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Comprehensive Certification Examination for Peritoneal Dialysis Nurses: Advanced Clinical Judgment in
Continuous Cycling Peritoneal Dialysis (CCPD), Automated Peritoneal Dialysis (APD) Prescription
Management, Cycler Technology, Infection Control, and Patient Safety Optimization.
Questions 1 – 150
Domain 1: APD/CCPD Fundamentals and Prescription Design (1–25)
1. A patient is prescribed CCPD with 5 nocturnal cycles of 2.5 L each, no day dwell. What is the total nightly dialysate
volume? A) 10 L B) 12.5 L C) 15 L D) 17.5 L
Correct Answer: B
Rationale: 5 cycles × 2.5 L = 12.5 L total.
2. In APD, the term "ultrafiltration" refers to:
A) Movement of solutes from blood to dialysate B) Movement of water from blood to dialysate across a pressure gradient C) Heating dialysate to body temperature D) Draining dialysate from the abdomen
Correct Answer: B
Rationale: UF is water removal driven by osmotic pressure (glucose) or hydrostatic pressure.
3. Which APD modality maintains a constant intraperitoneal volume throughout all cycles?
A) CCPD
B) NIPD
C) Tidal PD D) IPD
Correct Answer: C
Rationale: Tidal PD leaves a residual volume and replaces only a portion each cycle.
4. A patient with high average transport status on PET is on CCPD but has inadequate small solute clearance. Best
prescription change: A) Increase dwell time per cycle B) Decrease fill volume C) Increase number of cycles D) Add icodextrin for day dwell
Correct Answer: C
Rationale: More cycles increase total dialysate flow, improving clearance in average transporters.
5. The cycler parameter that determines the total duration of the APD treatment is:
A) Dwell time B) Fill time C) Total therapy time
D) Number of cycles only
Correct Answer: C
Rationale: Total therapy time = (fill + dwell + drain) × number of cycles.
6. A patient on CCPD has a night UF of 600 mL and day dwell UF of 150 mL. What is total 24-hour UF?
A) 450 mL B) 600 mL C) 750 mL D) 900 mL
Correct Answer: C
Rationale: 600 + 150 = 750 mL.
7. Which cycler feature automatically reduces fill volume when intraperitoneal pressure exceeds a preset threshold?
A) Tidal volume override B) Pressure-limited fill C) Dynamic fill sensor D) Last fill reduction
Correct Answer: C
Rationale: Dynamic fill sensors adjust volume to prevent leaks and pain.
8. Icodextrin is indicated for which specific clinical scenario in CCPD?
A) First nocturnal cycle for high transporters B) Day dwell in patients with poor UF on dextrose C) All cycles to reduce glucose load D) Last nocturnal cycle to enhance overnight UF
Correct Answer: B
Rationale: Icodextrin provides sustained UF over long dwells (≥8 hours).
9. A patient on APD complains of morning fatigue, dizziness on standing, supine BP 160/90, standing BP 100/60. Most
likely cause: A) Hypervolemia B) Intradialytic hypotension C) Nocturnal hypovolemia from excessive UF D) Autonomic neuropathy
Correct Answer: C
Rationale: Excessive overnight UF causes morning hypovolemia and supine hypertension.
10. In NIPD (nocturnal intermittent PD), the absence of a day dwell results in:
A) Higher total weekly Kt/V B) Lower middle molecule clearance compared to CCPD C) Better UF D) Reduced peritonitis risk
Correct Answer: B
Rationale: Without day dwell, continuous clearance of larger molecules is reduced.
11. According to ISPD 2020, the minimum recommended weekly Kt/V for a patient with significant residual renal
Rationale: Constipation increases intra-abdominal pressure progressively.
17. Which cycler alarm requires immediate disconnection and manual drainage?
A) Heater bag empty B) Low temperature C) Persistent "no drain" after repositioning and milking line D) Air in line
Correct Answer: C
Rationale: Unresolved no-drain risks overdistension; manual drainage needed.
