CDN Certified Dialysis Nurse Exam — Questions and Answers

Question 1: The target hemoglobin range for dialysis patients receiving erythropoiesis-stimulating agents (ESAs) per KDIGO guidelines is:

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

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

Heparin lock after every use
Apply antibiotic ointment to the exit site daily
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 3: The gradient of a substance's concentration, such as urea, during peritoneal dialysis

Increases
Decreases (Correct answer)
Remains consistent
Varies widely

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 4: What problem occurs when calcium or magnesium precipitates out of dialysate concentrate?

Reduced endotoxin load
Improved biocompatibility
Scale buildup in tubing that can contaminate dialysate and clog proportioning systems (Correct answer)
Increased dialyzer clearance

Correct answer: Scale buildup in tubing that can contaminate dialysate and clog proportioning systems

Precipitation of calcium and magnesium carbonates causes scale buildup in dialysate pathways, potentially contaminating the dialysate and clogging proportioning pumps.

Question 5: 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 6: 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)
Acetaminophen
Omeprazole
Ibuprofen

Correct answer: Meperidine (Demerol)

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

Question 7: What is the primary mechanism by which erythropoiesis-stimulating agents (ESAs) treat anemia in dialysis patients?

Increasing intestinal absorption of dietary iron
Inhibiting the destruction of mature red blood cells in the spleen
Binding to EPO receptors on erythroid progenitors to stimulate red blood cell production (Correct answer)
Increasing hemoglobin oxygen-carrying capacity per red cell

Correct answer: Binding to EPO receptors on erythroid progenitors to stimulate red blood cell production

ESAs bind to erythropoietin receptors on bone marrow erythroid progenitor cells, triggering proliferation and differentiation into mature red blood cells, replacing the EPO the diseased kidneys can no longer produce.

Question 8: Which type of vascular access has the highest rate of infection among ESRD patients?

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

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 9: When teaching a patient about AV fistula care at home, which instruction is most important?

Avoid blood pressure measurement and blood draws in that arm (Correct answer)
Massage the fistula twice daily to maintain flow
Wear a tight compression bandage when not on dialysis
Apply ice to reduce swelling daily

Correct answer: Avoid blood pressure measurement and blood draws in that arm

Avoiding BP cuffs, blood draws, and IV access in the fistula arm prevents compression and vessel damage that could compromise the access.

Question 10: What happens to the water softener resin during the regeneration process?

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

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 11: Which dialysate potassium concentration is most appropriate for a patient with a pre-dialysis serum potassium of 6.5 mEq/L?

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

Correct answer: 2 mEq/L

A 2 mEq/L potassium dialysate bath creates a favorable gradient for potassium removal in significantly hyperkalemic patients while reducing cardiac arrhythmia risk.

Question 12: Between hemodialysis treatments, weight gain shouldn't surpass

8% of dry weight
10% of dry weight
5% of dry weight (Correct answer)
1% 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 13: Intradialytic hypotension is most effectively prevented by which of the following interventions?

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

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

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

Correct answer: Hold dialysis and notify the physician

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

Question 15: What is the first action when an air embolism is suspected during hemodialysis?

Increase blood flow rate
Administer 100% oxygen and clamp the venous line (Correct answer)
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 16: What is the most common infectious complication in hemodialysis patients?

Peritonitis
Vascular access-related bloodstream infection (VRBI) (Correct answer)
Urinary tract infection
Pneumonia

Correct answer: Vascular access-related bloodstream infection (VRBI)

Vascular access-related bloodstream infections are the most common and serious infectious complication in hemodialysis patients, most often caused by Staphylococcus aureus.

Question 17: What action should be taken if the dialysis machine's venous pressure alarm activates with a sudden increase in venous pressure?

Increase the blood pump speed
Check for venous needle kinking, clotting, or access obstruction (Correct answer)
Decrease ultrafiltration rate
Administer normal saline bolus

Correct answer: Check for venous needle kinking, clotting, or access obstruction

A sudden increase in venous pressure suggests obstruction in the venous return pathway — check for needle kinking, clotting in the venous chamber, or access stenosis.

Question 18: The target hemoglobin range for most dialysis patients receiving erythropoiesis-stimulating agents (ESAs) per KDIGO guidelines is:

8–9 g/dL
12–13 g/dL
10–11.5 g/dL (Correct answer)
14–15 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 19: 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)
Vitamin K is removed by dialysis
Dialysis removes warfarin from the blood
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 20: Which patient education point is essential regarding AV fistula care between dialysis sessions?

Sleep with the fistula arm elevated above heart level
Apply ice packs to the fistula arm nightly
Keep the fistula arm immobile to prevent dislodgement
Avoid tight clothing, jewelry, or blood pressure cuffs on the fistula arm (Correct answer)

Correct answer: Avoid tight clothing, jewelry, or blood pressure cuffs on the fistula arm

Patients must protect their fistula arm from compression by avoiding tight clothing, jewelry, or blood pressure cuffs, which can impair flow or cause thrombosis.

Question 21: Which sign is the BEST indicator of AV graft thrombosis?

Elevated blood pressure
Prolonged bleeding after needle removal
Absence of bruit and thrill (Correct answer)
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 22: IV iron supplementation is indicated in dialysis patients when ferritin is below what threshold despite ESA therapy?

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

Correct answer: 200 ng/mL

IV iron is commonly indicated when serum ferritin is below 200 ng/mL or transferrin saturation is below 20%, suggesting functional iron deficiency limiting ESA response.

