CDN Certified Dialysis Nurse Exam — Questions and Answers

Question 1: Which type of dialyzer reaction is characterized by dyspnea and chest/back pain occurring within the first 5 minutes of dialysis?

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

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

Darbepoetin alfa
Epoetin alfa (Correct answer)
Romiplostim
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 3: How frequently must dialysis machines be disinfected according to standard infection control practice?

Monthly
Once weekly
After every patient treatment (Correct answer)
Daily at end of shift only

Correct answer: After every patient treatment

Dialysis machines must be disinfected after every patient treatment to prevent cross-contamination and protect subsequent patients from infectious agents.

Question 4: What is the primary purpose of the dialysate bicarbonate concentration in hemodialysis?

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

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 5: Which patient education point is essential regarding AV fistula care between dialysis sessions?

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)
Sleep with the fistula arm elevated above heart level

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 6: 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
Reposition the patient and check catheter kinks (Correct answer)
Switch to manual CAPD exchanges
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 7: 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%?

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

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 8: Which dialysate bicarbonate concentration is typically used for hemodialysis patients with metabolic acidosis?

35–38 mEq/L (Correct answer)
20–22 mEq/L
45–50 mEq/L
25–28 mEq/L

Correct answer: 35–38 mEq/L

A dialysate bicarbonate of 35–38 mEq/L provides a diffusion gradient to correct metabolic acidosis common in end-stage renal disease patients.

Question 9: Which dressing change technique is used for the buttonhole cannulation method?

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

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

12–13 g/dL
14–15 g/dL
8–9 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 to balance anemia correction with cardiovascular risk.

Question 11: 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?

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

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

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

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 13: Which serum laboratory value is the best indicator of long-term nutritional status in a hemodialysis patient?

Blood urea nitrogen
Serum albumin (Correct answer)
Serum phosphorus
Serum creatinine

Correct answer: Serum albumin

Serum albumin reflects long-term protein stores and nutritional status, with levels below 3.5 g/dL indicating malnutrition in dialysis patients.

Question 14: What does a rising venous pressure alarm during hemodialysis MOST likely indicate?

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

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 15: 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
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

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 16: 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 17: What is the most appropriate response when a patient newly diagnosed with ESRD expresses grief and anger about starting dialysis?

Acknowledge their feelings, validate their grief, and provide emotional support (Correct answer)
Explain that anger is inappropriate and focus on positive outcomes
Immediately refer to psychiatry for evaluation
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 18: A patient on dialysis is found unresponsive with a blood glucose of 38 mg/dL. After administering glucose, what additional assessment is critical?

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

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 19: A dialysis patient's pre-treatment potassium is 6.8 mEq/L with peaked T-waves on ECG. Which dialysate potassium concentration should the nurse anticipate using?

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

Correct answer: 2.0 mEq/L

A potassium-free or low-potassium (0–1 mEq/L) bath may be needed for severe hyperkalemia, but 2.0 mEq/L is often used to rapidly reduce dangerously elevated levels while avoiding too-rapid correction.

Question 20: 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)
800 ng/mL
200 ng/mL
300 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 21: Dialysis disequilibrium syndrome (DDS) is most likely to occur in which clinical scenario?

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

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

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

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 23: 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
Increase ultrafiltration rate to clear cramp-causing toxins
Reduce blood flow rate and administer hypertonic saline or glucose (Correct answer)
Discontinue dialysis immediately

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 24: 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 25: When assessing a tunneled hemodialysis catheter for infection, which finding requires immediate removal of the catheter?

Tunnel infection (purulent drainage along the tunnel) (Correct answer)
Superficial skin irritation
Slight blood-tinged drainage at exit site
Mild exit site redness

Correct answer: Tunnel infection (purulent drainage along the tunnel)

A tunnel infection with purulent drainage along the subcutaneous catheter tract indicates deep infection requiring catheter removal and systemic antibiotics.

Question 26: What is the first action when an air embolism is suspected during hemodialysis?

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

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

Administer midodrine
Increase dialysate sodium concentration
Administer 0.9% normal saline bolus
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 28: A patient develops fever and shaking chills approximately 45 minutes into hemodialysis. What is the most likely cause?