18. In CCPD, the last fill is typically prescribed with which solution for a patient needing maximal daytime UF?
A) 1.5% dextrose B) 2.5% dextrose C) 4.25% dextrose D) Icodextrin
Correct Answer: D
Rationale: Icodextrin provides sustained UF without glucose absorption.
19. A patient on APD has serum albumin 2.0 g/dL and nPCR 0.5 g/kg/day. First intervention:
A) Increase dialysate dextrose to 4.25% B) Start intraperitoneal amino acids C) Formal dietary assessment and protein supplementation D) Increase number of cycles
Correct Answer: C
Rationale: Low nPCR indicates inadequate protein intake; dietary intervention first.
20. The primary purpose of the cycler's drain phase is:
A) Infuse fresh dialysate B) Remove spent dialysate and measure UF C) Warm the solution D) Disinfect the tubing
Correct Answer: B
Rationale: Drain phase removes effluent and allows UF calculation.
21. A patient on APD with anuria has serum potassium 6.0 mEq/L. First step:
A) Add kayexalate to dialysate B) Review medications (ACEi, ARB, spironolactone) and dietary potassium intake C) Increase dextrose concentration D) Shorten dwell times
Correct Answer: B
Rationale: Medication and diet review first; adjust APD if needed.
22. In CCPD, which modification most improves phosphate removal?
A) Increase dextrose concentration B) Increase total dialysate volume (more cycles or larger fills) C) Add icodextrin
D) Decrease dwell time
Correct Answer: B
Rationale: Phosphate removal is flow-dependent; more dialysate = more removal.
23. A patient on APD reports severe inflow pain with each fill. Best initial intervention:
A) Increase fill rate B) Decrease fill rate (slow fill) C) Add heparin to dialysate D) Increase dextrose concentration
Correct Answer: B
Rationale: Slow fill reduces rapid peritoneal distension and pain.
24. Which cycler system allows remote prescription changes by the dialysis nurse?
A) Fresenius Liberty with no remote B) Baxter Claria with Sharesource C) Medtronic HomeChoice without modem D) Amia without connectivity
Correct Answer: B
Rationale: Sharesource enables bidirectional remote management.
25. APD is relatively contraindicated in which condition?
A) Diabetes mellitus B) Severe chronic obstructive pulmonary disease C) Uncorrected diaphragmatic hernia D) History of abdominal surgery 15 years ago
Correct Answer: C
Rationale: Diaphragmatic hernia risks hydrothorax with fills.
Domain 2: Infectious Complications and Prevention (26–50)
26. A patient on CCPD presents with cloudy effluent, WBC 3000/μL, 95% neutrophils. Gram stain shows gram-positive
cocci in clusters. Empiric IP antibiotics should include: A) Vancomycin + ceftazidime B) Cefazolin + ceftazidime C) Gentamicin alone D) Oral ciprofloxacin
Correct Answer: B
Rationale: ISPD: cefazolin (gram-positive) + ceftazidime (gram-negative) as empiric.
27. A patient on APD develops peritonitis with Candida parapsilosis. Appropriate management:
A) IP fluconazole for 14 days B) Catheter removal + IV antifungal C) Continue APD with oral fluconazole D) IP amphotericin B
Correct Answer: B
C) Icodextrin only D) 4.25% dextrose only
Correct Answer: B
Rationale: Biocompatible solutions preserve host defenses and reduce infection risk.
34. A patient on APD reports cloudy effluent but no pain. WBC 1500/μL, 80% eosinophils. Most likely diagnosis:
A) Bacterial peritonitis B) Chemical peritonitis from plasticizer (DEHP) C) Fungal peritonitis D) Tuberculous peritonitis
Correct Answer: B
Rationale: Eosinophilic predominance suggests allergic reaction to tubing or solution additives.
