DAVITA FINAL EXAM QUESTIONS AND VERIFIED ANSWERS 2023-2024, Exams of Nursing

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 kidney excretory functions: normalize electrolytes, remove wastes, provide fluid & acid

base balance

 fxn of acid concentration: concentration gradient for diffusion/osmosis to take place

 fxn of bicarbonate: buffers acid concentrate (in dialysate) & normalizes pH (in pt)

 hyperkalemia: > 5.5 mEq extreme muscle weakness, abn heart rhythm, cardiac arrest

 hypokalemia: < 3.5 mEq fatigue, muscle weakness, paralysis, resp failure, ar- rhythmias,

cardiac instability/arrest

 kidney endocrine fxn: renin & EPO secretion, vit D activation

 common causes of CKD: diabetes,

hypertension, polycystic kidney disease

 how much of normal kidney fxn replaced by hemodialysis: 15%

 signs & symptoms of fluid imbalance: hypertension, edema, shortness of breath

 consequence of prolonged fluid overload & hypertension: left ventricular hypertrophy

(LVH)

 treatment for pericarditis: decrease/stop heparin, more frequent dialysis

 common cause of hypertension: fluid overload

 why dialysis pts are anemic: primary cause: lack of EPO

secondary cause: inad. iron stores, inad. dialysis, malnutrition, blood loss during treatment

 how PCT can avoid contributing to lowered hemoglobin & blood loss: verify EPO stimulating

agent is correct, rinse back until venous line pink, avoid repeat lab draws

 four key elements contributing to CKD-mineral bone disorder (CKD-MBD)-

: Ca+ , P , PTH, Vit D (calcitriol)

 pre- , intra- & post-renal causes of AKI: pre: obstruction, vol depletion, im- paired cardiac

fxn, decreased cardiac output intra: ischemic ATN, sepsis, acute interstitial nephritis, septic shock, anaphalaxis, drugs... post: obstruction, bladder rupture, pregnancy

 AKI patients are at increased risk for which complications: hypovolemia & hypotension

 most common infections in ICHD patients: bacterial vascular access infec- tions

 what organism causes the most infections in ICHD patients: MRSA

 what is strikethrough: fluid penetration & contamination of internal pressure transducer

 HBsAg, HBsAb, HBcAb: HBsAG Hep B Surface ANTIGEN >> monthly testing

HBsAB Hep B Surface ANTIBODY HBcAB Hep B Core ANTIBODY

 Hep B and cross-contamination amongst pts: -care for HBsAg+ & Hep B immune at the

same time

-care for Hep B susceptible pts & those receiving vaccination at the same time -care for Hep B immune & susceptible pts at same time

 most common transmission route for HAIs & reason for increased risk of HAIs: contact

transmission & bc pts are immunosuppressant

 total proportion of dialysate used at davita: 45X

 2 most frequent K+ Rx's: 2.0 & 3.

 what part of kidney dors the dialyzer act as to provide filtration?: glomeru- lus

 2 waste products removed by dialysis monitored monthly: BUN & creatinine

 conductivity value range: manual & computer values must sync within +/- 0.

 safe dialysate pH range: 6.9-7.

 following recitculation how long can a dialyzer & blood lines be set up: 2 hrs as longer leads

to bacterial growth

 correct procedure for residual bleach testing after chemical disinfection of loops & equipment

fluid pathways: residual bleach testing performed after bleach disinfection & prior to equipment use

 4 reasons that we document in medical record: -proof care was rendered

-provide data continuity -communication tool -permanent legal record

 6 occurences to document: -change from baseline

-change in pt condition -procedure/treatment given -medication given & pt response -patient teaching -care plan review & interventions

 What does SMART stand for?: Simple Meaningful Actual Read Teach

 when is pre-treatment assessment by the RN required: CKD patients (state law) & AKI

patients

 cuff too small: false high reading

 cuff too large: false low reading

 normal heart rate range: 60-100 bpm

 normal resp range: 12-20 breaths/min

 normal temp: less then 100 or 2 difference from baseline

 6 Ws when completing REM: What When Where Why Witness Who

 interdialytic weight gain (IDWG) calculation: pre weight - last post weight

 UF goal calculation: (pre weight - target weight) + (prime and rinseback) + (oral intake /

infusions)

 maximum UF rate unless Rx: 13 mL/kg/hr

 4 consequences of NA+ loading during dialysis: -increased thirst

-large fluid gains -hypotension -ischemic events

 consequences of consistent fluid overload: LVH, increased Central Venous Pressure (CVP),

hypertension, increased mortality, pulmonary edema, increased hospitalization rate

 consequences of hypovolemia/hypotension during treatment: increases mortality,

ischemia, damage to vital organs (organ stunning), loss of remaining kidney fxn

 AVF vs AVG: direct fusion of artery & vein vs synthetic connection btw artery & vein

