulation

Bleeding from an aneurysmal access site

Extremely difficult

The situation

A dialysis access area with fragile skin suddenly bleeds heavily. The patient becomes pale and the blood loss is difficult to control.

What should catch your attention

Major access bleeding
Fragile access tissue
Shock risk

Your immediate priority

Activate emergency bleeding control and vascular/renal help using the approved access-hemorrhage response.

01Major access bleeding
02Activate emergency bleeding control and vascular/renal help using the approved access-hemorrhage response.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate emergency bleeding control and vascular/renal help using the approved access-hemorrhage response. [1]
Why it matters External loss can underestimate bleeding, and a normal early blood count cannot rule out shock.
2
Call and assess
Activate the local bleeding response for instability; assess airway, breathing, pulse, pressure, alertness and visible loss. [1]
Why it matters External loss can underestimate bleeding, and a normal early blood count cannot rule out shock.
3
Prepare safe resuscitation
Maintain or obtain suitable access within competence; prepare ordered fluids, blood tests and blood products using identification and compatibility checks. [1]
Why it matters Resuscitation supports circulation while the team seeks the bleeding source.
4
Track treatment and source control
Report procedure history, anticoagulants and last doses; help arrange urgent specialist review and prescribed monitoring. [1]
Why it matters Replacement alone cannot stop every source of bleeding or resolve medication-related risk.

What to look for next

Monitor perfusion and prepare prescribed resuscitation. Trend observations and loss after interventions. Escalate ongoing shock, respiratory change or a suspected transfusion reaction immediately.

Avoid this shortcut

Do not leave the patient to seek routine supplies. Do not wait for a laboratory result before responding to shock or independently select reversal drugs.

A clear way to hand it over

“I am calling about this new concern: bleeding from an aneurysmal access site. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Hemodynamic instability means circulation is not adequately supporting the body.

Sources behind the actions 2 primary references

NICE · NG24: Blood transfusion (updated February 2026)
General blood-product decisions, compatibility and patient monitoring; major bleeding follows a separate emergency pathway.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Safe critical-care transfer

Dialysis-dependent support is interrupted during an evacuation

Extremely difficult

The situation

A critically ill patient on continuous renal replacement therapy needs relocation. Essential infusions, ventilation and circuit safety must be coordinated.

What should catch your attention

Multiple supports
Unplanned transfer
Circuit interruption

Your immediate priority

Coordinate critical-care and renal staff for an authorized circuit and transport plan with adequate supplies and monitoring.

01Multiple supports
02Coordinate critical-care and renal staff for an authorized circuit and transport plan with adequate supplies and monitoring.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Coordinate critical-care and renal staff for an authorized circuit and transport plan with adequate supplies and monitoring. [1]
Why it matters A location change can interrupt lifesaving support and may require a different escort or stabilization first.
2
Check readiness
Review current instability, airway, oxygen or infusion needs and why transfer is needed; involve the responsible clinician. [1]
Why it matters A location change can interrupt lifesaving support and may require a different escort or stabilization first.
3
Prepare equipment and people
Confirm enough oxygen, charged devices, medicines, secure lines, emergency equipment and a trained escort for the person’s support needs. [1]
Why it matters The transport environment has fewer backup resources than the original clinical area.
4
Hand over the real status
Communicate trends, orders, treatment limits, device settings and contingency plans to the accepting team. [1]
Why it matters A destination and referral alone do not provide continuity of critical care.

What to look for next

Verify destination support and physiology throughout. Monitor during travel and reassess immediately on arrival; verify all connections, prescribed settings and continuing treatments.

Avoid this shortcut

Do not disconnect or return circuit blood without the situation-specific protocol. Do not send an unstable supported patient with an unprepared escort or assume devices will keep working because they did on the ward.

A clear way to hand it over

“I am calling about this new concern: dialysis-dependent support is interrupted during an evacuation. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English A contingency plan specifies what to do if the person or equipment deteriorates during transfer.

Sources behind the actions 2 primary references

WHO · Clinical checklists: emergency and transfer care
Structured handover and verification of support during emergency/transfer care.
AARC · Clinical practice guidelines: patient-ventilator assessment
Trained patient, airway, circuit and ventilator assessment.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

CONNECT UNDERSTANDING TO EXAM PRACTICE

The explanation is clear.
The exam asks you to choose.

Here, we explain the nursing response directly. In an NCLEX®-style question, several options may sound reasonable. You must weigh the cues, priority, timing and safety—not just recognize a familiar phrase.

Practise applying the reasoning, read why alternatives are less appropriate and review your decisions before exam day.

Build question-bank judgmentStudy by topic or system; review the rationale

Work through NGN casesConnect changing cues across a case

Explore standalone NGN itemsPractise decisions in different item formats

Rehearse a full mockPractise pacing and review your decisions

Try adaptive practiceA CAT-style learning simulator

For tutors & preceptors

Turn a scenario into a conversation.

Pause at the cues. Ask learners to identify the change from baseline and the immediate risk.
Explain the action. Ask what is independent nursing care and what requires a protocol or order.
Change one detail. Explore how unsafe swallowing, low pressure or kidney disease alters the plan.
Rehearse the handover. Compare with local policy, check the source and name what must be reassessed.

Explore the free teaching toolkit

Renal & Dialysis

The access arm is being used for routine measurements

What should catch your attention

What the RN should do—and why

Respond to the situation first

Assess patient and circuit

Use the emergency protocol

Continue clinical review

What to look for next

Avoid this shortcut

A clear way to hand it over

The weight does not match the dialysis record

What should catch your attention

What the RN should do—and why

Respond to the situation first

Assess patient and circuit

Use the emergency protocol

Continue clinical review

What to look for next

Avoid this shortcut

A clear way to hand it over

The patient misunderstands a fluid allowance

What should catch your attention

What the RN should do—and why

Respond to the situation first

Make the explanation accessible

Use a small teach-back

Repair the gap

What to look for next

Avoid this shortcut

A clear way to hand it over

The catheter dressing is wet after bathing

What should catch your attention

What the RN should do—and why

Respond to the situation first

Check simple causes

Escalate persistent problems

Review the indication

What to look for next

Avoid this shortcut

A clear way to hand it over

A medicine list misses an over-the-counter painkiller

What should catch your attention

What the RN should do—and why

Respond to the situation first

Pause and verify

Clarify with the team

Close the loop

What to look for next

Avoid this shortcut

A clear way to hand it over

Cramping with falling pressure during dialysis

What should catch your attention

What the RN should do—and why

Respond to the situation first

Assess patient and circuit

Use the emergency protocol

Continue clinical review

What to look for next

Avoid this shortcut

A clear way to hand it over

A fistula loses its usual palpable vibration

What should catch your attention

What the RN should do—and why

Respond to the situation first

Assess patient and circuit

Use the emergency protocol

Continue clinical review

What to look for next

Avoid this shortcut

A clear way to hand it over

Low glucose during dialysis

What should catch your attention

What the RN should do—and why

Respond to the situation first

Assess and act

Check the response

Prevent recurrence

What to look for next

Avoid this shortcut