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DAVITA RISE PCT Study Guide: Hemodialysis & CKD Management, Exams of Nursing

This study guide provides a comprehensive overview of hemodialysis and chronic kidney disease (ckd) management, focusing on key concepts, procedures, and patient care considerations. It includes a series of questions and answers covering topics such as transport mechanisms in hemodialysis, kidney functions, electrolyte imbalances, ckd-mineral bone disorder (mbd), acute kidney injury (aki), and infection control in dialysis patients. The guide is designed to aid pcts in understanding and applying essential knowledge related to hemodialysis and ckd management.

Typology: Exams

2024/2025

Available from 12/24/2024

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DAVITA RISE PCT STUDY GUIDE QUESTIONS WITH

CORRECT ANSWERS

List the four transport mechanisms that play a role in hemodialysis - VERIFIED ANSWER✔✔- Ultrafiltration Convection Diffusion Osmosis Explain ultrafiltration in hemodialysis - VERIFIED ANSWER✔✔-Fluid is pushed through the semipermeable membrane (SPM). Think: wringing out a wet rag. Explain convection in hemodialysis - VERIFIED ANSWER✔✔-Solutes DRAG across the semipermeable membrane with fluid Explain diffusion in hemodialysis - VERIFIED ANSWER✔✔-PARTICLES move from HIGH concentration to LOW concentration Explain osmosis in hemodialysis - VERIFIED ANSWER✔✔-FLUID moves LOW concentration to HIGH concentration What are the kidneys' excretory functions? - VERIFIED ANSWER✔✔-To normalize electrolytes, remove wastes, provide fluid and nutrient balance How do we replace normal excretory kidney functions? - VERIFIED ANSWER✔✔-By using acid concentrate to help normalize electrolytes and ultrafiltration to provide fluid balance What is the function of acid concentrate - VERIFIED ANSWER✔✔-Provides the concentration gradient for diffusion and helps normalize electrolytes

What is the function of bicarbonate in the dialysate solution? - VERIFIED ANSWER✔✔-It buffers the acid concentrate What is the function of bicarbonate when it diffuses into the patient's blood? - VERIFIED ANSWER✔✔-It normalizes body pH What are some S/Sx of hyperkalemia? - VERIFIED ANSWER✔✔-K+ > 6.5 mEq extreme muscle weakness, dysrhythmias, and possible cardiac arrest What are some S/Sx of hypokalemia? - VERIFIED ANSWER✔✔-K+ < 3.5 mEq fatigue, muscle weakness, paralysis, resp. failure, cardiac instability, arrhythmias, cardiac arrest What is the normal blood pH range? - VERIFIED ANSWER✔✔-7.35 - 7. What are the kidneys' endocrine functions? - VERIFIED ANSWER✔✔-Renin secretion Erythropoietin secretion Vitamin d activation How do we replace normal endocrine kidney functions? - VERIFIED ANSWER✔✔-By providing medications How much of normal kidney function is replaced by HD? - VERIFIED ANSWER✔✔-15% What is uremia? - VERIFIED ANSWER✔✔-Uremia is a buildup of wastes in the blood due to kidney failure What does uremia affect? - VERIFIED ANSWER✔✔-Uremia affects all body systems What are the most common causes of CKD in the US? - VERIFIED ANSWER✔✔-diabetes, HTN and polycystic kidney disease

List the treatment goals for a pt. w/ CKD - VERIFIED ANSWER✔✔--slowing the progression of CKD -managing comorbidities and complications -controlling symptoms -minimizing the effects if CKD on pt. lifestyles -kidney replacement therapy modality education -encouraging patients to actively participate in their healthcare Why is it so important to know what caused your pt.'s CKD? - VERIFIED ANSWER✔✔-So the RN and PCT can ask about possible problems during data collection and assessment List some S/Sx of fluid imbalance - VERIFIED ANSWER✔✔-HTN, edema, and SOB Why is sodium balance important? - VERIFIED ANSWER✔✔-Leads to volume expansion, increased cardiac output, increased peripheral vascular resistance and increased BP List some systemic effects of CKD - VERIFIED ANSWER✔✔--Dry, itchy skin -Peripheral neuropathy in the extremities -GI problems (N/V) -Psychological problems (anxiety, depression) What would you advise for a pt. with dry, itchy skin? - VERIFIED ANSWER✔✔--use hyper-fatted soaps and lotions -assess for safety at home -provide emotional support -control diabetes and phosphorus

