CNN EXAM

Question 1
Mrs. Kathy Dye, 45 years old, has end-stage renal disease secondary to glomerulonephritis. She
began dialysis emergently and has a cuffed, tunneled, central venous catheter.
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The preferred site for a central venous catheter for dialysis access is the -

right external jugular.

right internal jugular.
left external jugular.
left internal jugular.
Correct Answer:
right internal jugular.
The preferred site is the right internal jugular vein because this site offers a more direct route to
the right atrium than the left-sided great veins. Catheter insertion and maintenance in the right
internal jugular vein are associated with a lower risk for complications compared to other
potential catheter insertion sites.

Mrs. Kathy Dye, 45 years old, has end-stage renal disease secondary to glomerulonephritis. She
began dialysis emergently and has a cuffed, tunneled, central venous catheter.
============================================
Question 2
Mrs. Dye is diagnosed with pericarditis. Which of the following therapies would be effective in
resolving the pericarditis?

Increase the frequency of dialysis.

Increase the dose of heparin sodium.
Increase the dose of blood pressure medication.
Increase the fluid removal at each dialysis treatment.
Correct Answer:
Increase the frequency of dialysis.
Intensification of hemodialysis is the mainstay of therapy for pericarditis. This may be
accomplished by increasing dialysis frequency to 5-7 days per week.

Question 3
Mrs. Dye's pericarditis is resolved, and she resumes her regular hemodialysis treatments.
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Three hours into dialysis, Mrs. Dye complains of leg cramps. Leg cramps are most often related
to -

high blood flow rates.

rapid ultrafiltration.
inadequate oral fluid intake.
inappropriate levels of electrolytes in dialysate.
Correct Answer:
rapid ultrafiltration.
Leg cramps are usually due to a high ultrafiltration rate.

Question 4
Mrs. Dye's pericarditis is resolved, and she resumes her regular hemodialysis treatments.
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Mrs. Dye's interdialytic weight gains are typically 3-4 kg. (6.6-8.8 lb). In discussing ways to
decrease fluid intake, the nurse emphasizes the importance of reducing salt intake. The nurse
instructs Mrs. Dye that the best way for patients with chronic kidney disease to avoid salt is to -

use salt substitutes.

eat foods with a naturally high sodium content.
add sauces, e.g., soy or Worcestershire, to cooked food.
use herbs and spices in cooking.
Correct Answer:
use herbs and spices in cooking.
It is vital that patients receive education on sodium and fluid restriction, with the emphasis on
sodium. Herbs and spices effectively replace sodium to enhance the flavor of food.

Question 5
Mrs. Dye's pericarditis is resolved, and she resumes her regular hemodialysis treatments.
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Mrs. Dye inquires about the new home hemodialysis program which offers daily dialysis.
Medications typically decreased or discontinued in patients on daily hemodialysis include -

vitamin supplements.
cardiotonic drugs.
phosphorus binders.
heparin requirements.
Correct Answer:
phosphorus binders.
Daily dialysis improves phosphorus control by increasing dialytic phosphorus removal.
Therefore, the need for phosphorus binders is decreased.

Question 6
Mr. Carl Roney, a 68-year-old patient with chronic kidney disease, has been referred to a
nephrology practice.
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Mr. Roney asks why epoetin alfa (Epogen) has been prescribed. The nurse should explain that
the primary reason he needs Epogen is because -

his diseased kidneys no longer make enough erythropoietin.

his diseased kidneys no longer reabsorb endogenous erythropoietin.
patients with kidney disease have bone marrow resistance to endogenous erythropoietin.
patients with kidney disease need more erythropoietin than healthy individuals.
Correct Answer:
his diseased kidneys no longer make enough erythropoietin.
Anemia is a complication of renal failure and generally worsens as renal function deteriorates.
The major cause of anemia is decreased production of erythropoietin.

Mr. Carl Roney, a 68-year-old patient with chronic kidney disease, has been referred to a
nephrology practice.
Question 7
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Mrs. Roney asks the nurse if their adult children are at increased risk for developing chronic
kidney disease. Their children would be at risk if Mr. Roney had which of these conditions?

Glomerular disease.
Pyelonephritis.
Polycystic kidney disease.
Nephrosclerosis.
Correct Answer:
Polycystic kidney disease.
Polycystic kidney disease is a common genetic cause of renal failure accounting for
approximately 5% of dialysis patients worldwide.

Question 8
Mr. Carl Roney, a 68-year-old patient with chronic kidney disease, has been referred to a
nephrology practice.
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Mr. Roney returns to the clinic after three months. As the nurse discusses his medications with
Mr. Roney, he states that he is not taking the calcium carbonate (Tums(R)) as prescribed because
he has not had any indigestion. The nurse explains that patients with chronic kidney disease take
calcium carbonate because it -

replaces calcium lost in the urine.

corrects acidosis.
decreases the risk of cardiac arrhythmias.
 reduces serum phosphorus levels.
Correct Answer:
reduces serum phosphorus levels.
Phosphate binding medications are required for most patients for adequate phosphate control.
Calcium based binders, such as calcium carbonate (Tums®), bind with dietary phosphorous and
promote excretion of phosphorus through the gastrointestinal tract.

Question 9
Mr. Carl Roney, a 68-year-old patient with chronic kidney disease, has been referred to a
nephrology practice.
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The charge nurse reviews normal kidney physiology with a new nurse assigned to follow Mr.
Roney. The charge nurse should emphasize that the kidney removes creatinine both by filtration
and -

osmosis.
secretion.
transcapillary transfer.
tubular reabsorption.
Correct Answer:
secretion.
As the glomerular filtrate passes through the renal tubules, creatinine is not reabsorbed at all. In
fact, creatinine is secreted by the proximal tubules, raising the total quantity of creatinine
removed by about 20%.

Question 10
Hemodialysis is more efficient than peritoneal dialysis in removing -

phosphorus and albumin.

large molecular weight solutes.
beta2 microglobulin.
 urea and creatinine.
Correct Answer:
urea and creatinine.
Total weekly clearance by peritoneal dialysis of urea is typically 1/2 to 2/3 that of hemodialysis.
Clearance of creatinine by peritoneal dialysis is also significantly less than that of hemodialysis.

Question 11
The United Network for Organ Sharing has an algorithm for organ allocation. Additional points
are given to which of the following patients?

Children under 18.

Candidates who have had previous transplants.
Racial minorities.
Individuals who are actively employed.
Correct Answer:
Children under 18.
Research shows that children do better with transplant than other renal replacement modalities.
This algorithm helps to ensure that children will get transplanted more quickly.

Question12
During peritoneal dialysis, small amounts of fluid and solutes are continuously removed from the
peritoneal cavity by -

transfer into the gut.

uptake by the portal system of the liver.
drainage into the pancreatic system.
lymphatic absorption.
Correct Answer:
lymphatic absorption.
Lymph drainage from the peritoneal cavity occurs through a one-way system of specialized
lymph openings in the subdiaphragmatic peritoneum. The average lymph absorption rate during
peritoneal dialysis is estimated to be between 1.0-1.5 ml/minute, or approximately 1.2 liters per
day.

Question 13
Which of the following is a cause of chronic rejection following kidney transplant?

Alcohol consumption.
Elevated blood sugars.
Engaging in sexual promiscuity.
Failure to adhere to immunosuppressive regimen.
Correct Answer:
Failure to adhere to immunosuppressive regimen.
Low levels of immunosuppression contribute to chronic allograft nephropathy (the preferred
term for chronic rejection).

Question 14
A patient on peritoneal dialysis has bacterial peritonitis confirmed by culture. Peritoneal
inflammation causes changes in the peritoneal membrane. During long (4-6 hour) exchanges,
these changes would result in decreased -

solute clearances.
protein losses.
fluid removal.
glucose absorption.
Correct Answer:
fluid removal.
Increases in systemic glucose absorption during peritonitis result in a decrease in dialysate
glucose concentration over the dwell time. This results in decreased ultrafiltration during long-
dwell exchanges.
Question 15
The peritoneal membrane surface is composed of -

a single layer of striated muscle cells.

a single layer of mesothelial cells.
phospholipid cells.
gastroepiploic cells.
Correct Answer:
a single layer of mesothelial cells.
The peritoneum consists of a monolayer of mesothelium, flattened cells that line serous cavities
such as the peritoneum, pleura, and pericardium.

Question 16
One of the side effects of cyclosporine therapy is -

arthralgias.
hyperglycemia.
fluid retention.
renal insufficiency.
Correct Answer:
renal insufficiency.
Cyclosporine causes prominent arteriolar constriction and a subsequent decrease in glomerular
filtration rate.

Question 17
Compared to patients receiving hemodialysis, patients on self-care peritoneal dialysis are less
likely to -

require instruction about their care.

experience infectious complications.
accept the "sick identity."
 develop cardiovascular disease.
Correct Answer:
accept the "sick identity."
In a study of long-term PD patients, the patients considered themselves sick when they
experienced a complication or comorbid illness episode, but not at other times.

Question 18
Calcineurin inhibitors have been described as the cornerstone of immunosuppressive regimens.
Calcineurin inhibitors include which of these medications?

All glucocorticoids.
All antiproliferative agents.
Mycophenolate mofetil (CellCept).
Cyclosporine (Sandimmune, Neoral, Gengraf).
Correct Answer:
Cyclosporine (Sandimmune, Neoral, Gengraf).
Calcineurin inhibitors include cyclosporine and tacrolimus.

Question 19
Which of the following is a complication of long-term immunosuppressive therapy?

Uveitis.
Malignancy.
Development of new allergies.
Progressive neurological deficits.
Correct Answer:
Malignancy.
Malignancy is more common in people who are on immunosuppressive therapy than those who
are not. Skin cancer is the most common malignancy.
Question 20
Which of the following is a surgical complication seen in kidney transplant patients?

Lymphocele.
Ureteral dilitation.
Herniation.
Interstitial cystitis.
Correct Answer:
Lymphocele.
Because of the anatomic placement of the kidney allograft, lymph leakage can occur from the
severed lymphatics that overlie the iliac vessels. This can cause a lymphocele.

Question 21
Which of the following is added to buffer commercial peritoneal dialysis solutions?

Lactate.
Lactic acid.
Acetic acid.
Ascorbic acid.
Correct Answer:
Lactate.
Lactate is added to commercial peritoneal dialysis solutions (see package inserts) as a buffer.

Question 22
Which of the following equilibrates most rapidly during a peritoneal dialysis exchange?

Protein.
Potassium.
Phosphorus.
Urea.
Correct Answer:
Urea.
Small molecular weight substances reach equilibrium more rapidly than larger solutes. Urea has
the smallest molecular weight of these solutes. The dialysate-to-plasma ratio of urea at 4 hours
dwell is approximately 0.9 (1.0 would be completely equilibrated, reflecting equal values in
blood and dialysate).

Question 23
Which of the following medications typically given to transplanted patients should be taken on
an empty stomach?

Prednisone (Deltasone, Orasone).

Azathioprine (Imuran).
Mycophenolate mofetil (CellCept).
Antithymocyte globulin (Thymoglobulin).
Correct Answer:
Mycophenolate mofetil (CellCept).
CellCept should be taken on an empty stomach, or one hour before or two hours after meals.

Question 24
Which of the following strategies is used to decrease the risk of viral infections posttransplant?

Giving an anti-viral vaccine.

Protective isolation.
Prophylactic use of an antiviral drug.
Limiting the number of staff caring for the patient.
Correct Answer:
Prophylactic use of an antiviral drug.
Viral infections are common posttransplant. Antiviral prophylaxis is a standard part of
posttransplant care.
Question 25
A patient is receiving acute peritoneal dialysis with short hypertonic exchanges. The patient
complains of burning and abdominal pain after infusion of the dialysate. One intervention to
reduce the discomfort would be to -

raise the pH of the dialysis solution.

infuse cool dialysis solution.
increase the infusion flow rate.
use conscious sedation during the procedure.
Correct Answer:
raise the pH of the dialysis solution.
The acidic pH of peritoneal dialysis solutions can cause abdominal pain. Sodium bicarbonate can
be added to the dialysis solution to raise the pH and decrease symptoms.

Question 26
The nurse is planning to teach emergency preparedness to small groups of hemodialysis patients.
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Which of these learning objectives for the emergency preparedness educational program is stated
correctly? After completing the program, the learner will -

understand the importance of an egress path.

identify the location of the nearest fire extinguisher.
appreciate the importance of anticipatory planning for emergencies.
have increased awareness of the unit's emergency procedure.
Correct Answer:
identify the location of the nearest fire extinguisher.
A behavioral objective should contain a performance behavior specifying what the learner will
be able to do after the instruction is given. The verbs used in the objective should be active verbs,
such as "identify," "demonstrate," and "describe," which can be measured to determine if the
outcome was achieved.
Question 27
The nurse is planning to teach emergency preparedness to small groups of hemodialysis patients.
============================================
An advantage of small-group instruction is that it encourages -

reliance on the nurse as the expert leader.

compliance of group members.
a more structured learning environment.
peer-to-peer learning.
Correct Answer:
peer-to-peer learning.
Group instruction encourages peer-influenced learning. It can be especially effective with adult
learners who can share knowledge, lived experiences, and coping strategies.

Question 28
The nurse is planning to teach emergency preparedness to small groups of hemodialysis patients.
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According to adult learning principles, patients learn best when the instruction -

proceeds from abstract, theoretical concepts to complex information.

occurs in hour-long sessions that permit covering topics in depth.
helps patients deal with problems they are currently confronting.
gives patients information in a lecture format with accurate medical terminology.
Correct Answer:
helps patients deal with problems they are currently confronting.
Theories on adult education consistently state that adults will devote energy to learn something
in proportion to how they perceive it will help them perform tasks or deal with problems they are
currently confronting.
Question 29
The nurse is planning to teach emergency preparedness to small groups of hemodialysis patients.
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After completing the emergency preparedness teaching session, which of these approaches
would be most effective in determining learning outcomes?

Ask the patients to describe in their own words their emergency preparedness plans.
Administer a brief multiple-choice test on emergency preparedness procedures.
Survey the patients to determine their satisfaction with the emergency preparedness
program.
Ask the patients to evaluate each other's knowledge of emergency preparedness.
Correct Answer:
Ask the patients to describe in their own words their emergency preparedness plans.
The most effective evaluation method is to have patients demonstrate or describe what they
learned. In this way, patients become active participants; also, any misconceptions can be
corrected immediately.

Question 30
Mary Ellen O'Neill, 35 years old, has kidney failure secondary to glomerulonephritis. She
recently began peritoneal dialysis therapy.
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Mrs. O'Neill calls to report pink-tinged dialysate. The most common cause of this finding is -

a ruptured arteriole.
bleeding from catheter tip irritation.
diverticuli or bowel erosion.
ovulation or menstruation.
Correct Answer:
ovulation or menstruation.
Blood-tinged dialysate may occur before or during menses and at ovulation.
Question 31
Mary Ellen O'Neill, 35 years old, has kidney failure secondary to glomerulonephritis. She
recently began peritoneal dialysis therapy.
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One advantage of peritoneal dialysis over hemodialysis is increased self-efficacy. Which of these
statements made by Mrs. O'Neill is most indicative of self-efficacy?

"I know with dialysis I have a hole in my abdomen, and I can see it."
"If I see my blood pressure going up, I adjust my solution and bring it back down."
"Dialysis becomes a daily habit, like brushing your teeth."
"I like to know what's going on, so I ask the nurses a lot of questions."
Correct Answer:
"If I see my blood pressure going up, I adjust my solution and bring it back down."
Self-care/self-efficacy are aspects of autonomy/control of one's own health. In this example, the
patient is able to identify that the blood pressure is too high. The patient also demonstrates that
she is able to choose and implement an appropriate intervention to resolve the problem.
Therefore, this is an example of effective or efficacious self-care.

Question 32
Henrietta Marsh, 77 years old, has kidney failure secondary to diabetic nephropathy. She has
selected peritoneal dialysis for renal replacement therapy.
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Ms. Marsh has a peritoneal catheter implanted and begins peritoneal dialysis with cycler
exchanges every two hours. She develops watery diarrhea. A dipstick of the diarrheal stool is
ordered. A positive result for which of these substances would confirm a bowel perforation?

Creatinine.
Protein.
Glucose.
Leukocytes.
Correct Answer:
Glucose.
Dextrose-containing peritoneal dialysis solutions are very high in glucose. If there is a bowel
perforation, dialysate enters the gastrointestinal tract and causes diarrhea. The stool content will
have an unusually high glucose level.

Question 33
Henrietta Marsh, 77 years old, has kidney failure secondary to diabetic nephropathy. She has
selected peritoneal dialysis for renal replacement therapy.
============================================
The nurse observes Mrs. Marsh for complications of acute dialysis including accumulation of air
in the peritoneal cavity. The classic symptom of pneumoperitoneum is -

abdominal cramping.
shoulder pain.
back pain.
belching.
Correct Answer:
shoulder pain.
Air bubbles in the peritoneal cavity rise and accumulate under the diaphragm. Irritation of the
diaphragm can cause a referred pain to the shoulder.

Question 34
Henrietta Marsh, 77 years old, has kidney failure secondary to diabetic nephropathy. She has
selected peritoneal dialysis for renal replacement therapy.
============================================
On the second day of dialysis, the physician writes an order for potassium chloride to be added to
each of Mrs. Marsh's dialysis exchanges. Potassium chloride is packaged in single-dose vials
because it -

has a very short shelf life.

is inactivated when exposed to air.
 does not contain a bacteriostatic agent.
is always administered as a single unit dose.
Correct Answer:
does not contain a bacteriostatic agent.
Sutures are foreign bodies penetrating the skin, which increases the risk of infection. Sutures at
the PD catheter exit site are often associated with a wide tunnel tract. Thus, the exit site requires
more time to heal, which also increases the risk of infection.

Question 36
Henrietta Marsh, 77 years old, has kidney failure secondary to diabetic nephropathy. She has
selected peritoneal dialysis for renal replacement therapy.
============================================
The nurse continues to perform weekly dressing changes. Which of the following findings would
indicate normal progression of healing of a peritoneal catheter exit site?

Development of exuberant granulation tissue.

Formation of a "lip" of skin over the catheter.
Progression of epithelium into the sinus tract.
Development of a cuticle around the catheter.
Correct Answer:
Progression of epithelium into the sinus tract.
As the new catheter exit site heals, epithelium progresses into the sinus tract. Although there is
occasionally a cuticle-like rim around the external exit site or a "lip" of skin over the catheter,
these are seen only in mature exit sites.

Question 37
Henrietta Marsh, 77 years old, has kidney failure secondary to diabetic nephropathy. She has
selected peritoneal dialysis for renal replacement therapy.
============================================
After nine months of home dialysis, Mrs. Marsh presents with signs and symptoms of peritonitis.
Which of the following organisms that can cause peritonitis is waterborne?
 Pseudomonas aeruginosa.
Clostridium difficile.
Aquanata elaborans.
Staphylococcus aureus.
Correct Answer:
Pseudomonas aeruginosa.
Pseudomonas aeruginosa, a bacterium, is ubiquitous in soil and water. It is the most common
waterborne organism to cause peritonitis.

Question 38
Mr. Wayne Cronin is followed in an endocrinology practice for type 2 diabetes mellitus.
============================================
To delay the onset of end-stage renal disease, which of these classifications of antihypertensive
drugs is most likely to be prescribed for Mr. Cronin?

Angiotensin-converting enzyme (ACE) inhibitors.

Thiazide diuretics.
Calcium channel blockers.
Beta blockers.
Correct Answer:
Angiotensin-converting enzyme (ACE) inhibitors.
According to the NKF K/DOQI Clinical Practice Guidelines and Clinical Practice
Recommendations for Diabetes and Chronic Kidney Disease (CKD), interventions to slow the
progression of kidney disease should be considered in all patients with CKD. Interventions that
have been proven to be effective include strict blood pressure control with angiotensin-
converting enzyme inhibition or angiotensin receptor blockade.

Question 39
Mr. Wayne Cronin is followed in an endocrinology practice for type 2 diabetes mellitus.
============================================
Which of the following will be the first sign that Mr. Cronin has developed kidney disease?

Ketoacidosis.
Microalbuminuria.
Hematuria.
Lactic acidosis.
Correct Answer:
Microalbuminuria.
Diabetes affects the kidney's microvascular bed, leading to changes in the glomerular basement
membrane (GBM). As the integrity of the GBM is lost, albumin will be found in the urine.
Microalbuminuria can be detected before a urine dipstick will be positive for protein or albumin.

Question 40
Mr. Wayne Cronin is followed in an endocrinology practice for type 2 diabetes mellitus.
============================================
At which stage of chronic kidney disease would dialysis be initiated for Mr. Cronin?

Stage 2.
Stage 3.
Stage 4.
Stage 5.
Correct Answer:
Stage 5.
Stage 5 chronic kidney disease occurs when the GFR is <15 ml/min/1.73 m2. This stage is also
referred to as end-stage renal disease, in which there is total or near-total loss of kidney function
and patients must have dialysis initiated or receive a kidney transplant to stay alive.

Question 41
Mr. Cronin's kidney disease progresses, and he selects hemodialysis for renal replacement
therapy.
============================================
A forearm Polytetraflouroethylene (PTFE) loop graft is placed. Which of the following is the
most common cause of PTFE graft failure?

Arterial anastomosis stenosis.

Venous anastomosis stenosis.
Repeated cannulation in one location.
Pseudoaneurysm.
Correct Answer:
Venous anastomosis stenosis.
Stenosis of the venous anastamosis leads to slowed blood flow in the PTFE graft and graft
failure. This accounts for the majority of AV graft failures.

Question 42
Mr. Cronin's kidney disease progresses, and he selects hemodialysis for renal replacement
therapy.
============================================
Mr. Cronin has been receiving dialysis for two months. Today's testing indicates that Mr.
Cronin's Kt/Vurea has decreased since the last measurement. Which of these actions should the
nurse take?

Assess the vascular access.

Assess for occult bleeding.
Determine if Mr. Cronin is taking his medications as prescribed.
Determine if Mr. Cronin has lost lean body mass.
Correct Answer:
Assess the vascular access.
When Kt/Vurea falls, less dialysis is being delivered. One common cause is recirculation of
blood at the vascular access site. This happens when a large percentage of the blood that has just
been dialyzed returns to the dialyzer repeatedly.
Question 43
Crenation can occur as a complication of hemodialysis. Which of the following describes the
effect of crenation on cells?

Cell volume decreases.

Cell volume increases.
Cells clump together.
Cells burst apart.
Correct Answer:
Cell volume decreases.
Creation occurs when erythrocytes are exposed to a hypertonic solution. Water volume is lost
from the cell, and volume decreases as water moves from the intracellular to the extracellular
compartment through the process of osmosis.

Question 44
C-reactive protein is a marker of -

nutrition.
inflammation.
allergic response.
muscle metabolism.
Correct Answer:
inflammation.
C-reactive protein is a general marker of infection and inflammation.

Question 45
The measured percent recirculation is used to evaluate -

effectiveness of anticoagulation.
venous stenosis.
dialyzer clotting.
 adequacy of dialysis.
Correct Answer:
venous stenosis.
Low blood flow in an access can be caused by stenosis at the arterial end or, more commonly, by
stenosis at the venous end--usually associated with an increase in venous pressure. Venous
stenosis that obstructs venous outflow leads to backflow into the arterial needle and recirculation.

Question 46
The administration of which of these medications would lower serum potassium the fastest?

Potassium chloride (Potasalan).

Sodium polystryene sulfonate (Kayexalate).
Aluminum-based binders.
Glucose and insulin.
Correct Answer:
Glucose and insulin.
Glucose and insulin given intravenously drive excess potassium into the cells. The onset of
action is within 30 minutes, and the duration of the effect is 4-6 hours.

Question 47
The physician orders ultrafiltration profiling for a patient. The goal of ultrafiltration profiling is
to -

reduce the incidence of hypotension.

reduce the incidence of hypertension.
lower serum sodium concentration.
lower dialysate sodium concentration.
Correct Answer:
reduce the incidence of hypotension.
Ultrafiltration profiling or modeling is a method of systematically controlling the rate and pattern
of ultrafiltration over the course of a dialysis treatment to minimize the symptoms a patient
might experience from ultrafiltration, e.g., hypotension.

Question 48
Which of the following is an example of evidence-based practice?

Adhering to the ANA's Code of ethics for nurses with interpretive statements.
Reviewing reports of legal cases to identify areas of nurse liability in malpractice cases in
hemodialysis facilities.
Using the K/DOQI Clinical practice guidelines for hemodialysis adequacy to evaluate
treatment outcomes.
Seeking the advice of an experienced colleague to solve clinical problems.
Correct Answer:
Using the K/DOQI Clinical practice guidelines for hemodialysis adequacy to evaluate treatment
outcomes.
Evidence-based practice involves using research evidence and clinical expertise in patient care.
In nephrology, one of the best examples of evidence-based practice is the use of the NKF
K/DOQI clinical practice guidelines.

Question 49
Which structure of the kidney secretes renin?

Juxtaglomerular cells.
Ascending loop of Henle.
The glomerular membrane.
The mesangial lining.
Correct Answer:
Juxtaglomerular cells.
Juxtaglomerular (JG) cells adjacent to the afferent arteriole entering the renal glomerulus are the
primary site of renin storage and release in the body.
Question 50
A new technician is being oriented to the hemodialysis unit. The morning's topic is the water
treatment system for hemodialysis. Which of the following components of the water treatment
system removes calcium and magnesium salts?

Carbon tanks.
Reverse osmosis.
Water softener.
Ultraviolet irradiator.
Correct Answer:
Water softener.
A water softener exchanges calcium and magnesium ions for sodium ions on a milliequivalent-
for-milliequivalent basis. For each calcium ion removed, two sodium ions are added.
1. The healthy kidney performs several distinct functions. Which of the following is a function of
the
kidney?
a. Excretion of urea, uric acid, and water
b. Maintenance of body temperature
c. Regulation of lymphocyte production
d. Production of insulin and glucagon

2. One of the hormones produced by the kidney is erythropoietin. What is the action of this
hormone?
a. It promotes the absorption of calcium.
b. It enhances water reabsorption.
c. It stimulates erythrocyte production.
d. It balances human growth hormone (hGH) levels.

3. Which of the following tests are commonly used to diagnose renal failure?
a. Partial thromboplastin time (PTT), ABO, Rh factor
b. Chest x-ray, mammogram
c. MRI of lumbar spine, bladder ultrasound
d. Blood urea nitrogen (BUN), blood chemistry, creatinine level, kidney ultrasound, urinalysis

4. Which of the following statements most accurately describes acute renal failure (ARF)?
a. It takes several months to develop and is often irreversible.
b. It progresses quickly, lasts fewer than 3 months, and results in a loss of nephron function.
c. It is frequently linked to diabetes mellitus or lupus erythematosus.
d. It commonly lasts for at least 4 to 6 months, and then resolves completely.