 point where an artery & vein are connected to create an avf: anastomosis

 4 AVF evaluations for maturation: > 600 ml flow

< 0.6 cm in depth under skin

0.6 cm diameter 6- 8 weeks post op

 tunneled vs non-tunneled CVC: tunneled has cuff for skin to grow around (permanent)

non-tunneled does not (temporary)

 how long after heparin admin to start treatment: minimum of 3-5 mins

 needle gauges & BFR: 17g 200-250ml/min 16g 250-

350ml/min 15g 350-450ml/min 14g not to exceed 450 unless Rx

 needle insertion: AVF 25 degrees AVG 45

degrees

 distance from anastomosis? distance btw needle tips?: 1.5 inch

 BEST TIPS: B : Bleeding E :

Erosion S : Stenosis T : Thrombosis I : Infection P : Pseudoaneurysm / aneurysm S : Steal syndrome

 Order of draw: Dark Blue Red

Light Blue Gold SST Lavender Green -- POST only

 what is the goal for single pool (spKt/V) for 3x/week frequency of dialysis-

: greater than equal to 1.

 Kt/V: what is each letter: K clearance of urea t time of

dialysis V vol of urea distribution/vol of pts body water

 what factors increase/decrease K: increase: increased BFR, correct DFR, correct dialyzer,

correct TW decrease: inad coagulation, decreased BFR, poor priming, P&P disregarded, treat- ment ended early

 procedure for post BUN lab draw: -verify dialysis has been initiated for 30 mins w Rx BFR

-turn off/decrease UFR to 50 -bypass/decrease DFR to 300 -decrease BFR to 100 -wait 15 secs for all access types and draw post

 pre pump arterial pressure becomes too negative if exceeding what value-

: -260mmHg

 What 2 steps are preformed to replace fluid removed & prevent clotting dur- ing recirculation of

blood in extracorporeal circuit when treatment interrupted (pt using the restroom)?: saline

infusion line opened & heparin pump remains on

 labeling & expiration: labeled with initials & date

discarded within 28 days (21 if epogen)

 single vs multi-dose meds: single used once, vial entered once then discard- ed, same

syringe for 2 single vials of same meds/conc multi vial may be entered multiple times but requires new needles for each entry

 6 rights to med administration: Time Route

Amount Medication Patient Documentation

 4 meds via PCT: normal saline (up to 200ml) heparin

(by state) lidocaine topical anesthetic spray

 needle & syringe size for heparin: 21g x 1 inch

 Why would the nephrologist order a formulary exception of Citrasate or CitraPure dialysate

concentrate?: to use as part of anticoagulation therapy during dialysis when heparin is

contraindicted

 what is the frame time during which single use meds should be

prepped/administered?: 4 hrs

 2 reasons for water treatment: prevent equipment damage & patient safety

 Aluminum in water used for dialysis causes: Anemia, bone disease, nausea and vomiting

 chlorine in water used for hemodialysis causes: hemolysis

 excess Ca+ & Na- in water used for dialysis causes: hypertension

 excess Ca+ & Mg in water used for dialysis causes: muscle weakness

 what does the RO remove: organic inorganic materials, bacteria, & endotoxins

 2 concerns with using DI tanks?: -exhaust quickly

-when exhausted they dump/release previously removed ions back to water

 response to final water quality alarm: -bypass

-notify RN/FA/MDirector -if not restored terminate & REM

 water/dialysate culture results: acceptable level: below 50 cfu/ml action level:

50-99 cfu/ml unacceptable level: 200 cfu/ml or higher

 water endotoxin testing resuls: acceptable level: below 0.12 EU/ml action level:

0.12-<0.25 EU/ml

unacceptable level 0.25 or greater EU/ml

 how often are water & dialysate cultures drawn & monitored for bacteria & endotoxins:

monthly

 what removes chlorine/chloramines: carbon tanks

 when to perform chlorine/chloramine testing: when RO is actively supplying water: after RO

has operated for at least 15 mins first thing in the morning, before 1st shift of pts, every 4 hrs

 where to perform chlorine/chloramine testing: after primary carbon tank sample port

 acceptable results of chlorine/chloramine testing: > or equal to 0.1 mg/l

 actions if results are too high post primary tank for chlorine/chloramine testing: repeat test,

move onto secondary port & test, notify Biomed/FA

 F/Y if secondary test results are within limits: every 30 mins

 F/U if secondary test results are too high: stop dialysis via bypass & do not rinse blood back

 what is the purpose of water softener, what is removed & why important; when is the test

performed?: to remove hard minerals such as Ca+ and Mg for RO protection; end of day

 hypotension: systolic <

diastolic < drop in systolic more than 20 mm/Hg

 hypotension causes & symptoms: rapid/inappropriate fluid loss, antihyperten- sive drugs,

low blood vol, food ingestion, unstable cardiovascular condition flushing, yawning, dizziness, ringing in ears, tachycardia, anxious feeling, nau- sea/vomiting, cold clammy skin, seizures, cardiac arrest

 hypotension intervention & prevention: frequent assessment of target weight, limit UFR to