Type A hypersensitivity reaction
Dialysis disequilibrium syndrome
Pyrogenic reaction from contaminated dialysate or equipment (Correct answer)
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 29: 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 30: Which medication is used to treat pruritus (itching) in dialysis patients refractory to antihistamines?

Diazepam
Methylprednisolone
Naltrexone or difelikefalin (Correct answer)
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 31: Which of the following nutritional deficiencies, when present in a dialysis patient, can blunt the response to ESA therapy by impairing DNA synthesis in erythroid precursors?

Magnesium deficiency
Vitamin B12 (cobalamin) deficiency (Correct answer)
Vitamin A deficiency
Zinc deficiency

Correct answer: Vitamin B12 (cobalamin) deficiency

Vitamin B12 deficiency impairs DNA synthesis via its role in the methionine–folate cycle; without adequate B12, erythroid precursors cannot proliferate effectively, reducing the bone marrow's response to ESA stimulation.

Question 32: Which finding during the arteriovenous fistula assessment indicates adequate maturation for cannulation?

Fistula visible at skin surface within 2 weeks of creation
Blood pressure equal in both arms
Presence of a bruit only, without thrill
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 33: 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
Initiate CPR and activate the emergency response system (Correct answer)
Stop the dialysis machine and return blood to the patient
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 34: What is the most appropriate nursing action when a patient reports severe muscle cramps during hemodialysis?

Stop dialysis immediately
Administer IV potassium chloride
Reduce ultrafiltration rate and administer hypertonic saline or glucose (Correct answer)
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 35: Which finding during hemodialysis requires the nurse to immediately stop the blood pump and clamp all lines?

Blood pressure drops to 100/70 mmHg
Patient reports feeling cold
Patient complains of mild itching
Visible air bubbles detected in the venous drip chamber (Correct answer)

Correct answer: Visible air bubbles detected in the venous drip chamber

Visible air in the venous drip chamber indicates a risk of air embolism, requiring immediate cessation of blood flow and line clamping.

Question 36: Which metric best reflects the overall quality of a dialysis unit's patient care outcomes?

Patient satisfaction scores alone
Average treatment session length
Number of staff certifications held
Composite score of clinical indicators including Kt/V, hemoglobin, and infection rates (Correct answer)

Correct answer: Composite score of clinical indicators including Kt/V, hemoglobin, and infection rates

A composite of clinical outcome indicators provides a comprehensive view of care quality that reflects both technical performance and patient health outcomes.

Question 37: 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:

Fistula stenosis
Aneurysm formation
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 38: What is the maximum allowable endotoxin level in standard hemodialysis water per AAMI standards?

2 EU/mL
0.03 EU/mL
0.25 EU/mL (Correct answer)
5 EU/mL

Correct answer: 0.25 EU/mL

AAMI standards allow a maximum endotoxin level of 0.25 EU/mL in standard hemodialysis water, with stricter limits of 0.03 EU/mL for ultra-pure water.

Question 39: A dialysis patient presents with a serum calcium of 11.8 mg/dL. Which medication is the most likely culprit?

Sevelamer carbonate
Lanthanum 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 40: Which of the following is a sign of disequilibrium syndrome during hemodialysis?

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

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

Protein restriction is more severe
Phosphate intake is unrestricted
Potassium restriction is typically stricter
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 42: 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?

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

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

Type A (anaphylactic) dialyzer reaction (Correct answer)
Type B (hypersensitivity) dialyzer reaction
Hemolysis
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 44: 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 45: How often should the total chlorine level in dialysis water be tested at minimum?

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

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

Restrict potassium and phosphorus intake (Correct answer)
Limit protein to 20 g/day
Restrict dietary fat
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 47: When added, what causes peritoneal dialysate to become hyperosmolar?

Glucose (Correct answer)
Bicarbonate
Chloride
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 48: When calculating Kt/V for hemodialysis adequacy, what does 'K' represent?

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

Correct answer: Urea clearance of the dialyzer

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

Question 49: What is the significance of monitoring the pressure differential across the RO membrane?

