Acute Kidney Injury (AKI) and Hemodialysis Complications, Exams of Nursing

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DaVita Final Exam Questions with Answers Latest

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Ultrafiltration - Correct Answer Forcing fluids across semipermeable membrane via hydrostatic pressure Convection - Correct Answer Fluid and solutes being moved through spm during ultrafiltration Diffusion - Correct Answer solutes moving from high concentration to low concentration Osmosis - Correct Answer Diffusion of water through a selectively permeable membrane to area of high solute concentration what are kidneys excretory function? - Correct Answer filtering waste products normalize electrolytes provide fluid/nutrition balance what is the function of acid concentrate? - Correct Answer Provides the concentration gradient for diffusion what is the function of bicarbonate? - Correct Answer acts as a buffer, normalizes body pH S/S of hyperkalemia - Correct Answer >6.5 mEq, muscle weakness, arrhythmias, widened QRS, possible cardiac arrest S/S of hypokalemia - Correct Answer <3.5 mEq, muscle weakness, paralysis, respiratory failure, cardiac instability, cardiac arrest, arrhythmias what are kidneys endocrine function? - Correct Answer erythropoesis, secretion of renin, activation of vitamin D How do we replace normal endocrine kidney functions? - Correct Answer ACE inhibitors, phosphorus binders How much of normal kidney function is replaced by HD? - Correct Answer 15% What is uremia and what does it affect? - Correct Answer build up of wastes in blood affects neuro/psych, cardiovascular, hematologic, muscular, bone, gastro, skin

what are the most common causes of CKD in the US? - Correct Answer diabetes, hypertension, polycystic kidney disease Treatment goals for CKD patient - Correct Answer slow progression, control comorbidities, manage conditions causing CKD, control symptoms, educate, encourage pt to participate, minimize effect on pt lifestyle S/S fluid imbalance - Correct Answer Edema HTN Pulmonary edema CHF Why is sodium balance important? - Correct Answer increase sodium > water retention > damage to nephrons > nephrotic syndrome Treatment for dry itchy skin - Correct Answer fatty bars of soap treatment for peripheral neuropathy - Correct Answer monitor for changes in motor function, no walking barefoot treatment for GI problems - Correct Answer inform RN of any bleeding, constipation, diarrhea, ER visits take meds as ordered treatment for psychological problems - Correct Answer speak to social worker what does hypertension lead to? - Correct Answer left ventricular hypertrophy What is pericarditis? - Correct Answer inflammation of the pericardium treatment for pericarditis - Correct Answer good dialysis, fluids, anti inflammatories, antibiotics, surgery Why are dialysis patients anemic? - Correct Answer lack of erythropoietin, inadequate iron, inadequate dialysis, malnutrition, blood loss what are four key elements contributing to MBD? - Correct Answer calcium, phosphorus, parathyroid hormone, vitamin D what are the symptoms of MBD? - Correct Answer severe itching, calciphylaxis, muscle weakness, bone pain, fractures, tendon ruptures, compression of vertebrae, atherosclerosis, heart disease, growth failure (PEDS) AKI - Correct Answer acute kidney injury, encompasses wide range of kidney issues

Causes of pre-renal AKI - Correct Answer volume depletion, decreased cardiac output, severe hypotension, renal vascular obstruction causes of intra-renal AKI - Correct Answer acute glomerulonephritis, acute tubular necrosis, acute interstitial nephritis, rhabdomyolysis, hemolysis, myeloma, medications/toxins causes of post renal AKI - Correct Answer bladder/ureteral malignancy, kidney stones, enlarged prostate Difference between CKD and AKI - Correct Answer gradual permanent loss of kidney function vs sudden loss of kidney function that may partially or fully return How to aid in restoring kidney function - Correct Answer eliminate cause of AKI considerations for AKI patients - Correct Answer typical pt will have CVC do not dry pt out avoid renal toxic substances ask pt to track urine output and to report changes during nursing assessment pts are at increased risk for hypovolemia, infection and CKD What makes dialysis patients more susceptible to HAIs? - Correct Answer pts w/ CKD have impaired immune systems Why are dialysis patients at increased risk for acquiring a HAI at the facility? - Correct Answer prolonged access to pts blood what is the most common route for HAIs? - Correct Answer contact transmission most important intervention to prevent HAIs - Correct Answer hand hygiene for 20 secs most common infectious complication in HD pts? - Correct Answer vascular access infection What germ causes the most common infections in hemodialysis patients? - Correct Answer staphylococcus aureus (MRSA) Why is wearing gloves so important? - Correct Answer Decreases risk of hand contamination why do you need to perform hand hygiene after wearing gloves? - Correct Answer microscopic holes in gloves or removing gloves can contaminate hands difference between OSHA and CMS - Correct Answer OSHA protects employees CMS protects patients