< or equal to 13 ml/kg/hr, UF profiling, extend treatment time, pure ultrafiltration

 consequences of organ stunning: -heart: acute stress on cardiovasc system, development of

LV, arrhythmias, can lead to cardiac failure. -gut: releases endotoxin into circulation, inflammation -kidneys: causes fibrosis, loss of RRF -brain: causes multiple sites with white matter injury

 hypertension: pre-dialysis BP 140/90 post-

dialysis BP 130/

 hypertension causes & symptoms: disease process, fluid overload, non-ad- herence with

medication, renin-angiotensin cycle no symptoms, headaches, dizziness, irritability, blurred vision, nervousness, edema (secondary to fluid retention)

 hypertension intervention & prevention: take meds as rx'd, maintaining fluid balance

promote fluid & med adherence

 muscle cramps causes & symptoms: rapid/excessive fluid removal, hypo-os- molality, tissue

hypoxemia/ischemia, electrolyte imbalance (low Ca+, Na+, K, Mg) painful cramps usually late in dialysis session

 muscle cramps intervention & prevention: massage/opposing force, stretch, discontinue

UFR, provide O2 per Rx, assess target weight, administer NS dietary restrictions, UFR < or equal to 13 ml/kg/hr, decrease Na* loading, increase treatment time, UF profiling

 seizures causes & symptoms: dialysis side effect/adverse rxn, preexisting condition

 seizures intervention & prevention: protect from harm/airway (do not pry mouth open),

treat hypotension/DDS/hypoglycemia as needed, administer O2, dis- continue if no response/worsens

 Dialysis Disequilibrium Syndrome (DDS): condition of rapid/drastic change in pts

extracellular fluid affecting the brain

 DDS causes & symptoms: missed treatment, rapid drop in BUN

headache, hypertension, nausea, restlessness, seizures, confusion, blurred vision

 DDS intervention & prevention: slower BFR & DFR, shorter initial treatments

early recognition of mild symptoms decrease efficiency of dialyzer

 fever & chills: any temp over 100F or increase over baseline of 2F

 fever & chills causes & symptoms: systemic infections, access infections, contamination

of blood or dialysate, pyrogenic rxns notify RN, comfort

 pyrogen rxn: elevated temp usually 45-75 mins into treatment

 pyrogen rxn causes & symptoms: pyrogens (ex: endotoxin) chills,

shaking, fever, hypotension, vomiting, muscle pain

 pyrogen intervention & prevention: notify RN, comfort & discontinue dialysis

proper water treatment, preparation, set-up, disinfection

 disinfectant infusion: breach in procedure resulting in disinfectant infusing into pt

bloodstream

 disinfectant causes & symptoms: not performing/inaccurate residual disin- fectant testing,

sterilant rebound pain at venous needle, itching, restlessness, respiratory distress, chest pain, tingling around lips, back pain

 disinfectant intervention & prevention: turn off pump do not return, prime w new saline,

aspirate, notify RN/neph follow proper P&P

 dysrhythmia: irregular heart beat

 dysrhythmia causes & symptoms: electrolyte imbalance, hereditary, disease process, meds

irregular heart beat, palpations

 dysrhythmia intervention and prevention: treat cause

review H&P, labs, pt history

 chest pain/angina: chest pain or discomfort due to coronary heart disease; occurs when

the heart muscle doesn't get as much blood as needed (uncomfortable pressure, fullness, squeezing/pain in center of chest, discomfort in neck/jaw/shoul- der/back/ arm)

 chest pain/angina causes & symptoms: coronary artery disease, anemia, hypotension,

anxiety chest pain, difficulty breathing, nausea

 chest pain/angina interventions: decrease BFR to 150, if hypotensive re- store BP,

decrease UFR, monitor & notify RN

 cardiac arrest: cessation of a heart beat

 cardiac arrest causes & symptoms: lethal side effect: electrolyte imbalance, severe

hypotension, underlying cardiac disease/M.I., cardiac tamponade, air em- bolism, hemolysis, large blood loss, anaphylactic rxn absence of pulse, lack of respirations, pts unresponsive

 cardiac arrest intervention & prevention: complete CAS sheet at time of event starting

with CPR by EMS close monitoring of pts on dialysis

 first use syndrome: group of symptoms after 1st treatment begins w new dialyzer

 first use syndrome causes & symptoms: ETO sterilized or manufacturer residues in

dialyzer

nervousness, chest pain, back pain, palpations, itching, funny taste in mouth

 anaphalaxis: rapid immune response/inflammation due to allergen

 anaphalaxis causes & symptoms: pathogen, allergic rxn to meds/ETO/ger- micide

difficulty breathing, wheezing, tachycardia, hives, itching, lower back pain...

 anaphalaxis intervention & prevention: discontinue treatment do NOT rinse blood back,

monitor, CPR as needed verify vancomycin allergy is clearly marked in chart; always check for allergies before administering meds

 air embolism: blockage of blood supply due to air in vessels

 air embolism causes & symptoms: unarmed air detector, empty saline, loose/leaked

connection in extracorporeal blood visible air in venous line, chest tightness/pain, dyspnea, coughing, cyanosis...

 air embolism intervention & prevention: do NOT return blood, immediately stop

treatment, trendelenburg position on L side, disconnect, aspirate verify all connections are secure at all times

 blood loss causes: blood leak detector alarm, VP alarm if needle dislodged or line

separation

 blood loss intervention & prevention: observe/monitor, maintain visible ac- cess

securely tape needles, re-educate pt, if continued non-adherence involve IDT inter- vention

 clotted dialyzer causes & symptoms: insufficient anticoagulation

decrease in VP with no change in BFR, visible clots in venous drip chamber/line, rapid filling of transducer protectors, dark blood, unable to rinse back pts blood

 clotted dialyzer intervention & prevention: ensure proper use of heparin, monitor

pressure, maintain BFR respond to machine alarm immediately as blood that is not circulating tends to clot, intermittent saline flushes, additional saline to UF goal, refer for internal access placement

 hemolysis causes & symptoms: hypotonic dialysate, dialysate temp too high,

chlorine/chloramine exposure, disinfectant, conductivity/blood pump error cherry red blood, anxiety, restlessness, N/V, abdominal cramping, back pain, dysp- nea,

seizures, dysrhythmias, thready pulse, hyper/hypotension

 hemolysis intervention & prevention: stop blood pumps, clamp lines, do NOT return

blood, call RN arterial pressure monitoring, compatible needle gauge & BFR orders, conductivity monitoring, chlorine/chloramine/residual tests, equipment testing

 air/foam detector alarm: air in blood lines

check for air & do NOT return blood

 blood leak detector alarm: air/blood in dialysate line, dirty sensor

check dialysate connections, bleach machine

 transmembrane pressure (TMP) alarm: wet transducers, change in UF goal, clamped

transducer lines, clotting of low flux = high TMP, clotting of high flux = low TMP check transducer lines, evaluate goal, heparin per Rx, monitor

 arterial pressure HIGH/LOW alarm: HIGH: check needle placement, kinks, tape

LOW: separation of tubing & arterial access

 venous pressure HIGH/LOW alarms: HIGH: check needle placement, flush w NS

LOW: verify NS is clamped, increase BFR

 conductivity & pH alarm: recheck, bypass machine

 temperature alarm: broken thermometer, temp out of range

notify biomed

 heparin pump alarm: clamped or complete heparin line

evaluate, unclamp in needed/stop if dose complete

 what is the first thing you should do with dialysis machine & blood lines prior to returning a

pt's blood using hand crank during power failure?: remove venous blood line from air detector clamp

 four indicators of optimal status: -albumin greater than/equal to 4 g/dL

-stable target weight -adequate fat stores -appropriate appetite & intake

 S&S of fluid excess: shortness of breath, fatigue, edema, headaches, hyper- tension

 importance of limited potassium: prevents cardiac arrest, sudden death, bradycardia,

irregular heart beat, muscle weakness

 importance of limited phosphorus >> when to take BINDERS: take binders w food, meals,

snacks to prevent itching, bone damage, soft tissue calcification

 importance of keeping Ca+ within normal levels: heart disease & calcifica- tion of soft tissue

 commonly prescribed meds to treat CKD-MBD (mineral bone disorder): -

phosphate binders, vitamin D (calcitriol), calicimitics

 importance of vitamins: b/c some removed by dialysis & dietary restrictions limiting

certain food sources

 5 stages of grief: denial anger bargaining depression acceptance

 KDQOL 36: "Kidney Disease Quality of Life" used for mental/physical health, burden of

KD, symptoms/problems (test of depression)

 modality choices for those w kidney failure: renal transplant, peritoneal dialysis,

hemodialysis, conservative management of care

 DARN: desire ability reason need

 davita quality index (DQI): encourage continuous improvement across a broad range

of disease management processes

 purpose of davitas internal audit: to help the facility prepare for a state audit

 what are conditions for coverage (CfC)? how many are there?: require- ments that providers

must meet to be CMS certified, allows facility to be paid for the care of pts on

medicare/medicaid 17

 reasons for immediate jeopardy (IJ): uncovered access, not knowing the water room

components, not performing water checks correctly

 culture of safety: see it say it

 purpose of Flash Tour: enables surveyors to quickly assure pt safely prior to full audit