35. Diagnosis of tunnel infection without exit site purulence is best confirmed by:
A) Exit site culture B) Ultrasound of the tunnel tract C) Effluent culture D) MRI
Correct Answer: B
Rationale: Ultrasound reveals fluid collection along the tunnel.
36. Duration of IP antibiotic therapy for Streptococcus peritonitis without catheter removal:
A) 7 days B) 10 days C) 14 days D) 21 days
Correct Answer: C
Rationale: ISPD: minimum 14 days for gram-positive peritonitis.
37. Which patient activity most increases peritonitis risk?
A) Showering daily with exit site covered B) Swimming in a chlorinated pool with waterproof dressing C) Bathing in a bathtub without covering exit site D) Using a hot tub
Correct Answer: D
Rationale: Hot tubs are high-risk for Pseudomonas and other waterborne pathogens.
38. A patient on CCPD develops peritonitis with Mycobacterium chelonae. Management:
A) Standard IP antibiotics B) Catheter removal + specific antimycobacterial therapy C) Continue CCPD with clarithromycin IP D) No treatment
Correct Answer: B
Rationale: Atypical mycobacteria often require catheter removal and prolonged therapy.
39. Relapsing peritonitis (same organism, <4 weeks after stopping antibiotics) most likely indicates:
A) Inadequate initial antibiotic duration B) Biofilm on the catheter C) Antibiotic resistance D) New infection source
Correct Answer: B
Rationale: Biofilm protects organisms; often requires catheter exchange.
40. Which antifungal prophylaxis is recommended during antibiotic therapy for peritonitis?
A) IV fluconazole B) Oral nystatin or fluconazole C) Topical clotrimazole D) No prophylaxis needed
Correct Answer: B
Rationale: Oral antifungals reduce fungal peritonitis risk.
41. Twardowski exit site score of 3 indicates:
A) Normal exit site B) Mild erythema C) Moderate erythema with crusting D. Purulent drainage
Correct Answer: C
Rationale: Score 3 = moderate redness + crusting; 4 = purulent.
42. A patient on APD with peritonitis has clear effluent but fever and abdominal pain. Next step:
A) Discharge home B) Repeat effluent cell count and culture immediately C) Start oral antibiotics D) Remove catheter
Correct Answer: B
Rationale: Clear effluent does not rule out early peritonitis; repeat analysis.
43. Which antibiotic is contraindicated for intraperitoneal administration?
A) Vancomycin B) Amphotericin B C) Gentamicin D) Cefepime
Correct Answer: B
Rationale: Amphotericin B causes chemical peritonitis and is never given IP.
44. A patient on APD with recurrent S. aureus exit site infections has negative nasal swab. Next best step:
A) Stop all prophylaxis B) Screen household members for S. aureus carriage C) Switch to CAPD D) Add IV vancomycin weekly
Correct Answer: B
D) 1 year
Correct Answer: B
Rationale: Allow peritoneum to heal and infection to clear.
Domain 3: Mechanical Complications and Cycler Troubleshooting (51–75)
51. Cycler alarm "Fill time exceeded" occurs. First action:
A) Increase fill rate setting B) Check that patient line clamp is open and tubing not kinked C) Add heparin to bag D) Replace cassette
Correct Answer: B
Rationale: Closed clamp or kink prevents inflow.
52. A patient's cycler shows UF of +50 mL but patient reports weight gain of 1 kg. Possible explanation:
A) Patient ate a large meal during treatment B) Cycler UF measurement error C) Patient drank 1 liter of water D. All of the above
Correct Answer: D
Rationale: Weight change = UF + oral intake − output.
53. Drain pain is most severe when patient is:
A) Supine B) Left lateral C) Upright (sitting) D) Prone
Correct Answer: C
Rationale: Upright position causes catheter tip to irritate pelvic peritoneum.
54. Which finding suggests catheter tip is not in the pelvic pouch?
A) Rapid fill, normal drain B) Slow fill, rapid drain C) Drain only when patient stands or rolls to right side D) Normal fill and drain
Correct Answer: C
Rationale: Position-dependent drainage indicates malposition.