what are V tags? - Correct Answer they state regulations to be met i.e. infection control dialysis machines, even when cleaned, are always considered - Correct Answer a dirty area when should sharps be removed from the treatment floor? - Correct Answer 3/4 full 3 strategies to decrease risk of infection in CVC patients - Correct Answer wearing facemasks when lumens are exposed wearing gloves when touching anything exposed minimize lumen/exit sites from being exposed Who can use clean sinks for hand washing? - Correct Answer Teammates and patients how can you tell when an area is clean or dirty? - Correct Answer there's a sign which test is performed monthly on HBV susceptible patients? - Correct Answer HBsAg (Hepatitis B surface Antigen) how often are machine alarm tests performed - Correct Answer before each treatment what is the safe dialysate pH range? - Correct Answer Between 6.9 and 7. What is "strikethrough" of an external pressure transducer and why is it of concern?

• Correct Answer when blood or saline contaminates it. risk for infection why is it important to know when water treatment system disinfection was performed? - Correct Answer disinfectant will be introduced to delivery system via water inlet lines what are key concepts of Reasonable and Prudent Care? - Correct Answer care which a reasonable and prudent nurse would give under the same situation actions a nurse would do as well as avoid doing the skills and knowledge expected of a nephrology nurse is key to specialty of nephrology nursing Who established the standards for care for nephrology nursing - Correct Answer American Nephrology Nurses Association to establish standards of care and scope of practice what role does Davita's P&P play? - Correct Answer provides evidenced based guidance

meets CMS conditions for coverage complies w/state and federal laws What are 4 reasons why we document care? - Correct Answer proof provides data continuity establish permanent legal record communication tool 6 occurences to document - Correct Answer change from baseline change in pt condition procedure/treatment medication given and pt response patient teaching care plan review and interventions What does SMART stand for? - Correct Answer Simple Meaningful Actual Read Teach When is a pre-treatment assessment by the licensed nurse required? - Correct Answer abnormal findings, new patient, and before each treatment of an AKI patient pre-treatment data collection/ assessment - Correct Answer before treatment intuition or within one hour if pt is stable What BP reading error can be caused by an incorrect cuff size? - Correct Answer cuff too small = BP too high cuff too large = BP too low what is a normal pre-treatment BP? - Correct Answer systolic: 90- diastolic: < what is the normal heart rate range? - Correct Answer 60-100 bpm what is the normal RR? - Correct Answer 12- what is a normal temp? - Correct Answer <100 F and no more than a 2 degree change from baseline When is post-treatment assessment by the licensed nurse required? - Correct Answer if required by state law or if abnormal findings were observed 5 Ws when completing a REM - Correct Answer what happened who was involved