Measures water temperature
Determines chlorine levels
Detects air in the water system
Indicates membrane fouling or scaling when differential increases beyond normal (Correct answer)

Correct answer: Indicates membrane fouling or scaling when differential increases beyond normal

An increasing pressure differential across the RO membrane indicates fouling, scaling, or biofouling, signaling the need for cleaning or membrane replacement.

Question 50: A patient's AV graft has a pseudoaneurysm at a needle insertion site. The nurse should:

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)
Discontinue dialysis until surgically repaired

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

Hyperkalemia
Dialysis-related amyloidosis
Secondary hyperparathyroidism with elevated PTH (Correct answer)
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 52: Which cannulation technique involves rotating needle insertion sites along the entire length of the fistula?

Rope-ladder technique (Correct answer)
Area technique
Single-needle technique
Buttonhole technique

Correct answer: Rope-ladder technique

The rope-ladder technique distributes needle punctures along the entire length of the access, reducing localized damage and aneurysm formation.

Question 53: 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)
Hypokalemia and metabolic alkalosis
Hypernatremia and fluid overload

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 54: 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)
Quarterly group educational sessions
Posting dietary restriction lists in the dialysis unit waiting room
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 55: 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 56: Which electrolyte abnormality is the most common cause of cardiac arrest in hemodialysis patients between treatments?

Hyperkalemia (Correct answer)
Hyponatremia
Hyperphosphatemia
Hypocalcemia

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

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

Question 58: What is the purpose of carbon tanks in the dialysis water treatment system?

Remove bacteria
Remove dissolved minerals
Adjust pH of water
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 59: What role does aluminum toxicity play in dialysis patients?

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

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 60: Which of the following findings during hemodialysis requires the nurse to immediately stop treatment and return blood to the patient?

Patient complaint of thirst
Serum potassium of 5.5 mEq/L
New systolic blood pressure drop of 10 mmHg
Venous pressure alarm with clotted graft (Correct answer)

Correct answer: Venous pressure alarm with clotted graft

A clotted graft with venous pressure alarm indicates access failure requiring immediate discontinuation to prevent further complications.

Question 61: A patient on hemodialysis develops sudden onset of back and chest pain with pink-tinged plasma and falling hematocrit during treatment. What complication is occurring?

Hemolysis (Correct answer)
Anaphylactic reaction to dialyzer
Ultrafiltration failure
Air embolism

Correct answer: Hemolysis

Hemolysis causes destruction of red blood cells, releasing hemoglobin that turns plasma pink; it is a dialysis emergency caused by heat, kinking, or hypotonic dialysate.

Question 62: The gradient of a substance's concentration, such as urea, during peritoneal dialysis

Decreases (Correct answer)
Increases
Varies widely
Remains consistent

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

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

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 64: 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.
Warn the person at whom the threats are directed. (Correct answer)
Refer the patient to a psychiatrist.
Notify the police.

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

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

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 66: What blood flow rate and dialysate flow rate combination best optimizes small solute clearance during standard hemodialysis?

Qb 150 mL/min / Qd 800 mL/min
Qb 500 mL/min / Qd 200 mL/min
Qb 200 mL/min / Qd 300 mL/min
Qb 300 mL/min / Qd 500 mL/min (Correct answer)

Correct answer: Qb 300 mL/min / Qd 500 mL/min

A blood flow of 300 mL/min with a dialysate flow of 500 mL/min is the standard prescription that balances solute clearance efficiency with patient tolerance.

Question 67: A patient's interdialytic weight gain is consistently 4–5 kg. The most effective nursing intervention is:

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

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

Low bicarbonate in dialysate
High calcium in dialysate
Endotoxin contamination of dialysate causing pyrogenic reaction (Correct answer)
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 69: A patient with a forearm AV fistula reports hand pain, numbness, and coolness during dialysis. Which complication should the nurse suspect?

Steal syndrome (Correct answer)
Air embolism
Venous hypertension
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 70: Which drug class is commonly used to treat restless leg syndrome in dialysis patients?