What would you advise for a pt. with peripheral neuropathy? - VERIFIED ANSWER✔✔--Monitor pt. for changes in motor function, decreased strength in legs, C/O restless legs, and burning feet. -Advise not to walk barefoot -Practice good foot care What would you advise for a pt. with GI problems? - VERIFIED ANSWER✔✔--inform RN and MD of any bleeding problems, constipation, diarrhea

  • inform RN and MD of ER visits -Take meds as ordered (stool softeners, immodium, etc.) What would you advise for a pt. with psychological problems? - VERIFIED ANSWER✔✔-Verbalize struggles to IDT (core team), especially the social worker A common cause of HTN in dialysis patients is: - VERIFIED ANSWER✔✔-Fluid overload What does HTN lead to? - VERIFIED ANSWER✔✔-Left ventricular hypertrophy Left ventricular hypertrophy leads to: - VERIFIED ANSWER✔✔-Ischemic heart disease, arrhythmia, myocardial infarction, and sudden death. Define pericarditis - VERIFIED ANSWER✔✔-An inflammation of the membrane (pericardial sac) that surrounds the heart due to fluid an waste build up What is the Tx for pericarditis? - VERIFIED ANSWER✔✔-Decrease or stop heparin and give more frequent dialysis Why are dialysis patients anemic? - VERIFIED ANSWER✔✔-The lifespan of their red blood cell is 60 days, 1/2 of the normal 120 days. What is the primary cause of anemia in dialysis patients? - VERIFIED ANSWER✔✔-Lack of the hormone erythropoietin (EPO)

What are secondary causes of anemia in dialysis patients? - VERIFIED ANSWER✔✔--Inadequate iron stores, -inadequate dialysis, -malnutrition, -blood loss during Tx How can you prevent contributing to lower hemoglobin and blood loss in dialysis patients? - VERIFIED ANSWER✔✔--Verify epogen dose is correct and administered -Rinse back until venous line is pink tinged -Avoid repeat lab draws What are the four key elements contributing to CKD-Mineral Bone Disorder (MBD) - VERIFIED ANSWER✔✔--Calcium -Phosphorus -PTH -Vitamin D (calcitriol) can all lead to CKD-MBD when abnormal What are the S/Sx of CKD-MBD in addition to bone disease? - VERIFIED ANSWER✔✔--Soft tissue calcification -Itching -Muscle weakness -Pathological fractures -Tendon ruptures -Compression of vertebrae -Atherosclerosis -Heart disease

What is your role in CKD-MBD management? - VERIFIED ANSWER✔✔--report symptoms, -urge patients to take meds (home & treatment) -report noncompliance problems related to nonadherence Define AKI - VERIFIED ANSWER✔✔--Wide spectrum of kidney issues -Includes acute renal failure & renal function changes -May dialyze in an out-patient facility until kidney function recovers Give 3 examples of prerenal causes of AKI - VERIFIED ANSWER✔✔-Obstruction, volume depletion and impaired cardiac function Give 3 examples of intrarenal causes of AKI - VERIFIED ANSWER✔✔-Ischemic ATN, sepsis, SIRS, septic shock, anaphylaxis drugs, goodpasture syndrome, acute glomerulonephritis, trauma, open heart surgery Give 3 examples of postrenal causes of AKI - VERIFIED ANSWER✔✔-Obstruction, oliguria, bladder rupture and pregnancy Explain the difference between AKI and CKD - VERIFIED ANSWER✔✔-Eliminating the cause of the AKI can often lead to the return of kidney function. You cannot eliminate the cause of CKD which is HTN, Diabetes, genetic disorders (PKD) In the outpatient facility, how do you help in restoring kidney function? - VERIFIED ANSWER✔✔-Find the cause of the AKI In the outpatient facility, what do you need to consider in regards to pt. vasc. access? - VERIFIED ANSWER✔✔-Patients will typically have a dialysis catheter- be careful to avoid catheter related infections How do you protect kidneys from further injury? - VERIFIED ANSWER✔✔-Avoid substances to the kidney which may be toxic (radiographic contrast, amphotericin B, low dose aspirin, NSAIDS)