55. A patient on APD has recurrent "incomplete drain" alarms only on the last cycle of the night. Cause:
A) Low intraperitoneal volume at end of treatment B) Omental wrap C) Constipation D) Cycler software error
Correct Answer: A
Rationale: Last cycle has less volume, less gravity assist.
56. Which substance can cause catheter obstruction if accidentally injected intraperitoneally?
A) Heparin B) Crushed oral iron tablets C) IP vancomycin D) IP gentamicin
Correct Answer: B
Rationale: Never inject oral medications; they precipitate.
57. The cycler displays "Heater bag temperature low" 60 minutes into treatment. Room temperature is 18°C. Action:
A) Continue; cool fluid is safe B) Check heater plate connection and bag placement C) Increase room temperature to 25°C D) Replace cycler immediately
Correct Answer: B
Rationale: Poor contact between heater bag and plate is common.
58. A patient reports cycler stops with "Air in line" alarm. Most likely cause:
A) Empty heater bag B) Loose connection allowing air entry into system C) Catheter perforation D) High drain volume
Correct Answer: B
Rationale: Air enters through loose fittings.
59. Sudden onset of sharp chest pain and dyspnea after APD fill. Most likely:
A) Pulmonary embolism B) Hydrothorax (pleuroperitoneal leak) C) Myocardial infarction D) Peritonitis
Correct Answer: B
Rationale: Hydrothorax presents with pleuritic chest pain and dyspnea after fill.
60. Hydrothorax is confirmed by:
A) Chest X-ray showing effusion B) Pleural fluid-to-serum glucose ratio >1 (pleural glucose similar to dialysate) C) Elevated pleural LDH D) Low pleural protein
Correct Answer: B
Rationale: High pleural glucose indicates dialysate leak.
61. First-line management for fibrin clot obstruction of PD catheter:
A) Heparin 1000 U/L in dialysate for 3 days B) tPA (alteplase) 1 – 2 mg instillation C) Catheter replacement D) Increase fill volume
C) Warmer dialysate D) Lower glucose concentration
Correct Answer: B
Rationale: Slow fill reduces distension pain.
68. The cycler's occlusion sensor detects:
A) Patient temperature B) Pressure changes in the patient line indicating resistance C) Dialysate glucose concentration D) Bacterial contamination
Correct Answer: B
Rationale: Pressure rise indicates occlusion.
69. Which blood pressure pattern suggests hypovolemia from excessive UF?
A) High supine, low standing (orthostatic hypotension) B) Low supine, high standing C) Equal supine and standing D) High supine and high standing
Correct Answer: A
Rationale: Orthostatic hypotension + supine hypertension = hypovolemia.
70. A patient's cycler shows UF 1800 mL but patient reports weight loss of only 0.5 kg from previous day. Explanation:
A) Cycler overestimates UF B) Patient ate 1.3 kg of food and fluids during treatment C) Residual renal function loss D) Machine measures inflow only
Correct Answer: B
Rationale: Weight change = UF + oral intake − output.
71. Which cycler alarm requires immediate patient disconnection?
A) Low temperature B) Power failure C) Persistent high pressure alarm with inability to drain D) Heater bag empty
Correct Answer: C
Rationale: Inability to drain risks peritoneal overdistension.
72. A patient reports cycler "stops every night at 2 AM" with drain alarm. Likely:
A) Cycler software bug B. Patient sleeping position change (rolls onto back at 2 AM) C) Catheter tip suction against omentum D) Low battery
Correct Answer: B
Rationale: Position change can impede drain.
73. First action when cycler displays "Replace cassette" error:
A) Continue treatment B) Close clamps and replace cassette using aseptic technique C) Call manufacturer D) Increase dwell time
Correct Answer: B
Rationale: Cassette error requires replacement.