5. Which of the following is a cause of intrarenal ARF?

a. Dehydration
b. Glomerulonephritis
c. Systemic infection
d. Trauma

6. Which of the following are characteristics of chronic kidney disease (CKD)?

a. Duration of more than 3 months, glomerular filtration rate (GFR) of less than 60 mL/min,
abnormalities in blood chemistry, urinalysis and renal ultrasound
b. Rapid onset, symptoms lasting up to 2 months, result of blunt trauma
c. Confusion, paranoia, abnormal affect, facial tics
d. Sudden pain in upper right quadrant, nausea, vomiting, general prostration

7. Some conditions that contribute to the development of CKD may include the following
disease processes. Which of the following is least likely to be a direct cause of CKD?
a. Chronic obstructive pulmonary disease (COPD)
b. Diabetes mellitus (type 1 and 2)
c. Systemic lupus
d. Hypertension

8. Strict glycemic control is extremely important in diabetic patients to reduce their likelihood of
developing microvascular and macrovascular disease. Diabetic patients with well-controlled
blood sugar levels experience a slower progression to kidney involvement. Which of the
following statements is inaccurate?
a. Brittle (unstable) diabetic patients should be tested frequently to assess the current blood
glucose level.
b. High blood glucose levels may require a bolus of 50% dextrose to prevent insulin shock.
c. The optimal level of glycemic control is less than 7% HbA1c.
d. An elevated glucose level may require the administration of insulin to prevent diabetic coma.

9. The healthy kidney, in addition to synthesizing hormones, also acts as a receptor for certain
hormones. Which of the following hormones does the kidney receive?
a. Estrogen, progesterone, and testosterone
b. Erythropoietin
c. Calcitriol, renin
d. Antidiuretic hormone (ADH), aldosterone, and parathyroid hormones

10. What is the name of the cup-like structure with a thin, double membrane that surrounds the
glomerulus of each nephron?
a. Renal capsule
b. Bowman capsule
c. Afferent arteriole
d. Loop of Henle

11. Intrinsic or intrarenal kidney failure refers to a type of ARF that may be caused by which of
the following?
a. Toxins or medications
b. Bladder stones
c. Blocked urinary catheter
d. Hepatorenal syndrome

12. The National Kidney Foundation has identified factors that contribute to a person’s
susceptibility to CKD. Which of the following may influence the development of CKD?
a. Uncontrolled diabetes, hypertension, systemic lupus
b. Cirrhosis
c. Smoking, age, ethnicity, family history
d. High proteinuria, HIV
e. a, c, and d

13. The GFR refers to the velocity at which filtrates move through a kidney. Staging is a tool that
associates levels of the GFR with degrees of kidney damage. What are the main purposes of
staging?
a. Staging assesses the level of function of the kidney, predicts clinical signs and symptoms, and
aids in evaluating and managing the patient.
b. Staging determines azotemia levels, dehydration, and dialysis effectiveness.
c. Staging assesses the level of bicarbonate and uric acid in the blood.
d. Staging aids in determining fluid overload and anemia.

14. Which of the following tests would be appropriate for evaluating a possible CKD patient?
a. Complete physical exam, MRI of the lumbar spine, complete blood cell count (CBC), and
urinalysis (UA)
b. History and physical, clean-catch UA, CBC
c. Comprehensive personal/ familial history, complete physical examination, CBC, UA, blood
chemistry, and renal ultrasound
d. Physical exam, CBC, chest x-ray, UA

15. Which of the following disease processes may lead to the development of
glomerulonephritis?
a. Antigen-antibody complexes from a streptococcal infection
b. Congestive heart failure
c. COPD
d. Pancreatitis

16. Why is it so important to determine the type and cause of glomerulonephritis?

a. To prevent it from spreading to others
b. To develop a successful treatment plan
c. To keep it from infecting the liver
d. To avoid sepsis

17. Glomerulosclerosis refers to the scarring of the glomeruli, the minute blood vessels in the
kidney. Which of the following are signs or symptoms of glomerulosclerosis?
a. Blurred vision, confusion, restlessness
b. Proteinuria, swelling of the ankles, fluid retention in the abdomen
c. Albuminuria (frothy urine), periorbital edema, headaches
d. Caseation, sterile pyuria, hematuria
18. Conditions that may cause glomerulosclerosis are:
a. Excessive aluminum in diet
b. Anemia
c. Blood transfusion reaction
d. Diabetes, drug use, infection

19. In stage 3 of CKD, with a GFR of 30 to 59 mL/min per 1.73 m2, what level of kidney
damage would be expected?
a. Moderate
b. Severe
c. Little or no damage
d. Mild

20. What are some of the common complications of stage 5 CKD?

a. Ulcerative colitis, rectal bleeding
b. Neuropathy, bleeding disorders
c. Sexual dysfunction, serositis, malnutrition
d. b and c

21. Diabetic nephropathy is one of the main causes of CKD in Western countries. What are the
most common factors that greatly increase the risk of CKD in type 1 and type 2 diabetes?
a. High-carbohydrate diet, inadequate exercise routine
b. Poorly controlled blood sugar levels, unmanaged high blood pressure, high cholesterol levels
c. Obesity, alcohol and drug use
d. Fatty foods, sedentary lifestyle, low water intake

22. Diabetic nephropathy involves an increased blood flow to the kidney, caused by
hyperglycemia (uncontrolled blood sugar). This results in high blood pressure and overstresses
the glomeruli, which then thicken and allow albumen to pass through into the urine. Which of the
following are symptoms of diabetic nephropathy?
a. Hematuria, fever, chilling, prostration
b. Weight loss, diarrhea, dizziness
c. Periorbital edema, frothy urine, hiccoughs, itching
d. Sudden extreme flank pain, hematuria, nausea and vomiting

23. The third leading cause of renal failure is transferred genetically and is known as polycystic
kidney disease (PKD). Fluid-filled cysts replace healthy kidney tissue until renal function
deteriorates. Which of the following correctly explains the difference between PKD that is
transferred by a dominant gene and PKD that originates from a recessive gene?
a. Recessive PKD appears in elderly patients.
b. Symptoms of dominant PKD begin around age 40 and there is a poor prognosis.
c. Recessive PKD is rare and features childhood onset and poor prognosis; dominant PKD is
more common and appears in early adulthood.
d. Recessive PKD is common and appears in early adulthood; dominant PKD is rare.

24. In addition to cysts in the kidneys, PKD may cause cysts or aneurysms to form in other areas.
Which organs may be affected by PKD in addition to the kidneys?
a. Lung, stomach, small intestine, and heart
b. Liver, pancreas, testes, ovaries, spleen, and brain
c. Colon, spleen, and heart
d. Prostate, bladder, and gallbladder

25. Acute tubular necrosis (ATN), or death of the renal tubule, causes 75% of all ARF. What are
the most common causes of ATN?
a. Hemorrhagic shock, trauma, toxicity, sepsis, severe hypotension, blood transfusion reaction
b. Uncontrolled diabetes, atherosclerosis
c. Unmanaged hypertension, COPD
d. Liver disease, cholelithiasis

26. Nephrosclerosis refers to hardening of the arterioles of the kidneys. Which of the following
statement(s) is/are true regarding nephrosclerosis?
a. It is caused by uncontrolled hypertension.
b. Hypertension stretches out the preglomerular arteries and floods the glomeruli.
c. Malignant nephrosclerosis metastasizes to other organs.
d. Malignant nephrosclerosis occurs most frequently in Caucasians patients.

27. Which of the following groups of signs and symptoms may be attributed to benign
nephrosclerosis?
a. Nausea, vomiting, headache, confusion, blurred vision, restlessness
b. Suprapubic pain, fever, elevated white blood cell count, chilling
c. Weakness, shortness of breath, exercise intolerance, inability to think clearly
d. Proteinuria, hematuria, left ventricular hypertrophy, hypertensive retinal changes

28. Cardiovascular events cause more deaths in end-stage renal disease (ESRD) than any other
disease process. Which of the following are cardiovascular events frequently associated with
ESRD?
a. Congenital heart disease, cardiac arrhythmias
b. Aortic valve stenosis, aortic aneurysms
c. Hypertension, atherosclerosis, left ventricular hypertrophy and congestive heart failure,
pericarditis, pericardial effusion
d. Tachycardia and bradycardia

29. In ESRD patients, what is the name of the condition that results from defective
mineralization (calcification) of the bone, usually due to the lack of vitamin D?
a. Osteomalacia
b. Osteosarcoma
c. Adynamic bone disease
d. Metastatic calcification

30. ERSD patients may complain of gout-like (pseudogout) joint pain caused by high levels of
uric acid. What combination of treatments is recommended to alleviate pseudogout?
a. Aspirin regimen, and increased number and duration of dialysis treatments
b. Colchicine or nonsteroidal anti-inflammatory medications, and increased number of dialysis
treatments
c. Temporary cessation of dialysis treatments, and colchicine
d. Corticosteroid injections in the affected joints, maintain dialysis schedule

31. Azotemia (uremia) is an elevation of BUN and serum creatinine in the blood. If left
untreated, uremic encephalopathy may result. Which of the following describe symptoms that
may be seen when encephalopathy develops?
a. Nausea, vomiting, diarrhea, headache, joint pain
b. Flank pain, hematuria, fever, chills, dysuria, numbness and tingling in the fingers
c. Jaundice, urticaria, uremic frost, joint pain
d. Restless leg syndrome (RLS), lethargy, vomiting, emotional lability, coma, death

32. 80% of ESRD patients experience some type of neuropathy (deterioration of nerve function).
Which of the following symptoms may be caused by neuropathy?
a. Burning sensation in feet, RLS, twitching, decreased reflex
b. Itching, dry skin, jaundice, gangrene in toes and fingers
c. Metallic taste in mouth, fetid breath
d. Excessive skin wrinkling, half-and-half nails, ecchymosis

33. The effects of ESRD on the integumentary system (skin, nails, and hair) are varied.
What are the some indications of integumentary involvement?
a. Thinning of the hair, thickening of nails, generalized rash, flaking of scalp
b. Uremic frost, pruritus, hyperpigmentation of mucous membranes, excessive wrinkling,
halfand-half nails
c. Gangrene of toes, burning sensation of feet, fungus infection in nails
d. Deafness, impotence, hirsuitism

34. ESRD patients may experience pulmonary complications. Which of the following reflect
pulmonary complications that ESRD patients may develop as a result of ESRD?
a. Pulmonary embolisms and atelectasis
b. Infections and pulmonary edema
c. Lung carcinomas
d. Pneumothorax

35. The reproductive system of male and female ESRD patients may be affected. In women, this
may result in an interruption of menstruation and ovulation, low pregnancy rates, and low birth
weight and prematurity. What treatments are used to help resolve these complications?
a. Increase in number of dialysis treatments, correction of anemia, and administration of
estradiol
b. Iron supplement, decrease in number of dialysis treatments, exercise program
c. Multivitamin therapy, correction of anemia, psychological counseling
d. Temporary cessation of dialysis, iron supplement, and testosterone therapy

36. Men may also experience sexual complications because of ESRD. Which of the following
medications is prescribed to help alleviate the erectile dysfunction and low sperm count in ESRD
males?
a. Progesterone
b. Calcitriol
c. Deferoxamine mesylate
d. Epoetin alfa

37. The healthy kidney functions to eliminate excess hydrogen ions; however, in the ESRD
patient, the pH of the blood decreases because of the damaged kidney’s inability to produce
bicarbonate, resulting in metabolic acidosis. What are some of the signs and symptoms of
metabolic acidosis in the ESRD patient?
a. Dizziness, hypertension, headache, nausea and vomiting, agitation
b. Kussmaul respirations (deep, rapid breathing), lethargy, tachycardia, hypotension, seizures,
coma
c. Diarrhea, abdominal pain, diaphoresis
d. Frost-like appearance of skin, half-and-half nails, deep pigmentation of mucous membranes
38. Circulating uremic toxins cause frequent GI problems in the ESRD patient. What are the
most frequent complaints?
a. Strawberry tongue, stomach ulcers, diverticulosis, constipation
b. Excessive hunger, loose stools, hiatal hernia, lactose intolerance
c. Nausea, poor appetite, metallic taste, fetid breath, vomiting, GI bleeding, diarrhea or
constipation and impactions
d. Ulcerative colitis, pain in the lower abdomen, bloating, esophageal reflux, diarrhea, bile taste
in mouth

39. What is the explanation for the frequent occurrence of carpal tunnel syndrome (CTS), or
median neuropathy, in ESRD patients?
a. Amyloid deposits in the sheath of the carpal tunnel
b. Trauma from repeated injections
c. Repetitive writing required for dialysis forms
d. Aluminum in the diet

40. The entire endocrine system may be affected by ESRD. What are some of the consequences?
a. Decreased glucagon, from the pancreas, and lower levels of gastrin
b. Inconsistent insulin, epinephrine, and plasma norepinephrine and parathyroid levels
c. Hyperthyroidism, decrease in growth hormone
d. Extreme swings in TRH and TSH (thyroid hormones)

41. In ESRD patients, serum albumin levels are important in predicting morbidity and mortality.
Which of the following contain accurate statements regarding serum albumin?
a. Albumin transports the large molecules of potassium in the bloodstream.
b. Serum albumin is an accurate gauge of the nutritional status of the ESRD patient.
c. Symptoms of low serum albumin include edema, weight gain, increased muscle mass, and
hypertension.
d. As serum levels increase, the risks for morbidity and mortality increase.
42. The parathyroid hormone (PTH) helps maintain the proper levels of calcium and phosphorus
in the blood. Which of the following correctly portrays the role PTH plays in relationship to
calcium blood levels?
a. PTH decreases calcium absorption in the small intestines and increases its excretion through
the kidneys.
b. The optimal calcium-phosphorus product ranges between 80 and 100.
c. When serum calcium levels fall, PTH secretion increases, resulting in resorption of calcium
from the bones and an increased serum calcium level.
d. The lower the level of calcium, the lower the level of phosphorus

43. Damaged kidneys lose their ability to produce erythropoietin, a hormone that stimulates the
formation of red blood cells (RBC). Which of the following describe symptoms of low
hematocrit and/or hemoglobin levels?
a. Chest pain, shortness of breath, fatigue, palpitations, feeling cold
b. Flank pain, fatigue, bradycardia, flushing
c. Nausea and vomiting, diarrhea, edema of ankles, oliguria
d. Hypertension, irritability, emotional lability

44. Damaged kidneys lose their ability to produce erythropoietin, a hormone that stimulates the
formation of RBC. When an ESRD patient experiences low hematocrit and/or hemoglobin, what
is the drug of choice used to stimulate erythropoietin synthesis?
a. Iron supplements
b. Multivitamins
c. Epoetin alfa
d. Calcitriol

45. The ESRD patient may have BUN values that span from 60 to 100 mg/dL. What is the
normal BUN range?
a. 7 to 18 mg/dL
b. 40 to 60 mg/dL
c. 120 to 140 mg/dL
d. 2 to 6 mg/dL

46. Which of the following symptoms indicate an elevated BUN level?

a. Burning sensation in feet, twitching, RLS
b. Insomnia, dry, itchy skin, altered sense of taste and smell
c. Back pain, foot pain, fractures, gangrene in toes and fingers
d. Slurred speech, memory loss, behavioral changes

47. Which of the following statements best defines “creatinine clearance”?

a. The amount of creatinine filtered (cleared) by the kidney during a measured amount of time.
b. The amount of creatinine produced by the kidney in a 1-hour period.
c. The amount of time it takes for a specimen of urine, in an airtight container, to become clear.
d. The measurement of creatinine as compared with the level of the BUN.

48. Creatinine levels are precise markers of renal function. Why is this statement true?
a. Creatinine levels are tied to hemoglobin levels.
b. Creatinine levels do not fluctuate with fluid volume or diet changes.
c. Creatinine levels vary with aluminum intake.
d. Creatinine levels are determined by the amount of protein in the diet.

49. Muscle mass directly impacts creatinine levels. Elderly patients, with a decreased muscle
mass, will demonstrate lower serum creatinine levels. What is the normal serum creatinine level?
a. 5 to 15 mg/dL
b. 20 to 30 mg/dL
c. 0.5 to 1.5 mg/dL
d. 150 to 190 mg/dL

50. Name two drugs commonly used in CKD patients for their diuretic properties.
a. Epoetin alfa
b. Furosemide and bumetanide
c. Sevelamer hydrochloride and calcium carbonate
d. Calcium acetate and sodium bicarbonate

51. Phosphate binders are medications that bind phosphate to decrease the blood phosphate
levels. High blood phosphate may lead to weakening of the bones. Which of the following
medications are used for phosphate binding?
a. Sevelamer hydrochloride, calcium carbonate and calcium acetate
b. Furosemide and bumetanide
c. Epoetin alfa
d. Sodium bicarbonate and aspirin

52. The registered dietician plays an important role in educating the ESRD patient. Which of the
following statements illustrate the benefits of a proper diet for the ESRD patient?
a. High protein reduces nitrogenous wastes
b. May delay need for dialysis, reduce complications, provide adequate nutrition, improve
quality of life
c. Phosphorous supplements aid in bone strength
d. Restricted calories reduce obesity, a major concern in ESRD patients

53. ESRD patients face many life changes and benefit from meeting with social workers and
psychologists. Depression that may result from chronic illness, when experienced without social
support, has been linked to mortality in numerous studies of ESRD patients. Which of the
following stressors may affect the ESRD patient?
a. Family dynamics, dietary restrictions, time constraints, sexual changes
b. Employment adjustments, personal role modification, staff interaction
c. Effects of the illness, medication effects, concerns regarding mortality
d. All of the above

54. Which of the following is the correct description of osteitis fibrosa?

a. Defective mineralization (calcification) of the bone, usually due to lack of vitamin D
b. Low bone resorption and formation
c. Replacement of bone with fibrous tissue
d. Deposits of calcium in normal tissue

55. Which of the following may be considered nephrotoxic to some patients?

a. Intravenous normal saline solution
b. Certain antibiotics, radioisotopic contrast media, chemotherapy agents, street drugs
c. Hemoglobin and myoglobin from damaged muscle tissue
d. b and c

56. What is the term for a myriad of clinical findings that result in massive losses of protein
through the kidney due to leaky, damaged glomeruli?
a. Nephrotic syndrome
b. Acute tubular necrosis
c. Nephrosclerosis
d. Glomerulonephritis

57. Which of the following statements explains how the kidneys affect bone health?
a. Erythropoietin, produced by the kidney, stimulates calcium production
b. Calcitriol, produced by the kidney, enables absorption of calcium by the bones
c. PTH, synthesized by the kidney, aids in calcium absorption
d. TRH, produced by the kidney, facilitates calcium absorption

58. High blood phosphate levels may lead to a weakening of bone. Which of the following are
phosphate-binding medications?
a. Cinacalcet hydrochloride
b. Sodium bicarbonate
c. Sevelamer hydrochloride
d. Epoetin alfa

59. Which of the following symptoms may be associated with nephrotic syndrome?
a. Pitting edema of the legs, morning periorbital puffiness, pulmonary edema, foamy urine
b. Weight loss, fever, chilling, headache
c. Cloudy urine, flank pain, diarrhea, nausea
d. Gangrene of toes, fractures, joint pain, cough

60. What are some of the benefits of early referral of the ESRD patient to a nephrologist?
a. Establishment of dietary prescription
b. Placement of peritoneal or vascular access
c. Early diagnosis and treatment of hypertension, anemia, phosphatemia, and acidosis
d. Early diagnosis of atherosclerosis, hypotension, and alkalosis
e. a, b, and c

61. Which of the following should be included in the predialysis assessment?

a. Schedule gastroscopy and colonoscopy, Doppler exam of lower extremities, chest x-ray,
obtain all necessary consent forms
b. Evaluate social/psychological needs, determine home dialysis vs hemodialysis, assess and
treat infections, attain necessary consent forms, create dialysis access
c. Assess familial status, insert PICC line, spinal MRI, obtain all necessary consent forms
d. Evaluate nutritional status, schedule predialysis cystoscopy, obtain necessary consent forms

62. What are some of the most important predialysis education goals for the patient facing
dialysis?
a. Supplying information regarding dialysis modalities, encouraging self-reliance for personal
health
b. Encouraging in-center dialysis for optimal results, supplying information on nutrition
c. C. Endorsing best nephrologist, supplying information on dialysis modalities
d. . Bonding with patient, supplying personal cell phone for additional questions

63. Which of the following techniques should be used in group sessions for patient predialysis
education?
a. Allow time for interaction with other patients with similar health concerns
b. Schedule individual sessions after work at local restaurants
c. Encourage discussions on dialysis modalities
d. Invite current dialysis patients for their personal insights
e. a, c, and d

64. What is the definition of hemodialysis?

a. Process of removing or filtering metabolic wastes out of the blood through a semipermeable
membrane
b. Process of diluting metabolic wastes to ensure proper filtering through the kidney
c. Process of removing nitrogenous wastes through a permeable membrane
d. Process of filtering small molecules out of the blood through a semipermeable membrane,
while allowing large molecules to pass through

65. What is the main goal of hemodialysis?

a. Cure kidney disease by allowing kidney to rest while patient is dialyzed
b. Remove aluminum, lead, and mercury from the blood
c. Eliminate red blood cells, lymphocytes, and platelets from the blood
d. Supplement healthy kidney function by management of uremia, fluid overload, and electrolyte
imbalance

66. Aluminum toxicity is a concern in dialysis patients. Which of the following are sources that
contribute to the levels of aluminum in the body?
a. Aluminum-containing cookware, beverage cans, antiperspirants, cosmetics, antacids,
aluminum-containing phosphate binders
b. Stainless steel pots and pans, water bottles, shampoo, plastic wrap, soft drinks in bottles
c. Paint, glass thermometers, old toys, fluorescent light bulbs
d. Lipstick, fish, shellfish, certain fruits and vegetables

67. Most aluminum is protein bound so the kidneys may not be able to filter it out of the blood. It
is then stored in various tissues in the body, including the brain and bone. What are the
symptoms of aluminum toxicity?
a. Nausea, vomiting, diarrhea, fever, chills, upper respiratory tract infection, elevated white
blood count, headache
b. Behavioral changes, memory loss, slurred speech, lack of energy, loss of appetite bone
disease, dementia, anemia, constipation
c. Joint pain and redness, gangrene of fingers and toes, back pain, fractures, itching
d. Nausea, vomiting, poor appetite, metallic taste, fetid breath, GI bleeding, diarrhea, functional
constipation

68. Deferoxamine mesylate is a chelating agent. What is the purpose of a chelating drug?
a. Eliminates phosphates in the blood
b. Eliminates excessive pedal edema
c. Destroys microbes in the blood
d. Removes heavy metals such as lead, aluminum, or mercury from the blood

69. One available option for an ESRD patient facing renal replacement therapy is pre-emptive
kidney transplantation. How does the survival rate for this choice compare with other options?
a. Survival rate is better for a patient on dialysis than a transplantation patient
b. Survival rate is superior with transplantation than with standard dialysis
c. Survival rate is the same for dialysis and transplantation patients
d. Survival rate is better for the palliative care patient

70. One of the mechanisms of dialysis is ultrafiltration (convective transport). Ultrafiltration

occurs when what process takes place?
a. Hydrostatic or osmotic pressure forces a liquid through a semipermeable membrane, which
acts as a sieve, leaving larger molecules behind
b. Solutes move from an area of greater concentration to an area of lesser concentration.
c. The dialysate solution is under high pressure and is forced into the blood
d. Reverse filtration is used to “ultrafilter” the blood

71. Many factors affect the successful removal of toxins during dialysis. Which of the following
is correct?
a. Lower temperature of dialysate = higher amount of solutes removed
b. Slower flow of dialysate = greater removal of solutes
c. Lower molecular weight of solutes = more solutes removed
d. Greater blood flow rate = lesser removal of solutes

72. The definition of diffusion, conductive transport, is the movement of solutes from an area of
greater concentration to an area of lesser concentration. This movement is governed by random
molecular motion in which the following statement is accurate:
a. Larger molecules move more slowly, colliding with the membrane for a longer time, resulting
in higher transport rate
b. Smaller molecules move more rapidly, colliding with the membrane frequently, resulting in
higher transport rate
c. Since larger molecules move more slowly, they will collide with the membrane less often,
resulting in a higher transport rate
d. Since smaller molecules move more rapidly, they will collide with other molecules and result
in a lower transport rate

73. During dialysis, blood circulates through a synthetic extracorporeal membranous

compartment, which is bathed in dialyzing solution. Which of the following are too large to be
filtered out of the blood?
a. H2O and urea
b. Red blood cells, white blood cells, and platelets
c. Glucose
d. Creatinine

74. Which of the following best defines concentration gradient?

a. The difference in hydrostatic pressure between the blood and the dialysate solution
b. The movement of solute particles from the side of higher concentration to the side of lower
concentration through the dialysis membrane
c. The rate of movement through a membrane
d. The concentration of a certain type of particle is higher on one side of a membrane than on the
other side
75. During dialysis, when blood and dialysate flow in opposite directions, what type of flow is
present?
a. Concurrent
b. Countercurrent
c. Convective transport
d. Conductive transport

76. The dialysis unit must maintain a certain type of pressure to ensure that reverse filtration does
not occur. What type of pressure is needed in the blood and dialysate compartments?
a. Positive pressure in the dialysate compartment
b. Negative pressure in the blood compartment
c. Negative pressure in the dialysate compartment
d. Positive pressure in the blood compartment
e. d and d

77. If reverse filtration and dialysate solution moves into the blood, what are some possible
results?
a. Infections may result since the water used for dialysis is not sterile
b. Since dialysate is sterile, there would be no negative effects for the patient
c. Toxins cannot be filtered back into the blood because the molecules are too large
d. Bacteria cannot grow in dialysate solution, so no infection could occur

78. What preventative measure may be used to avoid unwanted molecular particles from entering
the patient’s bloodstream if reverse filtration were to occur?
a. Sodium bicarbonate could be added to the dialysate
b. Normal saline solution could be injected to dilute the dialysate
c. A molecular filter can be used to remove bacteria and pyrogens
d. A sodium variation system (SVS) can be employed
79. The geometric properties of the blood pathway refer to the physical properties, such as
length, width, surfaces, or cross-sections. Which of the following is true regarding the geometric
aspects of the blood pathway and the effects that their physical characteristics produce?
a. Length of the pathway: long pathways offer low resistance
b. Number of pathways: more pathways offer lower resistance
c. Cross-section area of the pathway: the larger the cross-sectional pathway, the lower the
resistance
d. Cross-section area of the pathway: the smaller the cross-sectional pathway, the higher the
amount of resistance
e. b, c, and d

80. The viscosity of blood affects resistance in the blood circuit of the dialyzer. Which of the
following statements is true?
a. The greater the number of RBCs in the blood, the higher the hematocrit level, and the more
viscous the blood.
b. The fewer the number of RBCs in the blood, the higher the hematocrit level, and the more
viscous the blood.
c. Hemoglobin levels indicate the number of red blood cells in the blood
d. Hematocrit values reflect the amount of iron in the blood

81. What is the definition of “mass transfer rate,” and is it a constant or does it fluctuate?
a. Mass transfer rate, or solute flux, refers to the stable rate of movement through the
semipermeable membrane during dialysis.
b. Mass transfer rate, or solute flux, refers to both blood and dialysate flowing through the
semipermeable membrane in opposite directions.
c. Mass transfer rate, or solute flux, refers to blood flowing in one direction and dialysate
flowing in the opposite direction through the semipermeable membrane.
d. Mass transfer rate, or solute flux, refers to the rate of movement through semipermeable
membrane during dialysis. It fluctuates constantly.
82. What are some of the advantages of dialysis machines capable of ultrafiltration profiling?
a. Automatically determines the total volume of fluid to be removed
b. Maintains the volume of fluid removal during the treatment to a set level per minute, allowing
for accurate volume control
c. Fluctuates the volume of fluid removal during treatment, automatically dividing the total
volume to be removed (determined by the nurse) by the length of the treatment
d. No advantage of ultrafiltration profiling dialysis machines over dialysis machines that do not
have this feature

83. What condition may develop if the ultrafiltration rate is excessive?

a. Hypovolemia
b. Hypotension
c. Hypertension
d. a and b

84. What are the three streams of fluid used in hemodialysis to maintain the acid-base balance?
a. Purified water, acid concentrate, and bicarbonate concentrate
b. Sterile water, NaCl concentrate, and bicarbonate concentrate
c. Calcium chloride concentrate, glucose concentrate, sterile water
d. Sterile water, acid concentrate, and bicarbonate concentrate

85. Why is bicarbonate dialysate the standard of practice in most dialysis facilities?
a. Bicarbonate dialysate is less expensive than sterile water.
b. The diffusion of bicarbonate acts as a buffer to the hydrogen ions during hemodialysis and
aids in the acid-base balance.
c. Calcium chloride concentrate may increase the calcium levels in the blood and adversely
affect the pulse rate.
d. Glucose concentrate may increase the blood sugar level of the diabetic patient.