What is important when monitoring weight and BP? - VERIFIED ANSWER✔✔-Keep a little extra fluid on them so it is available to the kidneys when they start filtering/ultra-filtrating on their own AKI patients are at increased risk for which complications? - VERIFIED ANSWER✔✔-Hypovolemia and hypotension What makes dialysis patients more susceptible to HAIs? - VERIFIED ANSWER✔✔-They are immunosuppressed and more vulnerable to infection, which leads to the 2nd most common cause of death in this population Why are dialysis patients at increased risk for acquiring a HAI at the facility? - VERIFIED ANSWER✔✔-The dialysis procedure itself requires prolonged access to the patient's blood, especially those involving CVC vascular accesses, making them more at risk What is the most common transmission route for HAIs - VERIFIED ANSWER✔✔-Contact What is the most important intervention you can do to to prevent HAIs - VERIFIED ANSWER✔✔-Hand hygiene What is the most common infectious complication in hemodialysis patients? - VERIFIED ANSWER✔✔- Vascular access infection What is the most common cause of bacterial infections in dialysis patients? - VERIFIED ANSWER✔✔-• The use of catheters for hemodialysis treatments What germ causes the most common infections in hemodialysis patients? - VERIFIED ANSWER✔✔- Methicillin-resistant Staphylococcus aureus (MRSA) - Must pay attention to infection control! Proper hand hygiene, cleaning & disinfecting procedures to prevent spread of infection (viable on surfaces for days) Why is wearing gloves so important? - VERIFIED ANSWER✔✔-It reduces the risk of hand contamination and prevents the transfer of organisms already on hands

Why do you need to perform hand hygiene before and after wearing gloves? - VERIFIED ANSWER✔✔- Gloves are not impervious and have microscopic pores Explain the acceptable hand hygiene technique when caring for a patient with active C-diff - VERIFIED ANSWER✔✔-Handwashing with soap and water per policy is the only acceptable hand hygiene What is the difference between OSHA and CMS infection control requirements? - VERIFIED ANSWER✔✔-OSHA: Requires employers to provide workers with a safe workplace CMS: Concerned with patient care and patient safety What are V-tags and why are they important? - VERIFIED ANSWER✔✔-They state specific regulations to be met within a condition such as infection control, providing interpretive guidance for each regulation and citing deficiencies by tag # Is a cleaned dialysis machine considered a'clean' area? - VERIFIED ANSWER✔✔-No When should sharps containers be removed from the treatment floor? - VERIFIED ANSWER✔✔-When they are ¾ full State the 3 strategies recommended by KDOQI to decrease the risk of infection when working with a CVC - VERIFIED ANSWER✔✔-• Using facemasks when lumens or exit site is exposed

  • Wearing clean gloves and avoid touching exposed surfaces
  • Minimizing catheter lumen or exit sites from being exposed Who can use clean sinks for hand washing? - VERIFIED ANSWER✔✔-Teammates and patients What is the correct procedure in regards to your hands when you have casual contact with a patient? - VERIFIED ANSWER✔✔-No gloves but hand hygiene is required How can you tell when an area or sink is clean or dirty in your facility? - VERIFIED ANSWER✔✔-It is clearly labeled with a 'clean' or 'dirty' sign

What do surveyors use to verify infection control training and education has been completed for teammates? - VERIFIED ANSWER✔✔-Documentation of infection control training in the teammate's file or transcript Explain the HBV classification and state which test is performed monthly on HBV susceptible patients - VERIFIED ANSWER✔✔-• HBsAg: Hepatitis B surface Antigen - tested monthly for susceptible pts and non-responders

  • Anti-HBs: Hepatitis B Surface Antibody
  • Anti-HBcIgM: Hepatitis B Core AB-IGM Which patient care assignments are appropriate when caring for Hepatitis B patients? - VERIFIED ANSWER✔✔-• Caring for HBsAg positive and Hepatitis B immune patients at the same time
  • Caring for Hepatitis B susceptible patients and those in the process of receiving the vaccination at the same time
  • Caring for Hepatitis B immune and susceptible patients at the same time How often are machine alarm tests performed? - VERIFIED ANSWER✔✔-Before the initiation of each patient treatment How long can a dialyzer be set up for once recirculation is complete? - VERIFIED ANSWER✔✔-2 hours Why can't a dialyzer remain set up longer than the allotted time? - VERIFIED ANSWER✔✔-It can grow bacteria Manual Conductivity must match _____________________ on the Fresenius (FMC) 2008K and K dialysis delivery system displayed conductivity - VERIFIED ANSWER✔✔-+/- 0.4 mS True or False: Checking independent conductivity is NOT required when using the Fresenius 2008T or T BlueStar models or B Braun hemodialysis machines. - VERIFIED ANSWER✔✔-True What is the safe dialysate pH range? - VERIFIED ANSWER✔✔-Between 6.9 and 7.

What is "strikethrough" of an external pressure transducer and why is it of concern? - VERIFIED ANSWER✔✔-It is when fluid could have entered the machine and contaminated the internal pressure transducer protector providing a reservoir for microorganisms and causing subsequent patient blood infections Why is it important for patient care teammates to know when the water treatment system disinfection was performed? - VERIFIED ANSWER✔✔-Because the end-to-end disinfection process will also introduce the disinfectant solution to the dialysis delivery systems through their water inlet lines What are the key concepts related to "Reasonable & Prudent" Care? - VERIFIED ANSWER✔✔-• The Standard of Care is care which a reasonable and prudent nephrology nurse would give under the same or similar circumstances.

  • Actions a reasonable and prudent nephrology nurse would do, as well as actions the nurse would avoid doing
  • The skills and knowledge expected of a nephrology nurse is key to the specialty of nephrology nursing Who established the Standards of Care for Nephrology Nursing and for what purpose? - VERIFIED ANSWER✔✔-• American Nephrology Nurses Association (ANNA) establish the standards of care and scope of practice for Nephrology nursing
  • Standards of Care can serve as a basis for many areas including policy and procedures, protocols, educational offerings, regulatory systems, and more. What are three considerations when delegating nursing care activities? - VERIFIED ANSWER✔✔-• Must be within the nurses scope of practice • Must be delegable by State Board of Nursing • Personnel must be adequately trained to perform activity What role does DaVita's P&Pplay? - VERIFIED ANSWER✔✔-• Provides evidenced-based guidance
  • Meets CMS' Conditions for Coverage (CfC)
  • Complies with state & federal laws What are the risks of performing activities your way? - VERIFIED ANSWER✔✔-Not providing safe evidence-based care can lead to Civil Liability

What are the four reasons why we document in the medical record? - VERIFIED ANSWER✔✔-• Proof care was rendered

  • Provides data continuity
  • Communication tool
  • Permanent legal record List six occurrences when to document - VERIFIED ANSWER✔✔-• Baseline assessment
  • Change from baseline assessment
  • Change in patient's condition
  • Procedure or treatment
  • Medication given and patient response
  • Patient teaching What does SMART communication stand for? - VERIFIED ANSWER✔✔-S: Simple: keep message clear and simple M: Meaningful: think about what and why you are sending the message A: Actual: just report the facts R: Read: make sure you are sending the message you intend T: Teach: others about SMART communication What is the difference between data collection and assessment - who does what? - VERIFIED ANSWER✔✔-• Assessment-Nurse o Determining depth of edema o Rate, rhythm, quality of heart sounds o Respiration rate, rhythm, effort being put into breathing, identifying unusual lung sounds
    • Data Collection-PCT o Noting presence of edema