74. Which substance can cause permanent damage to cycler internal components?
A) Heparin B) Icodextrin precipitate C) Dialysate spilled into the machine D) Dextrose residue
Correct Answer: C
Rationale: Fluid inside cycler causes electrical damage.
75. A patient on APD has dialysate leak from the exit site after catheter placement 3 days ago. Management:
A) Continue APD with reduced fill volume B) Stop PD for 3 – 7 days, use temporary HD or CAPD with minimal volume C) Apply pressure dressing D) Increase dextrose concentration
Correct Answer: B
Rationale: Leak requires rest to allow healing.
Domain 4: Metabolic and Clinical Complications (76–100)
76. Which electrolyte is most commonly depleted in PD patients?
A) Sodium B) Potassium C) Calcium D) Magnesium
Correct Answer: B
Rationale: PD removes 10 – 20 mEq potassium daily; hypokalemia common.
77. A patient on APD has serum phosphorus 8.0 mg/dL, calcium 8.5 mg/dL, PTH 1200 pg/mL. Best intervention:
A) Increase dialysate calcium B) Increase phosphate binders (calcium-based or non-calcium) and restrict dietary phosphorus C) Stop calcitriol D) Switch to icodextrin
Correct Answer: B
Rationale: Hyperphosphatemia with high PTH requires binders and diet.
78. Icodextrin falsely elevates which serum test?
A) Creatinine B) Glucose C) Amylase (colorimetric method) D) Potassium
B) 20 – 22 mEq/L C) 22 – 24 mEq/L D) >25 mEq/L
Correct Answer: B
Rationale: ISPD recommends 20 – 22 mEq/L to avoid overcorrection.
85. Hypomagnesemia in PD patient increases risk of:
A) Ventricular arrhythmias (torsades de pointes) B) Peritonitis C) Hypercalcemia D) Hypokalemia
Correct Answer: A
Rationale: Low magnesium prolongs QT interval.
86. Which imaging finding is diagnostic of encapsulating peritoneal sclerosis (EPS)?
A) CT with peritoneal calcification, bowel tethering, and loculated fluid B. High D/P creatinine on PET C) Low UF D) Bloody effluent
Correct Answer: A
Rationale: EPS diagnosed by characteristic CT findings.
87. Strongest risk factor for EPS:
A) PD duration <2 years B) PD duration >5– 8 years C) Use of icodextrin D) Low glucose exposure
Correct Answer: B
Rationale: Long-term PD (>5 years) increases EPS risk.
88. A patient on APD has severe hypoalbuminemia (1.8 g/dL) without peritonitis. Best initial step:
A) Increase dextrose to 4.25% B) Assess dietary protein intake and calculate nPCR C) Switch to HD
D) Add intraperitoneal albumin Correct
Answer: B Rationale: Assess
nutritional intake first.
89. Which vitamin is not removed significantly by PD?
A) Vitamin C B) Vitamin B C) Vitamin B D) Vitamin A
Correct Answer: D
Rationale: Fat-soluble vitamins (A, D, E, K) are not dialyzed.
90. A patient on APD has serum sodium 128 mEq/L, asymptomatic, on icodextrin day dwell. Cause:
A) Hyperglycemia B) Pseudohyponatremia from icodextrin metabolites C) Hypotonic dialysate D. Heart failure
Correct Answer: B
Rationale: Icodextrin causes osmotic shift, diluting sodium measurement.
91. True hyponatremia in PD patient is treated by:
A) Fluid restriction B) Increasing dialysate sodium concentration C) Stopping icodextrin D. Loop diuretics
Correct Answer: B
Rationale: Increase dialysate sodium if true sodium depletion.
92. Which drug’s serum level is significantly lowered by PD?
A) Digoxin B) Phenytoin C) Gentamicin D) Warfarin
Correct Answer: C
Rationale: Aminoglycosides are water-soluble and dialyzed.