86. Which of the following statements is the best description of a plate dialyzer?
a. It consists of sheets of membranes assembled on top of each other
b. Supporting grooved or ridged layers, holds the membrane
c. Blood and dialysate flow through alternate spaces
d. Compliance does not occur, and reuse is recommended
e. a, b, and c

87. The most widely used type of dialyzer is the hollow-fiber dialyzer, or hollow-fiber artificial
kidney (HFAK). What are the features of the hollow-fiber dialyzer?
a. Ultrafiltration can be precisely controlled, they are not compliant, they adapt well to reuse
b. Compliance occurs and reuse is not recommended
c. Sterilization is simple, by numerous methods
d. Layers of grooves and ridges keep the membrane in place

88. What type of membrane is used in Cuprophan, Cuprammonium rayon, and Hemophan?
a. Synthetic
b. Plastic
c. Silk
d. Cellulose

89. What are the main pros and cons of cellulosic membranes?
a. Low cost, but bioincompatibility with blood may occur
b. Readily available, but only available in hollow fiber form
c. Reusable, but expensive
d. Low cost, but only available in flat sheets

90. Polyacrylonitrile (PAN), polysulfone (PSf), polyamide, and polymethacrylate (PMMA) are
some of the varieties of synthetic membranes. Synthetic membranes made from thermoplastics
have their own advantages and disadvantages. Which of the following are accurate examples of
their pros and cons?
a. Bioincompatible and risk of back filtration from dialysate to blood
b. Biocompatible, but no ultrafiltration needs to be used
c. Reusable, but protein may be absorbed to the membrane surface
d. Inexpensive, but bioincompatible
e. a, b, and c

91. What is the best definition of biocompatibility when used in reference to hemodialysis
membranes?
a. Biocompatibility refers to a severe reaction with a high level of inflammation.
b. A membrane is biocompatible if the blood clots when it encounters the membrane.
c. Biocompatibility refers to the complete lack of response of the blood when it contacts the
membrane.
d. Biocompatibility refers to a mild reaction by the blood to contact with the membrane.

92. What are some of the possible negative effects and clinical signs and symptoms of long-term
usage of bioincompatible membranes?
a. Infection, malignancy, damaged nutritional state, β2-amyloid disease
b. Bone lesions, arthropathies, fractures, edema, carpal tunnel syndrome
c. Nausea, vomiting, diarrhea, fever, chills
d. a and b

93. What are the main disadvantages of reusing a dialyzer?

a. A large volume of dialysate is required to clean a dialyzer.
b. Processing, sterilizing, testing, and identifying require time, trained personnel, and storage
space.
c. “First-use syndrome” with chest or back pain, nausea, and malaise is common with reused
dialyzers.
d. Cost per dialysis is substantially increased with reused dialyzer.

94. What is the name of the method used to deliver solutions that produce dialysate to the
machine?
a. SDS, or solution delivery system
b. DSL, or delivery system line
c. SDL, or solution delivery line
d. DSS, or delivery solution system

95. Dialysate is a solution that is prepared as a chemical composition to be as similar to normal

plasma as possible. What are the usual chemical components of dialysate solution?
a. Sodium chloride, calcium chloride, glucose
b. Sodium bicarbonate, sodium chloride, calcium chloride, potassium chloride, magnesium
chloride
c. Potassium cyanide, magnesium chloride, sodium bicarbonate, calcium citrate
d. Magnesium sulfate, potassium chloride, sodium chloride, sodium bicarbonate, and glucose, if
needed

96. What are some of the potential problems associated with bicarbonate dialysate?
a. It is an unstable solution and requires a stabilizer to be added.
b. It is vulnerable to bacterial contamination.
c. Sterile water must be used.
d. It must be used within 24 hours of being mixed.
e. a, b, and d

97. What is the purpose of the primary and secondary tests that are performed on dialysate?
a. The primary test calculates the sterility of the solution, the secondary test is done for
conductivity.
b. The primary test calculates the osmolality of the dialysate, the secondary tests the
conductivity.
c. The primary test calculates the concentration of a solute by the laboratory method called
reliability; the secondary test uses overall conductivity.
d. The primary test calculates the freezing point of the dialysate, the secondary tests for vapor
pressure.

98. The sorbent regenerative system is the name of a system that uses a cartridge of absorbent
materials through which dialysate is recirculated and chemically regenerated. What are the
actions performed by this system?
a. Converts urea into ammonium carbonate, adsorbs creatinine, uses ion exchange resins
b. Removes metabolic wastes from the dialysate and the pH and electrolyte content are restored
c. Controls the blood flow rate
d. a and b

99. Dialysate temperature must be controlled. How is this accomplished and at what temperature
should the dialysate be set?
a. Temperature of dialysate is controlled by one or more sensors plus a micro-controller device,
and an additional independent online sensor, temperature at 35° to 38°C
b. Temperature is controlled by two sensors, one in the dialyzer and one online, temperature at
more than 41°C
c. Temperature is controlled by online thermometers set at 36-inch intervals, maintaining a
dialysate temperature at 36°C
d. Temperature of dialysate is controlled by one or more sensors plus a microcontroller device,
and an additional independent online sensor, temperature set at 0.5°C

100. Deaeration devices are used on dialysate solution. What is the rationale for this process?
a. Microbubbles and dissolved air are found in water.
b. As the temperature increases, the air trapped in the water is released as expanding
microbubbles.
c. Microbubbles negatively affect conductivity sensors, temperature, and flowmeters.
d. Bubbles increase contact of dialysate and membranes in hollow-fiber dialyzers.
e. a, b, and d

101. In the sorbent regenerative system, what is contained in the four chambers?
a. Activated charcoal, phosphate, uric acid, and cubic zirconium
b. Activated carbon, hydrated zirconium oxide, zirconium phosphate, and urease
c. Zinc oxide, activated carbon, urease, and zirconium
d. Hydrated zinc, zirconium phosphate, urease, and activated carbonation
102. In the two-tank sorbent regenerative system, what is the function of the first tank, the
“working tank”?
a. The working tank removes chlorine and chloramines.
b. The working tank removes bacteria and viruses.
c. The working tank absorbs aluminum.
d. The working tank absorbs iron and magnesium.

103. What is the purpose of rotating the first and second tanks in the two-tank sorbent
regenerative system?
a. Rotation of the polishing tank and the working tank helps mix the solutions.
b. The second tank, the polishing tank, has very little chlorine and chloramine and may contain
bacteria; rotating the tanks helps eliminate this problem.
c. Rotation of the working tank and polishing tank helps with the absorption of ammonia.
d. Rotation of the polishing tank with the working tank helps equalize the metabolic waste
distribution.

104. Which one of the following best describes the function of the blood leak detector?
a. Blood leak detectors work by monitoring the pressure of the blood at the injection site.
b. Blood leak detectors use a computerized cell to determine the number of microbubbles in the
dialysate line, then set off the alarm.
c. Blood leak detectors work by using a photoelectric cell to generate a light beam through the
dialysate, which detects any change in the translucence and sets off alarms to stop the blood
pump.
d. Blood leak detectors work by counting the number of erythrocytes that pass through the
dialysate.

105. The volumetric ultrafiltration device features which of the following?

a. It is more advanced than the flowmetric type, and ensures that the volume delivered to the
dialyzer equals the volume removed
b. It uses two diaphragm chambers to balance dialysate inflow and outflow.
c. Chamber 1 fills with spent fluid, while chamber 2 ejects an equal amount of dialysate
d. Varies speed of dialysate pump to equal volume through inflow meter.
e. a, b, and c

106. There is a possibility of reverse filtration occurring at the distal end of the dialyzer during
highflux dialysis. What test is used to determine contamination by endotoxins if reverse filtration
occurs?
a. Gram-negative test
b. Limulus amebocyte lysate (LAL) test
c. Partial thromboplastin time (PTT)
d. Gram-positive test

107. Which of the following steps must be taken in order to prepare a dialyzer prior to
patient use?
a. Remove all air from dialyzer, remove all disinfectants and residuals, flush and prime with
normal saline solution
b. Irrigate dialyzer with bactericide, remove all disinfectants and residuals, prime with sterile
water
c. Submerge dialyzer in sterile saline solution to remove air, remove disinfectants and residuals,
prime with sterile normal saline solution
d. Prime with sterile saline to remove manufacturing particulates, irrigate dialyzer with
disinfectant, hang to dry thoroughly

108. Which of the following describes the proper technique for removing air from a dialyzer?
a. Attach all bloodlines to the dialyzer, fill with normal saline solution, turn and tap to remove
all air bubbles.
b. Beginning at the bottom, attach bloodlines, turn venous side up and prime with normal saline
solution. Next use the arterial blood line, infuse normal saline solution through and out the
venous lines. Gently tap and turn dialyzer side to side to remove all air bubbles from the header.
c. Beginning at the top, attach bloodlines, irrigate with sterile water, repeat with venous lines.
Hold entire dialyzer under water to remove all air bubbles.
d. Attach venous bloodlines to the dialyzer. Irrigate with normal saline solution. Shake
vigorously to remove air bubbles.

109. New and reused dialyzers have to be primed before each use. Which of the following
statements best explains the priming process?
a. On all dialyzers, the flow should be counterclockwise, using 3000 mL of normal saline
solution.
b. A minimum of 2000 mL of normal saline solution must be used for priming for all
manufacturers.
c. 500 to 1000 mL of normal saline solution is used, depending on the type of unit. Each
manufacturer’s instructions should be carefully followed.
d. 1000 to 2000 mL of clean water must be used to ensure that all glycerin and particulates are
removed.

110. Name two advantages of reusing a dialyzer.

a. Reused dialyzers are less expensive, but patients are more apt to have life-threatening allergic
reactions to them; there are more reused dialyzers available than new ones.
b. Reused dialyzers are sterilized and may be used on any patient, not just the one they were
originally used on; they are less expensive than new ones.
c. Reused dialyzers are less expensive; patients can process them at home with bleach.
d. Once the patient’s dialyzer has been reprocessed, life-threatening reactions do not occur; cost
savings is an important aspect of reusing a dialyzer.

111. Disinfectants that are usually used for dialyzer reprocessing include which of the following?
a. Renalin, bleach, formaldehyde, heat, glutaraldehyde
b. Bleach, steam, ethylene oxide, radiation
c. Hydrogen peroxide, ozone, electron sterilization
d. Renalin, radiation, hydrogen peroxide, silver

112. What are the labeling requirements for reused dialyzers?

a. Patient’s name: must be used for only one patient
b. Number of prior uses, date of last reprocessing
c. Social security number or birth date
d. Manufacturer of dialyzer
e. a, b, and c

113. OSHA guidelines for personnel safety when using chemical disinfectants include which of
the following?
a. Protective gear, including eye shields, gloves, waterproof gowns, plus sufficient ventilation
b. Negative pressure decontamination room
c. Splashes on skin or in eyes must be immediately flushed with copious amount of water, then
medical attention sought
d. Shower and eyewash station available
e. a, c, and d

114. Either Renalin or formaldehyde is the product of choice most often used for the
decontamination process for dialyzers. Explain the makeup of Renalin and describe the
recommended contact times for each.
a. Renalin is a combination of paracetic acid, acetic acid, and hydrogen peroxide
b. Renalin is a combination of hydrogen peroxide and sodium hypochlorite
c. Aqueous formaldehyde (formalin) in a 4% solution must be used for 24 hours
d. Renalin in a 0.5% solution must be used for 11 hours
e. b, c, and d
f. a, c, and d

115. What are some of the potential hazards of formaldehyde exposure?

a. Irritation in the nose, eyes, and throat; allergic reactions such as wheezing, cough;
asthmarelated symptoms; nasal and lung cancer
b. Pulmonary edema and pneumonitis, which can be fatal
c. Skin redness, pain, and burns; splashes to eyes may cause blindness
d. Ingestion may cause nausea, but is not toxic
e. a, b, and c
116. The National Kidney Foundation (NKF) has determined the order of preference for
permanent vascular access points for patients receiving ongoing hemodialysis. What are the top
two sites?
a. Transposed brachiobasilic vein fistula, then elbow (brachiocephalic) primary arteriovenous
fistula
b. Wrist (radiocephalic) primary arteriovenous fistula, then elbow (brachiocephalic) primary
arteriovenous fistula
c. Cuffed tunneled central venous catheter, then transposed brachiobasilic vein fistula
d. Arteriovenous graft of synthetic material, then cuffed tunneled central venous catheter

117. What are the different configurations a surgeon can choose to create an internal
arteriovenous (AV) fistula?
a. Side-by-side
b. End of vein to artery
c. End of artery to vein
d. End-to-end spatulated artery and vein
e. a, b, and c
f. a, b, c, and d

118. When should the AV fistula surgery be done, as recommended by the K/DOQI Clinical
Practice Guidelines 2002?
a. When the GFR is more than 30 mL/min per 1.73 m2
b. When the GFR is less than 30 mL/min per 1.73 m2
c. When the GFR is more than 60 mL/min per 1.73 m2
d. When the GFR is less than 90 mL/min per 1.73 m2

119. What is the synthetic material that is most commonly used as AV grafting material?
a. Polytetrafluoroethylene (PTFE)
b. Hydroxyapatite
c. Dacron polyester
d. Polydioxanone (PDO)
120. When a loop graft is used, what technique is used to determine blood flow?
a. Once the needle is in place, the venous side will show a flashback of blood when the venous
side is depressed.
b. Depress the graft at the center, then listen for a bruit, or feel for a “thrill” on each side of the
graft.
c. Insert the needle and observe the color of the blood.
d. Send a sample of blood from each side of the loop to the lab.

121. What are some of the advantages of the AV fistula over the AV graft?
a. May last for decades, optimal patency rate, lowest rate of complications
b. Collateral circulation forms, performance improves with time, highest blood-flow rates
c. Ease of graft insertion, less time for maturation of site
d. a and b

122. List some of the disadvantages of the AV fistula over the AV graft.
a. In AV fistula, there may be failure of the vein to distend properly, and more difficulty with
cannulation than the AV graft
b. AV fistula is cosmetically unappealing, requires healthy, straight veins, and needs more time
to mature before ready for use.
c. In AV fistula, the reaction to surgery is greater than with AV graft, and there is a higher
thrombosis rate.
d. With AV fistula, there is a higher infection rate and possible stenosis at anastomoses site.
e. a and b
f. c and d

123. What are the ingredients found in the “A” concentrate (which indicates acidified) portion of
the dialysate?
a. Sodium, calcium, magnesium, potassium, chloride, and acetic acid
b. Sodium, aluminum, copper, and magnesium
c. Acetic acid, sodium, calcium, and lead
d. Acetic acid, potassium, and sodium bicarbonate
124. The “B” (bicarbonate) concentrate is made with sodium bicarbonate, and in some systems, a
portion of sodium chloride is mixed into this solution. What is the main purpose of mixing the
sodium chloride in with the sodium bicarbonate?
a. To increase the ability of the dialysate to remove metabolic wastes from the blood
b. To decrease the clotting of the blood
c. To decrease the patient’s blood pressure, which tends to rise during dialysis
d. To increase overall conductivity, producing a concentrate that is easy to monitor

125. Give details about the sodium variation system (SVS), also known as sodium modeling, and
the two methods used to deliver the sodium concentration to the dialyzer.
a. SVS is a device that may be used to decrease arm and leg cramping and hypotension.
b. SVS uses a computer to monitor the amount of sodium and water movement between
compartments during hemodialysis, then varies the sodium content.
c. SVS either adds a special NaCl concentrate, or varies the proportion of the usual concentrate.
d. SVS adds either NaCl or KCl to the dialysate.
e. a, b, and c
f. a, b, and d

126. Describe the clinical manifestations of the intradialytic complement activation.

a. Leukopenia that corrects itself after 15 minutes; C5a, the end product of the complement
cascade, activates white cells to be released and to clump (frequently in the lungs)
b. Reduction in the patient’s ability to exchange O2 and CO2, resulting in hypoxemia
c. Chest pain, back pain, coagulation abnormalities, and anaphylaxis may develop, reactions
usually peak in 15 minutes, but may last 90 minutes
d. Synthetic membranes cause the most severe reactions
e. a, b, and c
f. a, b, and d

127. As a nurse working closely with a long-term hemodialysis patient, you notice that he is
becoming increasingly quiet and withdrawn. You best option would be which of the following?
a. Invite him to a nice restaurant where the two of you can discuss his mental status in private.
b. Refer him to the social worker and psychologist for more professional help.
c. Maintain a professional relationship with him, but refuse to discuss his feelings.
d. Inform his physician of your concerns, then take yourself off his case.

128. A purification (not sterilization) system must be used if utilizing a municipal water supply
for dialysis, in order to remove small molecular weight contaminants that may be present. List
the most common contaminants and the effects they could have if they were to enter a patient’s
blood.
a. Aluminum, which could cause bone disease, fatal neurological deterioration, dialysis
encephalopathy syndrome, and anemia
b. Copper, zinc, and chloramine could cause hemolytic anemia
c. Fluoride may cause severe pruritus, nausea, and fatal ventricular fibrillation
d. Bacteria and endotoxins could cause infections and pyrogenic reactions
e. a, b, and c
f. a, b, c, and d

129. Systems used for the purification of water for use in dialysis employ three main processes,
pretreatment and softening, primary purification, and distribution. What is involved in
pretreatment?
a. Controlling the temperature of the water
b. Correction of the pH, if necessary
c. Removal of calcium
d. Removal of magnesium
e. a and b

130. The primary purification process, which is usually reverse osmosis plus deionization, is the
next step in the dialysis water purification process. Which of the following describe the effects of
reverse osmosis and deionization on water?
a. Removes more than 95% of ionic contaminants
b. Provides barrier against endotoxins and bacteria
c. Exchanges sodium, chloride, phosphate, fluoride, calcium, and aluminum for hydrogen and
hydroxyl ions, which combine to form water
d. Controls temperature of water
e. a, b, and c

131. The high-efficiency dialysis system consists of which of the following features?
a. Highly permeable cellulose membrane
b. Blood flow of 350 mL/min, dialysate flow of at least 750 mL/min
c. Bicarbonate dialysate delivery system
d. Highly permeable synthetic membrane
e. a, b, and c

132. The high-flux dialysis system consists of which of the following features?
a. High blood flow and high dialysate flow rates
b. Precise control of ultrafiltration volume
c. Highly permeable cellulose membranes
d. Highly permeable synthetic membranes
e. a, b, and c
f. a, b, and d

133. A tap water supply meets all the standards for the Safe Drinking Water Act and EPA. Which
of the following statements explain the reasons why this water is still not safe for use in dialysis?
a. It may be acidic or alkaline.
b. Contaminants, such as chemicals, silt, pesticides, or organic compounds, may enter the
patient’s bloodstream.
c. It is more likely to cause reverse filtration.
d. Substances harmless when ingested may be toxic when absorbed into the blood.
e. a, b, and c
f. a, b, and d

134. What is the proper placement of a venous dialysis needle?

a. In the same direction as the blood flow, antegrade
b. In the opposite direction of the blood flow, retrograde
c. Always using the same angle of insertion
d. A minimum of 10 cm distal to the arterial needle

135. Describe the proper placement of the arterial dialysis needle.

a. Must be at least 3 cm from the anastomoses
b. May be inserted antegrade or retrograde
c. Must always be inserted retrograde (away from the heart)
d. a and b

136. What is “black blood syndrome” and what causes it?

a. It refers to the dark appearance of the blood when recirculation occurs.
b. It refers to excessive bruising found on dialysis patients.
c. It refers to venous pooling in the feet.
d. It refers to a slow blood flow rate.

137. You are caring for a patient with a newly created dialysis fistula. What are some of the
techniques you should employ?
a. If bleeding lasts more than 5 minutes after needles are removed, adjust heparin dosage.
b. Elevate the arm to decrease the possibility of swelling.
c. Apply manual pressure or a light pressure dressing over the injection site for 10 to 20 minutes
after the needles have been removed.
d. Check for formation of hematomas under the skin and oozing at the puncture sites.
e. b, c, and d

138. Describe the features of the LifeSite Hemodialysis Access System.

a. It is an implantable device placed subcutaneously and used as a central venous blood access
port for hemodialysis.
b. It is comprised of a metal valve and cannula line.
c. It extends into the subclavian or jugular vein.
d. It extends into the inferior vena cava.
e. a, b, and c

139. Describe the “buttonhole” technique of accessing a vascular access point.

a. It involves entering the access point at various angles to prevent formation of scars.
b. It involves entering the access point through the exact same site and same angle, creating a
tunnel tract of scar tissue.
c. It results in less pain for the patient and fewer cases of infiltration.
d. b and c

140. What are advantages of cuffed dialysis catheters over uncuffed catheters?
a. Uncuffed catheters are associated with high infection rates.
b. Uncuffed catheters migrate.
c. Uncuffed catheters result in more recirculation.
d. a and b
e. a and c

141. A femoral catheter is sometimes used for hemodialysis. Which of the following
are indications for using the femoral site?
a. When an acutely ill patient is confined to bed
b. When dialysis is acutely needed and normal access is compromised
c. When dialysis is needed and the patient travels in his work
d. When the patient has subclavian vein stenosis
e. a, b, and d

142. When a femoral catheter is inserted, certain complications may occur. What are some
problems that may be seen after the placement of a femoral catheter?
a. Pneumothorax
b. Hemothorax
c. Air embolism
d. Bleeding from inadvertent puncture of femoral artery
e. a and c
f. a, b, c, and d

143. What are the advantages of a side-by-side (double-D) configuration catheter?

a. Less recirculation
b. Large separation of inlet and outlet ports
c. Less pliable catheters
d. a and b
e. b and c

144. Patients with difficulty breathing, who cannot be placed in supine or Trendelenburg
positions, are not good candidates for access to certain veins. Which veins should not be
considered for hemodialysis in this group of patients?
a. Subclavian and jugular
b. Cephalic and femoral
c. Brachiobasilic and jugular
d. Cephalic and subclavian

145. The “radial artery steal” syndrome is best explained by which of the following statements?
a. A syndrome in which the radial artery has extremely high pressure, which causes the ulnar
artery to flow into the fingers and hand
b. A syndrome in which the radial artery has a lower arterial pressure; the pressure gradient
causes the ulnar artery blood to flow into the fistula instead of supplying blood to the hand and
fingers, which become painful and cold
c. A syndrome in which the ulnar artery has low pressure, causing the blood to flow away from
the fistula, resulting in painful, cold fingers
d. A syndrome in which blood radiates from the fistula and leaks into surrounding tissue

146. If a patient receives an infusion of air during dialysis, what appropriate actions should
immediately ensue?
a. Clamp bloodlines
b. Discontinue dialysis
c. Position patient on left side, in Trendelenburg position, for several hours
d. Maintain airway, administer oxygen if necessary, obtain chest x-ray
e. a, b, and d
f. a, b, c, and d

147. When a dialyzer has been sterilized with formaldehyde, it must be adequately rinsed prior to
use. If this procedure has not been done completely, explain the symptoms of formaldehyde
exposure the patient may exhibit.
a. Anxiety, bitter, peppery taste in mouth
b. Burning at venous needle site
c. Chest pain, back pain, and shortness of breath
d. Numbness around the lips and mouth
e. a and c
f. a, b, c, and d

148. If a patient has been exposed to formaldehyde that was inadequately removed from the
dialyzer, what steps must be immediately taken?
a. Stop dialysis
b. Remove approximately 10 mL of blood from each needle
c. Place patient in Trendelenburg position
d. a and b

149. What are the common complications that occur during dialysis?
a. Hypotension and cramping
b. Nausea, vomiting, and itching
c. Headache, chest, back pain, fever, and chills
d. a and c
e. a, b, and c

150. What is the meaning of the term “dry weight” as it refers to the dialysis patient?
a. Weight of the patient prior to IV therapy
b. Weight of the patient in the morning before any oral intake
c. Weight of the patient postdialysis after all the excess body fluid has been removed
d. Weight of the patient prior to dialysis

151. If the patient’s dry weight is set too high, what could result?
a. Hypotension, cramping, dizziness
b. Edema and pulmonary congestion
c. Malaise
d. Nausea and vomiting

152. As the nurse in the dialysis unit, you use preventative measures to avoid the common
complication of hypotension. What are some of the techniques you use?
a. Use care in determining “dry weight.”
b. Encourage patient to avoid intradialytic food ingestion.
c. Instruct patient to limit salt intake and avoid interdialytic weight gain.
d. Administer antihypertensive medications after dialysis treatment, not before.
e. a and d
f. a, b, c, and d

153. Certain medications may help with hypotension and cramping during dialysis. Which of the
following medications are commonly used to prevent these complications?
a. Quinine sulfate, carnitine, oxazepam, and prazosin
b. Potassium chloride, calcium citrate
c. Enalapril, furosemide
d. Aminophylline, epinephrine

154. Which of the following complications could develop when using venous catheters for
dialysis as opposed to traditional hemodialysis access sites?
a. Infection, increased inflammatory markers, such as C-reactive protein
b. Higher mortality rate
c. Inadequate blood flow through catheters
d. a, b, and c
e. a and c

155. If severe hypotension occurs during dialysis, what immediate steps should be taken?
a. Place patient in Trendelenburg position (feet up, head down)
b. Administer a bolus of saline 0.9%, 100 mL or more, through the bloodline (if respiratory
status tolerates)
c. Reduce ultrafiltration rate to near zero
d. Increase ultrafiltration rate to maximum
e. a, b, and d
f. a, b, and c

156. During dialysis, it is important that the nurse constantly observes and documents the
condition of the patient and the patient’s response to the dialysis treatment. Which of the
following need to be monitored and evaluated by the nurse and patient care technician (PCT)?
a. Arterial and venous pressures, and vital signs
b. Blood flow rate, amount of ultrafiltrate removed
c. Transmembrane pressure (TMP), and amount of treatment time remaining
d. Dialysate temperature, dialysate flow, and conductivity
e. a and c
f. a, b, c, and d

157. Weight is an important indicator that must be monitored before, during, and after dialysis.
Which of the following best explains the role of weight in the dialysis patient?
a. Weight, before and after dialysis, assesses how well the patient is controlling fluid balance.
b. Predialysis weight indicates the level of ultrafiltration needed.
c. Postdialysis weight measures the amount of ultrafiltration that occurred during dialysis.
d. Intradialytic weight gain may be due to fluid retention.
e. a, b, c, and d
f. b and c
158. Blood pressure is another physical assessment that is necessary with the dialysis patient.
What are possible implications that hypertension and hypotension may signal during dialysis?
a. Hypertension may signal volume overload
b. Hypotension may indicate dehydration
c. Systolic values of more than 170 mm Hg should be reported to physician
d. Diastolic values of more than 100 mm Hg should be reported to physician
e. a and b
f. a, b, c, and d

159. Temperature, pulse, and respirations should be assessed during dialysis. What complications
of dialysis could be signaled by abnormal findings in the temperature, pulse, and respiration
(TPR)?
a. High temperature could indicate infection, pyrogen reaction, or high temperature of dialysate
b. Fast pulse may signal anemia or fluid overload and falling blood volume; arrhythmia may
denote cardiac complications
c. Fast respiratory rate may indicate fluid gain
d. a, b, c, and d
e. a and b

160. Thorough preassessment of the dialysis patient is very important. What are some of the
evaluations that need to be performed?
a. Fluid status (heart sounds, respiration rate, effort and breath sounds, jugular vein distension
[JVD], presence or absence of edema), weight
b. Bowel regularity, sleep problems, pain, residual renal function
c. Bleeding or bruising, skin color, integrity, turgor
d. Blood pressure, sitting and standing, TPR with apical/peripheral pulse assessment, vascular
access patency and status, laboratory tests and data
e. a and d
f. a, b, c, and d
161. Basic steps that must be taken prior to commencing dialysis treatment include which of the
following concerning the dialysate?
a. Is adequate to complete treatment and is as ordered by the physician
b. Is within proper safety limits (12.8 to 14.8 mho) per Myron-L meter
c. Meets prescribed potassium/calcium level
d. Is at proper temperature (35° to 37°C)
e. a and d
f. a, b, c, and d

162. Additional preassessments done prior to initiating a dialysis treatment consist of which of
the following that concern the blood line and pump?
a. Check blood tubing for leaks, kinks, and folds
b. Verify extracorporeal blood circuit is free of air
c. Confirm that blood pump is properly occluded
d. Ensure blood line is properly inserted in pump segment
e. a and d
f. a, b, c, and d

163. There are two sources of heparin. Which of the following statements is accurate?
a. One source of heparin is beef lung
b. One source of heparin is pork intestinal mucosa
c. Porcine heparin is more potent than beef lung heparin
d. Heparin comes from the coconut palm and the majesty palm
e. a, b, and c

164. What is the most commonly used heparin concentration in dialysis?

a. 1000 units/mL, from either source since both sources are formulated to produce the same
amount of anticoagulation properties
b. 100 units/mL, based on dry weight
c. Always ordered by physician, usually based on patient’s dry weight
d. a and c
165. What is the definition of “regional heparinization”?
a. An intermittent infusion of heparin via the arterial line during dialysis
b. A continual infusion of heparin via the arterial line during dialysis, with a concurrent infusion
of antidote into the venous line
c. Heparin administered by separate continuous IV drip during dialysis
d. Heparin administered orally during dialysis

166. Explain the term “tight heparinization.”

a. A technique of low-dosage heparin administration in which the amount given is determined by
frequent clotting times, maintaining a clotting time of 90 to 120 seconds by activated clotting
time (ACT).
b. A continual infusion of heparin via the arterial line during dialysis, with a concurrent infusion
of antidote into the venous line
c. A technique of high-dosage heparin in which the amount given is determined by frequent
clotting times, maintaining a clotting time of 120 to 140
d. A technique often used for first dialysis treatments, any patient at risk for bleeding, such as
postsurgery or menstruating, or one who has a central venous catheter that will be removed
postdialysis.
e. a and d

167. Hemodialysis done without the use of an anticoagulant is the therapy of choice for patients
with a certain conditions. Which of the following illnesses would possibly require heparin-free
dialysis?
a. Pericarditis, coagulopathy, thrombocytopenia
b. Diabetes, congestive heart failure
c. Pulmonary edema, fibromyalgia
d. Migraine headaches, rheumatoid arthritis

168. Proper techniques for assessing the internal access point, prior to inserting the needle,
include which of the following?
a. Observe for redness, inflammation, or warmth, which could indicate infection
b. Cold, which could indicate thrombosis
c. Check prior injection sites for healing, scabbing, and open sores
d. Assess for bruising, pain, numbness, or edema; if swelling is present, the circumference of the
arm should be tape-measured for later comparison to assess the progress.
e. a, b, c, and d
f. a and d

169. What is the meaning of the term “loading dose”?

a. “Loading dose” refers to the amount or dosage of a drug administered in order to obtain a
therapeutic plasma level as quickly as possible.
b. “Loading dose” refers to a drug that is administered over several weeks.
c. “Loading dose” refers to the first dialysis treatment.
d. “Loading dose” refers to the amount of drug given IV during dialysis.

170. Drug-induced renal damage is frequently reversible if certain steps are taken. What are
some of the techniques used to help terminate any damage that is occurring and prevent further
injury to the kidney?
a. Discontinue the nephrotoxic drug immediately.
b. Administer saline IV to dilute the nephrotoxins in the renal tubules.
c. Administer misoprostol to diminish damage from nonsteroidal anti-inflammatory drugs
(NSAIDs).
d. Prevent it by giving lowest effective dose of any drug, for shortest duration for effectiveness.
e. a, b, and c
f. a, b, c, and d

171. Patients undergoing dialysis for ESRD often experience psychological stressors due to
chronic illness and treatment constraints. Which of the following are considered psychological
complaints?
a. Sexual dysfunction
b. Anxiety, anger, hostility, depression
c. Expense of treatment
d. Dietary restrictions
172. What are the most common conditions found in adults, children, and infants who require
acute dialysis treatment?
a. Symptomatic uremia, despite BUN and creatinine levels
b. Pulmonary edema, fluid overload, or acute myocardial infarction
c. Hyperkalemia, acidosis, neurologic symptoms
d. Drug overdose or poisoning with high molecular weight and lipid soluble drugs
e. a, b, and c
f. a, b, and d

173. What is the most common cause of acute renal failure in children of North America?
a. Hemolytic uremic syndrome
b. Septic shock
c. Severe dehydration
d. Poststreptococcal glomerulonephritis

174. Causes of chronic kidney disease (CKD) in pediatric patients are different from the
etiologies of CKD in adults. What are some of the most common causes of pediatric CKD?
a. Congenital urinary tract anomalies, such as posterior urethral valves, obstructive uropathy,
reflux nephropathy, or renal dysplasia
b. Neurogenic bladder, associated with spina bifida
c. Hereditary diseases, including cystinosis, hyperoxaluria, and autosomal recessive polycystic
kidney disease
d. Acquired glomerulonephropathy, focal segmental glomerulosclerosis, and
membranoproliferative glomerulonephritis
e. a, b, c, and d
f. a and c

175. What is the preferred method of treatment for most pediatric patients with ESRD?
a. Hemodialysis with femoral venous line
b. Transplantation
c. Peritoneal dialysis
d. Hemodialysis with central venous line

176. What are some of the advantages of peritoneal dialysis (PD) over hemodialysis?
a. Equipment is easy to set up and use, simpler treatment
b. Home-based therapy
c. Little need for special water systems
d. a and b
e. a, b, and c

177. What are the two types of manual peritoneal dialysis (PD)?
a. Continuous ambulatory peritoneal dialysis (CAPD) in which the patient performs manual
exchanges 4 to 5 times a day
b. Continuous cycling peritoneal dialysis (CCPD) in which the exchanges are done while the
patient is sleeping
c. Intermittent peritoneal dialysis (IPD) in which frequent exchanges are done several times a
week, for patients with residual function or who are institutionalized
d. a and b
e. a and c

178. What are some of the contraindications for peritoneal dialysis (PD)?
a. Abdominal adhesions, fibrosis, or malignancy
b. Some diabetic patients experience an excessive glucose load supplied via PD and tend to
have a higher mortality rate than hemodialysis patients
c. Recurring peritonitis
d. a and c
e. a, b, and c

179. The peritoneum membrane consists of the lining of the abdominal cavity, pelvic walls,
including the diaphragm (parietal peritoneum), and the covering of the abdominal organs
(visceral peritoneum). How does it differ in males and females?
a. The peritoneum is completely sealed in males.
b. The peritoneum of females is open into the fallopian tubes and ovaries.
c. The peritoneum is open in males.
d. The peritoneum is sealed in females.
e. c and d
f. a and b

180. Peritoneal dialysis uses the peritoneal cavity, which is approximately equal to the body’s
surface area, as a reservoir in which the dialysate is infused via a catheter. In peritoneal dialyses,
what is the action of the peritoneum?
a. Semipermeable membrane through which surplus body fluid and solutes, including uremic
toxins, are removed (ultrafiltrate)
b. Permeable membrane through which dialysate filters
c. Permeable membrane through which metabolic wastes are removed
d. Semipermeable membrane through which blood is filtered to remove metabolic wastes

181. The peritoneal membrane maintains contact with an abundance of blood vessels that supply
the abdominal organs. In peritoneal dialysis, the dialysate is infused by means of a catheter,
permitted to remain in the peritoneal cavity for a set amount of time, and then removed
(effluent). What is this procedure called?
a. Effluent drainage
b. An exchange
c. Uremic toxins removal
d. Solute drag

182. Automated peritoneal dialysis is usually done during the night as the patient sleeps. A
cycler, which is programmed to meet the requirements of the physician’s prescription, performs
which of the following functions?
a. Measures and warms the dialysate
b. Times the regularity of exchanges and tallies the number of exchanges
c. Calculates the ultrafiltration (UF)
d. a, b, and c
e. b and c

183. Comorbidity conditions in the elderly ESRD patient may complicate treatment. Which of
the following are common disease processes that occur in the elderly?
a. Cardiovascular and pulmonary
b. Diabetes
c. Osteoporosis
d. a and b
e. a, b, and c

184. Many ESRD patients on dialysis are hyperkalemic, so potassium is not used in
commercially available dialysate solutions. If additional potassium is needed, how would it be
administered?
a. 2 to 4 mEq/L added to the dialysate solution
b. Oral supplement
c. 50 to 100 mEq/L added to IV solution
d. a and b
e. a and c

185. A newer peritoneal dialysis solution, icodextrin (Extraneal), uses a starch-derived osmotic
agent. What are the advantages and disadvantages of its usage?
a. Does not use dextrose
b. Enhances fluid removal from blood
c. Increases small solute clearance
d. Lowers incidence of net negative ultrafiltration
e. a and d
f. a, b, c, and d
186. Automated peritoneal dialysis refers to dialysis that is performed with the use of a cycler.
What are the four forms of automated peritoneal dialysis?
a. Continuous cycling peritoneal dialysis (CCPD) and nocturnal intermittent peritoneal dialysis
(NIPD)
b. Intermittent peritoneal dialysis (IPD)
c. Tidal peritoneal dialysis (TDP)
d. Continuous ambulatory peritoneal dialysis (CAPD)
e. a, b, and c
f. b, c, and d

187. A surgeon usually inserts a peritoneal dialysis catheter during a laparoscopy or laparotomy
procedure. These catheters are either straight or coiled. What are the advantages of the coiled
catheters?
a. Minimal migration
b. Less discomfort due to the configuration, which keeps the tip of the catheter away from the
peritoneal membrane
c. Lack of outflow problems
d. Less discomfort due to the soft material used for coiled catheters
e. a, b, and c
f. a, c, and d

188. One of the possible complications of peritoneal dialyses is an infection of the peritoneal
cavity. The usual cause is a break in the closed system, allowing the entrance of microorganisms.
Describe the signs and symptoms of peritonitis.
a. Cloudy effluent
b. Peritoneal cell count greater than 100/mcL white blood cell count (WBC), more than 50%
neutrophils
c. Abdominal pain, nausea and vomiting
d. Culture results: gram-positive, gram-negative, multiple organisms, fungi
e. a, b, and d
f. a, b, c, and d
189. What are the most important treatment steps for peritonitis?
a. Peritoneal flushes with dialysate 1.5%
b. IM antibiotics with added heparin
c. Prompt diagnosis
d. a and c
e. a, b, and c

190. When there is a dialysate leak around the exit site or into the subcutaneous tissue during
peritoneal dialysis, what are the signs and symptoms?
a. Drainage of blood from the exit site
b. Abdominal edema
c. Penile edema
d. Scrotal edema
e. a, b, and c
f. b, c, and d

191. Which of the following psychosocial issues should the physician, patient, and family
evaluate when considering peritoneal dialysis versus hemodialysis?
a. Patient’s ability and motivation for self-care
b. Physical characteristics of home, availability of water source, electricity, phone, storage room
for supplies, cleanliness
c. Availability of additional caregiver, such as spouse, relative, or friend
d. Patient’s state of mind and comprehension
e. a, b, and c
f. a, b, c, and d

192. One of the negatives associated with peritoneal dialysis includes protein malnutrition. What
are the causes of protein malnutrition?
a. Loss of amino acids and protein in the dialysate
b. Decreased appetite due to glucose load from dialysate
c. Lack of protein intake due to high-carbohydrate diet
d. a and b

193. What are some of the advantages of renal transplantation?

a. Improved quality of life, no further need for dialysis, cost over long-term is less
b. Cessation of uremic symptoms
c. Resume “normal” lifestyle, greatly improved survival rate
d. a, b, and c
e. a and b

194. What are some of the disadvantages of renal transplantation?

a. Lifelong risk of organ rejection and need for immunosuppressant therapy
b. Potential for complications from immunosuppression
c. Increased risk of infection and malignancies
d. Expense of immunosuppressive medications
e. a, b, and d
f. a, b, c, and d

195. The nephrology nurse who cares for the transplantation patient plays several important
roles. Which of the following are included?
a. Education regarding transplantation
b. Counseling the patient about transplantation
c. Assisting patient with the pretransplant evaluation
d. Provide dialysis treatments for those patients with transient loss of renal function due to acute
tubular necrosis (ATN), or who have experienced permanent loss of transplanted kidney, or
those with renal failure due to transplanted nonrenal organs (heart or liver)
e. a and d
f. a, b, c, and d

196. Which of the following patients cannot currently be considered for renal transplantation?
a. Those with active infections
b. Patients with history of malignancies
c. Patients who are current substance abusers
d. Patients who are unable to adhere to medication schedules
e. a, c, and d
197. What are the two sources for donor kidneys?
a. Living human donors and deceased human donors
b. Living human donors and genetically created organs
c. Deceased human donors and genetically created organs
d. Deceased human donors and pigs

198. What are the requirements the living donor must meet?
a. Voluntary, informed consent
b. Completely healthy
c. Voluntary consent
d. Consent given by family
e. a and b

199. In order for a deceased person to be used as a kidney donor, what requirements must be
met?
a. Consent must have been given by next of kin
b. Body must have been kept functioning by artificial ventilation and medications, and patient
must have had irreversible brain damage
c. No expense is incurred by donor family
d. Kidney must be recovered by organ recovery team and must go to regional tissue and organ
bank per national guidelines to be distributed to proper recipient
e. a, b, and d
f. a, b, c, and d

200. What are the main precautions that must be followed when performing dialysis on a recent
transplant patient?
a. Carefully observe for hypotension because of the risk of internal bleeding in first 24 hours
postsurgery, and watch for electrolyte imbalance.
b. Avoid hypotension to prevent ischemia of newly transplanted kidney, even if fluid removal
during dialysis is compromised.
c. Maintain the integrity of the surgical incision site.
d. Use heparin-free or minimal anticoagulation therapy for newly postoperative patients, and for
those who have had percutaneous renal biopsy.
e. a, b, and c
f. a, b, c, and d

Answer Explanations
1. A: Kidney function includes the excretion of metabolic wastes, including uric acid and water.
Body temperature is regulated by the hypothalamus, and is not directly associated with kidney
function. Lymphocyte production may be a result of infection. The kidney does not produce
insulin and glucagon; the pancreas synthesizes these hormones.

2. C: Erythropoietin is a hormone produced by the kidney as a response to low O2 levels; this

hormone stimulates erythrocyte production. Calcitriol, synthesized by the kidney, accelerates
calcium production. The kidney does act as a receptor for antidiuretic hormone (ADH), which
enhances water reabsorption; ADH and hGH are both hormones produced by the pituitary.

3. D: BUN, creatinine levels, and kidney ultrasound are used to determine the size of the kidney
and if there is a blockage, and blood chemistries and urinalysis are used to assess kidney status.
Chest x-rays and mammograms are used to determine lung disease and breast health. MRIs of
the lumbar spine are useful in evaluating the bones, discs and structures of the lower back.
Bladder ultrasounds are commonly used as tests to determine urinary retention or obstruction,
along with the PTT, ABO, and Rh factor, which are all tests done for blood typing, and would not
be commonly used to determine kidney disease.

4. B: ARF progresses quickly, lasts less than 3 months, and during the acute renal failure, there is
a loss of nephron function. ARF is usually reversible. Chronic renal failure may be the result of
diabetes or lupus, while acute renal failure is more likely the consequence of trauma, infection,
blockage, glomerulonephritis, or toxins.
5. B: Glomerulonephritis is an intrinsic or intrarenal type of acute renal failure. Dehydration,
systemic infection, and trauma are all possible causes of prerenal acute renal failure.

6. A: In chronic renal failure (CRF), the disease lasts more than 3 months, with the GFR
remaining at less than 60 mL/min, blood chemistry abnormalities including elevated creatinine
and BUN levels, and renal ultrasound results that exhibit a smaller than normal kidney. Although
diabetes is often associated with CRF, a high glucose level is not a hallmark of this disease.
Rapid onset, with symptoms following blunt trauma and with resolution within 2 months, would
usually be attributed to ARF. Confusion, paranoia, abnormal affect, and facial tics are frequently
linked to psychiatric disorders and side effects of their medications. Sudden upper right quadrant
pain, nausea, vomiting, and general prostration may be indicative of gallbladder disease.

7. A: Although many elderly patients may also suffer from chronic obstructive pulmonary
disease it is not considered a direct cause of CKD. Diabetes mellitus (both type 1 and type 2),
systemic lupus, and hypertension are all diseases that contribute to the development of CKD.

8. B: High glucose levels should be treated with insulin to lower the blood glucose and prevent
diabetic coma, not with added dextrose. Dextrose should be administered in cases where the
glucose level in the blood is less than 50 mg/dL. Brittle (unstable) diabetic patients should be
tested frequently to assess the blood glucose level with the optimal level of glycemic control at
less than 7% HbA1c.

9. D: The kidney acts as a receptor for ADH (anti-diuretic hormone), aldosterone, and
parathyroid hormones. ADH, which is produced by the pituitary, acts to enhance water
reabsorption. Aldosterone, synthesized by the adrenal cortex, causes the kidneys to retain water
and sodium, thereby increasing the blood pressure. Parathyroid hormone, produced by the
parathyroid glands, increases the calcium:phosphate ratio and enhances the calcium level in the
blood. Estrogen, progesterone, and testosterone are not synthesized by nor received by the
kidney. Erythropoietin, calcitriol, and renin are all hormones synthesized by the kidney.
10. B: The Bowman capsule is a cup-like structure with a thin double membrane that surrounds
the glomerulus of each nephron. The renal capsule is the membranous covering of the kidney. An
afferent arteriole is part of the renal circulatory system that supplies the blood to the glomerulus.
The loop of Henle is the portion of the nephron that connects the proximal convoluted tubule to
the distal convoluted tubule and features a hairpin curve that dips into the renal medulla.

11. A: Intrinsic, or intrarenal, ARF may be caused by toxins or medications, myoglobin (from
breakdown of muscle, as in blunt trauma), hemolysis, glomerulonephritis, or multiple myeloma.
Bladder stones and blockage of the urinary catheter may be causes of postrenal ARF.
Hepatorenal syndrome would be associated with prerenal ARF.

12. E: Uncontrolled diabetes (type 1 and type 2), hypertension, HIV, systemic lupus, and high
proteinuria are all conditions that contribute to the development of CKD. Outside factors include
smoking, age, ethnicity (African-Americans, Asians, Native Americans, Latinos, and Pacific
Islanders have a higher incidence of CKD), and a family history of kidney disease. Cirrhosis has
not been shown to be a cause of CKD.

13. A: Staging is useful as a tool to assess the level of function of the kidney and therefore aid in
predicting clinical signs and symptoms, as well as assessing and managing the patient. Answers
B, C, and D contain some of the complications associated with the various stages, but do not
explain what staging does.

14. C: The initial assessment of a patient suspected of chronic kidney disease should include a
thorough history, including familial history, complete physical examination, CBC, UA, blood
chemistry, and renal ultrasound. The MRI and chest x-ray are unnecessary, although the chest x-
ray may be indicated for evaluating lung congestion. The renal ultrasound is also an integral part
of the investigation; the size of the kidney is usually found to be small in CKD patients.

15. A: Antigen-antibody complexes that were formed as a result of a streptococcal infection

somewhere in the body collect in the glomeruli and block filtration, resulting in edema,
hypertension, low serum albumin, hematuria, and decreased urinary output. Congestive heart
failure, COPD, and pancreatitis are not direct causes of glomerulonephritis.
16. B: It is important to determine the type and cause of glomerulonephritis in order to develop
an appropriate and effective treatment plan. This in an inflammatory (not an infectious) process
and therefore it is not contagious, does not infect other organs, and does not progress to sepsis.

17. B: The scarring of the glomeruli allows protein to spill into the urine, resulting in proteinuria,
which is the main sign of glomerulosclerosis. As the disease progresses, swelling of the ankles
and retention of fluid in the abdomen may occur. Blurred vision, confusion, and restlessness are
all associated with malignant nephrosclerosis. Albumenuria (frothy urine), periorbital edema, and
headaches are commonly linked to diabetic nephropathy. Caseation, sterile pyuria, and hematuria
point to Mycobacterium tuberculosis.

18. D: Diabetes, drug use, and infection may lead to scarring of the glomeruli. This condition is
irreversible, but may be treated, depending on the cause, by immunosuppressants, low-protein
diets, drugs for hypertension, especially ACE inhibitors, and methods for lowering cholesterol
levels. Excess aluminum and anemia are not considered causes of scarring of the glomeruli.

19. A: In stage 3 of CKD with a GFR of 30 to 59 mL/min per 1.73m2, there would be moderate
kidney damage. Severe kidney damage is associated with stage 4. Mild damage would be found
in stage 2, and slight damage in stage 1.

20. D: The stage 5 CKD patient may display numerous symptoms, including neuropathy,
bleeding disorders, sexual dysfunction, serositis, and malnutrition. Ulcerative colitis and rectal
bleeding are not complications normally seen in stage 5 CKD.

21. B: Type 1 and type 2 diabetics are at a higher risk for developing CKD because their blood
sugar levels are poorly controlled, they have high blood pressure that is unmanaged, and they
have elevated cholesterol levels, especially low-density lipoprotein. Answers A, C, and D are
other habits may contribute to an unhealthy lifestyle, but they are not considered the most
common factors that lead to CKD.

22. C: Classic symptoms and signs of diabetic nephropathy include periorbital edema, especially
upon awakening, which progresses to generalized swelling. Frothy urine, hiccough, itching,
headache, malaise, weight gain, nausea, and vomiting all point to diabetic nephropathy.
Hematuria, fever, chilling, and prostration would most likely be signs of infection. Weight loss,
diarrhea, and dizziness may or may not be associated with kidney involvement. Sudden extreme
flank pain, hematuria, nausea, and vomiting may be associated with kidney stones.

23. C: The recessive gene type of PKD is rare, includes childhood onset of symptoms, and
carries with it a poor prognosis. Dominant genes transfer most cases of PKD, with symptoms
appearing in early adulthood.

24. B: In addition to cysts in the kidneys, PKD may cause cysts to form in the liver, pancreas,
testes, ovaries and spleen. Brain aneurysms have been found in approximately 10% of PKD
cases.

25. A: Hemorrhagic shock, trauma, toxicity, sepsis, severe hypotension, and reaction to a blood
transfusion are all causes of acute tubular necrosis (ATN). Nephrotoxins include certain
antibiotics, radioisotopic contrast media, chemotherapy agents, and street drugs. Hemoglobin and
myoglobin that release from red blood cells and damaged muscle tissue are also toxic to the
kidney. Uncontrolled diabetes, atherosclerosis, hypertension, COPD, liver disease, and gallstones
refer to chronic disease processes and are not causes of acute tubular necrosis.

26. A: Nephrosclerosis is caused by uncontrolled hypertension. If it develops rapidly, it is called

malignant nephrosclerosis, and if symptoms progress over several years, it is referred to as
benign. It does not stretch the preglomerular arteries and arterioles, but actually causes
narrowing of these structures, resulting in poor blood flow to the glomeruli. The term
“malignant” nephrosclerosis denotes the rapid onset of symptoms, not the ability to metastasize.
African-Americans develop malignant nephrosclerosis more frequently than do other races.
27. D: Benign nephrosclerosis symptoms develop over an extended period and occur most
frequently in elderly patients. Nausea, vomiting, headache, confusion, blurred vision, and
restlessness are classic symptoms of malignant nephrosclerosis. Suprapubic pain, fever, elevated
white count, and chilling are symptoms of a bladder infection. Weakness, shortness of breath,
exercise intolerance, and inability to think clearly are indicators of anemia.

28. C: Hypertension, atherosclerosis, left ventricular hypertrophy that may lead to congestive
heart failure, pericarditis, and pericardial effusion are all frequently associated with ESRD.
Congenital heart disease, as the name implies, would be a disease that is present at birth.
Arrhythmia refers to abnormal electrical activity, which is not directly associated with ESRD.
Tachycardia and bradycardia both refer to abnormal heart rates.

29. A: Osteomalacia is the condition that results from a defect in the calcification of the bone,
and is usually due to a lack of vitamin D. It causes the bones to be soft. Administration of active
vitamin D metabolites is now an established treatment in ESRD patients. Osteosarcoma is a
malignancy not specifically associated with ESRD. Adynamic bone disease is a condition seen in
ESRD patients where there is low bone resorption and formation. ESRD patients may have
metastatic calcification, which results in the deposit of calcium in normal tissue, usually in the
kidneys, lungs, or gastric mucosa.

30. B: Colchicine and nonsteroidal anti-inflammatory medications are the drugs of choice for
pseudogout. Increasing the number of dialysis treatments helps control uric acid levels and
should help decrease the symptoms. Aerobic exercises have not been shown to be an effective
treatment for pseudogout. Dialysis treatments should not be stopped and only nonsteroidal drugs
should be used.

31. D: Symptoms of uremic encephalopathy may include the following: restless leg syndrome
(RLS), lethargy, vomiting, and emotional lability, progressing to coma and, if untreated, death.
Diarrhea, joint pain, flank pain, jaundice, urticaria, and uremic frost, although possibly related to
renal disease, are not linked to uremic encephalopathy.
32. A: Neuropathy refers to the deterioration of nerve function. Burning sensations in the feet,
RLS, twitching, and decreased reflexes are all results of nerve deterioration. The other listed
symptoms are related to various renal disorders, but not to uremic neuropathy.
33. B: Uremic frost is a rare condition in which white urea crystals form on the skin, giving it a
“frosty” appearance. Pruritus from calcium deposits on the skin causes excessive itching.
Discoloration ranges from pallor to hyperpigmentation of the mucous membranes. Excessive
skin wrinkling results from degeneration of collagen, and half-and-half nails is a condition in
which half of the nail appears white because of edema, while the other half is normal. Thinning
of the hair, thickening of the nails, and generalized rash are not considered common effects of
ESRD. Answers C and D are not common effects of ESRD on the integumentary system.

34. B: ESRD patients are more susceptible to bacterial (including TB), viral, and fungal
infections of the lungs. Left ventricular dysfunction and excessive fluid volume may lead to
pulmonary edema. The rates of pulmonary embolisms, atelectasis, carcinoma, and pneumothorax
are not commonly considered to be above normal in ESRD patients.

35. A: The increase in the number of dialysis treatments along with correction of the anemia and
the administration of estradiol should help the female ERSD patient with sexual complications of
her disease. An iron supplement may be prescribed, and an exercise program for improvement of
general health, but not in combination with a decrease in the number of dialysis treatments.
Multivitamin therapy, correction of anemia, and psychological counseling may be added to the
treatment plan if ordered by the physician, but it would be in addition to answer A. Cessation of
dialysis would not be an option for a dialysis-dependant patient, and testosterone is a male
hormone.

36. D: Epoetin alfa is used to help eliminate anemia, which is one of the contributing factors in
low sperm count and erectile dysfunction. Progesterone would not be used since it is a female
hormone; calcitriol, which is active vitamin D, is used to promote calcium absorption; and
deferoxamine is a chelating agent.
37. B: These are the classic symptoms of metabolic acidosis. Although dizziness may occur
because of hypotension, hypertension and agitation are opposite of the usual symptoms.
Diarrhea, abdominal pain, diaphoresis, and abdominal pain are usually associated with a GI
disorder. Answer D includes signs of ESRD’s effects on the integumentary system.
38. C: These are the classic GI complaints of the ESRD patient. Strawberry tongue is a symptom
associated with scarlet fever in children; stomach ulcers and diverticulosis are conditions, not
symptoms. Excessive hunger is opposite of the usual symptom of poor appetite that is found in
ESRD patients. Hiatal hernia is caused by a weakness in the diaphragm muscle, and lactose
intolerance refers to an inability to endure milk products. Ulcerative colitis, lower abdominal
pain, bloating, esophageal reflux, and bile taste in the mouth are not commonly associated with
ESRD.

39. A: Amyloid, abnormal protein fibers, deposit in the sheath of the carpal tunnel causing
swelling and constriction of the nerve that passes through the tunnel. The carpal tunnel would not
be an appropriate site for injections. Although repetitive motion contributes to carpal tunnel
syndrome, this is not a common cause of this condition in the ESRD patient. Aluminum is not a
known cause of CTS.

40. B: ESRD usually affects the entire endocrine system, resulting in inconsistent insulin,
epinephrine, plasma norepinephrine, and parathyroid levels. It actually causes an increase in the
pancreatic hormone and glucagon (which stimulates carbohydrate metabolism), and enhances
levels of gastrin, which increases the production of gastric acid. Hypothyroidism and an increase
in growth hormone may occur. Thyroid hormones, TRH and TSH, usually remain close to
normal.

41. B: Serum albumin levels directly reflect the diet protein intake and are an accurate gauge of
the nutritional status of the ESRD patient. Albumin transports smaller molecules of drugs,
calcium, and bilirubin in the bloodstream. Symptoms of low serum albumin include edema,
weight loss, muscle wasting, fatigue, and hypotension. As serum albumin levels decrease, the
risks for morbidity and mortality increase.
42. C: When serum calcium levels fall, PTH secretion increases and calcium is pulled from
where it is stored (such as in the bones), raising the levels in the blood. PTH increases calcium
absorption in the small intestine and decreases its excretion through the kidneys. The optimal
calcium-phosphorus product (calcium level × phosphorus level = calcium-phosphorus product)
ranges between 40 and 60. Phosphorus and calcium have an inverse relationship in which the
higher the level of phosphorus, the lower the calcium level falls.

43. A: These are the classic symptoms of low hematocrit and/or hemoglobin. Flank pain may
indicate kidney stones, but is not a symptom of low hematocrit/hemoglobin levels. Bradycardia,
slow heart rate, would be the opposite of the effect; the heart would have to work faster to
provide adequate oxygen levels. Flushing, diarrhea, nausea and vomiting, edema, and oliguria
are not appropriate symptoms. Hypertension, irritability, and emotional lability are not linked to
low hematocrit and/or hemoglobin levels.

44. C: Epoetin alfa is the drug of choice for stimulating erythropoietin production, which then
accelerates red blood cell formation. Multivitamins, iron supplements, and calcitriol are all drugs
that may be used in ESRD patients, but epoetin alfa is specific for stimulating the kidneys to
produce erythropoietin.

45. A: 7 to 18 mg/dL is the normal range for BUN levels.

46. B: Symptoms that indicate an elevated BUN level include insomnia, dry, itchy skin, and
altered sense of taste and smell. Burning sensations in the feet, twitching, and RLS are related to
neuropathy. Back pain, foot pain, fractures, and gangrene are symptomatic of osteodystrophy.
Slurred speech, memory loss, and behavioral changes are related to aluminum toxicity.

47. A: Creatinine clearance refers to the amount of creatinine that is removed (filtered) by the
kidney over a measured amount of time. Creatinine phosphate in the muscle breaks down to form
creatinine, the kidney does not produce it. Creatinine clearance does not refer to a urine sample,
or to a comparison with BUN.
48. B: Since creatinine levels are fairly constant and not affected by diet or fluid volume,
monitoring these values provides excellent insight into kidney function. Creatinine phosphate in
the muscle breaks down to form creatinine, a protein that is produced at a nearly constant rate,
depending on muscle mass. They are not associated with hemoglobin or aluminum levels in the
blood.
49. C: 0.5 to 1.5 mg/dL is considered the normal serum creatinine level.

50. B: Furosemide and bumetanide are both diuretics. Epoetin alfa stimulates red blood cell
production. Sevelamer, calcium carbonate, and calcium acetate are all phosphate binders.
Sodium bicarbonate is administered for metabolic acidosis.

51. A: Sevelamer hydrochloride, calcium carbonate, and calcium acetate are phosphate-binding
medications. Furosemide and bumetanide are diuretics. Cinacalcet hydrochloride lowers
parathyroid hormone levels in the blood. Epoetin alfa stimulates red blood cell production.
Sodium bicarbonate is often used for treatment of metabolic acidosis, a condition that occurs
because of the damaged kidney’s inability to synthesize ammonia and excrete hydrogen ions.
Aspirin (acetylsalicylic acid) is an analgesic, antipyretic, and anti-inflammatory.

52. B: Adhering to a proper diet may delay the need for dialysis. Uremic symptoms may be
controlled by restricting protein intake in concert with ensuring proper caloric levels. Phosphorus
restriction aids in prevention of bone complications. Obesity, although a concern for overall
health of the ESRD patient, is not the central focus for the nutritionist when dealing with renal
complications.

53. D: All of the answers are problems the ESRD patients may encounter. Psychologists and
social workers supply the patients with tools that may help them manage these stresses.

54. C: Osteitis fibrosa is the replacement of bone with fibrous tissue due to the increased
resorption of calcium from the bones into the bloodstream. Defective mineralization
(calcification) of the bone, usually due to lack of vitamin D, is osteomalacia. Low bone
resorption and formation is adynamic bone disease (ABD). A deposit of calcium in normal tissue,
usually in the interstitial tissues of the kidneys, lungs, or gastric mucosa, is metastatic
calcification.

55. D is the correct answers. Certain antibiotics, contrast media, chemotherapy drugs, and street
drugs may be nephrotoxic. Hemoglobin and myoglobin that release from red blood cells and
damaged muscle tissue are also toxic to the kidney. Intravenous normal saline solution is not
considered nephrotoxic.

56. A: Nephrotic syndrome is a myriad of clinical findings that result in massive losses of protein
through the kidney, due to damaged, leaky glomeruli. Acute tubular necrosis (ATN) refers to the
death of renal tubules. Nephrosclerosis is the hardening of the arterioles of the kidneys caused by
uncontrolled high blood pressure. Glomerulonephritis (GN) is a renal disease characterized by
the inflammation of the small blood vessels, glomeruli, of the kidneys.

57. B: The hormone calcitriol, produced by the kidney, enables absorption of calcium from food
sources into the bloodstream and promotes formation of strong bones. Erythropoietin stimulates
red blood cell production. PTH refers to parathyroid hormone, which is synthesized by the
parathyroid glands. TRH is a hormone produced by the hypothalamus.

58. C: Sevelamer hydrochloride is a phosphate-binding drug. Cinacalcet reduces levels of

parathyroid hormone. Sodium bicarbonate and epoetin alfa are not used for phosphate-binding.

59. A: Nephrotic syndrome is a myriad of clinical findings that result in massive losses of protein
through the kidney, due to damaged, leaky glomeruli. When the protein level in the blood
declines, fluid shifts into the tissues, resulting in edema. Pitting edema in the legs, puffiness in
the periorbital area upon awakening, abdominal ascites, and pulmonary edema may be seen with
this syndrome. The high protein level may cause the urine to appear “foamy.” Weight loss is not
a classic symptom of nephrotic syndrome. Fever, chills, and cloudy urine are related to infection.
Gangrene, fractures, and joint pain are symptoms of osteodystrophy.

60. E: Some of the benefits of early referral of the ESRD patient to a nephrologist include
establishment of dietary prescription, placement of peritoneal or vascular access, and timely
diagnosis and treatment of hypertension, anemia, phosphatemia, and acidosis. Early diagnosis of
atherosclerosis, hypotension, and alkalosis are not commonly considered benefits of early
referral to a nephrologist.
61. B: Assessing the social and psychological needs of the patient, deciding on hemodialysis
versus peritoneal dialysis, determining location for dialysis (home of in center), prescribing
medications for existing infections, obtaining necessary signatures on consent forms, and
creating the dialysis access port are all important steps in the predialysis assessment. Any of
these other tests may be done to ascertain additional disease processes, but none of these
alternate combinations would be appropriate as part of routine predialysis assessment.

62. A: Predialysis education goals for the patient include supplying information on different
modes of dialysis, including the pros and cons of each, and encouraging self-reliance for the
patient’s personal health issues. In-center dialysis treatment may not be the best choice for the
patient and does not necessarily provide better results than home therapy. Information on
nutritional therapy would be appropriate, but not in combination with encouraging in-center
dialysis. The patient should choose their own nephrologists. Staff should bond with the patient,
but should not supply personal cell phone information.

63. E: During group predialysis education, interaction with other patients with similar diagnoses,
discussions about dialysis modalities, and hearing from current dialysis patients about their
personal experiences are all encouraged. Individual sessions should not be scheduled after work
at off-site locations.

64. A: Hemodialysis refers to the removal of metabolic wastes from the blood, through a
semipermeable membrane. It does not involve diluting the wastes and allowing them to filter
through the kidney; it either supplements the action of the damaged kidney or replaces it. A
permeable membrane would not filter; a semi-permeable membrane will allow passage of some
smaller molecules and filter out larger molecules.
65. D: The main goal of hemodialysis is to manage uremia, fluid overload, and electrolyte
imbalance by supplementing the function of the damaged or diseased kidney. There is no cure for
kidney disease at this time. The removal of aluminum, lead, and mercury from the blood is
chelation. Dialysis does not remove blood cells and platelets from the blood.
66. A: All of these items, aluminum-containing cookware, beverage cans, antiperspirants,
cosmetics, antacids, and aluminum-containing phosphate-binders may contribute to the
aluminum levels in the body. Stainless steel, plastic bottles or plastic wrap, and shampoo are not
considered sources of aluminum. Paint, if manufactured before 1978, contains lead; some old
painted toys will contain lead paint; certain lipsticks, especially red in color, may contain lead.
Glass thermometers, some fluorescent bulbs, and certain fish and shellfish may contain mercury.
Fruits and vegetables are usually safe if properly washed before consuming.

67. B: Since aluminum is usually stored in the brain or the bones, behavioral changes, memory
loss, slurred speech, lack of energy, dementia, and bone disease are symptoms of aluminum
toxicity. Anemia, constipation, and loss of appetite are also related to an excessive amount of
aluminum in the body. Nausea, vomiting, diarrhea, fever, chills, upper respiratory tract infection,
elevated WBC, and headache could be symptoms of influenza or multiple other infectious
processes. Joint pain and redness, gangrene, back pain, fractures, and itching are classic
symptoms of osteodystrophy. Nausea, vomiting, metallic taste, fetid breath, GI bleeding,
diarrhea, and functional constipation are the GI effects of uremia.

68. D: Chelating agents remove heavy metals from the blood. They do not destroy microbes,
eliminate phosphates, or reduce pedal edema.

69. B: Survival rate is superior with pre-emptive kidney transplantation than with standard
dialysis. Palliative care has a poor survival rate because the patient would receive comfort
measures only.

70. A: Ultrafiltration occurs when hydrostatic pressure or osmotic pressure forces fluid through
the semipermeable membrane. The solution carries solutes, at near their original concentration,
with it in a process called “solvent drag.” Larger molecules are left behind, with the membrane
acting as a filter, or sieve. When solutes move from an area of greater concentration to an area of
lesser concentration, this is known as diffusive or conductive transport. If the dialysate solution
were under high pressure and forced into the blood, this would result in an unsafe condition
known as reverse filtration.
71. C: The lower the molecular weight of the solutes, the greater the amount of solutes that will
be removed. The higher the temperature, the greater the amount of solutes removed, the faster
the flow rate of the dialysate, the greater the removal of solutes, and the faster the blood flow, the
greater the amount of solutes removed.

72. B: Smaller molecules move more rapidly and collide with the membrane more frequently,
resulting in a higher transport rate. Large molecules move more slowly and contact the
membrane less often; consequently, they have a slower transport rate through the membrane.

73. B: Red blood cells, white blood cells, platelets, and any other molecule that is too large to
pass through the membrane will remain in the blood. Water, urea, glucose, and creatinine are all
able to pass through the membrane.

74. D: Concentration gradient is the term used when the concentration of a certain particle is
higher on one side of a membrane than on the other side. Transmembrane pressure (TMP) refers
to the difference in hydrostatic pressure between the blood and the dialysate solution. Diffusive,
or conductive transport, refers to the movement of solute particles from the side of higher
concentration to the side of lower concentration through the dialysis membrane. Mass transfer
rate, or solute flux, refers to the rate of movement through a membrane.

75. B: Countercurrent flow refers to the blood and dialysate that flow in opposite directions.
Concurrent flow takes place when both the blood and the dialysate move in the same direction.
Convective transport refers to the movement of solute molecules across a membrane because of a
pressure gradient (ultrafiltration). Diffusive, or conductive transport, refers to the movement of
solute particles from the side of higher concentration to the side of lower concentration through
the dialysis membrane.
76. E: The pressure in the dialysate compartment needs to be negative and the pressure in the
blood compartment needs to be positive. It is crucial that the pressure in the dialysate
compartment remains in the negative range, so reverse filtration does not result.
77. A: Water for dialysis is not sterile, so infections may result from reverse filtration. Toxins can
reenter the bloodstream through reverse filtration. Bacteria can grow in dialysate solution if it
becomes contaminated.

78. C: A molecular filter (ultrafilter) device can be used to eradicate unwanted molecular
particles, while allowing dissolved solutes to pass through. This filter would remove bacteria and
pyrogens from the solution. Adding sodium bicarbonate or normal saline solution, or using a
sodium variation system would not be appropriate actions to avoid infection because of reverse
filtration.

79. E: The “geometric” properties of the blood pathway refer to the physical properties, such as
length, width, surfaces, or cross-sections. The length of the pathway is important; short pathways
(15 to 50 cm) as in the hollow-fiber dialyzers offer low resistance. The number of pathways
affects the resistance: the higher the number, the lower the resistance (eg, hollow-fiber dialyzers
with thousands of pathways have very low resistance). The cross-sectional area of a pathway
plays a significant role: the larger the cross-sectional pathway, the lower the amount of
resistance. In hollow-fiber dialyzers, the internal radius is the control factor.

80. A: Hematocrit levels measure the number of red blood cells in the blood. The greater the
number of red blood cells, the higher the hematocrit level. Viscosity refers to the thickness and
stickiness of the blood, which affects the resistance in the blood circuit of the dialyzer. The
higher the number of red blood cells in the blood, the more viscous it is. Hemoglobin refers the
amount of iron in the blood, and hematocrit refers to the number of red blood cells.

81. D: “Mass transfer rate” is the term used to describe the solute flux, which is the movement
through a semipermeable membrane during dialysis. It fluctuates constantly. When blood and
dialysate flow in opposite directions through the membrane, it is known as countercurrent flow.
If the blood and dialysate flow in the same direction, the term used is concurrent flow. Both
countercurrent and concurrent refer to the “flow geometry” of the blood and dialysate.
82. C: The ultrafiltration profiling feature allows fluctuation of the volume of fluid removed
during dialysis, by dividing the total volume that the nurse determines by the length of the
treatment. The nurse determines the total volume to be removed; the volume removed fluctuates.
The ultrafiltration profiling feature is an advantage because it automatically divides the total
volume to be removed by the length of the treatment.

83. D: When the ultrafiltration rate is excessive, hypovolemia and hypotension may result. In
order to avoid this outcome, the use of hypertonic saline, which enhances the osmolality in the
extravascular and vascular spaces, is recommended. This hypertonic solution draws fluid from
the vast intracellular reservoir, avoiding the hypovolemia that leads to hypotension.

84. A: Since one of the goals of hemodialysis is to correct acidosis associated with renal failure,
sodium bicarbonate concentrate is added to the dialysate as one of the three streams of fluid
used. The concentrate comes packaged in two sections. One is “acid concentrate” and the other is
“bicarbonate concentrate.” The third stream is water. The water used is not sterile, but is purified.
The most common purification processes are reverse osmosis, deionization, or carbon
absorption.

85. B: Bicarbonate dialysate acts as a buffer during hemodialysis and helps maintain the acid-
base balance. Sterile water is not used in dialysis; purified water is preferred. Calcium chloride
and glucose are not commonly used as dialysate solutions.

86. E: Plate dialyzers consist of sheets of membranes assembled on top of each other. Supporting
plates, which are ridged or grooved, hold the membrane and allow the movement of dialysate
along it. Blood and dialysate flow through alternate spaces. The disadvantage of this type of
dialyzer is that the volume of blood increases as the TMP increases, causing compliance. These
are not appropriate for reuse.

87. A: Hollow-fiber dialyzers, or hollow-fiber artificial kidney (HFAK), are the most widely used
type of dialyzer. The contained blood volume is minimal, and resistance to blood flow is low.
They are not compliant, ultrafiltration can be precisely controlled, and they adapt well to reuse.
The disadvantages are that meticulous desecration of the fiber bundle is required to prevent air
locks; there may be uneven distribution of blood at the inflow header base; and ethylene oxide is
needed for sterilization and this gas may be retained and cause adverse patient reactions. Layers
and grooves are features of the plate dialyzer.

88. D: These are all names for cellulose membranes used in hemodialysis. The cellulose
membrane used for hemodialysis derives from wood and cotton, which is processed with heat
into liquid slurry, and then coagulated into flat sheets or extruded to form hollow fibers. These
can be formed to meet different thickness requirements, and vary in water-absorptive qualities
and permeabilities. The cellulose fibers swell when saturated and form a twisted maze through
which the solution must travel until it eventually finds a pore to travel through.

89. A: The main advantage of the cellulosic membrane is the low cost, but the disadvantage is
that it may be bioincompatible with the patient’s blood. These membranes are readily available in
both hollow fiber and flat sheets, and they are not reusable.

90. C: Advantages of the synthetic membrane are reusability and biocompatibility.

Disadvantages of synthetic membranes include: (a) expensive in comparison to cellulose
membranes, (b) high water permeability (ultrafiltration needs to be used), (c) absorption of
protein to the membrane surface, and (d) risk of backfiltration from dialysate to blood.

91. D: An inflammatory response occurs when blood contacts a foreign surface. If the reaction is
severe with a high level of inflammation, the membrane is bioincompatible. When the reaction is
mild, the membrane is biocompatible.
92. D: The possible negative effects of long-term usage of bioincompatible membranes are
increased incidences of infection, malignancy, damaged nutritional state, and β2-amyloid
disease. Probable reasons for the higher incidences of these negative outcomes include the
following: cellulose membranes are incapable of removing large β2-microglobulin molecules,
and cellulose membranes cause increased complement generation, from which some of its
products may cause the release of β2-microglobin from monocytes. Clinical manifestations that
may result are bone lesions, arthropathies, pathological fractures, soft tissue edema, and carpal
tunnel syndrome. Nausea, vomiting, diarrhea, fever, and chills are all signs of a possible GI
infection, but are not usually associated with membrane reactions.

93. B: The main disadvantages of reusing a dialyzer include processing, sterilizing, testing
identifying require time, trained personnel, and storage space. In addition, a large volume of
high-quality water is used, the sterilizing agents may be health hazard for personnel and patients,
quality control is difficult to ensure, and the automated systems are expensive. Dialysate is not
used in the sterilizing process and “first-use syndrome” is associated with the first time a new,
not a reused, dialyzer is used. Cost per dialysis is substantially reduced when it is reused.

94. A: The method used to deliver solutions used to produce dialysate to the machine is called
the solution delivery system (SDS). The overhead holding tank is referred to as the “head” tank.
Bicarbonate from a mixing tank and acid from a storage tank are transferred to the head tank.
These solutions are gravity fed to a solution distribution system, and then routed to the treatment
area where they enter a series of pipes attached to the dialysis machines. Some supply only one
patient, while other solution delivery systems supply several dialyzers at the same time.

95. B: The five chemicals that are most frequently used to make dialysate are sodium chloride,
sodium bicarbonate, calcium chloride, potassium chloride, and magnesium chloride. In some
cases, glucose is also added to the formulation. Potassium cyanide is a poison, and magnesium
sulfate is a drug used for various conditions, but not as part of dialysate solution.

96. E: Bicarbonate dialysate is an unstable solution. It requires the addition of a stabilizer, such
as a polymer or dry NaHCO4 powder. It is also vulnerable to bacterial contamination and, once
mixed, the solution must be used within 24 hours. Proper sanitation of all containers and mixing
apparatuses is imperative to avoid contamination of the solution. The water used for preparation
of the B dialysate has to meet Association for Advancement of Medical Instrumentation (AAMI)
standards regarding the chemical makeup, pyrogen and bacterial content in order to be
considered “dialysis quality water.” The microbial count has to register as less than 200 CFU/mL
and the endotoxin concentration has to be less than 2 EU/mL. The water does not have to be
sterile.
97. C: The primary test calculates the concentration of a solute by the laboratory method called
reliability. Two such tests are flame photometry for testing sodium content and titration to find
chloride. This type of analysis is important to ensure the proper ratio of acid to bicarbonate and
to determine the ratio of concentrate to water. The secondary test uses overall conductivity. Most
suppliers of concentrate indicate on the label the proper level of conductivity that should be seen
when the solution is properly mixed. Another secondary test measures total osmolality by
freezing-point depression or vapor pressure to determine the total amount of solute in the
dialysate.

98. D: The sorbent regenerative system uses a cartridge of absorbent materials through which the
dialysate is recirculated and chemically regenerated. This process removes metabolic wastes
from the dialysate and the pH and electrolyte content are restored. This system performs these
actions: converts urea to ammonium carbonate, adsorbs creatinine and other nonionized solutes,
and uses ion exchange resins (sodium zirconium phosphate and zirconium oxide). It does not
control the blood flow rate.

99. A: One or more sensors and a microcontroller device control the dialysate temperature. The
optimal temperature should remain at 0.5°C of the set point. An additional sensor, which works
independent of the main heat control device on the heater or heat exchanger, should be used for
online monitoring with visual and audible alarms. Dialysate temperature in excess of 41°C could
cause hemolysis of red blood cells. End stage renal disease patients have a body temperature of
between 36° and 36.5°C. Increasing their core temperature would cause vasodilation, which
could be harmful to the patient.
100. E: Water from a public water source is below room temperature and needs to be heated
before being delivered to the dialyzer, usually at 35° to 38°C. Microbubbles and dissolved air are
found in water. As the temperature increases, the air trapped in the water is released as expanding
microbubbles. These microbubbles negatively affect conductivity sensors, temperature, and
flowmeters. These bubbles also diminish the contact of the dialysate and membrane in hollow-
fiber dialyzers. To release the dissolved air from the solution, deaeration devices use a
combination of heat and negative pressure.
101. B: The contents of the four chambers of the sorbent regenerative cartridge are activated
carbon, hydrated zirconium oxide, zirconium phosphate, and urease.

102. A: In the two-tank system, the first tank, called the “working tank” is used to remove the
chlorine and choramines, while the second tank, frequently referred to as the “polishing tank” is
used to remove any remaining chlorine or chloramines.

103. B: The working tank removes the chlorines and choramines. Since the polishing tank has
little chlorine, bacterial growth may be found. The purpose of rotating these tanks is to help
eliminate this bacterial growth.

104. C: Blood leak detectors work by using a photoelectric cell to generate a light beam through
the dialysate, which detects any change in the translucence and sets off alarms to stop the blood
pump. They do not monitor blood pressure or blood cells. False alarms can be caused by the
presence of air bubbles. Hemastix should be used as a backup test to determine the blood
content.

105. E: The volumetric ultrafiltration device is more advanced than the flowmetric. It ensures
that the volume delivered to the dialyzer equals the volume removed. It uses two diaphragm
chambers to balance the dialysate inflow and outflow. The flowmetric ultrafiltration device
varies the speed of the dialysate pump to equal volume through the inflow meter.

106. B: The limulus amebocyte lysate (LAL) test is performed to determine any endotoxins that
may be present after reverse filtration has occurred. Gram-negative and gram-positive are tests
done to determine the type of bacteria that will either retain or resist crystal violet staining. It is
not used for determining endotoxins. PTT, or partial thromboplastin time is a test used for blood-
clotting.

107. A: Sterile water is not used for the primer, sterile saline is not used, and the dialyzer would
not be hung to dry prior to patient usage. All air must be removed from the dialyzer; air could be
transported across the membrane into the patient’s bloodstream. If air is trapped in the walls of
the hollow fibers, it reduces dialyzer clearance by precluding the diffusion between the blood and
dialysate, and encourages clotting in the hollow fibers of the dialyzer. Priming the dialyzer with
saline to flush out any particulate material from the manufacturer, removing all disinfectant and
any residuals and flushing, and then priming with 0.9 g of NaCl per 100 mL of water
(physiologic saline solution) are the proper steps for preparing it for patient use.

108. B: All air needs to be removed from the dialyzer beginning at the bottom. Attach the
bloodlines to the dialyzer; turn the dialyzer venous side up, and prime with normal saline
solution. Next, use the arterial bloodline; infuse the normal saline solution through the dialyzer
and out the venous bloodline into a container. As the dialyzer is filled with saline, air will be
forced up and out the top. Gently tap the dialyzer and turn it side to side to ensure that all the air
is completely out of the header.

109. C: New and reused dialyzers have to be primed using 500 to 1000 mL of normal saline
solution, depending on the type of unit. All manufacturers have instructions on how to prime
their particular dialyzers. Their recommendations should be read and meticulously followed.
New units may contain glycerin and particulates that remained from the manufacturing method,
and will require 1000 mL of saline to ensure that all the contaminants are removed. 500 mL of
saline should be sufficient for priming a reused unit, with the primer flowing in a
counterclockwise pathway to remove any remaining disinfectant.

110. D: Ethylene oxide or a bioincompatible membrane may cause a life-threatening reaction to a

new dialyzer. One of the advantages of a reused dialyzer is that once it has been reprocessed,
these reactions do not occur. Cost-savings is an important aspect of reusing a dialyzer. Patients
are less apt to react to a reused dialyzer than a new one. Reused dialyzers must only be used on
the same patient who originally used it. Patients cannot sterilize dialyzers at home.

111. A: Renalin is the most commonly used disinfectant, used in approximately 70% of facilities.
It decreases membrane clearance of large solutes such as β2-microglobulin. Formaldehyde is the
second most commonly used disinfectant. Glutaraldehyde, heat, or bleach is used in some
facilities. The other forms of sterilization such as radiation, hydrogen peroxide, ozone, electron
sterilization, and silver, are not commonly used for disinfecting dialyzers.

112. E: The labeling requirements are (1) patient’s name (must be used for only one patient), (2)
number of prior uses, (3) date of last reprocessing, (4) social security number or birth date, (5)
and an additional warning label to notify staff of reuse status of dialyzer (not required, but
recommended).

113. E: OSHA guidelines for personnel safety when using chemical disinfectants include (1)
protective gear such as eye shields, gloves, and waterproof gowns, (2) sufficient ventilation, (3)
splashes on skin or in eyes must be immediately flushed with copious amount of water, then
medical attention sought, (4) shower and eyewash station available, (5) all personnel must be
well-informed about these hazardous chemicals and their toxicity, (6) printed OSHA
requirements and regulations in every dialysis facility, (7) Material Safety Data Sheets (MSDS)
must be accessible to staff at all times, and (8) facility must maintain education records and
health monitoring records for all employees. A negative pressure decontamination room is not
necessary.

114. F: Renalin is a combination of peracetic acid, acetic acid, and hydrogen peroxide. A 0.5%
solution of Renalin is required for disinfecting dialyzers and it must remain in use for 11 hours.
Aqueous formaldehyde (formalin) in a 4% solution must be used for 24 hours at room
temperature in order to kill all microorganisms, including viruses and spores. Hydrogen peroxide
and sodium hypochlorite would be an explosive combination.

115. E: Formaldehyde (formalin) has been linked to nasal and lung cancer. Airborne concentrates
as low as 0.1 parts per million may elicit an irritation response in the nose, eyes, and throat, as
well as allergic reactions such as wheezing, cough, and asthma-related symptoms. Pulmonary
edema, pneumonitis, and death can be the result of long-term exposure to formaldehyde. Skin
reactions are redness, pain, and burns, and splashes to the eyes may lead to blurry vision or
blindness. Formaldehyde is highly toxic and ingestion may lead to nausea, vomiting, diarrhea,
liver and kidney damage, and death.

116. B: The order of preference for the choice of permanent vascular access points for patients
receiving ongoing hemodialysis, as determined by the National Kidney Foundation (NKF), are
(1) the wrist (radiocephalic) primary arteriovenous fistula, (2) the elbow (brachiocephalic)
primary arteriovenous fistula, (3) an arteriovenous graft of synthetic material, (4) the transposed
brachiobasilic vein fistula and, (5) the cuffed, tunneled central venous catheter, which should be
discouraged as permanent vascular access according to the NKF-Kidney Dialysis Outcomes
Quality Initiative (K/DOQI) clinical practice guidelines for vascular access (2000). Existing
guidelines state that 40% of patients should have a native arteriovenous fistula with less than
10% using a central venous catheter.

117. F: A surgeon creates an internal arteriovenous (AV) fistula by anastomosing an adjoining

artery and a vein. This creates a fistula at the site of the anastomoses. The surgeon can choose
different configurations such as side-to-side, end of vein to artery, end of artery to vein, or end-
to-end spatulated artery and vein. The arterial blood is forced into the vein, causing the vein to
distend enough for large fistula needles to be inserted during hemodialysis. This AV fistula can
be located in the upper (brachial artery and cephalic vein) or lower arm (radial artery and
cephalic vein). Doppler flow studies or venography tests are often used to determine the best
vessels to be used.
118. B: The AV fistula surgery should be done when the GFR is less than 30 mL/min per 1.73
m2, as recommended by the K/DOQI Clinical Practice Guidelines (2002).

119. A: Polytetrafluoroethylene (PTFE), a synthetic, is the most popularly used grafting material
and it may be inserted as a loop, straight, or curved graft. This graft bridges an artery at one end
and a vein at the other. If the surgeon agrees, the graft may be ready for use in as little as 2 to 6
weeks. As the tissue surrounding the graft heals, the graft will become more stable.
Hydroxyapatite is used in some bone replacement and dental surgeries. Dacron polyester may be
used in some vascular surgeries; polydioxanone (PDO) is used in some coronary artery surgeries.
120. B: When using a loop graft, the technique used to determine blood flow is to depress the
graft at the center, then listen for a bruit, or feel for a “thrill” on each side of the graft. You will
be able to ascertain which side is the arterial side by determining which side has this bruit or
thrill. This would be the arterial, where the blood is entering. The opposite end would be the
venous side. Once the needles are in place, the arterial side will show a flashback of blood when
the midpoint of the graft is compressed.

121. D: The advantages of the AV fistula over the AV graft are (1) optimal patency rate, (2) may
last for decades, (3) highest blood-flow rates, (4) lowest rate of complications, (5) performance
improves with time as it develops, and (6) collateral circulation, which allows additional
branches to be used.

122. E: Some of the disadvantages of the AV fistula over the AV graft include the failure of the
vein to distend properly; the increased difficulty with cannulation; it is cosmetically unappealing;
requires healthy, straight veins; and needs more time to mature than the AV graft. In the AV graft,
the infection rate is higher and there is a chance of rejection of the graft. There is a greater
occurrence of thrombosis and more chance of stenosis at the anastomoses site with the AV graft.

123. A: The ingredients found in the “A” concentrate (which indicates acidified) portion of the
dialysate are sodium, calcium, magnesium, potassium, chloride, and a small amount of acetic
acid. Aluminum, copper, and lead are undesirable elements and would have been removed by the
water treatment process.

124. D: The main reason sodium chloride is added to the bicarbonate concentrate is to increase
its overall conductivity, producing a concentrate that is simple to monitor. It is not done to
remove metabolic wastes, does not affect the clotting of the blood, and is not added to decrease
the patient’s blood pressure.

125. E: The sodium variation system (SVS) or sodium modeling is used to decrease arm and leg
cramps and hypotension during hemodialysis by monitoring the amount of sodium and water
movement between compartments, and then varying the sodium content accordingly. It either
adds a special NaCl concentrate or varies the proportions of the standard concentrate.

126. F: The similarity of the cellulose surface to the cell wall of bacteria, with both being
composed of polysaccharide structures, causes the body to react as if it were being attacked by
bacteria. The main sources of the extreme complement activation are the free hydroxyl groups on
the membrane surface. In order to diminish this reaction, chemical alterations are employed to
buffer these free hydroxyl groups, producing “modified cellulosic membranes” such as cellulose
acetate and Hemophan. Both modified membranes reduce the reaction, but neither is as effective
as a synthetic membrane in diminishing the complement production. The clinical signs and
symptoms include the following: (1) leukopenia, that corrects itself after 15 minutes, (2) C5a, the
end product of the complement cascade, activates white cells to be released and to clump
(frequently in the lungs), (3) a reduction in the patient’s ability to exchange O2 and CO2,
resulting in hypoxemia, (4) chest pain, back pain, coagulation abnormalities, and anaphylaxis
may develop, and (5) reactions usually peak in 15 minutes, but may last 90 minutes.

127. B: You should maintain your relationship with the patient, but refer him for further
assistance through a social worker and a psychologist. Inviting him out to a restaurant would be
inappropriate and could jeopardize your nursing license.

128. E: 120 to 200 L of dialysis solution comes in direct contact with the patient’s blood during
dialysis. Aluminum could cause bone disease, fatal neurological deterioration, dialysis
encephalopathy syndrome, and anemia; copper, zinc, and chloramine might cause hemolytic
anemia; fluoride may cause severe pruritus, nausea, and fatal ventricular fibrillation; and bacteria
and endotoxins can cause infections and pyrogenic reactions.

129. E: The pretreatment phase of purification of the dialysis water involves controlling of the
water temperature and correction of the pH, if necessary. Removal of calcium and magnesium
occurs in the softening phase, where activated carbon is used for removing chlorine and
chloramines.
130. E: The primary purification process, which is usually reverse osmosis plus deionization, is
the next step in the water purification process. It removes more than 95% of ionic contaminants,
provides a barrier against endotoxins and bacteria, and exchanges sodium, chloride, phosphate,
fluoride, calcium, and aluminum for hydrogen and hydroxyl ions, which combine to form water.
These processes do not affect the temperature of the water.

131. E: High-efficiency dialysis requires a highly permeable cellulose membrane, a bicarbonate

dialysate delivery system, and an ultrafiltration control system. It does not require a high blood
flow rate.

132. F: High-flux dialysis requires high blood flow rate, high dialysate flow rate, precise control
of ultrafiltration volume, highly permeable synthetic membranes with convective transfer
providing a major share of the solute transport, and an ultrafiltration coefficient of 20 to 70
mL/hr/mmHg or more.

133. F: Tap water may be acidic or alkaline, causing problems with the bicarbonate mode of the
delivery system maintaining the proper pH. Any contaminants in the water could enter the
patient’s bloodstream through the dialysis membrane. Substances that may be harmless when
water is ingested through the GI system could be toxic if absorbed directly into the blood. Tap
water may contain chemicals, organic compounds, nonionic organic compounds, silt, pesticides,
herbicides, minerals, microorganisms, trace elements, and endotoxins not found in high-purity
water approved for dialysis. The dialyzer membrane cannot distinguish between ions to be
absorbed or rejected, making it necessary to eliminate these contaminants prior to their
introduction into the dialysis process. It would not affect the number of occurrences of reverse
filtration.

134. B: Venous needle must be placed in the same direction of the blood flow (also known as
antegrade) and it needs to be at least 5 cm proximal to the arterial needle. Since the AV fistula
and AV graft are cannulated at different angles, adjust insertion angle (from 20° to 45°) to
accommodate for these differences.
135. D: The arterial needle is inserted nearest the anastomoses (but at least 3 cm away from the
site to avoid its cannulation) and it may be antegrade or retrograde.

136. A: A fistula with low blood flow rate may lead to recirculation. This low blood flow rate is
often the result of stenosis at one of the ends of the fistula, and is associated with an increase in
venous pressure. Recirculation may lead to “black blood syndrome,” in which the blood’s acidity
level increases, causing the red blood cells to lose their ability to transport oxygen. When the pH
of the blood is below 7, it appears very dark in color.

137. E: The patient with a newly created fistula should have their arm elevated to decrease the
probability of swelling. Manual pressure or a light pressure dressing needs to be applied over the
injection sites for 10 to 20 minutes after the needles have been removed. Since heparin is used
during dialysis, care must be taken to avoid oozing from the injection sites and the formation of
hematomas under the skin around the puncture areas. If bleeding continues for more than 20
minutes after the needles have been removed, the dose of heparin should be readjusted.

138. E: The LifeSite Hemodialysis Access System refers to an implantable device that is used as
a central venous blood access port for hemodialysis. The system is comprised of a 1.2-inch
round, 0.5-inch high metal valve with a 25-inch cannula line. The valve is placed subcutaneously
with the cannula extending into the subclavian or jugular vein.
139. D: “Buttonhole” refers to a constant site technique in which an AV fistula is accessed for
cannulation through the exact same site and at the same angle, creating a tunnel tract of scar
tissue. This tract allows for easier cannulation, using the same scarred channel each time. This
results in less pain for the patient and fewer cases of infiltration, and may be a helpful alternative
for the patient who dialyzes at home.

140. D: Uncuffed catheters when used over a prolonged period are often associated with a high
infection rate. Cuffed are preferable because of their Dacron or felt cuffs, which reduce the
incidence of infection and catheter migration. The incidence of recirculation is not increased
because of catheters being uncuffed.
141. E: There are certain times that the use of a femoral catheter for dialysis is indicated. These
include when an acutely ill patient is confined to bed, when dialysis is needed immediately and
the access is compromised, in the end stage renal disease (ESRD patient, for continuous renal
replacement treatment, and when the patient has subclavian vein stenosis. Femoral access is not
preferable for the patient who travels for his work. In that case, peritoneal dialysis is the usual
method.

142. F: Complications that may occur immediately after insertion of a catheter into the femoral
vein include pneumothorax, hemothorax, air embolism, or bleeding from an inadvertent puncture
of femoral artery.

143. D: Dual-lumen catheters in a side-by-side (double-D) configuration result in less

recirculation, larger separation of inlet and outlet ports, and catheters that are more pliable.

144. A: Subclavian and jugular veins are used in certain patients, but for others these sites are
contraindicated. Patients with difficulty breathing who cannot be placed in supine or
Trendelenburg positions and those with subclavian vein stenosis are not candidates for
subclavian or jugular access.

145. B: “Radial artery steal” syndrome refers to a situation in which the radial artery has a lower
arterial pressure, and the pressure gradient causes the ulnar artery blood to flow into the fistula
instead of supplying blood to the hand and fingers, which become painful and cold. This may be
surgically corrected.

146. F: When a patient receives an infusion of air during dialysis, the following steps must be
taken immediately: (1) clamp bloodlines, (2) discontinue dialysis, (3) position patient on left
side, in Trendelenburg (head down, feet up), which decreases air movement to brain, traps air in
right atrium, above tricuspid valve, also diminishes foaming that occurs in right ventricle, (4)
maintain airway, administer oxygen, if necessary, and (5) keep patient still and in this position
for several hours, for reabsorption of nitrogen and other gases, and (6) obtain chest x-ray to
assess presence of air in heart.
147. F: It is critical that the symptoms of formaldehyde reaction are recognized early. If
formaldehyde has not been completely removed from the dialyzer, the patient may experience (1)
anxiety, (2) bitter, peppery taste in mouth, (3) burning at the venous needle site, (4) numbness
around the lips and mouth, chest pain, back pain, and shortness of breath.

148. D: Treatment for formaldehyde reaction involves the immediate cessation of dialysis to
prevent hemolysis of red blood cells, and the withdrawal of at least 10 mL of blood from each
needle to ensure the cessation of formaldehyde infusion. The Trendelenburg position is not
commonly needed.

149. E: The most common complications that occur during dialysis treatment are hypotension,
cramping, nausea and vomiting, headache, chest pain, back pain, fever, and chills.

150. C: The term “dry weight” refers to the postdialysis weight at which the patient has had all of
their excess body fluid removed.

151. B: If the measurement of dry weight is set too high, the patient will continue to be in a
fluidoverloaded state after the dialysis treatment. This could result in edema or pulmonary
congestion. If the number is too low, the patient may experience hypotension in the latter part of
the dialysis treatment, and complain of cramping, dizziness, and malaise after the treatment is
complete.

152. F: Hypotension is the most common complication patients experience during dialysis. Use
an ultrafiltration controller, which closely controls the fluid removal rate; if unavailable, use a
membrane with low permeability to water so transmembrane pressure fluctuations will remain
minimal. Encouraging the patients to avoid interdialytic weight gain, to limit their salt intake,
and avoid intradialytic food ingestion will help with the hypotension. Other techniques include
increasing the treatment time, using care in determining “dry weight,” and ensuring proper
dialysate temperature. Maintaining therapeutic dialysate calcium concentration (especially in
cardiac patients) and confirming the correct dialysis sodium level are important measures in
preventing a drop in blood pressure. Administer antihypertensive medications after dialysis
treatment, not before.

153. A: Quinine sulfate, carnitine, oxazepam, and prazosin (may help with cramping, but may
cause hypotension) are the most common medications used for cramping and hypotension during
dialysis.

154. D: Some patients develop the following complications when using venous catheters for
dialysis as opposed to traditional hemodialysis access sites. These complications include (1) a
higher likelihood of infection, (2) an increased level of inflammatory markers, such as C-reactive
protein, (3) a higher mortality rate (could be due to different patient population, risks from
receiving catheters, or some property of the catheter), (4) inadequate blood flow through venous
catheters, (5) a lower than average urea reduction rate (URR) in larger patients, (6) a fractional
urea clearance (Kt/V) in large patients, and (7) the survival rate for catheters is around 60% at 6
months, and 40% at 1 year (if revisions are done).

155. F: Immediate steps that need to be instituted in cases of severe hypotension that occur
during dialysis treatment are (1) place patient in Trendelenburg position (feet up, head down), (2)
administer a bolus of saline 0.9%, 100 mL or more, through the bloodline (if respiratory status
tolerates), and (3) reduce the ultrafiltration rate to near zero.
156. F: During dialysis, it is important that the nurse constantly observes and documents the
condition of the patient and the patient’s response to the dialysis treatment. Dialysis staff is
accountable for assessing the readings and responding appropriately. Areas to be monitored, with
appropriate technical equipment in conjunction with the nurse’s and the patient care technician’s
(PCT) expertise in evaluating the parameters, include: (1) arterial and venous pressures, (2)
blood flow rate, (3) amount of ultrafiltrate removed, (4) transmembrane pressure (TMP), (5)
dialysate temperature, (6) dialysate flow and conductivity, (7) amount of treatment time
remaining, and (7) vital signs every hour, or more frequently if required.

157. E: Weight, before and after dialysis, assesses how well the patient is controlling fluid
balance; predialysis weight indicates the level of ultrafiltration needed; postdialysis weight
measures the amount of ultrafiltration that occurred during dialysis; and intradialytic weight gain
(1 lb per day is the usual recommended limit) may be due to fluid retention.

158. F: Blood pressure must be closely monitored during dialysis. Hypertension may signal
volume overload and hypotension may indicate dehydration. Systolic values of more than 170
mm Hg or diastolic value more than 100 mm Hg should be reported to the physician.

159. D: It is important to monitor the temperature, pulse, and respirations of the dialysis patient.
An elevated temperature could indicate infection, pyrogen reaction, or high temperature of
dialysate. A fast pulse could be a sign of anemia, fluid overload, or falling blood volume.
Arrhythmia may denote cardiac complications, and fast respiratory rate may indicate fluid gain.
Any unusual finding should be reported to the physician.

160. F: Patient preassessment prior to the initiation of dialyses must be thorough. The areas that
need to be evaluated include (1) fluid status (heart sounds, respiration rate, effort and breath
sounds, JVD, presence or absence of edema), (2) weight, (3) bowel regularity, (4) sleep
problems, (5) pain, (6) residual renal function, (7) skin evaluation of bleeding or bruising, color,
temperature, integrity, turgor, (8) blood pressure, sitting and standing, (9) temperature, pulse, and
respiration (TPR) with apical/peripheral pulse assessment, (10) vascular access patency, lack of
infection, or bleeding, and (11) any additional physical and lab data evaluation for any necessary
interventions or medications.

161. F: The steps that must be taken prior to commencing dialysis treatment concerning the
dialysate include having an adequate amount of the prescribed dialysate to complete the
treatment, ensuring the dialysate is within the proper safety limits, and that it has the correct level
of potassium and calcium and is the right temperature.

162. F: Preassessment for blood lines includes checking the blood tubing for leaks, verifying that
extracorporeal blood circuit is free of air, confirming that blood pump is properly occluded,
checking blood line tubing for kinks or folds, and ensuring that the blood line tubing is correctly
inserted into the pump segment.
163. E: There are two sources of heparin: one is derived from beef lung and the other comes
from pork intestinal mucosa. The porcine (pork) derivative is more potent than the beef lung
heparin. Heparin is not derived from plants.

164. D: The most commonly used heparin concentration for dialysis is 1000 units/mL, whether
the source is porcine or beef lung (both are formulated to produce the same amount of
anticoagulation properties). The dosage for the patient is always ordered by the physician, and is
usually calculated on the patient’s dry weight.

165. B: Regional heparinization refers to the continual infusion of heparin via the arterial line
with a concurrent infusion of an antidote into the venous line before the blood is infused back
into the patient. Trisodium citrate is used in the arterial line. Since a calcium-free dialysate must
be used with trisodium citrate, calcium chloride must be added into the venous line to prevent
blood from returning to the patient with a low ionized calcium level. The major disadvantages of
this type of heparinization are that numerous laboratory tests are required to assess the clotting
time and calcium levels. Heparin is not administered intermittently for regional heparinization
and it is not available as an oral medication.

166. E: “Tight heparinization,” which is also known to as low-dose heparinization, refers to the
technique of heparin administration in which the dosage is determined by frequent clotting times,
in order to maintain a clotting time of 90 to 120 seconds by ACT. This technique is often used for
the patient’s first dialysis treatment, or for any patient at risk for bleeding, such as one who is
menstruating, postsurgery, or who has a central venous catheter that will be removed
postdialysis. After the minimal priming dose is given, the usual dosage is 10 units/kg and is
regulated to maintain an ACT of 110 ± 10 seconds.

167. A: Hemodialysis done without the use of an anticoagulant is the therapy of choice for
patients with an increased risk of bleeding, pericarditis, coagulopathy, or thrombocytopenia.
168. E: Proper techniques for assessing the internal access point before inserting the needle are
(1) assess the proposed site before cleaning it, (2) observe for signs of infection, including
redness, inflammation, or warmth, (3) cold could indicate thrombosis, (4) check prior injection
sites for healing, scabbing, and open sores, (4) assess for bruising, pain, numbness, or edema (if
swelling is present, the circumference of the arm should be tape-measured for later comparison
to assess the progress), (5) palpate the internal access for the “thrill,” a gentle vibration, which
should be present over the total length (a pulse indicates less than adequate blood flow, listen
with the bell of a stethoscope for the sound of a swoosh or bruit; if the bruit, swoosh, and thrill
are absent, the access may be clotted and should not be used).

169. A: “Loading dose” refers to the amount of a drug that is needed in order to obtain a
therapeutic plasma level as rapidly as possible. Loading doses can be dangerous because of their
rapid administration technique and the increase in the blood plasma level of the drug. Loading
doses are found in the drug reference literature but are calculated as the product of the required
plasma concentration level (blood level “Cp”) and the volume of distribution of the medication.
The formula is: Loading dose (mg/kg) = Vd (mL/kg) x Cp (mg/mL) Once this value is
determined in mg/kg, multiply this dose by the patient’s ideal weight.

170. F: Drug-induced renal damage can often be reversed and further damage prevented if the
following steps are taken: (1) discontinue nephrotoxic drug immediately, (2) administer saline
intravenously to decrease nephrotoxins such as cyclosporine or cisplatin by dilution of the drugs
in the renal tubules, (3) damage done by NSAIDs may be diminished by administering
misoprostol, a prostaglandin analog, (4) select drugs with least probability of nephrotoxicity,
such as acetaminophen, aspirin, nonacetylated salicylates, sulindac, or nabumetone, and (5) give
lowest effective dose of any drug, for shortest duration for effectiveness.

171. B: Psychological complaints that may be expressed by ESRD patients consist of anxiety,
anger, hostility, and depression, with feelings of lack of worth, lack of interest in daily activities,
changes in weight, altered sleep patterns, fatigue, inability to concentrate, and thoughts of
suicide. Sexual dysfunction is usually a physical complaint due to hormonal changes. Expense of
treatment and dietary restrictions may contribute to stress, but are not considered psychological
complaints.

172. E: Acute dialysis may be indicated in the following conditions: (1) symptomatic uremia,
despite BUN and creatinine levels, (2) pulmonary edema, a life-threatening complication of ARF,
fluid overload, or acute myocardial infarction, (3) hyperkalemia, when rapid reduction of plasma
potassium level is indicated, (4) acidosis, added sodium from IV sodium bicarbonate treatment
may increase the chance of fluid volume overload, (5) neurologic symptoms, toxic effects of
uremia, including headache, insomnia, lethargy, confusion, convulsions, and coma, and (6) drug
overdose or poisoning; water-soluble drugs with low molecular weight (including ethanol,
methanol, lithium, and salicylates), drugs with high molecular weight (such as vancomycin and
amphotericin B), or those that are protein bound (such as digoxin and acetylsalicylic acid), and
lipid-soluble drugs (such as glutethimide) are not removed by
dialysis.

173. A: Hemolytic uremic syndrome is the most common cause of acute renal failure in children
in North America. Other causes of acute renal failure include septic shock, resulting in
hypoperfusion of the kidneys, (2) hypotension, causing hypoperfusion of the kidneys, (3) severe
dehydration, from gastroenteritis or acute blood loss from surgery or an accident, also results in
hypoperfusion, (4) acute tubular necrosis, from nephrotoxic drugs such as aminoglycoside,
antibiotics, and amphotericin B, and (5) although acute poststreptococcal glomerulonephritis is
frequently seen in the pediatric population, it rarely results in the need for dialysis.

174. E: Some of the most common causes of pediatric CKD include the following: (1) congenital
urinary tract anomalies, such as posterior urethral valves, obstructive uropathy, reflux
nephropathy, renal dysplasia, (2) neurogenic bladder, associated with spina bifida, (3) hereditary
diseases, including cystinosis, hyperoxaluria, autosomal recessive polycystic kidney disease, and
(4) acquired glomerulonephropathy, focal segmental glomerulosclerosis, and
membranoproliferative glomerulonephritis.
175. B: The preferred method of treatment for most pediatric patients with ESRD is
transplantation. The next most common treatment is home peritoneal dialyses.

176. E: Peritoneal dialysis allows the patient a simpler, home-based therapy with little need for
special water systems. The equipment is easy to set up and use.

177. D: The two types of manual peritoneal dialysis (PD) are continuous ambulatory peritoneal
dialysis (CAPD) in which the patient performs manual exchanges 4 to 5 times a day, and
continuous cycling peritoneal dialysis (CCPD) in which the exchanges are done while the patient
is sleeping. Intermittent peritoneal dialysis (IPD) is an automatic type of PD, which involves
frequent exchanges that are done several times a week, for patients with residual function or who
are institutionalized.

178. E: Patients with abdominal adhesions, fibrosis, or malignancy are unsuitable candidates for
peritoneal dialysis. Some diabetic patients experience an excessive glucose load supplied via PD
and tend to have a higher mortality rate than the hemodialysis patients. One of the main reasons
patients abandon PD is the recurrence of peritonitis. Another reason patients decide to stop their
PD is simply burnout. Some just prefer to go to the dialysis center, leaving them liberated from
any other dialysis duties. In the past few years, better disconnect systems have decreased the
number of peritonitis cases seen in PD patients.
179. F: The peritoneal membrane is the term used to describe the lining of the abdominal cavity
and pelvic walls, including the diaphragm (parietal peritoneum) and the covering of the
abdominal organs (visceral peritoneum). In males, it is completely sealed, in females it opens
into the fallopian tubes and ovaries.

180. A: The peritoneum acts as a semipermeable membrane through which surplus body fluid
and solutes, including uremic toxins, are removed (ultrafiltrate). Peritoneal dialysis uses the
peritoneal cavity, which is approximately equal to the body’s surface area, as a reservoir in which
the dialysate is infused via a catheter. The peritoneum is not a permeable membrane; it is
semipermeable, and dialysate solution, not blood, is infused into the peritoneum for peritoneal
dialysis.
181. B: This procedure is termed “an exchange.” An osmotic gradient is created by using
dextrose in the dialysate, which causes the shift of water into the peritoneal cavity. The surplus of
water is removed when the effluent is drained. The process of diffusion causes electrolytes and
uremic toxins to be removed from areas of higher concentration (bloodstream), to the area of
lower concentration (peritoneal cavity). Low-molecular-weight solutes are “dragged” when
solute removal is enhanced by use of a hypertonic dialysate, which increases ultrafiltration (UF)
by means of convective transport.

182. D: A cycler, which is programmed to meet the requirements of the physician’s prescription,
(1) measures the volume of the dialysate, (2) warms the dialysate to body temperature, (3) time
the regularity of exchanges, tallies the number of exchanges, and (4) calculates the ultrafiltration.

183. E: Diabetes, pulmonary disease, cardiovascular disease, and osteoporosis are all
comorbidity factors in the elderly ESRD patient.

184. D: Potassium is not used in these dialysate solutions because many patients are
hyperkalemic. Potassium may be added to the dialysate solution (2 to 4 mEq/L) if needed, or an
oral supplement may be prescribed.
185. F: It uses a starch-based osmotic agent made from glucose polymers. This starch-based
solution allows for enhanced fluid removal from the blood during peritoneal dialysis, increases
small solute clearance, and lowers the incidence of net negative ultrafiltration. Icodextrin is
prescribed for use once in a 24-hour period, via a long-dwelling exchange lasting 8 to 16 hours.

186. E: The four forms of automated peritoneal dialysis include: (1) continuous cycling
peritoneal dialysis (CCPD), (2) nocturnal intermittent peritoneal dialysis (NIPD), (3) intermittent
peritoneal dialysis (IPD), and (4) tidal peritoneal dialysis (TDP). Continuous ambulatory
peritoneal dialysis (CAPD) refers to a type of manual peritoneal dialysis.

187. E: Coiled catheters are frequently preferred because of their minimal migration from the
original insertion location and their lack of outflow problems. Coiled catheters also seem to
cause less discomfort for the patient because of the configuration that keeps the tip of the
catheter away from the peritoneal membrane.

188. F: The usual cause of an infection in the peritoneum is a break in the closed system,
allowing the entrance of microorganisms into the peritoneal cavity. Signs and symptoms of this
type of infection include cloudy effluent, abdominal pain, nausea and vomiting, peritoneal cell
count greater than 100/mcL WBC, more than 50% neutrophils, and culture results: gram-
positive, gram-negative, multiple organisms, or fungi.

189. D: Treatment involves prompt diagnosis, peritoneal flushes with dialysate 1.5%, and IP
(intraperitoneal) antibiotics with added heparin to prevent fibrin and adhesion formation
(appropriate antibiotic based on culture results).

190. F: When there is a dialysate leak around the exit site or into the subcutaneous tissue during
peritoneal dialysis, the following signs and symptoms may be noted: (1) drainage of clear fluid
from the exit site, (2) abdominal edema, (3) penile edema, and (4) scrotal edema.

191. F: The following psychosocial issues should be included when the physician, patient, and
family decide between peritoneal dialysis and hemodialysis: (1) the patient’s ability and
motivation for selfcare, (2) the physical characteristics of home, availability of water source,
electricity, phone, storage room for supplies, and cleanliness, (3) the availability of an additional
caregiver, such as spouse, relative, or friend, and (4) the patient’s state of mind and
comprehension.

192. D: Some of the negatives associated with peritoneal dialysis (PD) include protein
malnutrition and inadequate dialysis. The protein malnutrition results from the loss of amino
acids and protein in the dialysate. The appetite is decreased because of the glucose load absorbed
from the dialysis. This frequently results in hypertriglyceridemia, which causes weight gain from
the caloric increase (not from a high-carbohydrate diet).
193. D: The advantages of renal transplantation include an improved quality of life, no further
need for dialysis, a cessation of uremic symptoms, resumption of a more “normal” lifestyle, and
the total cost over the long term is much less than dialysis.

194. F: The disadvantages of renal transplantation include a lifelong risk of organ rejection and
need for immunosuppressant therapy, the potential for complications from immunosuppression,
an increased risk of infection and malignancies, medications that may potentially cause bone
disease, cataracts, diabetes mellitus, hyperlipidemia, ulcers, hyperkalemia, obesity, hirsutism,
and gingival hyperplasia, the expense of immunosuppressive medications, and the stress on the
patient and family from the transplantation process.

195. F: The nephrology nurse who cares for the transplantation patient plays several important
roles, including education and counseling of the patient regarding transplantation, assisting
patient with the pretransplant evaluation, and providing dialysis treatments for those patients
with transient loss of renal function due to ATN, patients who have experienced permanent loss
of a transplanted kidney, and patients who are experiencing acute or chronic renal failure due to
transplanted nonrenal organs (heart or liver).

196. E: Patients who cannot currently be considered for renal transplantation include those with
active infections, those with ongoing malignancies, those who are current substance abusers, and
those who are unable to adhere to medication schedules.

197. A: Living and deceased human donors are used as sources for kidney donations.

198. E: The only requirements for a living donor to be considered as the source for a kidney are
that they must voluntarily give informed consent, and that they are completely healthy.

199. F: In order for a deceased person to be used as a kidney donor, the following requirements
must be met, (1) the patient must have had irreversible brain damage, (2) consent must have been
given by next of kin, (3) body must have been kept functioning by artificial ventilation and
medications, (4) kidney must be recovered by organ recovery team, (5) kidney must go to
regional tissue and organ bank per national guidelines to be distributed to proper recipient, and
(6) no expense is incurred by donor family.

200. F: The main precautions that must be followed when performing dialysis on a recent
transplant recipient include: (1) close observation for hypotension, due to risk of internal
bleeding in first 24 hours postsurgery (alert physician if hypotension occurs), (2) hypotension
must be avoided to prevent ischemia of newly transplanted kidney, even if fluid removal during
dialysis is compromised, (3) maintain the integrity of the surgical incision site, (4) use heparin-
free or minimal anticoagulation therapy for newly postoperative patients, and for those who have
had percutaneous renal biopsy, and (5) observe for electrolyte imbalance, especially
hyperkalemia.

Review of Hemodialysis for Nurses and Dialysis Personnel, 27.5: Eighth Edition

1.) Responsibilities and requirements of the medical director of a dialysis facility may include:
Writing policies and procedures that show compliance with the standards of the local medical
community.
Being knowledgeable regarding the integrity of the water treatment system in the facility.
Being physically present in the dialysis unit whenever a patient is receiving a dialysis. treatment.
Accessing fistulas or grafts prior to the beginning of the dialysis session.

2.) Prior to beginning dialysis, the physician order must include:

Specific dialyzer.
Blood flow rate.
Duration of the dialysis.
Three units of packed red blood cells.

1, 3, and 4
2, 3, and 4.
1, 2, and 4.
1, 2, and 3.

3.) The primary goal of the dialysis nurse is to:

Oversee the financial billing for the service.

Access devices.
Collect all lab specimens.
Be an advocate for the patient.

4.) What qualities would be most beneficial for a dialysis nurse to possess?

The ability to work well under stress.

The ability to follow leaders but not necessarily have mastered working with other team
members.
A strong knowledge base and critical thinking skills.
The ability to work independently, to work in isolation, and to have minimal interaction with
others.
2 and 4
1 and 3
2 and 3
1 and 4

5.) To qualify for the role of dialysis nurse manager, the nurse must:
Have at least 6 months experience in case management along with 2 months of clinical practice.
Be credentialed as a CNN-NP (certified nephrology nurse-nurse practitioner).
Have a minimum of 12 months of experience in clinical nursing.
Be at least a part-time employee working a minimum of 24 hours/week.

6.) A dialysis technician should have knowledge of:

Equipment setup and maintenance.

Principles of computer technology.
How to administer intravenous medication if an emergency arises.
Patient education related to dialysis and financial obligations.
3 and 4.
2 and 3.
1 and 2.
1 and 4.

7.) Which of the following statements about consent for treatment is accurate?

A written consent for dialysis includes consent for placement of an access catheter.
Two consents are needed for dialysis: one for the dialysis itself and one for access procedures or
modifications.
In an emergency, such as an aspirin overdose, it is not necessary to have consent prior to
beginning hemodialysis.
A renal patient who has been admitted to the hospital with sepsis has given implied consent upon
signing the initial admission paperwork.

8.) What was the primary anticoagulant used in the first artificial kidney?

Warfarin.
Hirudin.
Low-molecular weight heparin.
Salicylic acid.

9.) The first dialyzer suitable for human use (rotating drum dialyzer) was created in 1943. What
material was used to construct the hollow tubes on this device?

Rubber.
Teflon.
Glass.
Cellophane.

10.) The first arteriovenous (AV) shunt for chronic renal patients was placed:

Intravascularly using 4 inch catheters.

Internally in the carotid vessels.
Externally using Teflon tubes.
Via surgical cutdown.

11.) Early xenograft kidney recipients died from complications related to:

The inability to control hypertension.

The lack of immunosuppressive therapy.
Hemorrhaging.
Sepsis.

12.) A dialysate solution containing too much sodium may result in:

The patient experiencing heart failure and ventricular dysrhythmias.

Fluid leaving the cells causing blood cells to shrivel.
Water shifting into the patient’s blood cells.
The patient experiencing hypotension and cramping.

13.) Kidney failure causes retention of hydrogen ions, resulting in:

Respiratory alkalosis.
Metabolic acidosis.
Metabolic alkalosis.
Respiratory acidosis.

14.) Which of these patient populations has the highest proportion of body water?

Female patients.
Male patients.
Geriatric patients.
Infants.

15.) Cell walls are impermeable to:

Sodium.
Protein.
Phosphate complexes.
Amino acids.
1 and 4.
2 and 3.
1 and 2.
3 and 4.

16.) The vas recta capillaries surround the loop of Henle and nephrons and play a major role in:

Excretion of waste products.

Fluid secretion and reabsorption.
Concentration of urine.
Electrolyte balance.

17.) The distal tubule can adjust water-to-solute load based on which hormone secretion?

Aldosterone.
Epinephrine.
Antidiuretic hormone (ADH).
Cortisol.

18.) Blood urea levels may be increased as a result of:

Drinking too much fluid.

Low protein intake.
Gastrointestinal bleeding.
Steroid use.
2 and 3.
1 and 4.
3 and 4.
1 and 2.

19.) What co-morbidity factors accelerate the progression of kidney disease?

Drinking 6 beers each week.

Smoking.
Poor control of diabetes.
Intense exercise regimens.
3 and 4.
2 and 3.
1 and 2.
1 and 4.
20.) Clients with glomerulonephritis may exhibit which of these clinical manifestations?

Hematuria.
Flank pain.
Edema.
Anuria.
3 and 4.
1 and 3.
1 and 2.
2 and 4.

21.) The primary cause of nephrosclerosis is:

Renal artery aneurysm.

Elevated cholesterol levels.
Severe, uncontrolled hypertension.
Alcohol abuse.

22.) Which of the following may be a cause of postrenal acute renal failure (RF)?

Toxicity related to antibiotic administration.

Heart failure.
Obstructive kidney stones in the ureter.
Severe dehydration.

23.) The nurse should assess an ICU patient for rhabdomyolysis, which may result in acute RF,
when the patient has experienced:

A large blood loss following coronary bypass graft surgery.

A crush injury following a car accident.
A near drowning following a boating accident.
A head injury related to football.

24.) Uremic toxins can irritate the pericardial membrane, leading to which of the following
clinical manifestations?

Shortness of breath, substernal chest pain unaffected by respirations, and dizziness.

Coronary artery inflammation causing myocardial infarction.
Loud systolic murmur located in upper left sternal border caused by valvular heart disease.
Chest pain, low-grade fever, and pericardial friction rub.

25.) Common skin changes related to stage 5 CKD include:

Brittle nails.
Excessive sweating.
Ecchymosis.
Increased number of moles.
3 and 4.
2 and 4.
1 and 2.
1 and 3.

26.) Clinical manifestations of anemia in CKD patients include:

Pallor and prolonged capillary refill.

Dyspnea and fatigue.
Bruising and edema.
Confusion and insomnia.

27.) Due to an imbalance in calcium-phosphorus metabolism, the CKD patient is at high risk for
developing:
Bruising on the skin and arrhythmias.
Osteoporosis and hip fractures.
Gallstones.
Decreased production of PTH.

28.)The nurse should be prepared to administer ____________ for patients with persistently high
uric acid levels.

1, 25-dihydroxycholecalciferol.
Allopurinol.
Nonsteroidal anti-inflammatory drugs (NSAIDs).
Vitamin D.

29.) Patients who have developed metabolic acidosis may display which of the following
respiratory signs/symptoms?

Alternating episodes of apnea and hyperpnea.

Normal breathing interrupted by sudden apnea.
Increased rate and depth of respirations (Kussmaul respirations).
Decreased rate of respiration with shallow effort.

30.) Patients sensitive to ethylene oxide sterilization techniques may benefit from
_______________ because it does not use chemicals or radioactive materials.

Immersion in soapy water.

Electron beam sterilization.
Gamma irradiation.
Microwave sterilization.

31.) What are some negative aspects of synthetic membranes?

They are expensive.
They require automated ultrafiltration control.
They can adsorb proteins on the membrane surface.
The patient may develop allergies.
2 and 3.
2, 3, and 4.
3 and 4.
1, 2 and 3.

32.) What clinical manifestation of complement activation may occur immediately after starting
hemodialysis with cellulosic membranes?

Elevated histamines.
Anaphylaxis.
Severe anemia.
Leukopenia.

33.) Long-term exposure to cellulosic membranes used during dialysis has been associated with:

Red blood cell destruction.

Infection.
Malignancy.
Human immunodeficiency virus.
1 and 4.
2 and 3.
1 and 2.
3 and 4.

34.) Which of the following statements about bicarbonate dialysate is accurate?

The “B” (bicarbonate) concentrate is very stable and has a long shelf life.
The “A” (acidified) concentrate is made up primarily of potassium.
Calcium and magnesium are very stable in solution with bicarbonate.
The bicarbonate concentrate is very susceptible to bacterial contamination.

35.) What are the effects of overmixing the bicarbonate concentrate?

A serum increase in magnesium levels can be seen.

The patient can experience a drop in phosphate levels.
The patient can experience an increase in sodium levels.
The patient can experience a decrease in serum calcium levels.

36.) Which of these lab tests is utilized to detect bacterial endotoxins?

Enzyme-linked immunosorbent assay (ELISA).

Colony forming units (CFU).
Culture and sensitivity (C & S).
Limulus amebocyte lysate (LAL).

37.) Which of these exchange resins takes up ammonium ions and releases sodium and hydrogen
(in 1:9 ratio) in their place?

Hydrated zirconium oxide.

Sodium zirconium phosphate.
Carbon layer.
Urease.

38.) During a dialysis session, it is important for the nurse to monitor dialysate temperature since
fluid temperature _____ will result in hemolysis of RBCs.

>30o C.
>41o C.
<36o C.
<40o

39.) Nurses working with patients undergoing high-flux dialysis should be alert to the
development of bacterial infection related to:

The lack of filters placed in the dialysate path so that high volumes can be maintained.
The inability of cleaning solutions to reach the inner portion of the membrane during reuse.
Breaks in the blood tubing due to high volume pressure.
Permeability of the membranes passing particles of 2,000-10,000 Da in size.

40.) Which of the following statements regarding the removal of toxins in dialysis is accurate?

The lower the concentration gradient, the greater the amount of diffusion.
The greater the dialysate flow rate, the greater the removal of solutes.
The higher the dialysate temperature, the lower the solute removal.
The larger the molecular weight, the greater the removal of solutes.
41.) To achieve an optimal concentration gradient, what direction should blood and dialysate
flow?

As determined by flux.
In a cyclic fashion.
In the same direction.
In opposite directions.

42.) During ultrafiltration, what happens when positive pressure is applied to the blood side of
the dialyzer?

All endotoxins will be pushed out.

Plasma fluid will be pushed out.
Red blood cells will be pushed out.
An increased amount of electrolytes will be pushed out.

43.) What potential patient complication should be monitored by dialysis personnel if reverse
filtration occurs and dialysis water is moved into the blood?

Hypertensive crisis.
Pyrogenic reactions.
Rupture of blood vessels.
Water on the brain.

44.) What principle is used to decrease complications related to fluid removal?

Reverse filtration.
Diffusion.
Ultrafiltration profiling.
Osmosis.
45.) Which of the following chemicals may cause methemoglobinemia, in which red cell
hemoglobin cannot transport oxygen?

Nitrates.
Chloramines.
Fluoride.
Aluminum.
3 and 4.
1 and 2.
2 and 3.
1 and 4.

46.) In order to remove smaller solutes, such as endotoxins, which filter should be utilized?
Carbon filter.
Membrane cartridge.
Ultrafilter.
Wound filament.

47.) Which statement regarding the removal of chlorine from water utilizing two carbon tanks is
accurate?

Chlorine testing must be done at the beginning of each treatment week.

If sampling reveals there is chlorine in the water leaving the first tank, then water must be
sampled after leaving the second tank.
If a sample from the second tank contains chlorine, then the nurse will need to use a smaller in-
line filter during the dialysis session.
Sampling must be done to ensure that the carbon tank does not remove too many electrolytes.

48.) Polyamide membranes:

Have a very long service life.

Have a wide pH tolerance.
Degrade at temperatures greater than 35o C.
Are susceptible to degradation by free chlorine.
3 and 4.
1 and 3.
2 and 4.
1 and 2.

49.) Which of the following is an advantage of reverse osmosis (RO) water treatment?

Use of a carbon filter ahead of the RO system removes any chloramines.

Rejection of bacteria, viruses and pyrogen materials if the membrane is intact.
Good tolerance for free chlorine.
No need to keep membrane wet at all times.

50.) Deionizers produce:

Water free of micro-bubbles.

Water of high ionic purity.
Pyrogens free of bacteria.
Sterile water with a neutral pH.

51.) Ultraviolet light is used in treating water in order to:

Heat the water to desired range.

Destroy microorganisms.
Break up suspended particles.
Remove all mold and algae.
52.) Which of the following contaminants in water may result in the hemolysis of RBCs?

Copper.
Nitrate.
Aluminum.
Cadmium.

53.) A reused dialyzer should be rejected if:

Visual inspection reveals a few clotted fibers.

Applied pressure causes the dialyzer to maintain pressure.
Exposure to disinfectant lasted one hour just prior to reuse.
Total cell volume (TCV) is 90% of initial volume.
54.) Which protective gear should be used when working with chemical disinfectants?

Gloves.
Eye shields.
Full HAZMAT suit and respirator.
Waterproof gown.
1, 2 and 3.
1, 2 and 4.
2 and 3.
1 and 2.

55.) When initiating and terminating dialysis, what personal protective equipment (PPE) should
dialysis healthcare personnel use?

Gloves.
HEPA filter mask.
Face shields.
Gown.
2, 3 and 4.
1, 3 and 4.
1 and 2.
1 and 4.

56.) Which of the following statements regarding handwashing is accurate?

Handwashing need only be done just prior to beginning a dialysis session but is not necessary if
gloves are used.
Handwashing should be done before and after glove removal.
Hands should be washed before and after entering patient areas.
Hands should be washed between patient contacts and after touching any environmental surface.
1.
2.
3 and 4.
2, 3, and 4.

57.) To safely dialyze a patient who is hepatitis B-positive, the nurse should ensure that the:

Only precaution followed is that staff washes their hands between patients if they are caring for
both HBsAg-positive and seronegative patients on the same shift.
Patient’s reused dialyzer is labeled: “For HBsAg-positive use” only.
Patient is placed in an isolation room and has a dedicated machine.
Patient is restricted from visiting with other renal patients during dialysis treatment to reduce the
risk of airborne transmission.

58.) A staff member who is immune to hepatitis B due to the vaccination series will have which
of the following lab results?

HBsAG positive.
Anti-HBc negative.
Anti-HBs positive.
IgM anti-HBc negative.
3 and 4.
1 and 4.
2 and 3.
1 and 2.

59.) Following exposure to blood via needlestick, the first action by the nurse should be to:

Call the nursing supervisor to report the incident.

Wash the area with soap and water.
Go to the emergency room or employee health center.
Fill out an incident report.
60. ) What infection control precautions should be instituted for an HIV-infected patient on a
dialysis unit?

The same precautions taken with HBV patients.

Standard precautions.
Strict isolation during dialysis.
Group (cohort) all HIV-positive patients together during dialysis.

61.) CDC recommendations for hepatitis C-positive dialysis patients include which of the
following?

All patients should be vaccinated against hepatitis C virus.

All patients should be monitored monthly for liver enzyme elevations.
Routine screening of patients as a requirement prior to beginning dialysis.
Hepatitis C-positive patients must be isolated and dialyzed on dedicated machines.

62.) A dialysis patient who has an active case of tuberculosis should:

Have repeat Mantoux skin testing weekly until the test becomes negative, then may return to
their outpatient dialysis center for runs.
Wear a mask during treatment to limit exposure to other dialysis patients.
Be referred to hospitals that have isolation rooms equipped with negative pressure.
Have dialysis at times when no other patients are in the outpatient dialysis unit.

63.) Patients who are infected with methicillin-resistant Staphylococcus aureus (MRSA) or
vancomycin-resistant enterococci (VRE) can safely be cared for in the dialysis unit by:

Standard precautions, making sure to wear gloves if touching soiled skin or clothing.
Hanging IV antibiotics and infusing throughout the entire dialysis treatment.
Isolating patients with draining wounds in a room dedicated to all infectious patients.
Making sure all surfaces (of machine, equipment, and chairs, etc.) have been cleaned with 1:100
to 1:10 bleach solution following every treatment.
3 and 4.
2 and 3.
1 and 4.
1 and 2.

64.) After heparin is given intravenously, the peak anticoagulant activity is reached in
__________, with a half-life of __________.

30 minutes; 6 hours.
5-10 minutes; 90 minutes.
30-60 seconds; 30 minutes.
1-2 minutes; 60 minutes.

65.) Which of the following patients would be a candidate for heparin-free dialysis?

The patient with newly diagnosed pericarditis.

The chemotherapy patient experiencing thrombocytopenia.
The patient experiencing back spasms following injury.
The patient with a history of smoking and drug abuse.
3 and 4.
1 and 2.
2 and 3.
1 and 4.

66.) When the dialysis treatment is completed, the best way to maintain vascular catheter patency
is for the nurse to perform which of the following interventions first?
Rinse the dialyzer with 100 mL normal saline and instill enough tissue plasminogen activator
(tPA) into the dialyzer to completely fill it if any clotting is noted.
After flushing the lines with normal saline, quickly inject heparin into the access lumens to
prevent mixing of heparin with saline, thereby diluting the heparin.
Rinse bloodlines with saline and heparin solution before priming the lines with saline.
Flush each lumen of the catheter with heparin, 1000 units/ml until the entire line is filled.

67.) What is the preferred vascular access in patients undergoing chronic hemodialysis?

Polytetrafluoroethylene graft in forearm.

Transposed brachiobasilic vein fistula.
Radial-cephalic arteriovenous fistula.
Brachiocephalic arteriovenous fistula.

68.) Which of the following statements about arteriovenous fistulas is accurate?

A synthetic graft is implanted subcutaneously into the forearm to bridge an artery on one end and
a vein on the other end.
Two vessels are joined surgically whereby the pressure in the artery dilates and thickens the
venous segment, making it suitable for needle cannulation.
Six weeks after creation, the diameter of the fistula should be at least 6 mm with discernible
margins.
The main cause for fistula failure is clotting of blood in the venous portion due to low blood
flow.
3 and 4.
2 and 3.
1 and 2.
1 and 4.

69.) What action should the nurse employ when cannulating a proximal radial artery
arteriovenous fistula when both needles are placed in the forearm?

Place both needles pointing retrograde towards the patient’s hand.

Place the venous needle upward toward the patient’s shoulder.
Point the arterial needle downstream toward the patient’s fingers.
Place the venous needle pointing retrograde toward the hand.

70.) If the nurse gently depresses the midpoint in a looped arteriovenous graft, the arterial side
can be located by which of the following?

Watching for a flashback of blood underneath the skin (hematoma formation) to verify arterial
blood flow.
Feeling for a thrill on the side where the blood is entering the access (arterial side).
Palpating for weak radial pulses.
Watching for color changes in the patient’s hand (turning cyanotic).

71. ) Which of the following are advantages of an arteriovenous graft over a fistula?

A graft may last for decades.

A graft develops strong collateral circulation.
A graft can be accessed shortly after placement (~2 weeks).
A graft is easier to cannulate.
2 and 3.
3 and 4.
1 and 4.
1 and 2.

72.) What is the most common complication of AV fistulas?

Aneurysm.
Edema.
Infection.
Thrombosis.

73.) What does the absence of a bruit or thrill indicate?

The access is ideal for cannulation.

The venous return is sluggish and requires use of heparin.
The access is not useable at this time due to low blood pressure.
A clot is present or the access is not patent.

74.) Dialyzing a patient at a high blood flow rate with a small-gauge needle may result in:

Inadequate removal of waste products.

Hemolysis of RBCs.
Infiltration.
Increase in pressure readings.

75.) Clinical manifestations that a fistula has a low blood flow due to stenosis include:

below 7.00.
Very dark blood.
Elevated arterial pressure reading.
Visible clots in the lines.
2 and 3.
1 and 2.
1 and 4.
3 and 4.
76.) What special nursing interventions are needed after a temporary catheter access device is
placed in the jugular vein?

Watch for shifting of the trachea to non-accessed side.

Assess the patient for increased intracranial pressure.
Keep the patient supine for a minimum of 4 hours.
Confirm placement by chest x-ray prior to use.

77.) Before initiating or terminating dialysis via femoral catheter placement, the nurse should:

Keep firm pressure on the lines for a minimum of 30 minutes after the treatment using sandbags.
Wrap the caps and ports in 4 x 4 dressings soaked in hospital-approved disinfectant.
Palpate popliteal and pedal pulses; document findings.
Flush the lines to instill the heparin that has remained in the lines post-treatment.

78.) The patient with low post-dialysis weight is at risk for:

Developing cachexia.
Hypovolemia.
Clotting of the vascular access.
Hyponatremia and hyperkalemia.
3 and 4.
1 and 4.
1 and 2.
2 and 3.

79.) A patient with an AV fistula on the right arm and a history of left-sided mastectomy should
have her blood pressure checked on the:
Dialysis machine after the treatment has begun.
Lower limbs, usually beginning with the popliteal position.
Left arm, since the risk of lymphedema is low.
Right arm as long as the BP cuff is not inflated for too long.

80.) What procedure(s) should take place prior to the first hemodialysis treatment?

Provide the patient ample time to roam the unit and visit with experienced dialysis patients.
Ensure the patient has signed a consent form.
Review the usual course of treatment and begin a 4 hour dialysis treatment session.
Begin a detailed discussion of the advantages and disadvantages of dialysis.

81.) Which of the following assessments may indicate that the patient is experiencing a problem
with fluid balance?

Jugular vein distention (JVD).

Presence of crackles bilaterally in lung fields.
Elevated temperature.
Slow irregular pulse rate.
3 and 4.
1 and 2.
1 and 4.
2 and 3.

82.) Which of the following patients might benefit from sequential ultrafiltration?

An 81-year-old patient with acute abdominal pain associated with metastatic cancer.
A 22-year-old pregnant patient who has demonstrated some proteinuria.
A 14-year-old patient who overdosed on Tylenol.
A 56-year-old patient who is experiencing severe hypertension.
83.) When compared with high-efficiency dialysis, high-flux dialysis:

Does not require bicarbonate dialysate for cardiovascular stability.

Requires a blood flow rate to be <250 mL/min.
Allows only solutes of low molecular weight (<5,000 Da) to be removed.
Demonstrates much higher water permeability.

84.) If a patient experiences hypotension at the beginning of dialysis due to volume shifts, the
nurse should be prepared to:

Stop the dialysis treatment and have the patient return the next day.
Administer small amounts of normal saline.
Discontinue all antihypertensive medications.
Infuse albumin as prescribed in unit protocols.
1 and 2.
2 and 4.
1 and 3.
1 and 2.

85.) If a young pediatric patient experiences hypertension during dialysis, which of the following
corrections may help?

Request a physician order for a beta blocker.

Infuse 3% saline solution.
Use a smaller surface area dialyzer.
Increase blood flow rates.

86. ) Air embolism is a serious event that requires immediate action. What should the nurse’s
first response be to this event?

Have the patient perform a Valsalva maneuver.

Clamp the bloodlines and stop dialysis.
Place the patient supine in the reverse Trendelenburg position.
Call the physician for orders.

87. ) The primary reasons to institute protein restriction before initiation of dialysis are to:

Help the patient lose weight.

Reduce the amount of fluid being retained in the interstitial space.
Minimize nitrogenous wastes.
Aid in the control of uremic symptoms.
2 and 4.
3 and 4.
1 and 2.
1 and 3.

88.) The average recommendation for daily sodium intake for the hemodialysis patient is:

1500 mg/day.
1000 mg/day.
2000 mg/day.
500 mg/day.

89.) When calculating fluid intake, which of the following statements is accurate?

The patient’s daily weight will predict how much fluid they can have for the day.
Patients must carry a chart that lists the amount of fluids contained in fruits and add this amount
into their total fluid intake for the day.
Foods such as soups and gelatin are counted in the daily fluid allotment.
Every dialysis patient is allotted 2 liters of fluid/day.
90.) Intradialytic parenteral nutrition can provide approximately how many calories per one liter
of solution?

1200-1400.
800-1000.
400-500.
600-750.

91.) Compared to hemodialysis patients, patients on continuous cycling peritoneal dialysis

(CCPD):

Have more problems with potassium control.

Will consume more calories due to the amount of dextrose in the dialysate.
Have lower protein needs overall than hemodialysis patients.
Have a more restrictive sodium diet, usually <1000 mg/day.

92.) Carnitine may be routinely supplemented in patients on dialysis in order to:

Stimulate urine production in the remaining functioning nephrons.

Lower triglyceride levels.
Decrease CNS changes associated with disequilibrium syndrome.
Decrease red blood cell fragility.
3 and 4.
2 and 3.
2 and 4.
1 and 2.

93.) A renal patient taking herbal remedies should be informed that __________¬¬¬ should not
be taken if he/she has had a transplant, due to possible allergic reactions.
Ginkgo biloba.
Garlic.
Echinacea.
Aloe.

94.) An elevated C-reactive protein level in combination with a low serum albumin level may
place the dialysis patient at a higher risk for developing:

Increased intracranial pressure.

Acute pericarditis.
Hypovolemic shock.
Heart disease.

95.) Clinical manifestations that indicate a dialysis patient has high serum aluminum levels may
include:

Behavioral changes.
Slurred speech.
Projectile vomiting.
High fevers resulting in seizures.
3 and 4.
1 and 2.
1 and 3.
2 and 4.

96.) What symptoms will be present if a dialysis patient is experiencing low magnesium levels?

Muscle weakness and sedation.

Muscular twitching and spasms.
Excessive bleeding and bruising.
Excessive sweating and fatigue.
97.) Low hematocrit levels are associated with the dialysis patient experiencing:

Itchy, flaky skin and dry mucous membranes.

Insomnia and irritability
Bone loss resulting in a risk for fractures.
Heart palpitations and shortness of breath.

98.) For a dialysis patient, the normal pretreatment BUN range is:

45-55 mg/dL.
60-100 mg/dL.
30-40 mg/dL.
5-25 mg/dL.

100.) When the goal is to delay the progression of diabetic nephropathy, the nurse should
anticipate administering which of these medications?

Metoprolol (Lopressor), a beta-adrenergic blocker.

Insulin by pump.
Furosemide (Lasix), a potassium-sparing diuretic.
Lisinopril (Zestril), an ACE inhibitor.

101.) Which of the following complications that can occur in patients with diabetes and
autonomic neuropathy may result in underdialysis?

Blurred vision and photosensitivity.

Numbness and tingling in lower extremities.
Hypotension.
Hypoglycemia.
102.) If hyperglycemia is noted via glucometer during hemodialysis, the treatment of choice is:

Assess the patient for possible rupture of the intestines.

Administer regular insulin per protocol.
Decrease heparin dose to prevent excess bleeding.
Infuse a bolus of normal saline.

103.) A patient with a hemoglobin A1c level of 8% would have an estimated average glucose
(eAG) level of:

169 mg/dL.
183 mg/dL.
140 mg/dL.
126 mg/dL.

104.) The most common medications causing nephrotoxicity in dialysis patients include:

Antibiotics.
Radiocontrast agents.
Loop diuretics.
Proton pump inhibitors.
3 and 4.
2 and 4.
1 and 3.
1 and 2.

105.) Which of these medications may cause renal vascular alterations (such as thrombotic
microangiopathy) that can damage the kidney?
Adrenergic drugs.
Oral contraceptives.
Lisinopril, an ACE inhibitor.
Lovastatin, a HMG-CoA reductase inhibitor.

106.) As a response to an administration of epinephrine, uremic patients may experience:

An inability to excrete any of the medication thereby causing toxicity.

A faster absorption rate of epinephrine than expected.
Tachycardia and hypertension.
Resistance to the effects of epinephrine.

107.) When allopurinol is prescribed for gout, the dialysis patient will require:

Repeated administration, since it normally is cleared unchanged by the kidneys.

Lower doses than that for a patient with normal renal function.
Much higher doses than normal in order to achieve the desired effect.
Close observation, since this drug may cause liver failure.

108.) The nurse caring for an elderly CKD patient who may have accidently overdosed on
digoxin should know that it:

May take 1.5 hours to reach half-life, is 90% protein bound, and is not dialyzable.
May take up to 100 hours to reach the half-life and is dialyzable.
May take 24 hours to reach the half-life and is not dialyzable.
Takes only 2 hours to reach the half-life and is dialyzable.

109.) If a loading dose of a drug is not given, how many half-lives of repeated maintenance
dosing are required to reach steady state?

Six.
Three.
Four.
Two.

110.) When a trough level is ordered for a certain drug, the blood specimen is to be drawn:

Routinely with the usual morning lab draw.

30 minutes after a parenteral dose has been given.
Immediately before the next scheduled dose is to be administered.
1-2 hours after the oral medication has been given.

111.) What is a major complication of epoetin alfa therapy in the renal patient?

Bone marrow suppression.

Hypertension.
Pulmonary emboli.
Heart failure.
112.) A severely anemic dialysis patient receives a blood transfusion. Which of these complaints
soon after beginning the transfusion indicate that he/she may be having a blood incompatibility
reaction, and that the transfusion must be stopped immediately?

Back pain.
Fever and chills.
General malaise.
Nausea and vomiting.
3 and 4.
1 and 2.
1 and 3.
2 and 4.
113.) Which of the following statements regarding the administration of iron to the dialysis
patient is accurate?

When administering sodium ferric gluconate (Ferrlecit), the nurse should note that there is a high
risk for patients to develop anaphylaxis.
Oral iron supplements are every effective and compatible with the majority of medications
prescribed for the dialysis patient.
It is common practice for iron to be given intravenously during hemodialysis.
When the serum ferritin level is <100 ng/mL, the patient is usually started on oral iron
supplements.

114.) When administering lisinopril (Zestril) to a renal patient, the nurse should monitor which of
these lab results for possible side effects of ACE inhibitors?

Elevated serum potassium.

Decreased serum magnesium.
Increased serum creatinine.
Decreased serum calcium.
3 and 4
1 and 3.
1 and 2.
2 and 4

115.) A renal patient asks the nurse how a calcium channel blocker works to lower blood
pressure. The nurse responds that the calcium channel blocker:

Slows the nerve impulses that travel through the heart, causing the heart to work less hard.
Slows the rate at which calcium passes into the heart muscle and blood vessel walls, helping
them to relax so blood can flow more easily through them.
Is basically a smooth muscle relaxer that helps the blood vessels relax to let blood flow with less
tension.
Blocks the enzyme angiotensin II, which makes the blood vessels constrict.

116.) The nurse will know that levocarnitine (Carnitor) is effective when the patient states:

“I no longer need blood transfusions every week.”

“I have noticed that my muscle cramps have decreased.”
“The amount of urine that I produce during the day has increased since taking this medication.”
“My doctor tells me that my bones are getting stronger.”

117.) The renal nurse notes a new order for paricalcitol (Zemplar). Prior to administering this
medication, the nurse reviews lab results and withholds the medication when the:

Hemoglobin level is 14 g/dL.

Vitamin D level is 31 pg/mL.
Serum parathyroid hormone (PTH) level is 20 pg/mL.
Serum calcium level is 12.9 mg/dL.

118.) In the adult ICU setting, which of the following patients would the nurse consider at
highest risk for developing prerenal acute kidney injury (AKI)?

A 17-year-old with altered mental status following head injury from boxing.
A 22-year-old auto accident victim who lost copious amounts of blood following traumatic
amputation to the right lower limb.
A 53-year-old who develops cardiogenic shock following massive myocardial infarction.
A 77-year-old hospitalized with respiratory distress following exposure to smoke from a house
fire.
1 and 4.
3 and 4.
1 and 2.
2 and 3.
119.) Which of these signs/symptoms in an AKI patient would likely lead to a prescription for
acute dialysis?

A BUN level of 50 mg/dL.

Acute respiratory distress associated with bilateral crackles to mid-scapular area.
A serum potassium level of 5.5 that responds to an insulin drip.
Drowsiness and confusion.
3 and 4.
2 and 4.
1 and 2.
1 and 3.

120.) What is the most common complication that may occur with AKI?

Peripheral ischemia.
Heart failure.
Thrombocytopenia.
Tetany.

121.) Which of the following symptoms of the patient who is being dialyzed for the first time
would lead the nurse to suspect “first-use” syndrome?

Abdominal distention.
Painful voiding.
Periorbital edema.
BP 80/58.

122.) The nurse should anticipate the physician will order __________ for the AKI patient
experiencing less severe symptoms of first-use syndrome.

Epinephrine.
Dopamine.
Mannitol.
Benadryl.

123. ) Patients experiencing hypotension who do not respond to normal saline infusion may
require:

Epinephrine.
Albumin.
Drotrecogin alfa.
Sodium bicarbonate.

124.) Which of the following signs/symptoms are associated with dialysis disequilibrium?

Inability to walk in a straight line.

Severe pain and ringing of the ears.
Muscle twitching.
Grand mal seizure.
1 and 2.
1 and 3.
2 and 4.
3 and 4.

125.) Continuous renal replacement therapy (CRRT) is primarily recommended to treat patients
with AKI who have associated:

Hepatitis B diagnosis.
Multiple organ failure.
Bleeding disorders.
Parathyroid complications.
126.) Which of the following treatments utilizes a double lumen catheter and can be used in a
critical care unit since it does not require arterial access?

Slow continuous ultrafiltration (SCUF).

Continuous arteriovenous hemodialysis (CAVHD).
Continuous arteriovenous hemofiltration (CAVH).
Continuous venovenous hemofiltration (CVVH).

127.) What should the nurse’s assessment include when caring for a patient on slow continuous
ultrafiltration (SCUF) who is experiencing a low ultrafiltrate?

Checking for an elevated arterial pressure.

Noting the saline infusion rate.
Ensuring that the tubing does not have a kink.
Checking for air in the line.

128.) A severely acidotic patient has been prescribed continuous arteriovenous hemofiltration
(CAVH). To prepare for this treatment, the nurse should:

Start a 20-guage IV catheter into the antecubital site.

Prepare the groin for catheter placement into the femoral artery.
Acquire a double lumen catheter to be inserted into the subclavian vein.
Flush the blood pump with normal saline solution to remove air.

129.) The advantages of continuous venovenous hemodialysis (CVVH) compared to CAVH

include:

Cannulation of an artery can last a long time.

Blood flow to the accessed limb is uncompromised.
A single dual lumen catheter is used, preferably in the subclavian or internal jugular vein.
Blood flow through the hemofilter is consistent and controlled by the nurse.
2 and 4.
1 and 3.
1 and 2.
3 and 4.

130.) Patients allergic to heparin are usually prescribed ____________ as an anticoagulant

during CRRT.

Oxalate.
Citrate.
Aspirin.
Warfarin.

131.) What is one of the clinical advantages of hemofiltration?

Hemofiltration allows for removal of small molecular size substances.

Small volumes of parenteral nutrition can be used, providing a stable fluid balance.
Increased shift of intracellular osmolar fluids.
Fewer problems with hypotension.

132.) What are some of the adverse effects of hemoperfusion that require close observation?

Thrombocytopenia.
Hypertension.
Increased cerebral edema.
Post-procedure bleeding.
3 and 4.
2 and 3.
1 and 4.
1 and 2.
133.) Which poisoning is best treated by charcoal hemoperfusion?

Mushrooms.
Barbiturates.
Salicylates.
Lithium carbonate.

134.) Patients being dialyzed for IV drug overdose may develop hypotension that will respond
only to infusion of a pressor agent such as:

Atropine.
Albumin.
Calcium carbonate.
Dopamine.

135.) Peritoneal dialysis (PD):

Requires installation of a synthetic semipermeable membrane before dialysis can begin.

Is primarily a home dialysis therapy for chronic kidney disease.
Is the most common dialysis modality for patients with acute kidney disease.
Despite an unproven safety record, has been increasing in popularity since the mid-1990s.

136.) What education/teaching should be provided to a patient receiving icodextrin (Extraneal) as

the dialysis solution?

The most common adverse effect is hypotension related to volume deficit.

The product is recommended for long dwell exchanges lasting 8+ hours.
This solution should only be used if there is edema related to fluid retention.
Icodextrin is the solution of choice for patients with glycogen storage diseases.
137.) What are the advantages of patients using home automated peritoneal dialysis (APD) with
cyclers?

APD machines measure the volume of dialysate to be infused.

The dialysate is warmed to body temperature.
The patient’s blood pressure is monitored on a programmed schedule.
The cycler will discontinue the exchange if blood glucose levels become too high.
3 and 4.
1 and 2.
2 and 3.
1 and 4.

138.) What should your nursing assessment include when caring for a patient who has undergone
a rigid PD catheter placement for acute renal failure?

Monitor for a change in level of consciousness (LOC) related to dehydration.

Evaluate for hematuria related to bladder perforation.
Assess the location of the catheter tip.
Monitor for fever related to the dialysate infusion being too warm.

139.) During the postoperative phase following catheter placement, nursing personnel should:

Instill dialysate at least every 2 hours, increasing the amount/infusion until the prescribed amount
can be instilled over the first 24 hours post-op.
Minimize any increase in intra-abdominal pressure by giving stool softeners or cough medicine
as needed.
Have the patient get out of bed and walk around as much as possible to prevent deep vein
thrombosis (DVT).
Inject a minimum of 5,000 units of heparin into the catheter daily to prevent clot formation
around the catheter tip.
140.) Which teaching should be provided to help the patient care for his PD catheter exit site
during the postoperative period?

Discuss the importance of using a cytotoxic agent such as 1% povidone-iodine and how to apply.
Instruct the patient how to clean the exit site and apply an occlusive sterile dressing.
Inform the patient that it is normal to have redness, exudate and tenderness around the exit site.
Demonstrate how the catheter should be secured to the skin to avoid trauma.

141.) What are signs and symptoms that indicate your patient has developed peritonitis related to
a break in the PD catheter?

Whitish strands in effluent.

Cloudy effluent.
Abdominal pain.
Blood in effluent.
3 and 4.
2 and 3.
1 and 2.
1 and 4.

142.) When a PD patient complains of shoulder pain resulting from air in the peritoneum, which
of the following interventions should the nurse perform?

Slow the infusion of dialysate.

Drain the patient in knee-chest or Trendelenburg position.
Flush the dialysis catheter with a heparin infusion to remove any blood clots.
Keep the patient supine and test effluent for glucose.

143.) Why does a patient’s total daily intraperitoneal dose of insulin need to be much higher than
a subcutaneous dose?
Insulin absorption is slower from the peritoneal cavity.
There is usually a low concentration of insulin in each dialysate bag to control blood glucose
level via the abdominal cavity.
Insulin may bind to the plastic bags and tubing.
The liver has a hard time breaking the insulin down into a usable chemical.
3 and 4.
1 and 3.
1 and 2.
2 and 4.

144.) If yeast is diagnosed on Gram stain or culture, the nurse should anticipate the patient being
prescribed which of the following medications?

Cephalosporin.
Tobramycin.
Flucytosine.
Fluconazole.
2 and 4.
1 and 3.
3 and 4.
1 and 2.

145. ) What are advantages of daily nocturnal hemodialysis (DNHD)?

It can be performed at home during sleep without the need of an assistant.

DNHD allows for shorter dialysis times, usually 2-3 hours/night with blood flows ~400 mL/min.
DNHD can be monitored via Internet and the patient can receive care if alarms are not responded
to in a timely manner.
There is an overall cost reduction, as fewer trips to the dialysis center are required.
3 and 4.
1 and 3.
1 and 2.
2 and 4.

146.) Lifelong immunosuppression can result in an increased risk for developing:

Type I diabetes mellitus related to pancreatic injury from steroids.

Infections and some malignancies.
Lice and other communicable skin infections due to contact from chairs/beds during the dialysis
sessions.
HIV infection via dialysis equipment exposure.
147.) Which of the following statements about kidney-pancreas transplantation is accurate?

This type of transplant may slow or stop the progression of diabetic complications.
The patient’s diabetes will disappear and they will no longer need to check their glucose levels or
take insulin.
The patient will be at risk for developing metabolic alkalosis due to reconstruction of exocrine
drainage of amylase.
The patient will more than likely require larger amounts of immunosuppressive medications than
with just one organ (kidney) transplant.
3 and 4.
2 and 3.
1 and 2.
1 and 4.
148.) Which of the following patients would not be a candidate for transplantation due to an
absolute contraindication?

A 48-year-old patient with bipolar disorder that is well controlled on lithium and antipsychotic
medications.
A 66-year-old patient with Stage 2 lung cancer currently undergoing chemotherapy.
A 36-year-old patient with a history of kidney failure from exposure to toxic materials
A 25-year-old patient with chronic HIV infection, well controlled on medication, who has a
normal CD4 count.

149.) With regard to transplantation and the immune system, what are the most important cell
components?

Natural killer cells and eosinophils.

T lymphocytes and B lymphocytes.
White blood cells and plasma.
Red blood cells and platelets.
150.) What are some reasons why a transplant surgery patient may require dialysis?

Fluid volume excess.

Electrolyte imbalance.
Honeymoon period where the transplanted kidney is not functioning yet.
Effects of anesthesia on the renal system.
3 and 4.
1 and 2.
1 and 4.
2 and 3.

151.) The kidney transplant patient is more prone to develop __________ infections several
weeks after surgery.
Anaerobic.
Viral.
Bacterial.
Yeast.

152.) When administering cyclosporine (Sandimmune) following a kidney transplant, the patient
should be assessed for which of these side effects?

Headache and flulike symptoms.

Hypertension and tremors.
Leucopenia and thrombocytopenia.
Anaphylaxis and respiratory distress.

153.) When a new kidney transplant patient asks the nurse how mycophenolate mofetil
(CellCept) works, the best response is:

The humanized antibodies help your body to not recognize your new kidney as a foreign protein.
This drug blocks the action of your T-cells, thus preventing infection.
Like all steroids, CellCept works against your body’s immune cells.
This drug has beta cell-blocking action, making it helpful to treat chronic rejection.

154.) What are the cardinal physical symptoms of acute renal transplant rejection?

The kidney turns black when clamps are removed while still in the operating room.
Weight gain associated with edema.
Tenderness over the graft site.
Extreme nausea and vomiting.
3 and 4.
1 and 4.
1 and 2.
2 and 3.
155.) Following irreversible failure of a kidney transplant, immunosuppression medication is:

Continued at the same rate as previously since the medication will prevent the need to have the
failed organ removed surgically.
Continued with a much lower dose than normal to prevent sudden immune reactions.
Discontinued immediately since it is no longer effective.
Tapered off gradually to allow the adrenal glands to regain function.

156.) When interpreting lab results for a 2-year-old child, a creatinine level of 1.0 mg/dL
indicates:

Cannot be interpreted without other lab results.

Decreased level due to antibiotic toxicity.
Elevated level resulting from renal failure.
Normal value.

157.) A child receiving hemodialysis should be isolated when:

The child tests positive for HIV following blood transfusions at birth.
The child tests positive for HBsAg.
There has been exposure to varicella in the previous week.
Hepatitis C results are positive due to the mother’s use of IV drugs during pregnancy.
3 and 4.
1 and 4.
2 and 3.
1 and 2.

158.) The access site for a pediatric patient weighing less than 10 kg is an:

Implantable port.
Arteriovenous graft in the forearm.
Arteriovenous fistula at the wrist.
Indwelling catheter placed in a major vessel.

159.) In preschool children, pain control during access insertion may be primarily focused on:

Applying EMLA cream to the insertion site and then having all available personnel to assist with
restraining.
Utilizing distractions such as blowing bubbles or inverting a glitter wand.
Explaining the procedure to the child and placing him/her in a papoose board.
Restraining the child and injecting 1% lidocaine at the insertion site.

160.) Premature infants who require hemodialysis will need very tight control of heparin levels
due to their high risk for developing:

Thrombus formation.
Cerebral hemorrhage.
Short gut syndrome.
Pancreas failure.

161.) What is the hemoglobin goal for pediatric patients?

13-14 g/dL.
11-12 g/dL.
6-7 g/dL.
8-10 g/dL.

162.) When a child’s height falls below the 5th percentile for children over 2 years of age, the
physician may recommend which of these medications?

Calcitriol.
Calcium carbonate.
Recombinant human growth hormone.
Anabolic steroids such as methyltestosterone.

163.) When comparing the cost of pediatric hemodialysis to the cost for adult hemodialysis,
pediatric care is:

Less, since there is a high volume of pediatric dialysis patients.

About the same, since the same equipment and supplies are needed for both in the dialysis
treatment.
More, because of the increased cost of pediatric supply items and services.
Less, since the child’s parents provide most of the interventions and assessments throughout the
treatment.

164.) Which of the following patients may not benefit from renal replacement therapy?

A 67-year-old with impaired pulmonary function caused by cigarette smoking.

An 80-year-old with type 2 diabetes who walks 2 miles every day.
A 77-year-old who has severe osteoporosis with a noticeable hump in the upper back region.
A 56-year-old with irreversible dementia brought on by early-onset Alzheimer’s disease.

165.) What are the advantages of peritoneal dialysis in the elderly population?

Elderly patients do not need a vascular access.

Dietary and fluid restrictions are less rigid.
The elderly population may not have fluctuations in blood pressure related to rigid vessels.
Elderly patients can cope better with the dietary and fluid restrictions than younger patients.
3 and 4.
2 and 3.
1 and 4.
1 and 2.
166.) When compared to younger PD patients, elderly PD patients have a higher incidence for
developing:

Hemorrhage.
Dementia.
Inadequate urea results.
Dislodgement of catheter.

167.) Research has demonstrated that elderly patients who exercise during the last hour of
hemodialysis can:

Reduce or prevent bone disease commonly experienced in dialysis patients.

Reduce the incidence and severity of muscle cramps.
Build muscle strength to increase stamina.
Maintain or increase their heart rate by at least 10 beats/min.
168.) What is the most predictable indicator of how a patient will react to the stress of
hemodialysis?

The patient’s overall general physical strength and fitness.

A person’s coping methods and how they have dealt with issues throughout their life.
The ability to tolerate change and discomfort based on temperament type.
Social and economic status.

169.) During which stage of adjustment to dialysis does the patient exhibit feelings of sadness
and helplessness?

The acceptance phase.

The period of disenchantment.
The “honeymoon” period.
The period of long-term adaptation.
170.) When hostility towards dialysis personnel is expressed, staff needs to remember that this
reaction may actually be from:

How “healthy” the staff looks.

Limitations imposed by the disease.
The dying process.
The inability to financially pay for the treatment being prescribed.

171.) When exhibiting nonadherent behavior, many patients are more accepting of which type of
consultation?

A planned “intervention” where all family members confront the patient about their behavior.
Group session involving patient and family under direction of a skilled social worker or nurse.
Private, one-on-one session with psychiatrist.
Private family consultation with psychiatrist.
172.) What key points should be discussed when orienting new staff to professional boundaries?

Spending time with patients outside of the workplace is not recommended.

Gifts, monetary or otherwise, should never be accepted from a patient or family member.
Socializing with patients is acceptable as long as family members are present.
It is acceptable to establish a business relationship with patients who have experience in the field
about which you are seeking information.
3 and 4.
2 and 3.
1 and 4.
1 and 2.

173.) With dialysis patients, which of the following medications may result in sexual
dysfunction?
Calcium supplements.
Antihypertensives.
Long-term antibiotics.
Phosphate-binding agents.

174.) What can patients expect when they decide not to initiate dialysis and elect palliative care
instead?

That treatment for fluid overload symptoms will be withheld.

To die pain-free with dignity.
That all further treatment options will be discontinued.
That death will occur in a matter of days.

175.) The Medicare Improvements for Patients and Providers Act (MIPPA) assists dialysis
patients by:

Monitoring dialysis facilities’ use of expensive medications such as erythropoiesis-stimulating

ages.
Covering the cost of most oral medications that a CKD patient would be prescribed.
Providing unlimited care for any patient over 65 years of age who requires dialysis.
Including an educational condition to help patients with CKD manage their disease process.

176.) If a dialysis program does not achieve satisfactory dialysis results, it could:

Result in an audit by the Center for Medicare & Medicaid Service.

Increase costs if the patient requires hospitalization for emergency treatment.
Lead to a site visit from The Joint Commission (TJC).
Require the patient to stay at the outpatient facility for a longer length of time.
177.) Utilizing the FOCUS format for quality improvement, once a process to improve has been
identified, the next step would be to:

Examine the data for the causes of variation.

Collect and analyze data specific to the process.
Implement statistical control of the data.
Organize a team to work together to improve the situation.

178.) One centimeter equals _____ millimeters.

1000.
10.
0.1.
100.

179.) A female patient has a pre-weight of 123.2 pounds. Her weight after her last treatment was
53 kg. Calculate her weight gain.

5 pounds.
2.40 kg.
3 kg.
3.5 pounds.

180.) Mr. B arrives with a pre-weight of 67.8 kg. His last treatment weight was 65.4 kg. Mr. B’s
estimated dry weight (EDW) is 65 kg. The physician has ordered one unit (250 mL) of packed
red blood cells (PRBCs). Mr. B’s rinseback is usually 350 mL saline. Calculate the available
weight (AW).

350 mL.
600 mL.
2.8 kg.
2.4 kg.

181.) Based on the patient scenario above, calculate the fluid removal goal for this dialysis.

4550 mL.
3200 mL.
3400 mL.
3040 mL.
182.) You have a vial of heparin with 5000 units/mL. Following protocol, you need to administer
7000 units of heparin. How many mL will you administer?

0.14 mL.
1.4 mL.
.70 mL.
2.0 mL.