Question 23: Which laboratory value best reflects total iron stores in dialysis patients when assessing for iron deficiency?

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

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 24: What does the term 'dry weight' mean in the context of hemodialysis?

Ideal body weight based on BMI
Lowest tolerated post-dialysis weight without hypotension or symptoms (Correct answer)
Weight after 12-hour fast
Pre-dialysis weight minus estimated fluid in lungs

Correct answer: Lowest tolerated post-dialysis weight without hypotension or symptoms

Dry weight is the lowest post-dialysis weight a patient can tolerate without symptoms of hypovolemia, reflecting euvolemic or normovolemic state.

Question 25: 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)
Increase blood flow to flush air through system quickly
Administer heparin IV and continue dialysis
Administer oxygen and reduce ultrafiltration rate

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 26: 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?

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

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 27: A hemodialysis patient develops sudden chest pain, dyspnea, and hypotension during treatment. What is the FIRST nursing action?

Administer IV normal saline bolus immediately
Stop dialysis, return blood to patient, and call for emergency help (Correct answer)
Slow the blood flow rate and notify the physician
Place patient in Trendelenburg position

Correct answer: Stop dialysis, return blood to patient, and call for emergency help

Sudden cardiopulmonary emergency during HD requires stopping treatment, returning blood to prevent additional fluid/electrolyte shifts, and activating emergency response.

Question 28: 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)
Assign modality based on clinical assessment alone
Begin hemodialysis immediately and discuss options after stabilization
Recommend home dialysis for all suitable patients without discussion

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.

Question 29: A peritoneal dialysis patient using automated peritoneal dialysis (APD) reports the machine alarming 'drain incomplete.' The nurse's first intervention is to:

Increase the dwell time on the next cycle
Switch to manual CAPD exchanges
Reposition the patient and check catheter kinks (Correct answer)
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 30: Which level of requirements has the highest priority when using Maslow's Hierarchy of requirements to define priorities in nursing care for hemodialysis patients?

Safety and security
Love and belonging
Self-esteem
Physiologic (Correct answer)

Correct answer: Physiologic

The need for oxygen, food, urination, temperature regulation, sex, mobility, relaxation, and comfort are examples of physiological demands. Security and safety come next, then a sense of love and belonging, and finally self-worth. The highest level, self-actualization, frequently depends on addressing needs at lower levels.

Question 31: What interdialytic weight gain is generally considered the maximum acceptable limit for a hemodialysis patient?

8–10% of dry body weight
3–5% of dry body weight (Correct answer)
2 kg
1 kg

Correct answer: 3–5% of dry body weight

Interdialytic weight gain up to 3–5% of dry body weight is generally considered acceptable, though lower gains are associated with better outcomes.

Question 32: A patient's AV graft has a palpable thrill that becomes weaker than usual. What does this most likely indicate?

Aneurysm formation
Hypotension
Infection
Thrombosis or stenosis (Correct answer)

Correct answer: Thrombosis or stenosis

A weakened or absent thrill in an AV graft suggests reduced blood flow, most commonly caused by thrombosis or upstream/downstream stenosis.

Question 33: What does the ESRD Quality Incentive Program (QIP) in the United States primarily measure?

Patient satisfaction scores only
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)

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 34: 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 35: A dialysis patient is prescribed active vitamin D therapy. Which laboratory values must be monitored to prevent complications?

Serum potassium and sodium
Serum calcium and phosphorus (Correct answer)
BUN and creatinine
Hemoglobin and ferritin

Correct answer: Serum calcium and phosphorus

Active vitamin D (calcitriol or paricalcitol) can cause hypercalcemia and hyperphosphatemia, which must be monitored to prevent vascular calcification.

Question 36: Which electrolyte imbalance is most commonly associated with muscle cramps during hemodialysis?

Hypernatremia
Hypocalcemia (Correct answer)
Hyperphosphatemia
Hyperkalemia

Correct answer: Hypocalcemia

Hypocalcemia is a common cause of muscle cramps during dialysis due to calcium shifts across the dialyzer membrane.

Question 37: What is the most appropriate nursing action when a patient reports severe muscle cramps during hemodialysis?

Stop dialysis immediately
Reduce ultrafiltration rate and administer hypertonic saline or glucose (Correct answer)
Administer IV potassium chloride
Increase blood flow rate

Correct answer: Reduce ultrafiltration rate and administer hypertonic saline or glucose

Muscle cramping during dialysis is caused by hypovolemia and electrolyte shifts; reducing ultrafiltration and administering hypertonic saline (23.4% NaCl) or 50% dextrose relieves symptoms.

Question 38: Which condition is an absolute contraindication to continued ESA therapy in a dialysis patient?

Active infection with elevated CRP
Recent myocardial infarction
Uncontrolled hypertension
Confirmed pure red cell aplasia (PRCA) due to anti-EPO antibodies (Correct answer)

Correct answer: Confirmed pure red cell aplasia (PRCA) due to anti-EPO antibodies

Pure red cell aplasia caused by anti-EPO antibodies is an absolute contraindication because continuing ESA therapy will worsen PRCA and could be life-threatening; ESA must be permanently discontinued.

Question 39: Which parameter is used to determine the ultrafiltration volume goal for a hemodialysis patient?

Difference between current weight and estimated dry weight (Correct answer)
Serum creatinine level
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 40: How is Kt/V used in hemodialysis?

Determines optimal dialysate sodium concentration
Measures calcium-phosphorus product
Calculates the ultrafiltration goal
Quantifies the adequacy of urea removal during dialysis (Correct answer)

Correct answer: Quantifies the adequacy of urea removal during dialysis

Kt/V is the primary measure of hemodialysis adequacy, representing the fraction of patient's total body water cleared of urea per treatment.