when did it happen what was the result any witnesses? what are the 3 things you should not include in a REM? - Correct Answer personal opinions speculation/theories vendettas UF goal calculation - Correct Answer pre weight - target weight + prime and rinseback + oral intake / infusions UFR calculation - Correct Answer UF goal / tx hours four consequences of sodium loading - Correct Answer increased thirst large fluid gain more hypotension and ischemic events during tx 3 ways we can contribute to sodium loading during dialysis - Correct Answer broth normal saline Na in dialysate Consequences if pt is consistently overloaded - Correct Answer LVH, increased cardiovascular pressure, hypertension, pulmonary edema, increased risk of hospitalization and death consequences of hypovolemia during tx - Correct Answer organ stunning, loss of residual kidney function, increased mortality difference between AVF and AVG - Correct Answer AVF- connection of native artery to vein AVG- uses artificial material and requires 2 surgical connections what is the connection point of an AVF called? - Correct Answer anastomosis KDOQI Rule of 6's - Correct Answer depth is 0.6 cm below skin 6-8 weeks post op check up access blood flow >600 ml/min vessel diameter >0.6cm Beginner cannulator - Correct Answer < 6 months, < 10 successful cannulations intermediate cannulator - Correct Answer at least 6 months experience and 10 successful cannulations

advanced cannulator - Correct Answer completed all competencies of NFACT skills checklist Newly mature fistula - Correct Answer A new fistula that has received it's post op exam by the surgeon/nephrologist and meets the criteria listed in the KDOQI rule of 6's. Should only be cannulated through physician order by an advanced cannulator mature fistula - Correct Answer A fistula that has successfully tolerated it's prescribed needle gauge and blood flow rate for at least six treatments. This fistula may be cannulated by an intermediate cannulator Established fistula - Correct Answer A fistula that has been cannulated by arterial and venous needles for at least two months without signs or symptoms of dysfunction. A beginner cannulator may insert this patient's needles. Recommended needle gauge and max BFR for new AVF initial cannulation - Correct Answer 17g, 250 ml/min BFR for 17G needle - Correct Answer 200- BFR for 16G needle - Correct Answer 250- BFR for 15G needle - Correct Answer 350- BFR for 14G needle - Correct Answer > use of one needle - Correct Answer -per MD order -used for arterial pull use of torniquet - Correct Answer applied above AVF and must be removed after cannulation evaluation of blood flow - Correct Answer thrill/bruit distances needles must be from anastomosis - Correct Answer 1.5 inches distance between needle tips - Correct Answer 1.5 inches BEST TIPS (complications and prevention) - Correct Answer bleeding erosion stenosis thrombosis infection pseudoaneurysm/ aneurysms steal syndrome

successful lab draws - Correct Answer know the 20 tips no handwritten or double label, know order of tubes rules for spinning samples - Correct Answer must balance centrifuge When not to refrigerate - Correct Answer culturettes, swabs, occult stool goal for single pool Kt/V for 3x week treatment pt? - Correct Answer >/= 1. What is K? - Correct Answer Clearance of urea what treatment factors decrease K? - Correct Answer Inadequate coagulation, decreased BFR, poor priming, not following p&p, pt not staying on tx as prescribed what treatment factors increase K? - Correct Answer Increased BFR, correct DFR, correct dialyzer, correct target weight- amputation factor what is the goal for URR? - Correct Answer >/= 65% what is t? - Correct Answer time what factors influence t? - Correct Answer Running prescribed tx time, follow physician orders- encourage pt to run entire tx. Getting off early will impact time (missing tx also impact tx time) what is V? - Correct Answer volume of urea distribution what factors influence V? - Correct Answer height, weight, sex, age, amputations, access site Procedure for Post BUN lab draw: - Correct Answer 1) Turn off UFR or decrease it to 50

2. decrease DFR to 300 or put in bypass
3. decrease BFR to 100
4. Wait 15 secs for all access types and draw post Lab draws mistakes that would falsely increase Kt/V - Correct Answer BFR not reduced, waiting 5 seconds, drawing from venous line Lab draw mistakes that would falsely decrease Kt/V - Correct Answer - Diluting pre tx arterial BUN sample with saline

waiting longer than 15 seconds to draw sample what are the 3 meds that PCTs can administer? - Correct Answer Saline, Heparin, Lidocaine Six items included administered medications? - Correct Answer time, route of administration, reason for giving, dosage, reason for administering, patient response How do you administer topical spray - Correct Answer spray for 4-10 seconds at a 3-7 inch distance from site until skin starts to blanche why is citrapure dialysate used? - Correct Answer if pt are contraindicated for heparin what does TRAMP stand for - Correct Answer Time, Route, Amount, Medication, Patient Aluminum in water used for dialysis causes - Correct Answer Anemia, bone disease, nausea and vomiting chlorine in water used for hemodialysis causes - Correct Answer hemolysis Excess calcium and sodium in water used for dialysis causes - Correct Answer hypertension Excess calcium and magnesium in water used for dialysis causes - Correct Answer muscle weakness what does RO remove? - Correct Answer organic and inorganic materials, bacteria, and endotoxins Concerns with using DI tanks - Correct Answer exhaust quickly when exhausted will dump previously removed ions back into water response to final water quality alarm - Correct Answer 1. put all machines in bypass mode

2. notify charge nurse, FA, biomed, Medical director
3. if water quality cannot be restored terminate all treatments Water/Dialysate culture results - Correct Answer Acceptable Level: below 50 cfu/ml Action level: 50-99 cfu/ml Unacceptable level: 100 cfu/ml or higher Water endotoxin testing results - Correct Answer acceptable level: 0.12 EU

action level: 0.12 to <0.25 EU unacceptable level >/= 0.25 EU Dialysate endotoxin testing results - Correct Answer acceptable level: <0.25 EU action level: 0.25 to <0.50 EU unacceptable level: </= 0.50 EU What removes chlorine/chloramines? - Correct Answer Carbon tanks Chlorine/chloramine testing - Correct Answer after RO has been on 15 mins, before first shift, every 4 hours via primary carbon sample port what happens if first carbon tank fails chlorine test - Correct Answer repeat test, move to secondary port, notify biomed and FA, test every 30 mins if second tank fails as well, put delivery system into bypass and do not return blood hardness testing - Correct Answer removing calcium and magnesium for RO protection. Done at the end of each day Patient complication: hypotension - Correct Answer systolic <90 diastolic <50 or drop in BP 20 mmHg or higher causes: hypovolemia, antihypertensives, indigestion, unstable CV conditions symptoms: flushing, yawning, fatigue, dizziness, tinnitus, nausea/vomiting, feeling cold, anxiety, clammy skin, seizures, CA intervention: place in supine position (on side if pt is nauseas), turn off uf, administer 200 ml of saline (if severe, oral fluids if minor), monitor bp, notify RN consequences of organ stunning - Correct Answer heart: acute stress, development of LVRWA, arrythmias GI: releases endotoxins, inflammation kidneys: fibrosis, loss of residual kidney function brain: white matter injury Patient Complication: Hypertension - Correct Answer predialysis: >140/90 post dialysis: >130/ causes: disease, fluid overload, nonadherence, renin-angiotensin cycle symptoms: none, headache, dizziness, irritability, blurred vision, nervousness, edema, interventions: take meds as ordered, maintain fluid balance

Patient Complication: Seizures - Correct Answer involuntary muscle spasms and LOC causes: seizure disorder, side effect/ adverse reaction to dialysis/dialysate intervention: protect pt and access from harm, protect airway, treat underlying cause, administer oxygen and provide airway support, discontinue dialysis if no response Patient Complication: Dialysis Disequilibrium syndrome - Correct Answer rapid/drastic changes in pts extracellular fluid in brain causes: missed tx, rapid drop in BUN symptoms: headache, hypertension, nausea, restlessness, seizures, confusion, blurred vision, intervention: slow BFR and DFR in CKD pts, shorter treatments Patient complication: Pyrogen reaction - Correct Answer elevated temp occurring 45-75 mins into tx causes: pyrogens in dialysate symptoms: chills, shaking, fever, hypotension, vomiting, muscle pain intervention: provide support, report to nurse, stop tx, notify physician, do not return blood Patient complication: Disinfectant infusion - Correct Answer disinfectant coming into contact w/ bloodstream symptoms: pain at venous needle, tingling around mouth, itching, restlessness, flushing, respiratory distress, chest pain, back pain intervention: discard bicarbonate and rinse mixer, do not initiate tx until tests are negative, rinse until machines are clear Patient Complication: Chest pain/Angina - Correct Answer causes: CAD, anemia, hypotension, anxiety intervention: reduce BFR to 150, treat hypotension, decrease ufr, monitor vitals, administer O2 and meds as prescribed, report to RN

Patient complication: Cardiac Arrest - Correct Answer causes: electrolyte imbalance, severe hypotension, underlying CVD, hemolysis, large blood loss, anaphylaxis, cardiac tamponade, air embolism, heart attack Intervention: establish unresponsiveness, call for help, place pt in supine position and start CPR, return blood if possible, maintain patency of needles Patient complication: First Use Syndrome - Correct Answer reaction that occurs after starting tx w/ new dialyzer causes: ETO sterilzed or other residues symptoms: nervousness, chest pain, back pain, palpitations, itching, funny taste in mouth intervention: notify nurse, discontinue tx and do not return blood, manage symptoms, notify physician Patient Complication: Air embolism - Correct Answer air bubbles enter bloodstream causes: empty saline bags, poor priming, underfilled chambers, disconnected bloodlines, unarmed air detector, unclamped catheter lumen, manufacturer defect intervention: stop blood pump, clamp lines and do not return blood, place patient into Trendelenburg position on left side, contact EMS, disconnect access lines, provide O2, draw labs from arterial access and attach syringe, aspriate 10 ml from venous and attach another sterile syringe Patient Complication: Hemolysis - Correct Answer bursting of red blood cells, extremely critical causes: high dialysate temp, chlorine, disinfectant, hypotonic dialysate, blood pump miscalibrated, conductivity alarm failure symptoms: cherry red (kool aid) blood, restlessness, chest pain, anxiety, nausea/vomiting, back pain, thready pulse, hyper/hypotension, abdominal cramping, SOB, seizures interventions: stop blood pump and do not return blood, administer O2, monitor vitals, check Hg and K Machine Alarms: TMP - Correct Answer causes: wet transducers, UF goal change, clamped transducer intervention: check transducer, evaluate UF goal

Machine Alarms: Venous pressure - Correct Answer high alarm: clotting in chamber, infiltration, poor needle placement, poor CVC, stenosis, increase in blood flow intervention: flush w/normal saline, check position, reverse lines on catheter, decrease BFR low alarm: disconnected line, clotted dialyzer, low BFR, saline line open, blockage in blood tubing intervention: verify saline line is closed Four indicators of optimal nutrition status - Correct Answer albumin >/= 4 g/dl stable target weight adequate fat stores appropriate appetite and intake importance of protein - Correct Answer - maintains health helps fight infection prevents anemia builds/maintains muscle heals wounds Importance of limiting potassium - Correct Answer prevents sudden death, bradycardia, irregular HR, muscle weakness Importance of limiting phosphorus - when to take binders - Correct Answer excess phosphorus = itching, bone damage, soft tissue calcification take binders w/meals importance of maintaining calcium levels - Correct Answer increased risk of heart disease and calcification of small tissues, confusion, muscle spasms, numbness, seizures Role of social worker - Correct Answer Counselor educator advocate coach 5 stages of grief - Correct Answer denial, anger, bargaining, depression, acceptance What does the DARN acronym stand for? - Correct Answer Desire Ability Reason Need what are the three listening skills? - Correct Answer asking, listening, informing

Reflective listening - Correct Answer restate: provide short summary deduce: reflect on pt feelings summarize: provide summary of entire conversation Educational tips for visual learners - Correct Answer surroundings, note taking, visual aid, short lectures, eye contact Educational tips for auditory learners - Correct Answer Word associations/mnemonics Repeat information Read notes out loud Watch videos Discuss and explain Give them time to read Educational tips for tactile learners - Correct Answer frequent short breaks, background music, encourage to highlight, short lectures, hands on activities