Beta-blockers
SSRIs
Antihistamines
Dopamine agonists (Correct answer)

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

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

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 72: 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?

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

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 73: A dialysis patient asks why they need to take erythropoiesis-stimulating agents (ESAs). What is the best response?

'Your damaged kidneys produce less erythropoietin, so ESAs stimulate your bone marrow to produce red blood cells.' (Correct answer)
'ESAs help remove excess potassium from your blood.'
'Your kidneys cannot remove toxins, so ESAs help with that.'
'ESAs protect your blood vessels from calcium buildup.'

Correct answer: 'Your damaged kidneys produce less erythropoietin, so ESAs stimulate your bone marrow to produce red blood cells.'

The failing kidneys produce insufficient erythropoietin, leading to anemia; ESAs mimic this hormone to stimulate red blood cell production in the bone marrow.

Question 74: What does the Kt/V measurement represent in hemodialysis?

Dialyzer clearance times treatment time divided by urea distribution volume (Correct answer)
Blood flow rate times treatment volume
Potassium-to-volume ratio
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 75: What is the most common acute complication during hemodialysis?

Dialyzer reaction
Hypotension (Correct answer)
Hyperkalemia
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 76: Intradialytic hypotension is most effectively prevented by which of the following interventions?

Using a higher sodium dialysate concentration
Limiting the ultrafiltration rate to ≤13 mL/kg/hour (Correct answer)
Administering IV albumin before each session
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 77: What is the emergency treatment for suspected air embolism during hemodialysis?

Administer oxygen and reduce ultrafiltration rate
Administer heparin IV and continue dialysis
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

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 78: When assessing a patient for adequacy of PD, the nurse calculates a weekly Kt/V of 1.5. How should this be interpreted?

Adequate — no changes needed as any value above 1.0 is acceptable
Inadequate — target is ≥1.7 (Correct answer)
Inadequate — target is ≥2.0
Adequate — meets the minimum target of ≥1.7

Correct answer: Inadequate — target is ≥1.7

KDOQI recommends a minimum total weekly Kt/V of ≥1.7 for peritoneal dialysis; a value of 1.5 is below this target and requires intervention.

Question 79: Which type of dialyzer membrane is associated with the highest biocompatibility?

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

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 80: Which disinfection method is most commonly used for the internal water distribution loop in a dialysis facility?

High-dose chlorination
Ozone treatment
Heat disinfection or chemical disinfection with bleach or peracetic acid (Correct answer)
Ultraviolet light only

Correct answer: Heat disinfection or chemical disinfection with bleach or peracetic acid

Heat disinfection (hot water flushing) or chemical disinfection with sodium hypochlorite or peracetic acid are the standard methods for disinfecting dialysis water distribution loops.

Question 81: A dialysis patient reports feeling hopeless and states 'I don't see the point in continuing treatment.' What is the nurse's priority action?

Remind the patient of the importance of dialysis adherence
Document the statement and continue with treatment
Ask family members to monitor the patient at home
Conduct a suicide risk assessment and notify the physician and social worker (Correct answer)

Correct answer: Conduct a suicide risk assessment and notify the physician and social worker

Statements of hopelessness in dialysis patients require immediate suicide risk assessment, as this population has significantly elevated rates of depression and suicidal ideation.

Question 82: 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?

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

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

Serum ferritin (Correct answer)
Total iron-binding capacity (TIBC)
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 84: What is the immediate treatment for intradialytic hypotension?

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

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 85: What is the most common cause of intradialytic hypotension?

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

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

Increase dwell time for all exchanges
Decrease the fill volume per exchange
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 87: What is the primary purpose of sodium profiling during hemodialysis?

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

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

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

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 89: Secondary hyperparathyroidism in dialysis patients is primarily triggered by:

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

Correct answer: Vitamin D deficiency and hyperphosphatemia

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

Question 90: What is the main use of an amino-based dialysate solution?

Electrolyte imbalance
Nutritional supplementation (Correct answer)
Increased ultrafiltration
Decreased 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 91: 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)
Omeprazole
Acetaminophen
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 92: What is the recommended minimum maturation time for an AV fistula before first cannulation?

3–6 months
2–4 weeks
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 93: Which electrolyte imbalance is MOST commonly associated with muscle cramps during hemodialysis?

Hyperkalemia
Hypernatremia
Hypocalcemia
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 patient develops pink-tinged blood in the dialysate port during hemodialysis. What does this most likely indicate?

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

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 95: What does the peritoneal equilibration test measure?

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

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 96: 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 analysis
Data elements for collection
Time period for observation (Correct answer)
Methods of data 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 97: 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 no risk of developing the disease
Have a 25% risk of developing the disease
Have a 50% risk of developing the disease (Correct answer)
Have a 100% risk of developing the disease

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

Palpable thrill along the graft (Correct answer)
Equal blood pressure in both arms
Visible pulsation at the anastomosis site
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 99: Which advance care planning topic is most important to discuss with dialysis patients early in their treatment?

Transplant eligibility criteria
Preferred vascular access type
Goals of care, code status, and preferences regarding dialysis withdrawal (Correct answer)
Preferred dialysis shift times

Correct answer: Goals of care, code status, and preferences regarding dialysis withdrawal

Early discussion of advance directives, code status, and dialysis withdrawal preferences ensures patient wishes are respected if health deteriorates, reducing unwanted aggressive care.

Question 100: A hemodialysis patient develops sudden hypotension during treatment. Which intervention should the nurse perform first?

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

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 101: A patient's post-dialysis BUN is 30 mg/dL and pre-dialysis BUN was 90 mg/dL. What is the URR?

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

Correct answer: 67%

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

Question 102: Which dialysis complication is specifically associated with inadequate bicarbonate delivery in the dialysate?

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

Correct answer: Metabolic acidosis

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

Question 103: A dialysis patient's pre-treatment blood pressure is 85/50 mmHg. The appropriate nursing action is to:

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

Correct answer: Hold dialysis and notify the physician

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

Question 104: Which dietary restriction is most critical for a hemodialysis patient between treatments?

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

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 105: 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?

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

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

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

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

Vitamin C
Folic acid (Vitamin B9) (Correct answer)
Vitamin K
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 108: 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 109: Which sign indicates that a patient is not adhering to fluid restrictions between dialysis sessions?

Hemoglobin of 11 g/dL
Pre-dialysis blood pressure of 130/80 mmHg
Pre-dialysis potassium of 4.8 mEq/L
Consistent interdialytic weight gain of 4–5 kg (Correct answer)

Correct answer: Consistent interdialytic weight gain of 4–5 kg

Consistently high interdialytic weight gains of 4–5 kg strongly suggest non-adherence to fluid restrictions, as this far exceeds the recommended 2–3 kg between treatments.

Question 110: What is the AAMI recommended maximum level for bacteria in dialysis water?

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

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 111: A home peritoneal dialysis patient reports that their dwell time has been shortened due to work. The nurse's priority concern is:

Excessive ultrafiltration leading to dehydration
Increased risk of peritonitis
Inadequate solute clearance and underdialysis (Correct answer)
Catheter exit site infection

Correct answer: Inadequate solute clearance and underdialysis

Shortened dwell times reduce equilibration and solute clearance, leading to inadequate dialysis and uremic toxin accumulation.

Question 112: Which electrolyte imbalance is most likely to cause life-threatening cardiac arrhythmias in a dialysis patient?

Hypercalcemia
Hyperphosphatemia
Hyperkalemia (Correct answer)
Hyponatremia

Correct answer: Hyperkalemia

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

Question 113: 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
Iron deficiency from dietary intake
Vitamin B12 deficiency from uremic gastritis

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

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

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

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

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 116: 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)
Every 6 months routinely
Only when the patient reports symptoms
Annually at the care plan review

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

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

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 118: IV iron supplementation is indicated in dialysis patients when ferritin is below what threshold despite ESA therapy?

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

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

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

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

Reduced endotoxin load
Scale buildup in tubing that can contaminate dialysate and clog proportioning systems (Correct answer)
Improved biocompatibility
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 121: What is the recommended target range for dialysis adequacy (Kt/V) in hemodialysis patients per KDOQI guidelines?

≥1.2 per session (Correct answer)
≥1.4 per session
≥1.8 per session
≥0.8 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 122: Which medication should be administered with meals to a dialysis patient with hyperphosphatemia?

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

Correct answer: Phosphate binder

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

Question 123: 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)
Return blood and switch to a new dialyzer
Slow the blood pump and give antihistamines

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 124: Which sign indicates that a newly placed AV fistula has matured and is ready for use?

Edema resolved and skin over fistula intact
Fistula is visible with no palpable thrill
Fistula diameter ≥6mm, flow ≥600 mL/min, depth <6mm (Correct answer)
Absence of thrill or bruit

Correct answer: Fistula diameter ≥6mm, flow ≥600 mL/min, depth <6mm

The 'Rule of 6s' defines fistula maturity: flow ≥600 mL/min, diameter ≥6mm, and depth ≤6mm from skin surface, typically after 6 weeks.

Question 125: How is Kt/V used in hemodialysis?

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

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 126: 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
Self-esteem
Love and belonging
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 127: A dialysis patient on warfarin for atrial fibrillation has an INR of 4.8 before treatment. The nurse should:

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

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 128: Between hemodialysis treatments, weight gain shouldn't surpass

5% of dry weight (Correct answer)
1% of dry weight
10% of dry weight
8% 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 129: Which electrolyte imbalance is most commonly associated with muscle cramps during hemodialysis?

Hyperphosphatemia
Hyperkalemia
Hypocalcemia (Correct answer)
Hypernatremia

Correct answer: Hypocalcemia

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

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

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

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

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 132: Which fluid restriction guideline is commonly recommended for anuric hemodialysis patients?

No restriction needed
Urine output plus 500–750 mL/day (Correct answer)
Urine output plus 1,000 mL/day
500 mL/day

Correct answer: Urine output plus 500–750 mL/day

Non-anuric patients are restricted to their urine output plus 500–750 mL/day to account for insensible losses while preventing interdialytic fluid overload.

Question 133: Sodium bicarbonate is sometimes given to a dialysis patient prior to an emergency session. What is the indication?

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

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

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

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 135: 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
Implement a Plan-Do-Study-Act (PDSA) cycle targeting standardized access care protocols (Correct answer)
Switch to a different type of dialyzer
Punish staff members when infections occur

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

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

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

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

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

Calcium channel blockers
ACE inhibitors or ARBs (Correct answer)
Beta-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 139: 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)
Low dialysate temperature
High blood flow rate

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 140: 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)?

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

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

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

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.

Question 142: Which electrolyte imbalance most commonly causes muscle cramps during hemodialysis?

Hyperphosphatemia
Hyperkalemia
Hypernatremia
Hypocalcemia (Correct answer)

Correct answer: Hypocalcemia

Hypocalcemia during dialysis causes neuromuscular irritability leading to muscle cramps.

Question 143: Which parameter best guides the adjustment of a peritoneal dialysis patient's dry weight (target weight)?

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

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

Calcium carbonate
Calcium acetate
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 145: 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 creatinine
Pitting edema and hypertension (Correct answer)
Elevated serum albumin
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 146: What is the primary goal of emergency ultrafiltration in a dialysis patient presenting with acute pulmonary edema?

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

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

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

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 148: A hemodialysis patient reports headache, nausea, and confusion toward the end of treatment. Which complication should the nurse suspect?

Dialysis disequilibrium syndrome (Correct answer)
Air embolism
Hemolysis
Hypercalcemia

Correct answer: Dialysis disequilibrium syndrome

Dialysis disequilibrium syndrome results from rapid solute removal causing cerebral edema, presenting with neurological symptoms especially at end of treatment.

Question 149: Which medication used to lower blood pressure is dialyzable and may require supplemental dosing after hemodialysis?

Lisinopril
Amlodipine
Atenolol (Correct answer)
Carvedilol

Correct answer: Atenolol

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

Question 150: What action should be taken if the dialysis machine's venous pressure alarm activates with a sudden increase in venous pressure?

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

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%

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