93. A patient on APD has Hb 8.5 g/dL on ESA, ferritin 800 ng/mL, TSAT 12%. Diagnosis:
A) Absolute iron deficiency B) Functional iron deficiency C) Anemia of chronic disease D) Pure red cell aplasia
Correct Answer: B
Rationale: High ferritin + low TSAT = functional iron deficiency; IV iron indicated.
94. Which complication is associated with chronic use of 4.25% dextrose?
A) Weight loss B) Peritoneal membrane angiogenesis and fibrosis C) Hyperkalemia D) Hypoglycemia
Correct Answer: B
Rationale: High glucose exposure damages the peritoneum.
95. Icodextrin is preferred over 4.25% dextrose for long dwell because it:
A) Provides better small solute clearance B) Provides sustained UF without glucose absorption C) Is cheaper D) Prevents peritonitis
Domain 5: Patient Education and Self-Care (101–125)
101. Before discharge on APD, patient must demonstrate:
A) Programming all cycler settings B) Sterile connection technique and aseptic exit site care C) Interpreting PET results D. Ordering supplies online
Correct Answer: B
Rationale: Aseptic technique prevents peritonitis.
102. Which patient statement indicates need for re-education?
A) “I wash my hands with soap and water before each connection.” B) “I reuse the drain line clamp to save money.” C) “I wear a surgical mask during connections.” D) “I check the solution expiration date.”
Correct Answer: B
Rationale: Clamps are single-use; reuse increases infection risk.
103. During air travel with APD cycler, patient should:
A) Pre-order dialysate to destination B) Pack cycler in checked luggage C) Rely on hotel to provide supplies D) Skip dialysis during travel
Correct Answer: A
Rationale: Pre-delivered supplies ensure continuity.
104. APD patient asks about sexual activity. Nurse advises:
A) Avoid completely B) Drain dialysate before intercourse for comfort C) No change needed D) Only allowed in supine position
Correct Answer: B
Rationale: Empty abdomen improves comfort.
105. Which exercise is safest for APD patient?
A) Heavy weightlifting B) Swimming in ocean with waterproof dressing over exit site C) Contact sports (football) D) Running on treadmill with full dialysate dwell
Correct Answer: B
Rationale: Ocean swimming allowed if exit site healed and covered.
106. A patient on APD has anxiety about cycler alarms. Best intervention:
A) Prescribe anti-anxiety medication B) Hands-on alarm troubleshooting practice during training
C) Turn off alarm sounds D) Switch to CAPD
Correct Answer: B
Rationale: Practice reduces anxiety.
107. Patient with Parkinson's disease and tremors starting APD. Adaptation:
A) CAPD only B) Pre-attached cassettes and caregiver assistance C) In-center HD only D) No adaptation possible
Correct Answer: B
Rationale: Caregiver support or adaptive devices.
108. Which dietary teaching is correct for anuric APD patient?
A) High potassium foods encouraged B) Fluid restriction = 1000 mL + UF volume C) Unlimited protein D) No phosphorus restriction
Correct Answer: B
Rationale: Fluid allowance = UF + urine output + 500 – 1000 mL.
109. A patient works night shifts as a nurse. APD schedule adjustment:
A) Perform APD during daytime sleep B) Skip APD on work nights C) Switch to CAPD D) Reduce fill volume
Correct Answer: A
Rationale: APD can be done during any 8-10 hour period.
110. Which sign of caregiver burnout requires immediate intervention?
A) Caregiver asks questions B) Missed connections or rushed, incorrect aseptic technique C) Caregiver takes detailed notes D) Patient’s labs are stable
Correct Answer: B
Rationale: Errors suggest fatigue; need respite.
111. During power outage, patient should first:
A) Wait for power to return B) Drain and disconnect, perform CAPD manually C) Call 911 D) Connect cycler to car battery
Correct Answer: B
Rationale: Manual CAPD bridges power loss.
112. Patient reports "cycler beeps every night but I ignore it." Nurse action:
