CDN Certified Dialysis Nurse Exam — Questions and Answers

Question 1: Hypermagnesemia in dialysis patients most commonly results from which of the following?

Regular use of magnesium-containing antacids or laxatives (Correct answer)
Hyperparathyroidism
High dialysate magnesium concentration
Excessive dietary protein intake

Correct answer: Regular use of magnesium-containing antacids or laxatives

Dialysis patients who use magnesium-containing antacids or laxatives are at risk for hypermagnesemia because the kidneys cannot excrete excess magnesium.

Question 2: When added, what causes peritoneal dialysate to become hyperosmolar?

Chloride
Bicarbonate
Glucose (Correct answer)
Sodium

Correct answer: Glucose

Dialysate typically comprises lactate or bicarbonate, sodium, and chloride. Although there are other osmotic agents, like icodextrin and amino acid solutions, glucose is still the most popular choice, even though patients may absorb 200–300 g of glucose daily. Due to the added calories, this may also promote hyperglycemia and weight gain. It may also raise your risk of hyperlipidemia and cardiovascular disease.

Question 3: A dialysis patient presents with sudden onset chest pain, dyspnea, and cyanosis during treatment. Air embolism is suspected. The immediate nursing action is to:

Administer oxygen and notify the physician
Increase the ultrafiltration rate to remove fluid
Return blood and disconnect the patient from the machine
Stop the blood pump, clamp the venous line, and position patient on left side in Trendelenburg (Correct answer)

Correct answer: Stop the blood pump, clamp the venous line, and position patient on left side in Trendelenburg

Stopping blood flow, clamping the venous line, and positioning the patient left lateral Trendelenburg traps air in the right ventricle apex away from the pulmonary circulation.

Question 4: What is the primary purpose of sodium profiling during hemodialysis?

Improve cardiovascular stability and reduce intradialytic hypotension (Correct answer)
Reduce bicarbonate concentration
Prevent hypernatremia
Increase potassium removal

Correct answer: Improve cardiovascular stability and reduce intradialytic hypotension

Sodium profiling uses higher sodium concentrations early in treatment to maintain plasma osmolality and improve hemodynamic stability, reducing intradialytic hypotension.

Question 5: Which dietary restriction is unique to peritoneal dialysis patients compared to hemodialysis patients?

Fluid restriction is typically more liberal (Correct answer)
Potassium restriction is typically stricter
Phosphate intake is unrestricted
Protein restriction is more severe

Correct answer: Fluid restriction is typically more liberal

Peritoneal dialysis provides continuous fluid removal, so fluid restrictions are generally more liberal than in intermittent hemodialysis.

Question 6: Which patient symptom suggests the dry weight target needs to be increased?

Persistent hypotension and cramping during dialysis (Correct answer)
Hypertension before dialysis
Dyspnea at rest between treatments
Peripheral edema between treatments

Correct answer: Persistent hypotension and cramping during dialysis

Persistent hypotension and cramping during dialysis indicate the fluid removal target may be set too aggressively, and the dry weight may need upward adjustment.

Question 7: A dialysis patient on warfarin for atrial fibrillation requires more frequent INR monitoring. Why?

Altered protein binding and volume of distribution affect drug levels (Correct answer)
Dialysis removes warfarin from the blood
Vitamin K is removed by dialysis
Heparin used during dialysis reverses warfarin

Correct answer: Altered protein binding and volume of distribution affect drug levels

Uremia alters plasma protein binding and drug metabolism, making anticoagulation levels unpredictable and requiring more frequent INR monitoring.

Question 8: The target hemoglobin range for dialysis patients receiving erythropoiesis-stimulating agents (ESAs) per KDIGO guidelines is:

13–14 g/dL
10–11.5 g/dL (Correct answer)
12–13 g/dL
8–9 g/dL

Correct answer: 10–11.5 g/dL

KDIGO guidelines recommend maintaining hemoglobin between 10–11.5 g/dL for dialysis patients on ESAs to balance benefit and cardiovascular risk.

Question 9: Which medication requires dose adjustment or avoidance in dialysis patients due to accumulation of active metabolites that can cause neurological toxicity?

Meperidine (Demerol) (Correct answer)
Ibuprofen
Omeprazole
Acetaminophen

Correct answer: Meperidine (Demerol)

Meperidine's active metabolite normeperidine accumulates in renal failure and can cause seizures, making it contraindicated in dialysis patients.

Question 10: Which vitamin is routinely supplemented alongside ESA therapy in hemodialysis patients to support effective erythropoiesis?

Folic acid (Vitamin B9) (Correct answer)
Vitamin K
Vitamin C
Vitamin D

Correct answer: Folic acid (Vitamin B9)

Folic acid is water-soluble and dialyzed out during each treatment; adequate folate is essential for DNA synthesis in proliferating red cell precursors, and deficiency impairs the response to ESA therapy.

Question 11: Which of the following is a sign of disequilibrium syndrome during hemodialysis?

Fever and chills
Headache, nausea, and altered consciousness (Correct answer)
Pruritus and muscle cramping
Hypotension and bradycardia

Correct answer: Headache, nausea, and altered consciousness

Disequilibrium syndrome presents with neurological symptoms including headache, nausea, and altered mental status due to rapid osmotic shifts.

Question 12: Because of the necessity to review procedures, a new nurse in the critical care unit works slowly and adds to the workload of other staff members. She is unfamiliar with the CRRT equipment being utilized. The ideal response is to?

Advise the new nurse to take materials home to study.
Allow the new nurse all the time needed to learn.
Complain to the director.
Offer to assist and mentor the new nurse. (Correct answer)

Correct answer: Offer to assist and mentor the new nurse.

Working one-on-one with an experienced nurse can help you develop your abilities and reduce patient risks because mistakes can happen while using equipment that you are new with.

Question 13: Which sign/symptom is associated with hyponatremia in a dialysis patient?

Periorbital edema only
Confusion, seizures, and muscle weakness (Correct answer)
Dry mucous membranes and thirst
Hypertension and bradycardia

Correct answer: Confusion, seizures, and muscle weakness

Severe or rapidly developing hyponatremia causes neurological symptoms including confusion, seizures, and weakness due to cerebral edema.

Question 14: When should phosphate binders be administered to achieve maximum effectiveness?

During hemodialysis treatment
30 minutes before meals
With or immediately after meals (Correct answer)
At bedtime

Correct answer: With or immediately after meals

Phosphate binders must be taken with meals to bind dietary phosphate in the gut before it is absorbed, reducing serum phosphorus levels.

Question 15: A dialysis nurse notes the transmembrane pressure (TMP) alarm is triggered repeatedly during treatment. This most likely indicates:

Clotting in the dialyzer (Correct answer)
Venous access infiltration
Arterial line disconnection
Air detector malfunction

Correct answer: Clotting in the dialyzer

Rising TMP indicates increased resistance to ultrafiltration, most commonly caused by clot formation within the dialyzer fibers.

Question 16: What is the minimum white blood cell count in peritoneal dialysis effluent that is diagnostic of peritonitis?

100 WBC/mm³ with >50% neutrophils (Correct answer)
500 WBC/mm³ with >50% neutrophils
200 WBC/mm³ with >50% neutrophils
50 WBC/mm³ with >50% neutrophils

Correct answer: 100 WBC/mm³ with >50% neutrophils

ISPD guidelines define peritonitis as effluent WBC ≥100/mm³ with >50% polymorphonuclear cells after a minimum two-hour dwell.

Question 17: A dialysis patient with diabetes has an AV fistula. When assessing the fistula, the nurse palpates a thrill and hears a bruit. This finding indicates:

Aneurysm formation
Fistula stenosis
Early fistula thrombosis
Normal fistula function (Correct answer)

Correct answer: Normal fistula function

A palpable thrill and audible bruit indicate adequate blood flow through a patent, functional AV fistula.

Question 18: Secondary hyperparathyroidism in dialysis patients is primarily triggered by:

Vitamin D deficiency and hyperphosphatemia (Correct answer)
High aluminum levels from dialysate
Excess dietary calcium intake
Sodium imbalance during treatment

Correct answer: Vitamin D deficiency and hyperphosphatemia

Reduced kidney activation of vitamin D and elevated phosphate both stimulate PTH secretion, causing secondary hyperparathyroidism.

Question 19: Secondary hyperparathyroidism in ESRD patients is primarily driven by which combination of factors?

Hypernatremia and fluid overload
Aluminum toxicity and anemia
Hyperphosphatemia, hypocalcemia, and low active vitamin D (Correct answer)
Hypokalemia and metabolic alkalosis

Correct answer: Hyperphosphatemia, hypocalcemia, and low active vitamin D

The kidneys' inability to activate vitamin D and excrete phosphorus leads to hyperphosphatemia and hypocalcemia, driving excess PTH secretion.

Question 20: A patient on dialysis is found unresponsive with a blood glucose of 38 mg/dL. After administering glucose, what additional assessment is critical?

Increase heparin dosing
Evaluate dialysate glucose concentration and assess medication regimen for hypoglycemic agents (Correct answer)
Assess for air embolism
Check dialyzer membrane integrity

Correct answer: Evaluate dialysate glucose concentration and assess medication regimen for hypoglycemic agents

After treating hypoglycemia, the nurse must identify the cause — some dialysate formulations contain no glucose, and patients on insulin or sulfonylureas are at increased risk during treatment.

Question 21: A dialysis patient on warfarin for atrial fibrillation has an INR of 4.8 before treatment. The nurse should:

Proceed with dialysis using standard heparin protocol
Hold dialysis until INR normalizes to therapeutic range
Notify the physician and withhold heparin during dialysis (Correct answer)
Administer vitamin K and begin dialysis immediately

Correct answer: Notify the physician and withhold heparin during dialysis

A supratherapeutic INR increases bleeding risk; the physician should be notified and heparin withheld to minimize hemorrhagic complications during access cannulation.

Question 22: Which sign is the BEST indicator of AV graft thrombosis?

Absence of bruit and thrill (Correct answer)
Prolonged bleeding after needle removal
Elevated blood pressure
Increased access blood flow on monitoring

Correct answer: Absence of bruit and thrill

Loss of the bruit (audible sound) and thrill (palpable vibration) over an AV graft is the most reliable clinical indicator of thrombosis.

Question 23: Which antihypertensive class is preferred for dialysis patients with diabetic nephropathy to slow residual kidney disease progression?

ACE inhibitors or ARBs (Correct answer)
Calcium channel blockers
Alpha-blockers
Beta-blockers

Correct answer: ACE inhibitors or ARBs

ACE inhibitors and ARBs block the renin-angiotensin-aldosterone system, reducing intraglomerular pressure and proteinuria, thereby slowing CKD progression.

Question 24: A patient's AV graft has a pseudoaneurysm at a needle insertion site. The nurse should:

Discontinue dialysis until surgically repaired
Apply firm pressure for 30 minutes
Continue using the site with extra care
Rotate needle sites away from the pseudoaneurysm and notify the physician (Correct answer)

Correct answer: Rotate needle sites away from the pseudoaneurysm and notify the physician

Pseudoaneurysms require physician notification and needle sites should be rotated away to prevent rupture while awaiting surgical evaluation.

Question 25: What is the most likely cause of repeated clotting in the extracorporeal circuit during hemodialysis despite adequate heparin dosing?

High dialyzer surface area
Heparin-induced thrombocytopenia (HIT) or inadequate anticoagulation monitoring (Correct answer)
High blood flow rate
Low dialysate temperature

Correct answer: Heparin-induced thrombocytopenia (HIT) or inadequate anticoagulation monitoring

Repeated clotting despite heparin therapy should raise suspicion for heparin-induced thrombocytopenia (HIT), where heparin paradoxically causes platelet aggregation and thrombosis.

Question 26: During hemodialysis, the conductivity alarm activates and the bypass alarm sounds. What should the nurse do IMMEDIATELY?

Disconnect the patient and flush lines with saline
Slow blood flow rate and continue treatment
Clamp the blood lines to prevent patient exposure to incorrect dialysate (Correct answer)
Increase ultrafiltration rate to compensate

Correct answer: Clamp the blood lines to prevent patient exposure to incorrect dialysate

A conductivity alarm indicates the dialysate concentration is incorrect; clamping the blood lines prevents exposure to potentially dangerous dialysate until the issue is resolved.

Question 27: A patient on hemodialysis has a target dry weight of 72 kg and arrives weighing 75.5 kg. What is the interdialytic weight gain, and is it within recommended limits?

1.5 kg — below recommended minimum
3.5 kg — within limits for a 72 kg patient
2.5 kg — within limits
3.5 kg — exceeds the recommended 2–3 kg limit (Correct answer)

Correct answer: 3.5 kg — exceeds the recommended 2–3 kg limit

The interdialytic weight gain is 3.5 kg (75.5 − 72 = 3.5), which exceeds the generally recommended limit of 2–3 kg between sessions.

Question 28: Which dietary restriction is MOST critical for end-stage renal disease (ESRD) patients on hemodialysis to prevent life-threatening complications?

Avoiding all dairy products
Restricting potassium and phosphorus intake (Correct answer)
Limiting vitamin C intake
Eliminating all dietary protein

Correct answer: Restricting potassium and phosphorus intake

Potassium restriction prevents fatal hyperkalemia, and phosphorus restriction prevents secondary hyperparathyroidism, vascular calcification, and bone disease in ESRD patients.

Question 29: What does a rising venous pressure alarm during hemodialysis MOST likely indicate?

Arterial needle dislodgement
Low blood flow rate
Air in the blood circuit
Clotting or kinking in the venous return line or needle (Correct answer)

Correct answer: Clotting or kinking in the venous return line or needle

Rising venous pressure indicates increased resistance to blood return, most commonly caused by clotting, kinking, or positional occlusion of the venous needle or tubing.

Question 30: Which phosphate binder should be used with caution in dialysis patients with cardiovascular disease?

Calcium carbonate (Correct answer)
Lanthanum carbonate
Ferric citrate
Sevelamer carbonate

Correct answer: Calcium carbonate

Calcium-based binders like calcium carbonate increase calcium load and can worsen vascular calcification in patients with cardiovascular disease.

Question 31: A dialysis patient suddenly develops chest pain, dyspnea, cyanosis, and frothy pink sputum during treatment. What complication should be suspected?

Dialyzer clotting
Acute pulmonary edema (Correct answer)
Air embolism
Dialysis disequilibrium syndrome

Correct answer: Acute pulmonary edema

Frothy pink sputum, dyspnea, and cyanosis during dialysis indicate acute pulmonary edema, which may occur if ultrafiltration is insufficient or if the patient develops a cardiac event.

Question 32: A patient with a suspected hydrothorax has been receiving peritoneal dialysis for three years and has recently started experiencing episodes of increasing dyspnea while being treated. Technetium radionuclide scanning will be performed on the patient. The patient should be instructed to once technetium is injected into the peritoneal cavity, right?

Remain ambulatory. (Correct answer)
Massage the abdomen.
Sit in a chair and lean forward.
Lie quietly in the supine position between scans.

Correct answer: Remain ambulatory.

After the injection and in between scans, the patient should be urged to continue walking around so that the intra-abdominal pressure can rise and the tracer can enter the pleural cavity. Typically, a scan is performed immediately after injection and then four more scans are performed every ten minutes (0, 10, 20, 30). Another scan might be finished in a few instances in two to three hours.

Question 33: Which electrolyte imbalance is most likely to cause life-threatening cardiac arrhythmias in a dialysis patient?

Hyponatremia
Hyperkalemia (Correct answer)
Hyperphosphatemia
Hypercalcemia

Correct answer: Hyperkalemia

Hyperkalemia is the most immediately life-threatening electrolyte abnormality in dialysis patients, capable of causing fatal ventricular arrhythmias.

Question 34: A chronic kidney disease patient has started threatening a member of his family. He declares that he intends to shoot the victim and that he wants them dead. The major duty of the nurse is to?

Warn the person at whom the threats are directed. (Correct answer)
Notify the police.
Maintain the patient’s confidentiality.
Refer the patient to a psychiatrist.

Correct answer: Warn the person at whom the threats are directed.

This example illustrates one situation where confidentiality may be compromised. In Tarasoff v. Regents of the University of California, the court held that healthcare professionals have a responsibility to alert others who have been threatened by their patient and are in risk. When a patient threatens to hurt another person, warning that person should come first even though the police may need to be called. The attending clinician should also refer the patient for examination to a psychiatrist and should check for uremic encephalopathy, which can cause unusual behavior, but this is not the first concern.

Question 35: Which vital sign change during hemodialysis should prompt the nurse to assess for hypovolemia first?

Temperature increase of 0.5°C
Blood pressure drop of more than 20 mmHg systolic (Correct answer)
Heart rate of 78 beats/minute
Respiratory rate of 18 breaths/minute

Correct answer: Blood pressure drop of more than 20 mmHg systolic

A systolic blood pressure drop of more than 20 mmHg from baseline during dialysis is a primary indicator of intradialytic hypotension and requires immediate assessment for hypovolemia.

Question 36: What infection prevention measure is MOST important when caring for a central venous catheter (CVC) used for hemodialysis?

Apply antibiotic ointment to the exit site daily
Heparin lock after every use
Change tubing after every treatment
Use strict aseptic technique with mask and sterile gloves during hub access (Correct answer)

Correct answer: Use strict aseptic technique with mask and sterile gloves during hub access

Strict aseptic technique including mask and sterile gloves during catheter hub manipulation is the most critical measure to prevent catheter-related bloodstream infections.

Question 37: What is the primary goal of sodium profiling during hemodialysis?

Improve phosphorus clearance
Prevent hypernatremia
Reduce the risk of disequilibrium syndrome
Reduce intradialytic hypotension while limiting thirst and interdialytic weight gain (Correct answer)

Correct answer: Reduce intradialytic hypotension while limiting thirst and interdialytic weight gain

Sodium profiling uses higher dialysate sodium early in treatment to maintain hemodynamic stability, then lowers it to limit post-dialysis thirst and fluid intake.

Question 38: A dialysis patient has Hgb 9.6 g/dL, TSAT 26%, and ferritin 680 ng/mL while receiving ESA therapy. What is the most appropriate next step?

Order a packed red blood cell transfusion
Increase the ESA dose by 25%
Investigate other causes of anemia such as occult bleeding, folate/B12 deficiency, or inflammation (Correct answer)
Initiate IV iron therapy immediately

Correct answer: Investigate other causes of anemia such as occult bleeding, folate/B12 deficiency, or inflammation

With TSAT >20% and ferritin >500 ng/mL, iron deficiency is not the likely cause; the nurse should work with the provider to investigate other contributors such as GI blood loss, nutritional deficiencies, infection, or aluminum toxicity.

Question 39: A hemodialysis patient has a hemoglobin of 8.4 g/dL, serum ferritin of 140 ng/mL, and TSAT of 17%. Which intervention is most appropriate?

Immediately increase the ESA dose
Administer intravenous (IV) iron supplementation (Correct answer)
Arrange for a packed red blood cell transfusion
Switch the patient to oral iron supplements

Correct answer: Administer intravenous (IV) iron supplementation

With TSAT <20% and ferritin <200 ng/mL, this patient has iron deficiency anemia; IV iron is preferred over oral iron in hemodialysis patients due to superior absorption and avoidance of GI side effects.

Question 40: A patient with end-stage renal disease on hemodialysis suddenly becomes unresponsive with no palpable pulse. What is the nurse's immediate priority?

Administer epinephrine via the venous access
Check the dialysis machine alarms
Stop the dialysis machine and return blood to the patient
Initiate CPR and activate the emergency response system (Correct answer)

Correct answer: Initiate CPR and activate the emergency response system

Cardiac arrest requires immediate initiation of CPR and emergency system activation; all other dialysis-specific actions are secondary to life support.

Question 41: During CRRT using citrate anticoagulation, which lab value indicates citrate toxicity?

Declining platelet count
Widening gap between ionized and total calcium (Correct answer)
Increasing BUN levels
Elevated serum sodium

Correct answer: Widening gap between ionized and total calcium

Citrate toxicity causes chelation of ionized calcium while total calcium rises, creating a widening total-to-ionized calcium ratio.

Question 42: Which set of symptoms is most consistent with a Type A hypersensitivity reaction to the dialyzer?

Hypotension, nausea, and muscle cramps mid-treatment
Burning, flushing, dyspnea, and anaphylaxis in the first few minutes (Correct answer)
Chest pain, back pain, and pink dialysate
Fever, chills, and rigors 30 minutes into dialysis

Correct answer: Burning, flushing, dyspnea, and anaphylaxis in the first few minutes

Type A (anaphylactic) reactions occur within the first few minutes of dialysis due to IgE-mediated sensitivity to ETO sterilization or membrane components.

Question 43: What is the recommended minimum maturation time for an AV fistula before first cannulation?

3–6 months
6–8 weeks (Correct answer)
1–2 weeks
2–4 weeks

Correct answer: 6–8 weeks

An AV fistula should mature for at least 6–8 weeks before cannulation to allow adequate vessel dilation and wall thickening.

Question 44: What is the primary cause of anemia in patients with chronic kidney disease (CKD)?

Decreased erythropoietin production by damaged kidneys (Correct answer)
Folate deficiency due to poor nutrition
Vitamin B12 deficiency from uremic gastritis
Iron deficiency from dietary intake

Correct answer: Decreased erythropoietin production by damaged kidneys

The diseased kidneys produce insufficient erythropoietin (EPO), the hormone that stimulates bone marrow red blood cell production, making EPO deficiency the principal cause of CKD anemia.

Question 45: Which laboratory value best reflects total iron stores in dialysis patients when assessing for iron deficiency?

Serum ferritin (Correct answer)
Reticulocyte count
Total iron-binding capacity (TIBC)
Serum iron level

Correct answer: Serum ferritin

Serum ferritin is an acute-phase protein that reflects total body iron stores and is the most reliable single marker used to assess iron adequacy in dialysis patients.

Question 46: What is the most effective strategy for improving a dialysis patient's understanding of dietary restrictions?

Quarterly group educational sessions
Posting dietary restriction lists in the dialysis unit waiting room
Ongoing individualized counseling using teach-back method with a registered dietitian (Correct answer)
Provide a single written handout at initiation

Correct answer: Ongoing individualized counseling using teach-back method with a registered dietitian

Ongoing individualized counseling using the teach-back method ensures understanding is assessed and reinforced over time, accounting for individual dietary habits and literacy levels.

Question 47: What is the purpose of measuring serum albumin in a dialysis patient's monthly labs?

Evaluate dialysis adequacy
Assess nutritional status as a predictor of morbidity and mortality (Correct answer)
Measure protein losses during dialysis
Monitor liver function

Correct answer: Assess nutritional status as a predictor of morbidity and mortality

Serum albumin is a key marker of nutritional status in dialysis patients; levels below 3.5 g/dL are associated with significantly increased morbidity and mortality.

Question 48: What is the main use of an amino-based dialysate solution?

Nutritional supplementation (Correct answer)
Electrolyte imbalance
Decreased ultrafiltration
Increased ultrafiltration

Correct answer: Nutritional supplementation

An amino-based dialysate solution is used for peritoneal dialysis primarily as a nutritional supplement because it helps skeletal muscles absorb amino acids. To avoid acidosis and elevated serum urea levels, the amino-based solution is limited to one dose per day. The solution is most effective when given after meals to promote protein synthesis because it is typically absorbed within 4-6 hours. Osmotically, amino-acid solution is similar to 1.36% glucose.

Question 49: Which dialysis complication is specifically associated with inadequate bicarbonate delivery in the dialysate?

Dialyzer membrane rupture
Hypercalcemia
Muscle cramps
Metabolic acidosis (Correct answer)

Correct answer: Metabolic acidosis

Inadequate bicarbonate in dialysate fails to correct the chronic metabolic acidosis that accumulates between hemodialysis sessions.

Question 50: What should the dialysis nurse do first when a patient experiences venous needle dislodgement during treatment?

Clamp the arterial line and return blood through arterial needle
Immediately turn off the blood pump and apply firm pressure to the site (Correct answer)
Apply pressure to the site and slow the blood pump
Increase the blood pump speed to prevent clotting

Correct answer: Immediately turn off the blood pump and apply firm pressure to the site

Venous needle dislodgement requires immediately stopping the blood pump and applying firm pressure to prevent significant blood loss.

Question 51: A patient develops pink-tinged blood in the dialysate port during hemodialysis. What does this most likely indicate?

Hypersensitivity reaction type A
Heparin overdose
Air embolism
Dialyzer membrane leak (Correct answer)

Correct answer: Dialyzer membrane leak

Pink or red-tinged dialysate indicates a dialyzer membrane rupture, which can allow blood to leak into the dialysate compartment.

Question 52: Between hemodialysis treatments, weight gain shouldn't surpass

5% of dry weight (Correct answer)
8% of dry weight
1% of dry weight
10% of dry weight

Correct answer: 5% of dry weight

A weight gain of 1 kg (2.2 lb) corresponds to a fluid retention of 1 liter. The ideal post-dialysis weight is dry weight after extra fluid has been eliminated. Patients may put on weight due to the glucose in dialysate solutions or lose weight due to depleted fat or muscle storage, therefore it's crucial to reassess the patient's dry weight at least every two weeks to make sure enough fluid is being removed.

Question 53: Which erythropoiesis-stimulating agent (ESA) is most commonly used to treat anemia of chronic kidney disease in dialysis patients?

Epoetin alfa (Correct answer)
Romiplostim
Darbepoetin alfa
Filgrastim

Correct answer: Epoetin alfa

Epoetin alfa is the most widely used ESA for dialysis-associated anemia, stimulating bone marrow production of red blood cells.

Question 54: What is the primary goal of emergency ultrafiltration in a dialysis patient presenting with acute pulmonary edema?

Lower serum potassium
Rapidly remove excess fluid to relieve respiratory compromise (Correct answer)
Improve dialysis adequacy Kt/V
Correct metabolic acidosis

Correct answer: Rapidly remove excess fluid to relieve respiratory compromise

Emergency isolated ultrafiltration rapidly removes excess fluid from the overloaded patient to relieve pulmonary edema and restore respiratory function.

Question 55: Heparin is administered at the start of hemodialysis primarily to prevent:

Membrane fouling
Clotting in the extracorporeal circuit (Correct answer)
Access infection
Hypotension

Correct answer: Clotting in the extracorporeal circuit

Heparin prevents thrombus formation in the blood tubing, dialyzer, and needle during passage of blood through the extracorporeal circuit.

Question 56: What is the maximum recommended ultrafiltration rate to minimize cardiovascular stress during hemodialysis?

10 mL/kg/hour
5 mL/kg/hour
13 mL/kg/hour (Correct answer)
20 mL/kg/hour

Correct answer: 13 mL/kg/hour

Ultrafiltration rates exceeding 13 mL/kg/hour are associated with increased cardiovascular stress, myocardial stunning, and higher mortality risk.

Question 57: The target hemoglobin range for most dialysis patients receiving erythropoiesis-stimulating agents (ESAs) per KDIGO guidelines is:

8–9 g/dL
14–15 g/dL
10–11.5 g/dL (Correct answer)
12–13 g/dL

Correct answer: 10–11.5 g/dL

KDIGO guidelines recommend maintaining hemoglobin between 10–11.5 g/dL to balance anemia correction with cardiovascular risk.

Question 58: What is the primary purpose of including the patient in developing their interdialytic weight gain goal?

To improve adherence through shared decision-making (Correct answer)
To reduce nursing documentation burden
To comply with CMS billing requirements
To eliminate the need for physician oversight

Correct answer: To improve adherence through shared decision-making

Shared decision-making in setting weight gain goals improves patient engagement and adherence because patients who participate in their care plan are more likely to follow it.

Question 59: A dialysis patient reports following their diet strictly but their potassium remains elevated. What assessment should the nurse prioritize?

Assume non-compliance and counsel the patient
Order a repeat potassium level
Increase dialysis treatment time
Review a detailed 3-day food diary with the patient (Correct answer)

Correct answer: Review a detailed 3-day food diary with the patient

A detailed food diary review can uncover hidden dietary potassium sources the patient may not recognize, enabling targeted and effective nutritional counseling.

Question 60: What is the recommended target range for dialysis adequacy (Kt/V) in hemodialysis patients per KDOQI guidelines?

≥1.2 per session (Correct answer)
≥1.8 per session
≥0.8 per session
≥1.4 per session

Correct answer: ≥1.2 per session

KDOQI guidelines recommend a minimum delivered spKt/V of 1.2 per hemodialysis session to ensure adequate solute clearance.

Question 61: When a patient receiving hemodialysis exhibits marked eosinophilia, what is the patient more likely to experience?

Type B (hypersensitivity) dialyzer reaction
Hemolysis
Type A (anaphylactic) dialyzer reaction (Correct answer)
Air embolism

Correct answer: Type A (anaphylactic) dialyzer reaction

The cause of eosinophilia in people with renal illness is unclear, however there is some evidence that it is more closely linked to vascular disease than uremia, such as that which can develop with diabetes. According to studies, eosinophil counts decrease during the first quarter of the dialysis session and then sharply rise at the end.

Question 62: Gabapentin requires significant dose reduction in dialysis patients primarily because of:

Reduced GI absorption
Renal elimination and accumulation causing CNS toxicity (Correct answer)
Protein binding changes
Increased hepatic metabolism

Correct answer: Renal elimination and accumulation causing CNS toxicity

Gabapentin is renally excreted and accumulates in ESRD, leading to excessive sedation, confusion, myoclonus, and respiratory depression.

Question 63: Which sign best indicates that an AV graft is functioning adequately during assessment?

Equal blood pressure in both arms
Visible pulsation at the anastomosis site
Palpable thrill along the graft (Correct answer)
Audible bruits only at the venous end

Correct answer: Palpable thrill along the graft

A continuous palpable thrill throughout the graft length indicates adequate arteriovenous flow and patent graft.

Question 64: A person with kidney illness in stage 4 is thinking about his alternatives. The patient should be aware that the highest percentage of survival is linked to?

Hemodialysis
Peritoneal dialysis
Post-dialytic transplantation
Preemptive transplantation (Correct answer)

Correct answer: Preemptive transplantation

If the patient is receiving a donated kidney from a family member or friend, preemptive transplantation is a particularly advantageous choice because the surgery may be planned for and arranged in advance without worrying that a kidney may not be available. Another benefit is a reduction in long-term expenditures, but the patient must take long-term immunosuppressive medications.

Question 65: What happens to the water softener resin during the regeneration process?

Carbon particles are backwashed out of the system
Sodium ions replace accumulated calcium and magnesium ions via a salt brine flush (Correct answer)
Resin is sterilized with bleach
Resin is replaced with new material

Correct answer: Sodium ions replace accumulated calcium and magnesium ions via a salt brine flush

During regeneration, a concentrated sodium chloride (brine) solution flushes through the resin, replacing accumulated calcium and magnesium with sodium ions, restoring softening capacity.

Question 66: What does the ESRD Quality Incentive Program (QIP) in the United States primarily measure?

The number of patients transplanted per facility
Staff-to-patient ratios at dialysis facilities
Clinical outcomes and quality metrics to determine Medicare reimbursement (Correct answer)
Patient satisfaction scores only

Correct answer: Clinical outcomes and quality metrics to determine Medicare reimbursement

The ESRD QIP ties Medicare payment reductions to performance on clinical and reporting quality measures such as Kt/V adequacy, hemoglobin, and infection rates.

Question 67: How often should the total chlorine level in dialysis water be tested at minimum?

Quarterly
Monthly
Weekly
Daily before each patient treatment (Correct answer)

Correct answer: Daily before each patient treatment

Total chlorine must be tested daily before each patient treatment shift, as breakthrough can occur rapidly and cause patient harm if not detected promptly.

Question 68: What is the MOST common cause of death in patients with end-stage renal disease on dialysis?

Infection and sepsis
Cardiovascular disease (Correct answer)
Stroke
Malignancy

Correct answer: Cardiovascular disease

Cardiovascular disease (including cardiac arrest, myocardial infarction, and heart failure) accounts for approximately 40–50% of deaths in ESRD patients on dialysis.

Question 69: Patients taking oral iron should be encouraged to enhance absorption, right?

Take the supplement on an empty stomach. (Correct answer)
Take the supplement with phosphate binders.
Take the supplement with dairy products, such as milk.
Take enteric-coated preparations of the supplement.

Correct answer: Take the supplement on an empty stomach.

It should be explained to patients that taking the supplement with food may result in decreased absorption. Patients should also refrain from taking supplements containing phosphate binders and should not take enteric-coated medications. Since 325 mg of ferrous sulfate three times per day is equivalent to 200 g of elemental iron per day, it is typically administered to patients.

Question 70: A patient on hemodialysis suddenly develops nausea, headache, and altered consciousness near the end of treatment. What condition should the nurse suspect?

Hemolysis
Dialysis disequilibrium syndrome (Correct answer)
Hypersensitivity reaction
Air embolism

Correct answer: Dialysis disequilibrium syndrome

Dialysis disequilibrium syndrome (DDS) occurs due to rapid solute removal causing osmotic cerebral edema, typically in new or high-BUN patients.

Question 71: During hemodialysis, the venous pressure alarm sounds high. Which cause should the nurse investigate first?

Blood pump speed too low
Inadequate heparin dosing
Dialysate temperature too high
Kinked or occluded venous blood line (Correct answer)

Correct answer: Kinked or occluded venous blood line

A kinked or occluded venous line creates resistance to blood return, causing high venous pressure alarms.

Question 72: Which secondary hyperparathyroidism finding is a consequence of chronic kidney disease and impacts dialysis nursing care?

Elevated PTH driving bone disease, hypercalcemia, and vascular calcification (Correct answer)
Suppressed calcitriol production causing hyperphosphatemia only
Reduced phosphorus reabsorption from the gut
Decreased osteocalcin and low bone turnover

Correct answer: Elevated PTH driving bone disease, hypercalcemia, and vascular calcification

CKD-MBD involves elevated PTH due to reduced vitamin D activation and hyperphosphatemia, leading to renal osteodystrophy and cardiovascular calcification.

Question 73: Dialysis disequilibrium syndrome (DDS) is most likely to occur in which clinical scenario?

New patient receiving first aggressive hemodialysis treatment with high BUN (Correct answer)
Experienced patient undergoing routine treatment
Patient receiving slow continuous renal replacement therapy
Patient with well-controlled uremia receiving maintenance dialysis

Correct answer: New patient receiving first aggressive hemodialysis treatment with high BUN

DDS occurs when rapid urea removal creates an osmotic gradient that draws water into brain cells, most commonly in new patients with very high BUN receiving their first aggressive dialysis.

Question 74: During a dialysis machine's self-test, a conductivity alarm activates indicating high conductivity. What does this most likely indicate?

Low blood flow rate
Low dialysate temperature
Air detector malfunction
Incorrect proportioning of dialysate concentrate (Correct answer)

Correct answer: Incorrect proportioning of dialysate concentrate

High conductivity in the dialysate circuit indicates improper proportioning of the acid or bicarbonate concentrate, resulting in a solution that is too concentrated.

Question 75: What is the primary purpose of the dialysate bicarbonate concentration in hemodialysis?

To enhance potassium removal
To correct metabolic acidosis common in ESRD (Correct answer)
To prevent hypotension during treatment
To remove excess phosphorus

Correct answer: To correct metabolic acidosis common in ESRD

ESRD patients accumulate acid from metabolism; dialysate bicarbonate (usually 35–40 mEq/L) diffuses into the blood to correct metabolic acidosis.

Question 76: A patient on hemodialysis has a serum potassium of 6.8 mEq/L before treatment. Which dialysate potassium concentration is most appropriate?

3 mEq/L
4 mEq/L
2 mEq/L (Correct answer)
0 mEq/L

Correct answer: 2 mEq/L

A 2 mEq/L dialysate potassium creates an adequate gradient to remove excess potassium from a severely hyperkalemic patient.

Question 77: A dialysis patient consistently achieves Kt/V of 1.0 despite correct treatment prescription. What is the most likely cause?

Low phosphorus levels
Access recirculation reducing effective clearance (Correct answer)
High protein intake increasing urea generation
Excessive fluid removal

Correct answer: Access recirculation reducing effective clearance

Access recirculation allows already-dialyzed blood to re-enter the arterial needle, reducing effective urea clearance and resulting in lower-than-expected Kt/V values.

Question 78: A newly diagnosed ESRD patient expresses denial and refuses to learn about dialysis. What is the best therapeutic approach?

Insist they attend mandatory education sessions immediately
Document refusal and limit nursing contact
Acknowledge emotions, provide time to adjust, and offer information at the patient's pace (Correct answer)
Contact the patient's family to override the refusal

Correct answer: Acknowledge emotions, provide time to adjust, and offer information at the patient's pace

Acknowledging grief and denial while offering flexible, patient-paced education supports the psychological adjustment process without creating adversarial dynamics.

Question 79: A dialysis patient presents with a serum calcium of 11.8 mg/dL. Which medication is the most likely culprit?

Lanthanum carbonate
Sevelamer carbonate
Calcium carbonate phosphate binder (Correct answer)
Cinacalcet

Correct answer: Calcium carbonate phosphate binder

Calcium carbonate is a calcium-based phosphate binder that contributes to hypercalcemia when taken in excess or with high-calcium dialysate.

Question 80: A dialysis patient develops sudden severe headache, visual changes, and confusion during treatment. What complication should be considered first?

Anaphylaxis
Dialysis disequilibrium syndrome or hypertensive emergency (Correct answer)
Air embolism
Hypoglycemia

Correct answer: Dialysis disequilibrium syndrome or hypertensive emergency

Sudden severe headache, visual disturbances, and altered mental status during dialysis suggest either dialysis disequilibrium syndrome from rapid urea removal or hypertensive emergency requiring urgent evaluation.

Question 81: Which clinical finding most strongly suggests air embolism during hemodialysis?

Cyanosis, dyspnea, and millwheel murmur over the precordium (Correct answer)
Fever and shaking chills after 30 minutes
High arterial pressure alarm with access pain
Sudden hypotension with bradycardia

Correct answer: Cyanosis, dyspnea, and millwheel murmur over the precordium

Air embolism classically presents with cyanosis, respiratory distress, and a churning millwheel murmur caused by air in the right heart.

Question 82: Which medication should be administered with meals to a dialysis patient with hyperphosphatemia?

Phosphate binder (Correct answer)
Iron supplement
Vitamin D analog
Erythropoiesis-stimulating agent

Correct answer: Phosphate binder

Phosphate binders must be taken with meals to bind dietary phosphate in the gut before absorption.

Question 83: The 'KDOQI first' principle recommends which vascular access as the preferred option for new hemodialysis patients?

Subclavian catheter
Arteriovenous graft
Tunneled central venous catheter
Arteriovenous fistula (Correct answer)

Correct answer: Arteriovenous fistula

KDOQI guidelines strongly recommend the native AV fistula as the first choice due to its superior longevity and lowest complication rates.

Question 84: The recirculation rate in a functioning AV fistula is measured to be 15%. This finding indicates:

Adequate dialysis adequacy
Need to increase dialysis time only
Normal fistula function
Significant access dysfunction requiring evaluation (Correct answer)

Correct answer: Significant access dysfunction requiring evaluation

Recirculation above 10% suggests access dysfunction such as stenosis, which reduces dialysis efficiency and requires vascular evaluation.

Question 85: What is the rationale for timing the administration of intravenous antibiotics in hemodialysis patients?

Antibiotics should be given 2 hours before dialysis
Dialysis increases antibiotic bioavailability
Antibiotics are ineffective in dialysis patients
Antibiotics should be dosed after dialysis to prevent removal by the procedure (Correct answer)

Correct answer: Antibiotics should be dosed after dialysis to prevent removal by the procedure

Many antibiotics are dialyzable, so post-dialysis dosing prevents drug removal and ensures therapeutic blood levels persist until the next session.

Question 86: Which nursing assessment finding is MOST consistent with catheter-related bloodstream infection in a dialysis patient?

Elevated BUN only
Bruit over the catheter site
Fever, chills, and bacteremia without another source (Correct answer)
Increased ultrafiltration rates

Correct answer: Fever, chills, and bacteremia without another source

CRBSI presents with fever and chills during or after dialysis with positive blood cultures and no other identifiable source of infection.

Question 87: A patient receiving erythropoiesis-stimulating agents (ESAs) for CKD-related anemia has a hemoglobin of 13.5 g/dL. What action should the nurse take?

Increase the ESA dose to maintain higher hemoglobin
Continue current dose as 13.5 is within normal range
Switch to IV iron supplementation instead
Hold or reduce the ESA dose to keep hemoglobin within 10–11.5 g/dL (Correct answer)

Correct answer: Hold or reduce the ESA dose to keep hemoglobin within 10–11.5 g/dL

Targeting hemoglobin >13 g/dL with ESAs increases cardiovascular risk; KDIGO guidelines recommend a target of 10–11.5 g/dL in dialysis patients.

Question 88: A patient on peritoneal dialysis presents with cloudy dialysate effluent, abdominal pain, and fever. What is the most likely diagnosis?

Catheter malposition
Dialysate leak
Ultrafiltration failure
Peritonitis (Correct answer)

Correct answer: Peritonitis

Cloudy effluent, abdominal pain, and fever are the classic triad of peritonitis, the most serious complication of peritoneal dialysis.

Question 89: What is a primary advantage of the buttonhole cannulation technique over rope-ladder technique?

Lower infection risk than rope-ladder
Reduced cannulation pain and fewer hematomas (Correct answer)
Faster fistula maturation
Higher blood flow rates

Correct answer: Reduced cannulation pain and fewer hematomas

Buttonhole cannulation uses blunt needles inserted into established tracts, significantly reducing pain and the risk of hematoma formation with each treatment.

Question 90: A dialysis patient asks why their residual renal function (RRF) should be preserved. What is the BEST nursing response?

RRF contributes to solute and fluid clearance, improves outcomes, and should be protected (Correct answer)
RRF measurement is used only to determine if dialysis can be discontinued
RRF only matters for PD patients, not HD patients
Preserving RRF has no impact once ESRD is reached

Correct answer: RRF contributes to solute and fluid clearance, improves outcomes, and should be protected

Even small amounts of residual kidney function significantly improve solute clearance, blood pressure control, and survival in both HD and PD patients.

Question 91: A bloodstream infection (BSI) surveillance system has been installed at a hemodialysis facility. What should be decided after choosing this event for monitoring?

Methods of data collection
Methods of data analysis
Time period for observation (Correct answer)
Data elements for collection

Correct answer: Time period for observation

The last step is to choose the duration of the observation, which might be a month, quarter, or year. A longer time period is suggested to assure measurement validity if BSIs are uncommon. Following the determination of the surveillance criteria and data items to be gathered, the method for data analysis and the procedures for data collection must be described.

Question 92: Which electrolyte imbalance is MOST commonly associated with muscle cramps during hemodialysis?

Hyperkalemia
Rapid ultrafiltration causing hypovolemia (Correct answer)
Hypocalcemia
Hypernatremia

Correct answer: Rapid ultrafiltration causing hypovolemia

Muscle cramps during HD are most often caused by rapid fluid removal leading to intravascular volume depletion and tissue hypoperfusion.

Question 93: What is the purpose of carbon tanks in the dialysis water treatment system?

Remove bacteria
Adjust pH of water
Remove dissolved minerals
Remove chlorine and chloramines via adsorption (Correct answer)

Correct answer: Remove chlorine and chloramines via adsorption

Activated carbon tanks remove chlorine and chloramines through adsorption, protecting the RO membrane and preventing patient exposure to these hemolytic agents.

Question 94: A peritoneal dialysis patient using automated peritoneal dialysis (APD) reports the machine alarming 'drain incomplete.' The nurse's first intervention is to:

Switch to manual CAPD exchanges
Reposition the patient and check catheter kinks (Correct answer)
Increase the dwell time on the next cycle
Replace the PD catheter immediately

Correct answer: Reposition the patient and check catheter kinks

Repositioning the patient and checking for catheter kinks addresses the most common mechanical causes of incomplete drainage.

Question 95: How frequently should hemoglobin be monitored in stable hemodialysis patients receiving ESA therapy?

Weekly
Every 3 months
Monthly (Correct answer)
Every 6 months

Correct answer: Monthly

Monthly hemoglobin monitoring is recommended for stable dialysis patients on ESA therapy to allow timely dose adjustments and detect trends before hemoglobin rises above or falls below target range.

Question 96: A chronic dialysis patient has a serum phosphorus of 7.2 mg/dL. In addition to dialysis, what is the MOST important nursing intervention?

Encourage high-protein diet
Administer phosphate binders with meals (Correct answer)
Increase dialysate calcium concentration
Restrict potassium intake

Correct answer: Administer phosphate binders with meals

Phosphate binders taken with meals bind dietary phosphorus in the gut, preventing its absorption and are the primary pharmacological management of hyperphosphatemia.

Question 97: Which acid-base disorder is most commonly observed in patients with end-stage renal disease prior to dialysis?

Respiratory alkalosis
Metabolic alkalosis
Respiratory acidosis
Metabolic acidosis (Correct answer)

Correct answer: Metabolic acidosis

Failed kidneys cannot excrete fixed acids or regenerate bicarbonate, leading to chronic metabolic acidosis in ESRD patients.

Question 98: According to KDIGO guidelines, what is the target hemoglobin range for dialysis patients receiving erythropoiesis-stimulating agent (ESA) therapy?

10–11.5 g/dL (Correct answer)
8–9 g/dL
12–13 g/dL
13–14 g/dL

Correct answer: 10–11.5 g/dL

KDIGO guidelines recommend maintaining hemoglobin between 10–11.5 g/dL in dialysis patients on ESA therapy to balance symptom relief while minimizing cardiovascular risks.

Question 99: Which dressing change technique is used for the buttonhole cannulation method?

Removal of scab with sterile technique before needle insertion (Correct answer)
Transparent occlusive dressing only
Betadine-soaked gauze left in place 24 hours
Alcohol swab applied immediately before needle insertion

Correct answer: Removal of scab with sterile technique before needle insertion

In the buttonhole technique, the scab at the tract entrance must be removed using sterile technique before inserting the blunt needle to maintain tract integrity.

Question 100: Which parameter is used to determine the ultrafiltration volume goal for a hemodialysis patient?

Serum creatinine level
Difference between current weight and estimated dry weight (Correct answer)
Predialysis BUN level
Residual renal function

Correct answer: Difference between current weight and estimated dry weight

Ultrafiltration volume is calculated as the difference between the patient's current (wet) weight and their estimated dry weight (ideal fluid-free weight).

Question 101: The gradient of a substance's concentration, such as urea, during peritoneal dialysis

Remains consistent
Decreases (Correct answer)
Varies widely
Increases

Correct answer: Decreases

The gradient of a substance's concentration, such urea, diminishes during peritoneal dialysis. In other words, when the concentration is low, more urea diffuses into the implanted dialysate than when the concentration is higher. More frequent exchanges (as with APD, for example) or a larger dwell volume (usually not more than 2.5–3.0 L) can be done to make up for this shift in concentration gradient.

Question 102: Which chemical contaminant in municipal water poses the greatest risk of hemolytic anemia in dialysis patients if not removed?

Fluoride
Chloramine (Correct answer)
Calcium
Nitrate

Correct answer: Chloramine

Chloramine, used in municipal water disinfection, causes oxidative hemolytic anemia if not adequately removed before dialysis water reaches the patient.

Question 103: A dialysis patient collapses immediately after leaving the unit post-treatment. Emergency responders find ventricular fibrillation. What is the most likely contributing factor?

Hypoglycemia from glucose-free dialysate
Post-dialysis rebound hyperkalemia combined with post-treatment hemodynamic instability (Correct answer)
Hypocalcemia from calcium-free dialysate
Dialysis disequilibrium syndrome

Correct answer: Post-dialysis rebound hyperkalemia combined with post-treatment hemodynamic instability

Post-dialysis VF can result from hypokalemia during treatment (from low-potassium dialysate) followed by rapid potassium rebound, combined with QT prolongation and hemodynamic instability after treatment.

Question 104: A dialysis patient develops severe hypocalcemia during a session using a low-calcium dialysate. What is the preferred treatment?

Administering parathyroid hormone
Increasing dialysate phosphorus
IV calcium gluconate (Correct answer)
Oral calcium carbonate

Correct answer: IV calcium gluconate

Symptomatic acute hypocalcemia requires IV calcium gluconate for rapid correction, as oral calcium acts too slowly.

Question 105: A dialysis patient's pre-treatment blood pressure is 85/50 mmHg. The appropriate nursing action is to:

Administer a fluid bolus of normal saline per protocol
Begin dialysis at standard settings
Hold dialysis and notify the physician (Correct answer)
Begin dialysis at a reduced ultrafiltration rate

Correct answer: Hold dialysis and notify the physician

Symptomatic hypotension before dialysis initiation requires physician notification before proceeding with treatment.

Question 106: When a CAPD patient performs an exchange, the effluent appears bloody. After ruling out trauma, the nurse should assess for:

Catheter migration into the chest
Peritonitis
Herniation
Menstruation or ovulation in female patients (Correct answer)

Correct answer: Menstruation or ovulation in female patients

In female patients, retrograde menstruation or ovulation are common benign causes of bloody peritoneal effluent and should be assessed.

Question 107: What is the correct response when a Type A (anaphylactic) dialyzer reaction is suspected?

Administer IV diphenhydramine and continue treatment at reduced flow
Stop dialysis, clamp blood lines, do NOT return blood, administer epinephrine and supportive care (Correct answer)
Slow the blood pump and give antihistamines
Return blood and switch to a new dialyzer

Correct answer: Stop dialysis, clamp blood lines, do NOT return blood, administer epinephrine and supportive care

In a Type A anaphylactic reaction, the blood must not be returned (it contains the causative agent), dialysis is stopped, and epinephrine with full anaphylaxis management is initiated immediately.

Question 108: Which type of vascular access is considered the gold standard for hemodialysis?

Arteriovenous fistula (Correct answer)
Arteriovenous graft
Non-tunneled catheter
Tunneled cuffed catheter

Correct answer: Arteriovenous fistula

The arteriovenous (AV) fistula is the gold standard for hemodialysis access due to its lower infection risk, longer patency, and better outcomes.

Question 109: Which phosphate binder is safe to use in dialysis patients with hypercalcemia?

Calcium carbonate
All calcium-containing binders
Sevelamer hydrochloride (Correct answer)
Calcium acetate

Correct answer: Sevelamer hydrochloride

Sevelamer is a non-calcium, non-aluminum phosphate binder that effectively lowers serum phosphorus without contributing to hypercalcemia.

Question 110: Which type of dialyzer reaction is characterized by dyspnea and chest/back pain occurring within the first 5 minutes of dialysis?

Pyrogenic reaction
Type A reaction (anaphylactic — IgE-mediated) (Correct answer)
Hemolytic reaction
Type B reaction (non-specific)

Correct answer: Type A reaction (anaphylactic — IgE-mediated)

Type A (anaphylactic) dialyzer reactions occur within 5 minutes of treatment initiation due to IgE-mediated hypersensitivity, often to ethylene oxide sterilant or membrane components, and can be life-threatening.

Question 111: Which of the following is a contraindication to using a tunneled dialysis catheter as permanent long-term access?

Patient is awaiting AV fistula maturation
Patient has inadequate peripheral veins
Patient is on anticoagulation therapy
Patient has an active bloodstream infection (Correct answer)

Correct answer: Patient has an active bloodstream infection

Active bloodstream infection is an absolute contraindication to placing any new tunneled catheter, as it would seed the device and worsen infection.

Question 112: A hemodialysis patient who has been on epoetin alfa for 14 months develops a sudden severe drop in hemoglobin with near-absent reticulocytes. What should the nurse suspect?

Hemolysis from dialyzer reaction
Pure red cell aplasia (PRCA) from anti-EPO antibodies (Correct answer)
Folate deficiency anemia
Acute iron deficiency from GI blood loss

Correct answer: Pure red cell aplasia (PRCA) from anti-EPO antibodies

The combination of sudden severe anemia with reticulocytopenia after prolonged ESA exposure is the classic presentation of PRCA caused by neutralizing anti-erythropoietin antibodies.

Question 113: The subcutaneous tunnel's typical length while inserting a catheter for peritoneal dialysis is?

10–15 cm
3–5 cm (Correct answer)
3–4cm
2–3 cm

Correct answer: 3–5 cm

The tunnel travels from the peritoneal cavity to the skin, passing through muscle and subcutaneous tissue. With one cuff distal to the peritoneum and the other subcutaneously at least 2 cm from the exit, the catheters typically have a set of cuffs. The cuffs secure the catheter, stop leaks, and act as barriers to lower the risk of infection.

Question 114: A patient with ESRD secondary to diabetic nephropathy is on HD. Which complication of diabetes requires ADDITIONAL monitoring during dialysis sessions?

Hypoglycemia due to glucose-free dialysate or insulin accumulation (Correct answer)
Respiratory alkalosis
Polycythemia
Hyperthyroidism

Correct answer: Hypoglycemia due to glucose-free dialysate or insulin accumulation

Diabetic dialysis patients are at risk for hypoglycemia during HD because glucose-free or low-glucose dialysate removes blood glucose, and insulin clearance is reduced in ESRD.

Question 115: A patient's dialysis access shows a bruit that has changed from soft to high-pitched. What does this finding indicate?

Infection at the access site
Possible stenosis or partial occlusion of the access (Correct answer)
Normal maturation of a new AV fistula
Increased blood flow through the access

Correct answer: Possible stenosis or partial occlusion of the access

A high-pitched or harsh bruit replacing a soft, low-pitched one suggests turbulent flow from stenosis, which requires prompt evaluation.

Question 116: A hemodialysis patient's access site shows redness, warmth, and purulent drainage. What is the nurse's priority action?

Increase the dialysis flow rate
Document findings and reassess in 4 hours
Notify the physician and obtain a culture (Correct answer)
Apply a warm compress and monitor

Correct answer: Notify the physician and obtain a culture

Signs of access site infection require immediate physician notification and culture collection to guide antibiotic therapy.

Question 117: Which dietary restriction is most critical for a hemodialysis patient between treatments?

Restrict fluid intake to 1,000 mL/day plus urine output (Correct answer)
Eliminate all dietary sodium
Avoid all protein-containing foods
Limit vitamin C intake to prevent oxalate stones

Correct answer: Restrict fluid intake to 1,000 mL/day plus urine output

Fluid restriction to 1,000 mL plus urine output prevents dangerous interdialytic weight gain and pulmonary edema.

Question 118: A patient's interdialytic weight gain is consistently 4–5 kg. The most effective nursing intervention is:

Increase ultrafiltration to remove more fluid each session
Provide education on fluid restriction and sodium reduction (Correct answer)
Decrease the dry weight target
Recommend additional dialysis sessions each week

Correct answer: Provide education on fluid restriction and sodium reduction

Education on fluid restriction and dietary sodium reduction addresses the root cause of excessive interdialytic weight gain.

Question 119: Sodium bicarbonate is sometimes given to a dialysis patient prior to an emergency session. What is the indication?

Hypocalcemia
Fluid overload
Hyperkalemia with severe acidosis (Correct answer)
Hypernatremia

Correct answer: Hyperkalemia with severe acidosis

IV sodium bicarbonate can temporarily shift potassium intracellularly and correct severe acidosis as a bridge to urgent hemodialysis.

Question 120: Which medication used to lower blood pressure is dialyzable and may require supplemental dosing after hemodialysis?

Atenolol (Correct answer)
Amlodipine
Lisinopril
Carvedilol

Correct answer: Atenolol

Atenolol is hydrophilic, minimally protein-bound, and substantially removed by hemodialysis, often requiring a supplemental post-dialysis dose.

Question 121: A dialysis patient with chronic fluid overload develops worsening left ventricular hypertrophy. What is the primary modifiable contributing factor?

Anemia
Hyperphosphatemia
Persistent fluid overload and hypertension (Correct answer)
Elevated PTH

Correct answer: Persistent fluid overload and hypertension

Chronic fluid overload causes sustained hypertension and increased cardiac preload, driving left ventricular hypertrophy and heart failure in dialysis patients.

Question 122: A peritoneal dialysis patient using a 4.25% dextrose exchange complains of hyperglycemia. This concentration is most appropriate for which clinical situation?

Prevention of peritonitis
Replacement of lost proteins during dialysis
Maintenance fluid removal in a stable patient
Management of severe fluid overload requiring enhanced ultrafiltration (Correct answer)

Correct answer: Management of severe fluid overload requiring enhanced ultrafiltration

The 4.25% dextrose solution creates a higher osmotic gradient to achieve greater ultrafiltration in fluid-overloaded patients.

Question 123: A dialysis nurse notes the patient's interdialytic weight gain is consistently 4–5 kg between sessions. What is the PRIORITY patient education topic?

Protein intake and dietary adequacy
Phosphorus-rich foods to avoid
Exercise between treatments
Fluid and sodium restriction (Correct answer)

Correct answer: Fluid and sodium restriction

Excessive interdialytic weight gain (>2–3 kg) reflects fluid and sodium excess, requiring education on fluid restriction and limiting high-sodium foods.

Question 124: When treating intradialytic hypotension, which intervention should be performed first?

Administer 0.9% normal saline bolus
Administer midodrine
Increase dialysate sodium concentration
Place patient in Trendelenburg position and reduce ultrafiltration (Correct answer)

Correct answer: Place patient in Trendelenburg position and reduce ultrafiltration

Placing the patient flat or in Trendelenburg and reducing or stopping ultrafiltration is the immediate first response to intradialytic hypotension.

Question 125: Which factor would most directly increase the Kt/V delivered to a patient?

Increasing ultrafiltration rate
Increasing the dialysate sodium concentration
Using a larger gauge needle
Extending the treatment time from 3 to 4 hours (Correct answer)

Correct answer: Extending the treatment time from 3 to 4 hours

Extending treatment time increases the total amount of urea cleared (K×t), thereby raising the Kt/V when urea distribution volume (V) remains constant.

Question 126: If Ms. Precy's spouse is disease-free, she queries the nurse as to the likelihood that any children may contract the illness. Should the nurse tell the patient that a child will?

Have a 100% risk of developing the disease
Have a 25% risk of developing the disease
Have no risk of developing the disease
Have a 50% risk of developing the disease (Correct answer)

Correct answer: Have a 50% risk of developing the disease

An autosomal dominant illness called polycystic kidney disease typically doesn't manifest until the third or fourth decade of life. Both kidneys are affected, and the cortex and medulla swell with many, sizable cysts that eat away at the kidney tissue.

Question 127: When a dialysis nurse suspects a patient is experiencing intimate partner violence, what is the most appropriate action?

Notify law enforcement without patient consent
Conduct a private, non-judgmental screening and provide resources (Correct answer)
Confront the suspected abuser directly
Document suspicions and wait for the patient to report it

Correct answer: Conduct a private, non-judgmental screening and provide resources

Conducting a private, compassionate screening and offering community resources respects patient autonomy while fulfilling the nurse's duty to identify and support victims.

Question 128: What is the first action when an air embolism is suspected during hemodialysis?

Administer 100% oxygen and clamp the venous line (Correct answer)
Increase blood flow rate
Reduce ultrafiltration immediately
Notify the physician and continue dialysis

Correct answer: Administer 100% oxygen and clamp the venous line

Clamping the venous blood line immediately stops air from entering the patient while 100% oxygen helps reabsorb nitrogen bubbles.

Question 129: Which erythropoiesis-stimulating agent (ESA) has a significantly longer half-life than epoetin alfa, allowing for less frequent dosing?

Epoetin beta
Methyl-epoetin
Darbepoetin alfa (Correct answer)
Ferric gluconate

Correct answer: Darbepoetin alfa

Darbepoetin alfa (Aranesp) has a half-life approximately three times longer than epoetin alfa due to additional sialic acid residues, allowing weekly or biweekly dosing instead of three times per week.

Question 130: A patient reports painful leg and foot cramps during the last hour of hemodialysis. What is the most appropriate initial intervention?

Reduce blood flow rate and administer hypertonic saline or glucose (Correct answer)
Increase ultrafiltration rate to clear cramp-causing toxins
Discontinue dialysis immediately
Administer IV calcium gluconate

Correct answer: Reduce blood flow rate and administer hypertonic saline or glucose

Dialysis-related muscle cramps are treated by reducing ultrafiltration rate and administering hypertonic saline or glucose to rapidly expand intravascular volume.

Question 131: What is the AAMI recommended maximum level for bacteria in dialysis water?

500 CFU/mL
10 CFU/mL
200 CFU/mL
100 CFU/mL (Correct answer)

Correct answer: 100 CFU/mL

AAMI standards specify that dialysis water should contain no more than 100 colony-forming units per milliliter (CFU/mL) of bacteria.

Question 132: Which parameter best guides the adjustment of a peritoneal dialysis patient's dry weight (target weight)?

Clinical signs of fluid status: blood pressure, edema, and lung sounds (Correct answer)
Serum albumin level
Peritoneal equilibration test (PET) results
Weekly BUN and creatinine trends

Correct answer: Clinical signs of fluid status: blood pressure, edema, and lung sounds

Dry weight in PD is determined clinically by assessing blood pressure, presence of edema, and auscultation for fluid in the lungs.

Question 133: Which finding during the arteriovenous fistula assessment indicates adequate maturation for cannulation?

Presence of a bruit only, without thrill
Fistula visible at skin surface within 2 weeks of creation
Blood pressure equal in both arms
Fistula diameter ≥ 6 mm with flow ≥ 600 mL/min at 6 weeks (Correct answer)

Correct answer: Fistula diameter ≥ 6 mm with flow ≥ 600 mL/min at 6 weeks

A mature fistula should have a diameter of at least 6 mm and blood flow of at least 600 mL/min, typically assessed at 6 weeks post-creation.

Question 134: The target weight loss for Ms. Precy's hemodialysis session has been determined by the nurse, but the patient claims that the target is incorrect and is 1 kg too high. The nurse ought to

Reassure the patient that the target is correct.
Recalculate the target weight loss. (Correct answer)
Advise the patient that 1 kg is inconsequential.
Ignore the patient.

Correct answer: Recalculate the target weight loss.

To decide which target is accurate, the nurse should recalculate the desired weight loss with the patient. Because anyone can make mistakes and because patients are frequently extremely knowledgeable about their ailments and needs, patients should be taught to monitor their own care.

Question 135: Which type of vascular access has the highest rate of infection among ESRD patients?

Arteriovenous fistula
Tunneled dialysis catheter (Correct answer)
Arteriovenous graft
Temporary non-tunneled catheter

Correct answer: Tunneled dialysis catheter

Tunneled dialysis catheters have significantly higher infection rates compared to fistulas and grafts due to the direct bloodstream access they provide.

Question 136: The nurse notes that a hemodialysis patient's blood urea nitrogen (BUN) is 95 mg/dL pre-dialysis but 88 mg/dL post-dialysis. The URR is approximately:

65%
7% (Correct answer)
92%
8%

Correct answer: 7%

URR = (pre-BUN minus post-BUN) / pre-BUN × 100 = (95−88)/95 × 100 ≈ 7%, indicating severely inadequate dialysis.

Question 137: A patient develops fever and shaking chills approximately 45 minutes into hemodialysis. What is the most likely cause?

Pyrogenic reaction from contaminated dialysate or equipment (Correct answer)
Dialysis disequilibrium syndrome
Type A hypersensitivity reaction
Hemolysis due to overheated dialysate

Correct answer: Pyrogenic reaction from contaminated dialysate or equipment

Pyrogenic reactions are caused by bacterial endotoxins in dialysate or equipment, triggering an immune response with fever and rigors.

Question 138: When educating a dialysis patient about phosphorus restriction, which food group should be emphasized most strongly?

Processed foods, dairy, and dark colas containing phosphate additives (Correct answer)
Whole grain breads
Fresh fruits and vegetables
Fresh lean meats in all quantities

Correct answer: Processed foods, dairy, and dark colas containing phosphate additives

Processed foods contain phosphate additives that are nearly 100% absorbed, making them the highest-risk category for hyperphosphatemia in dialysis patients.

Question 139: What does the peritoneal equilibration test measure?

Determine the patient’s serum urea and serum creatinine after a 4-hour dwell is drained.
Determine the amount of residual glucose that remains in the dialysate after a 4-hour dwell is drained.
Determine the amount of urea in a 24-hour collection of drained dialysate compared to the amount of urea in the blood.
Determine the amount of glucose absorbed from dialysate and the amount of urea and creatinine filtered into the dialysate in a 4-hour dwell. (Correct answer)

Correct answer: Determine the amount of glucose absorbed from dialysate and the amount of urea and creatinine filtered into the dialysate in a 4-hour dwell.

This is one way to gauge how well peritoneal dialysis is working. Due to their potential for rapid glucose absorption and potential requirement for shorter stay durations, patients with high rate of transport may also benefit from this test's ability to detect them. The patient could require a longer dwell time or more exchanges if not enough urea and creatinine are being filtered.

Question 140: What is the recommended fluid intake guideline for a hemodialysis patient with minimal residual urine output?

Limit to 1000–1500 mL/day (Correct answer)
No fluid restriction needed if on dialysis 3×/week
Limit to 500 mL/day plus output
Unrestricted — drink as much as desired

Correct answer: Limit to 1000–1500 mL/day

Hemodialysis patients with minimal urine output should generally restrict fluid intake to approximately 1000–1500 mL per day to prevent excessive interdialytic weight gain.

Question 141: Intradialytic hypotension is most effectively prevented by which of the following interventions?

Administering IV albumin before each session
Using a higher sodium dialysate concentration
Limiting the ultrafiltration rate to ≤13 mL/kg/hour (Correct answer)
Increasing the dialysate temperature

Correct answer: Limiting the ultrafiltration rate to ≤13 mL/kg/hour

Limiting ultrafiltration to ≤13 mL/kg/hour reduces the rate of fluid removal, allowing adequate plasma refilling and preventing hemodynamic instability.

Question 142: Which electrolyte abnormality is the most common cause of cardiac arrest in hemodialysis patients between treatments?

Hypocalcemia
Hyperkalemia (Correct answer)
Hyponatremia
Hyperphosphatemia

Correct answer: Hyperkalemia

Hyperkalemia is the leading electrolyte cause of between-treatment cardiac arrest in hemodialysis patients, as potassium accumulates rapidly without renal excretion.

Question 143: What is the emergency treatment for suspected air embolism during hemodialysis?

Immediately clamp venous line, stop blood pump, place patient in left lateral Trendelenburg position, and call for emergency help (Correct answer)
Administer oxygen and reduce ultrafiltration rate
Increase blood flow to flush air through system quickly
Administer heparin IV and continue dialysis

Correct answer: Immediately clamp venous line, stop blood pump, place patient in left lateral Trendelenburg position, and call for emergency help

Air embolism requires immediate cessation of blood flow, left lateral Trendelenburg positioning (to trap air in right ventricle away from pulmonary circulation), and emergency medical support.

Question 144: During hemodialysis, the blood pump stops and blood is observed to be dark in the arterial line. What is the most likely cause?

Air embolism
Arterial needle clotting or dislodgement (Correct answer)
Venous needle dislodgement
Hemolysis

Correct answer: Arterial needle clotting or dislodgement

Dark, de-oxygenated blood backing up in the arterial line suggests the arterial needle has clotted or dislodged, severely limiting blood flow.

Question 145: What is the minimum acceptable blood flow rate (Qb) recommended for adequate hemodialysis through a permanent access?

300–400 mL/min (Correct answer)
150–200 mL/min
100–150 mL/min
500–600 mL/min

Correct answer: 300–400 mL/min

Effective hemodialysis typically requires blood flow rates of 300–400 mL/min through permanent access to achieve adequate solute clearance.

Question 146: What is the minimum single-pool Kt/V (spKt/V) recommended by KDOQI guidelines for thrice-weekly hemodialysis?

0.8
1.2 (Correct answer)
1.4
1.0

Correct answer: 1.2

KDOQI guidelines recommend a minimum spKt/V of 1.2 for patients on thrice-weekly hemodialysis to ensure adequate uremic toxin removal.

Question 147: According to KDIGO guidelines, above what serum ferritin level should IV iron supplementation generally not be routinely administered due to risk of iron overload?

200 ng/mL
500 ng/mL (Correct answer)
300 ng/mL
800 ng/mL

Correct answer: 500 ng/mL

KDIGO 2012 guidelines recommend withholding routine IV iron when ferritin exceeds 500 ng/mL, as higher levels suggest adequate stores and raise concern for iron overload and toxicity.

Question 148: What is the immediate treatment for intradialytic hypotension?

Place the patient in Trendelenburg position, reduce or stop ultrafiltration, and give a normal saline bolus (Correct answer)
Stop dialysis and transfer to the emergency department
Administer sublingual nitroglycerin
Increase the blood pump speed

Correct answer: Place the patient in Trendelenburg position, reduce or stop ultrafiltration, and give a normal saline bolus

Immediate management of IDH includes Trendelenburg positioning, stopping or reducing ultrafiltration, and administering a normal saline bolus of 100–250 mL to restore intravascular volume.

Question 149: What is the most common cause of ESA hyporesponsiveness (failure to achieve target hemoglobin despite adequate ESA doses) in dialysis patients?

Vitamin B12 deficiency
Folate deficiency
Aluminum toxicity
Iron deficiency (Correct answer)

Correct answer: Iron deficiency

Iron deficiency is by far the most frequent cause of ESA hyporesponsiveness because adequate iron supply is essential for the bone marrow to respond to ESA stimulation and synthesize hemoglobin.

Question 150: What is the recommended approach to discussing modality options (hemodialysis, peritoneal dialysis, transplant, conservative care) with a new ESRD patient?

Provide shared decision-making with thorough education on all options including conservative management (Correct answer)
Recommend home dialysis for all suitable patients without discussion
Begin hemodialysis immediately and discuss options after stabilization
Assign modality based on clinical assessment alone

Correct answer: Provide shared decision-making with thorough education on all options including conservative management

Shared decision-making ensures patients receive comprehensive education on all modalities including conservative (non-dialytic) management, allowing them to make informed, values-based choices.

CDN Certified Dialysis Nurse Exam

The CDN (Certified Dialysis Nurse) exam, administered by the Nephrology Nursing Certification Commission (NNCC), validates specialized knowledge and competency in dialysis nursing care including hemodialysis, peritoneal dialysis, and kidney disease management.

150

Questions

180 min

Time Limit

70%

To Pass

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