Question 41: Heparin is administered at the start of hemodialysis primarily to prevent:

Membrane fouling
Access infection
Clotting in the extracorporeal circuit (Correct answer)
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 42: What hemoglobin range is targeted when using ESA therapy in dialysis patients according to KDIGO guidelines?

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

Correct answer: 10–11.5 g/dL

KDIGO guidelines recommend targeting hemoglobin between 10–11.5 g/dL with ESA therapy to improve quality of life while avoiding the increased cardiovascular risks associated with higher levels.

Question 43: What is the best way to make sure a patient is aware of the discharge plan when they are leaving the hospital and will be referred to a home health organization for help with peritoneal dialysis?

Ask the home health agency for a follow-up report.
Telephone the patient after discharge to discuss the discharge plan. (Correct answer)
Mail the patient a reminder of the discharge plan.
Have the patient complete a post-discharge survey.

Correct answer: Telephone the patient after discharge to discuss the discharge plan.

A phone call the day following discharge is frequently appreciated and helps to ensure that the patient knows and adheres to the discharge plan because patients are frequently uncertain about discharge plans and worried about going home.

Question 44: Which type of dialysate concentrate contains the electrolytes and glucose for hemodialysis?

Both A and B mixed equally
Bicarbonate concentrate (Part B)
Acid concentrate (Part A) (Correct answer)
Reverse osmosis water alone

Correct answer: Acid concentrate (Part A)

The acid concentrate (Part A) contains sodium, potassium, calcium, magnesium, glucose, and acetic or citric acid to prevent calcium precipitation.

Question 45: Cinacalcet (Sensipar) is used in dialysis patients primarily to treat which condition?

Dialysis-related amyloidosis
Secondary hyperparathyroidism with elevated PTH (Correct answer)
Hyperkalemia
Anemia of chronic kidney disease

Correct answer: Secondary hyperparathyroidism with elevated PTH

Cinacalcet is a calcimimetic that increases the parathyroid gland's sensitivity to calcium, suppressing PTH secretion and treating secondary hyperparathyroidism.

Question 46: An adolescent patient who had been receiving peritoneal dialysis for three years turns 18 but refuses to continue the treatment because he doesn't think he needs it, even if he is willing to take medicine. In order to live with three pals in an apartment, he has left his parents' house. The ideal reaction is to?

Refer the patient to a psychiatrist.
Advise the parents to cut off all support until the patient agrees to dialysis.
Advise the parents to get a court order mandating treatment.
Provide education and support to the patient. (Correct answer)

Correct answer: Provide education and support to the patient.

Legally speaking, a patient who is 18 years old can decide to stop receiving therapy, and if they are of sound mind, there isn't much that can be done to stop them. The best course of action is to educate and assist the patient while expressing respect for their decision to continue taking their drugs because they have consented to do so. The patient should be well informed of the symptoms of uremia because if his condition worsens, he might decide to change his mind.

Question 47: What is the primary purpose of reverse osmosis (RO) in the dialysis water treatment system?

Remove chlorine and chloramines
Soften hard water by removing calcium
Remove bacteria and endotoxins
Remove dissolved ionic contaminants including heavy metals (Correct answer)

Correct answer: Remove dissolved ionic contaminants including heavy metals

Reverse osmosis removes dissolved ionic contaminants such as aluminum, fluoride, and heavy metals by forcing water through a semi-permeable membrane under pressure.

Question 48: Sodium bicarbonate is sometimes given to a dialysis patient prior to an emergency session. What is the indication?

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

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

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

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

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

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 51: Which cardiovascular complication is the leading cause of death in hemodialysis patients?

Stroke
Sudden cardiac death and cardiovascular disease (Correct answer)
Peripheral arterial disease
Pulmonary embolism

Correct answer: Sudden cardiac death and cardiovascular disease

Cardiovascular disease, particularly sudden cardiac death from arrhythmia and coronary artery disease, accounts for approximately 40–50% of deaths in ESRD patients on hemodialysis.

Question 52: What is the most common cause of ESA hyporesponsiveness (failure to achieve target hemoglobin despite adequate ESA doses) in dialysis patients?

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

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 53: Which of the following best describes the role of the dialyzer membrane in hemodialysis?

It actively pumps solutes from blood to dialysate
It filters only large molecular weight toxins
It allows diffusion of solutes down concentration gradients (Correct answer)
It maintains blood pressure by removing excess fluid actively

Correct answer: It allows diffusion of solutes down concentration gradients

The dialyzer membrane allows passive diffusion of solutes from areas of higher concentration (blood) to lower concentration (dialysate).

Question 54: Which dressing change technique is used for the buttonhole cannulation method?

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

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

Beta-blockers
ACE inhibitors or ARBs (Correct answer)
Calcium channel blockers
Alpha-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 56: 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
Arrange for a packed red blood cell transfusion
Administer intravenous (IV) iron supplementation (Correct answer)
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 57: A patient's post-dialysis BUN is 30 mg/dL and pre-dialysis BUN was 90 mg/dL. What is the URR?

33%
50%
75%
67% (Correct answer)

Correct answer: 67%

URR = (pre-BUN − post-BUN) / pre-BUN × 100 = (90 − 30) / 90 × 100 = 67%, which meets the minimum recommended 65% target.

Question 58: During hemodialysis, a nurse notes the patient's blood in the extracorporeal circuit appears unusually dark. The patient denies symptoms. The hemoglobin drawn pre-treatment was 11.2 g/dL. What is the most likely explanation?

Iron deficiency causing hypochromic red cells that appear darker
Normal venous blood appearance due to high oxygen extraction by tissues
Hemolysis from dialyzer reaction causing bright red lysed blood
Adequate hemoglobin with normal venous oxygen saturation (Correct answer)

Correct answer: Adequate hemoglobin with normal venous oxygen saturation

Dark venous blood returning through the extracorporeal circuit is normal; it reflects deoxygenated venous blood with a hemoglobin of 11.2 g/dL, which is within acceptable target range for a dialysis patient.

Question 59: Which phosphate binder is safe to use in dialysis patients with hypercalcemia?

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

Correct answer: Sevelamer hydrochloride

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

Question 60: Which set of symptoms is most consistent with a Type A hypersensitivity reaction to the dialyzer?

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

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 61: What is the function of the bicarbonate cartridge in a bicarbonate dialysate delivery system?

Remove excess carbon dioxide from dialysate
Buffer the acid concentrate
Neutralize acidic dialysate
Provide the bicarbonate concentrate dissolved by proportioning water (Correct answer)

Correct answer: Provide the bicarbonate concentrate dissolved by proportioning water

The bicarbonate cartridge contains dry or liquid sodium bicarbonate concentrate that is dissolved by proportioning water to create the bicarbonate portion of the final dialysate.

Question 62: A patient on automated peritoneal dialysis (APD) has gained 5 kg since last clinic visit. Which assessment finding would confirm this is fluid rather than true weight gain?

Elevated serum albumin
Elevated serum creatinine
Pitting edema and hypertension (Correct answer)
Increased appetite and food intake

Correct answer: Pitting edema and hypertension

Pitting edema and hypertension confirm fluid overload as the cause of weight gain, indicating inadequate ultrafiltration.

Question 63: What is the primary purpose of documenting the pre- and post-dialysis weights for every treatment?

To monitor patient nutritional status only
To calculate ultrafiltration goals and assess fluid balance outcomes (Correct answer)
To meet state licensing requirements
To determine dialysis machine settings

Correct answer: To calculate ultrafiltration goals and assess fluid balance outcomes

Pre/post weights allow calculation of fluid removed, assessment of dry weight accuracy, and tracking of interdialytic fluid gains for individualized care planning.

Question 64: What is the recommended minimum maturation time for an AV fistula before first cannulation?

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

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

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

Correct answer: IV calcium gluconate

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

Question 66: What role does aluminum toxicity play in dialysis patients?

Causes hyperphosphatemia
Increases erythropoietin resistance by raising hemoglobin
Causes hyperkalemia
Leads to adynamic bone disease and encephalopathy (Correct answer)

Correct answer: Leads to adynamic bone disease and encephalopathy

Aluminum accumulation in dialysis patients, historically from aluminum-containing phosphate binders and contaminated water, causes adynamic bone disease, anemia, and encephalopathy.

Question 67: What is the minimum single-pool Kt/V (spKt/V) recommended by KDOQI guidelines for thrice-weekly hemodialysis?

1.4
1.0
0.8
1.2 (Correct answer)

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

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)
Administer epinephrine via the venous access

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 69: What does the Kt/V measurement represent in hemodialysis?

Blood flow rate times treatment volume
Potassium-to-volume ratio
Dialyzer clearance times treatment time divided by urea distribution volume (Correct answer)
Fluid removal rate per treatment

Correct answer: Dialyzer clearance times treatment time divided by urea distribution volume

Kt/V is a dimensionless index where K=dialyzer urea clearance, t=treatment time, and V=patient's urea distribution volume, measuring dialysis dose.

Question 70: Which drug class is commonly used to treat restless leg syndrome in dialysis patients?

Dopamine agonists (Correct answer)
SSRIs
Antihistamines
Beta-blockers

Correct answer: Dopamine agonists

Dopamine agonists such as pramipexole and ropinirole are first-line treatments for restless leg syndrome, which is highly prevalent in dialysis patients.

Question 71: A large clinical trial (TREAT) showed that targeting hemoglobin levels above 13 g/dL with ESA therapy in CKD patients significantly increased the risk of which adverse outcome?

Severe hyperkalemia
Stroke and cardiovascular events (Correct answer)
Peritoneal membrane failure
Dialysis-related hypotension

Correct answer: Stroke and cardiovascular events

The TREAT trial demonstrated a significantly increased risk of stroke when darbepoetin alfa was used to target near-normal hemoglobin (≥13 g/dL), establishing that higher hemoglobin targets are harmful in this population.

Question 72: Which diagnostic test is used to confirm the presence of anti-erythropoietin antibodies when pure red cell aplasia (PRCA) is suspected in a dialysis patient?

Flow cytometry of peripheral blood
Peripheral blood smear review
Anti-EPO antibody assay (ELISA) (Correct answer)
Direct Coombs (antiglobulin) test

Correct answer: Anti-EPO antibody assay (ELISA)

An anti-EPO antibody assay (ELISA) detects neutralizing antibodies against erythropoietin to confirm the diagnosis of PRCA; bone marrow biopsy showing absent erythroid precursors is also required for definitive diagnosis.

Question 73: A dialysis patient presents with sudden onset chest pain, dyspnea, and cyanosis during treatment. Air embolism is suspected. The immediate nursing action is to:

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

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 74: Which modality of kidney replacement therapy offers the most independence and the ability to work or travel for suitable patients?

In-center hemodialysis three times per week
Home hemodialysis
Nocturnal in-center hemodialysis
Home peritoneal dialysis (CAPD or APD) (Correct answer)

Correct answer: Home peritoneal dialysis (CAPD or APD)

Peritoneal dialysis allows patients to perform dialysis at home or while traveling on their own schedule, supporting greater independence and quality of life.

Question 75: What is the main use of an amino-based dialysate solution?

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

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

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

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 77: Which dietary restriction is most important for ESRD patients between hemodialysis sessions to prevent life-threatening complications?

Restrict dietary fat
Restrict potassium and phosphorus intake (Correct answer)
Limit protein to 20 g/day
Avoid all sodium

Correct answer: Restrict potassium and phosphorus intake

Limiting potassium prevents fatal hyperkalemia and limiting phosphorus prevents secondary hyperparathyroidism and vascular calcification between dialysis sessions.

Question 78: Which dietary restriction is MOST critical for end-stage renal disease (ESRD) patients on hemodialysis to prevent life-threatening complications?

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

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 79: Which of the following best describes functional iron deficiency in dialysis patients?

Low serum ferritin with low TSAT
Normal or elevated ferritin with low TSAT indicating inadequate iron mobilization (Correct answer)
Low ferritin with high TSAT from recent IV iron infusion
High ferritin with high TSAT indicating iron overload

Correct answer: Normal or elevated ferritin with low TSAT indicating inadequate iron mobilization

Functional iron deficiency occurs when iron stores appear adequate (normal/high ferritin) but iron cannot be mobilized rapidly enough to meet the demands of ESA-stimulated erythropoiesis, resulting in a low TSAT.

Question 80: During a dialysis machine's self-test, a conductivity alarm activates indicating high conductivity. What does this most likely indicate?

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

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

Hyponatremia
Hypercalcemia
Hyperphosphatemia
Hyperkalemia (Correct answer)

Correct answer: Hyperkalemia

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

Question 82: Which patient symptom suggests the dry weight target needs to be increased?

Hypertension before dialysis
Persistent hypotension and cramping during dialysis (Correct answer)
Peripheral edema between treatments
Dyspnea at rest 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 83: A dialysis unit wants to reduce the rate of vascular access infections. Which data-driven approach is most consistent with quality improvement methodology?

Add more nurses to each shift
Switch to a different type of dialyzer
Punish staff members when infections occur
Implement a Plan-Do-Study-Act (PDSA) cycle targeting standardized access care protocols (Correct answer)

Correct answer: Implement a Plan-Do-Study-Act (PDSA) cycle targeting standardized access care protocols

The PDSA quality improvement framework allows systematic testing and evaluation of protocol changes to identify effective interventions for reducing infection rates.

Question 84: Which type of dialyzer membrane is associated with the highest biocompatibility?

Regenerated cellulose
Modified cellulose (hemophan)
Synthetic polymer (polysulfone) (Correct answer)
Cellulose (cuprophan)

Correct answer: Synthetic polymer (polysulfone)

Synthetic polymer membranes such as polysulfone demonstrate the highest biocompatibility, activating complement and inflammatory pathways less than cellulosic membranes.

Question 85: A patient on hemodialysis suddenly develops nausea, headache, and altered consciousness near the end of treatment. What condition should the nurse suspect?

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

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

Dialyzer membrane rupture
Muscle cramps
Hypercalcemia
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 87: 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?

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

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 88: 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

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

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 89: A dialysis patient develops peaked T-waves and widened QRS on ECG. Which electrolyte abnormality is most likely responsible?

Hypocalcemia
Hyperkalemia (Correct answer)
Hypokalemia
Hypermagnesemia

Correct answer: Hyperkalemia

Hyperkalemia produces sequential ECG changes including peaked T-waves, PR prolongation, widened QRS, and ultimately sine-wave pattern with cardiac arrest.

Question 90: What is the minimum white blood cell count in peritoneal dialysis effluent that is diagnostic of peritonitis?

50 WBC/mm³ with >50% neutrophils
100 WBC/mm³ with >50% neutrophils (Correct answer)
200 WBC/mm³ with >50% neutrophils
500 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 91: What is the primary goal of sodium profiling during hemodialysis?

Prevent hypernatremia
Reduce the risk of disequilibrium syndrome
Improve phosphorus clearance
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 92: A patient with a forearm AV fistula reports hand pain, numbness, and coolness during dialysis. Which complication should the nurse suspect?

Air embolism
Venous hypertension
Steal syndrome (Correct answer)
Pseudoaneurysm

Correct answer: Steal syndrome

Hand pain, numbness, and coolness during dialysis in a patient with an AV fistula are classic signs of steal syndrome, where blood is diverted away from the distal extremity.

Question 93: Which electrolyte imbalance is MOST commonly associated with muscle cramps during hemodialysis?

Hypocalcemia
Hyperkalemia
Hypernatremia
Rapid ultrafiltration causing hypovolemia (Correct answer)

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 94: A dialysis patient's predialysis serum potassium is 6.8 mEq/L. Which dialysate potassium concentration is most appropriate?

2.0 mEq/L (Correct answer)
0 mEq/L
3.0 mEq/L
4.0 mEq/L

Correct answer: 2.0 mEq/L

A 2.0 mEq/L dialysate potassium provides adequate gradient to remove excess potassium while reducing the risk of arrhythmia from overly rapid shifts.

Question 95: How long should pressure be held at the cannulation site after needle removal at the end of dialysis?

2–3 minutes
15–20 minutes always
5–10 minutes or until bleeding stops (Correct answer)
30 seconds to 1 minute

Correct answer: 5–10 minutes or until bleeding stops

Pressure should be held for 5–10 minutes or until hemostasis is achieved, as over-compression can occlude the access.

Question 96: Which erythropoiesis-stimulating agent (ESA) has a significantly longer half-life than epoetin alfa, allowing for less frequent dosing?

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

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

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

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 98: What is the recommended frequency for reassessing a dialysis patient's dry weight?

Monthly or whenever there are signs of fluid imbalance, weight changes, or clinical change (Correct answer)
Only when the patient reports symptoms
Annually at the care plan review
Every 6 months routinely

Correct answer: Monthly or whenever there are signs of fluid imbalance, weight changes, or clinical change

Dry weight should be reassessed monthly or whenever clinical changes occur because fluctuations in nutritional status, illness, or body composition alter the target weight.

Question 99: Patients taking oral iron should be encouraged to enhance absorption, right?

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

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 100: 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 101: 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)
Hemolysis
Venous needle dislodgement

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

Venous access infiltration
Arterial line disconnection
Clotting in the dialyzer (Correct answer)
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 103: A peritoneal dialysis patient reports cloudy effluent with abdominal pain and fever. The nurse should suspect:

Ultrafiltration failure
Tunnel infection
Catheter malposition
Peritonitis (Correct answer)

Correct answer: Peritonitis

Cloudy effluent combined with abdominal pain and fever is the classic triad of peritoneal dialysis-associated peritonitis.

Question 104: When treating intradialytic hypotension, which intervention should be performed first?

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

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 105: A patient on CAPD exchanges 2 L of 2.5% dextrose dialysate four times daily. What does the higher dextrose concentration indicate compared to 1.5%?

Slower glucose absorption
Lower risk of peritonitis
Greater osmotic gradient for enhanced ultrafiltration (Correct answer)
Less effective solute removal

Correct answer: Greater osmotic gradient for enhanced ultrafiltration

Higher dextrose concentrations create a stronger osmotic gradient across the peritoneal membrane, increasing ultrafiltration to remove more fluid.

Question 106: What is the most likely cause of repeated clotting in the extracorporeal circuit during hemodialysis despite adequate heparin dosing?

High dialyzer surface area
High blood flow rate
Heparin-induced thrombocytopenia (HIT) or inadequate anticoagulation monitoring (Correct answer)
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 107: A patient's pre-dialysis BUN is 80 mg/dL and post-dialysis BUN is 28 mg/dL. What is the urea reduction ratio (URR)?

35%
45%
72%
65% (Correct answer)

Correct answer: 65%

URR = [(Pre-BUN − Post-BUN) / Pre-BUN] × 100 = [(80−28)/80] × 100 = 65%, which meets the minimum recommended threshold of 65%.

Question 108: The subcutaneous tunnel's typical length while inserting a catheter for peritoneal dialysis is?

3–4cm
10–15 cm
3–5 cm (Correct answer)
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 109: What is the role of the dialysis social worker in the care of ESRD patients?

Manage dialysis equipment maintenance
Perform monthly lab draws
Provide psychosocial assessment, counseling, and help with financial/transportation barriers (Correct answer)
Adjust dialysis prescriptions

Correct answer: Provide psychosocial assessment, counseling, and help with financial/transportation barriers

The dialysis social worker addresses psychosocial needs, depression screening, financial assistance programs (Medicare/Medicaid), insurance issues, and transportation barriers to treatment.

Question 110: A dialysis patient develops sudden fever, chills, and hypotension during treatment. After ruling out sepsis from access, what water-related contamination should be suspected?

Endotoxin contamination of dialysate causing pyrogenic reaction (Correct answer)
High calcium in dialysate
Low bicarbonate in dialysate
Chlorine breakthrough

Correct answer: Endotoxin contamination of dialysate causing pyrogenic reaction

Sudden fever, rigors, and hypotension during dialysis without obvious access infection suggest a pyrogenic reaction from endotoxin contamination of the water or dialysate.

Question 111: What is the normal serum phosphorus target range for dialysis patients per KDIGO guidelines?

1.0–2.0 mg/dL
2.5–4.5 mg/dL (Correct answer)
4.5–6.5 mg/dL
3.5–5.5 mg/dL

Correct answer: 2.5–4.5 mg/dL

KDIGO guidelines recommend lowering elevated serum phosphorus toward the normal range of approximately 2.5–4.5 mg/dL in dialysis patients.

Question 112: 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?

Maintain the patient’s confidentiality.
Notify the police.
Warn the person at whom the threats are directed. (Correct answer)
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 113: Hypermagnesemia in dialysis patients most commonly results from which of the following?

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

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 114: What is the most appropriate response when a patient newly diagnosed with ESRD expresses grief and anger about starting dialysis?

Immediately refer to psychiatry for evaluation
Explain that anger is inappropriate and focus on positive outcomes
Acknowledge their feelings, validate their grief, and provide emotional support (Correct answer)
Distract the patient by focusing on procedural education

Correct answer: Acknowledge their feelings, validate their grief, and provide emotional support

Acknowledging and validating the emotional response to a life-altering diagnosis is the therapeutic priority before providing clinical education, establishing trust and emotional safety.

Question 115: What is the most common cause of intradialytic hypotension?

Dialyzer membrane incompatibility
Ultrafiltration rate exceeding plasma refilling rate (Correct answer)
High dialysate temperature
Dialysate sodium that is too low

Correct answer: Ultrafiltration rate exceeding plasma refilling rate

Intradialytic hypotension most commonly occurs when the ultrafiltration rate exceeds the body's ability to refill the intravascular space from interstitial fluid.

Question 116: Secondary hyperparathyroidism in ESRD patients is primarily driven by which combination of factors?

Aluminum toxicity and anemia
Hyperphosphatemia, hypocalcemia, and low active vitamin D (Correct answer)
Hypernatremia and fluid overload
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 117: What is the recommended target URR for hemodialysis patients according to current guidelines?

≥55%
≥80%
≥50%
≥65% (Correct answer)

Correct answer: ≥65%

Current guidelines recommend a minimum URR of 65% for hemodialysis patients, corresponding to an spKt/V of approximately 1.2.

Question 118: What is the most effective strategy for improving a dialysis patient's understanding of dietary restrictions?

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

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 119: A patient on peritoneal dialysis has persistent poor ultrafiltration. Which intervention should the nurse anticipate?

Decrease the fill volume per exchange
Increase dwell time for all exchanges
Reduce the number of daily exchanges
Switch to higher dextrose concentration dialysate (Correct answer)

Correct answer: Switch to higher dextrose concentration dialysate

Higher dextrose concentration (2.5% or 4.25%) creates a stronger osmotic gradient to enhance fluid removal when ultrafiltration is inadequate.

Question 120: A patient develops fever and shaking chills approximately 45 minutes into hemodialysis. What is the most likely cause?

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

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 121: A "zero lift" policy has been implemented at the hemodialysis center. Such a policy's main objective is to?

Prevent injuries. (Correct answer)
Reduce staffing.
Reduce liability.
Promote patient independence.

Correct answer: Prevent injuries.

A "zero lift" program's goal is to prevent injuries, most frequently musculoskeletal conditions that affect the muscles, nerves, and tendons. Staff members should try to avoid manual lifting as much as they can, even though they can still help patients walk and ambulate. When implementing a "zero lift" program, it's crucial that staff members are instructed on alternative techniques, such the use of assistive technology, and that the essential supplies are accessible.

Question 122: How is residual renal function (RRF) factored into the overall dialysis adequacy assessment?

RRF contributes to total weekly clearance and may allow reduced treatment frequency (Correct answer)
RRF increases the required Kt/V target
RRF only matters in peritoneal dialysis patients
RRF is ignored once dialysis starts

Correct answer: RRF contributes to total weekly clearance and may allow reduced treatment frequency

Residual renal function contributes to total weekly solute clearance and middle molecule removal, potentially supporting reduced dialysis frequency or session length.

Question 123: According to KDIGO guidelines, above what serum ferritin level should IV iron supplementation generally not be routinely administered due to risk of iron overload?

500 ng/mL (Correct answer)
300 ng/mL
200 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 124: Which intravenous iron preparation is most widely used during hemodialysis sessions in the United States due to its established safety profile and ease of administration?

Ferumoxytol (Feraheme)
Iron sucrose (Venofer) (Correct answer)
Ferric gluconate (Ferrlecit)
Ferric carboxymaltose (Injectafer)

Correct answer: Iron sucrose (Venofer)

Iron sucrose (Venofer) has an excellent safety record, can be administered in small doses over each dialysis session without a test dose, and is one of the most widely used IV iron preparations in US dialysis centers.

Question 125: What is the most typical infection that develops after a kidney transplant?

Cardiovascular
Abdominal
Urinary tract (Correct answer)
Pulmonary

Correct answer: Urinary tract

After transplantation, 45–47% of infections are caused by UTIs. They affect the donor kidney's functionality or result in renal loss and, in severe situations, death. If an infection develops within the first six months following transplant, it poses a particular risk. Due to immunosuppression, bacteriuria and UTIs may be asymptomatic. Infection rates have decreased with the use of antibiotic prophylaxis and prompt urethral catheter removal, but they still remain high.

Question 126: When calculating Kt/V for hemodialysis adequacy, what does 'K' represent?

Duration of dialysis in minutes
Dialysate potassium concentration
Urea clearance of the dialyzer (Correct answer)
Patient's body weight in kilograms

Correct answer: Urea clearance of the dialyzer

In the Kt/V formula, K represents the dialyzer's urea clearance rate in mL/min.

Question 127: A dialysis patient with chronic fluid overload develops worsening left ventricular hypertrophy. What is the primary modifiable contributing factor?

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

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

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

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

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

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 130: At what hemoglobin level should a dialysis nurse notify the provider to consider reducing or holding the ESA dose to avoid adverse outcomes?

Greater than 10 g/dL
Greater than 14 g/dL
Greater than 11 g/dL
Greater than 12 g/dL (Correct answer)

Correct answer: Greater than 12 g/dL

ESA dose should be reduced or held when hemoglobin exceeds 12 g/dL in dialysis patients, as higher levels are associated with increased cardiovascular events and stroke risk per FDA labeling.

Question 131: A patient on hemodialysis has a Kt/V of 1.1 and a recirculation rate of 22% in their AV fistula. What is the most likely cause?

High blood flow rate
Low dialysate flow rate
Access stenosis causing venous hypertension (Correct answer)
Patient non-compliance

Correct answer: Access stenosis causing venous hypertension

High recirculation rates in an AV fistula typically indicate venous outflow stenosis, which causes treated blood to re-enter the arterial needle before reaching systemic circulation.

Question 132: A hemodialysis patient develops sudden hypotension during treatment. Which intervention should the nurse perform first?

Administer a loop diuretic
Place the patient in Trendelenburg position and reduce ultrafiltration rate (Correct answer)
Administer antihypertensive medication
Increase the blood pump speed

Correct answer: Place the patient in Trendelenburg position and reduce ultrafiltration rate

Trendelenburg positioning improves venous return while reducing the ultrafiltration rate addresses the primary cause of intradialytic hypotension.

Question 133: A dialysis patient suddenly develops chest pain, dyspnea, cyanosis, and frothy pink sputum during treatment. What complication should be suspected?

Air embolism
Acute pulmonary edema (Correct answer)
Dialyzer clotting
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 134: What is the minimum acceptable blood flow rate (Qb) recommended for adequate hemodialysis through a permanent access?

300–400 mL/min (Correct answer)
500–600 mL/min
150–200 mL/min
100–150 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 135: Which medication is used to treat pruritus (itching) in dialysis patients refractory to antihistamines?

Methylprednisolone
Naltrexone or difelikefalin (Correct answer)
Diazepam
Ondansetron

Correct answer: Naltrexone or difelikefalin

Naltrexone (opioid antagonist) and difelikefalin (kappa-opioid receptor agonist) target uremic pruritus pathways and are used when standard antihistamines fail.

Question 136: What is the most common acute complication during hemodialysis?

Hypotension (Correct answer)
Hyperkalemia
Dialyzer reaction
Air embolism

Correct answer: Hypotension

Intradialytic hypotension (IDH) is the most common acute complication of hemodialysis, occurring in approximately 20–30% of treatments due to rapid fluid removal and autonomic dysfunction.

Question 137: Which dietary education point is MOST important for a dialysis patient with consistently elevated pre-dialysis potassium levels?

Avoid all fruits and vegetables completely
Identify and limit high-potassium foods like bananas, oranges, potatoes, and tomatoes (Correct answer)
Increase dialysis session frequency to manage potassium
Stop taking all medications that contain potassium

Correct answer: Identify and limit high-potassium foods like bananas, oranges, potatoes, and tomatoes

Educating patients to identify and limit specific high-potassium foods is the primary dietary strategy for managing hyperkalemia between dialysis sessions.

Question 138: Gabapentin requires significant dose reduction in dialysis patients primarily because of:

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

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 139: Which of the following acts allows for prosecution if a dialysis center's management bills for goods and services that were not delivered?

Public Health Service Act
Snyder Act
Affordable Care Act
False Claims Act (Correct answer)

Correct answer: False Claims Act

The False Claims Act forbids anybody from submitting a false claim to the United States if they are aware that it is fraudulent. In addition, billing for services that were rendered but not necessary, billing for subpar services that were rendered but were delivered, taking or paying bribes, and unbundling of payments for supplies or services that should be grouped are all forbidden.

Question 140: A dialysis patient develops sudden severe headache, visual changes, and confusion during treatment. What complication should be considered first?

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

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

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

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

Ultrafiltration failure
Dialysate leak
Catheter malposition
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 143: When a patient receiving hemodialysis exhibits marked eosinophilia, what is the patient more likely to experience?

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

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

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

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

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

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

Increase the dialysis flow rate
Notify the physician and obtain cultures before starting antibiotics (Correct answer)
Document findings and reassess in 2 hours
Apply a warm compress and continue dialysis

Correct answer: Notify the physician and obtain cultures before starting antibiotics

Signs of access infection require prompt physician notification and cultures before antibiotic initiation to guide targeted therapy.

Question 147: Which laboratory finding would most suggest early AV fistula maturation failure?

BUN of 85 mg/dL pre-dialysis
Serum phosphorus of 5.5 mg/dL
Hemoglobin of 10 g/dL
Access blood flow less than 500 mL/min at 6 weeks (Correct answer)

Correct answer: Access blood flow less than 500 mL/min at 6 weeks

An access blood flow below 500 mL/min at six weeks post-creation indicates inadequate fistula maturation and may require intervention or alternative access planning.

Question 148: 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:

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

Correct answer: Normal fistula function

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

Question 149: A patient with ESRD on hemodialysis is prescribed cinacalcet. The nurse understands this medication works by:

Chelating phosphate in the gastrointestinal tract
Replacing calcitriol deficiency in renal failure
Blocking phosphate absorption in the intestine
Increasing sensitivity of calcium-sensing receptors to suppress PTH (Correct answer)

Correct answer: Increasing sensitivity of calcium-sensing receptors to suppress PTH

Cinacalcet is a calcimimetic that increases calcium-sensing receptor sensitivity, reducing PTH secretion in secondary hyperparathyroidism.

Question 150: Which infection control practice is most effective in reducing catheter-related bloodstream infections in dialysis patients?

Routine weekly blood cultures for catheter patients
Prophylactic oral antibiotics for all catheter patients
Strict hand hygiene and aseptic technique during catheter access (Correct answer)
Weekly antibiotic lock therapy for all catheters

Correct answer: Strict hand hygiene and aseptic technique during catheter access

Consistent hand hygiene and aseptic technique during every catheter access are the most evidence-based and cost-effective interventions for preventing CRBSIs.

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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These practice questions were written with AI tools. They are not real exam questions. Exam facts are checked against the official sources listed below. Not reviewed by a subject-matter expert. Editorial policy

Sources & references

Exam facts on this page (fees, format, dates, passing scores) are checked against these official sources; the date is our last check. Editorial policy

cnetnurse.com — Test delivery, fees, score release · verified Oct 2026
nncc-exam.org — Score validity, passing score, registration deadline, retake policy, test dates, exam format, time limit · verified Oct 2026