o Heart rate and rhythm o Respiration rate, rhythm, recognizing unusual breath sounds o Machine parameters, safety checks What is the role of the licensed nurse prior to treatment initiation? - VERIFIED ANSWER✔✔-Assess abnormal findings from data collection, determine appropriate interventions (based on physician orders) and contact physician if needed When is a pre-treatment assessment by the licensed nurse required? - VERIFIED ANSWER✔✔-• For a CKD hemodialysis patient: Based on State law (may be before tx initiation or within an hour of tx initiation) or if data collection has abnormal findings

  • For patients with AKI - a pre-treatment assessment is always required What is the role of the PCT prior to treatment initiation - VERIFIED ANSWER✔✔-Complete data collection and PCT must notify the RN if there are any abnormal findings prior to initiation of tx What are the appropriate times for documentation? PRE - VERIFIED ANSWER✔✔-• Pre-treatment safety checks: o Prior to treatment initiation
  • Pre-treatment patient data collection o Done pre-treatment /assessment: prior to treatment initiation if required by state law or within the first hour of dialysis treatment What are the appropriate times for documentation? DUR - VERIFIED ANSWER✔✔-• Observations during treatment o Document Assessment pre-treatment, continuous monitoring during treatment, as they occur What are the appropriate times for documentation? POST - VERIFIED ANSWER✔✔-Post treatment data collection/assessment o Must be done after treatment is complete - some of the things needed post tx: o Documentation of clearance of dialyzer after rinse back.

o Blood pressure o Heart rate o Temperature o Respiratory rate o Weight What are possible consequences of poor or incomplete documentation? - VERIFIED ANSWER✔✔-Entries may be discarded if unable to be read, can be left open to interpretation or attack on your care What policy should you refer to to document late entries - VERIFIED ANSWER✔✔-From Policy 3-02-02: Medical Record Preparation and Charting Guidance How do you document late entries - VERIFIED ANSWER✔✔-If unable to chart immediately after rendering a service or at the time of an observation, the teammate is to make the appropriate entry as soon as possible How do you document late electronic entries - VERIFIED ANSWER✔✔-If documenting within the electronic medical record, the notation will automatically contain your electronic signature, date and time How do you document late paper chart entries - VERIFIED ANSWER✔✔-o The late entry must be signed by the person making the late entry o The late entry must be timed and dated at the time it is entered

. How do you document charting errors? - VERIFIED ANSWER✔✔-When documenting on paper draw a single line through the entry, date/ signature/ teammate credentials, chart the correct information. If documenting in an electronic health record system follow facility procedure for that system. What is the preferred location for taking an accurate blood pressure? - VERIFIED ANSWER✔✔-Upper, non-vascular access arm

What BP reading error can be caused by a cuff that's too small - VERIFIED ANSWER✔✔-Reading may be higher than actual BP What BP reading error can be caused by a cuff that's too big - VERIFIED ANSWER✔✔-Reading may be lower than actual BP What is a normal pre-treatment blood pressure? - VERIFIED ANSWER✔✔-Systolic equal to or less than 180 mm/Hg or equal to or greater than 90 mm/Hg and diastolic less than 100 mm/Hg What is the normal heart rate range? - VERIFIED ANSWER✔✔-60-100 bpm What is the normal respiratory range? - VERIFIED ANSWER✔✔-12-16 breaths/minute What is a normal temperature? - VERIFIED ANSWER✔✔-Less than 100˚ Fahrenheit or 37.8˚ Celsius or less than 2˚F (1˚C) of baseline (pre-treatment temperature reading) The three words DaVita uses in order to easily recall the pre-treatment AVF/AVG access evaluation are: - VERIFIED ANSWER✔✔-'Look, Listen, Feel' When is post-treatment assessment by the licensed nurse required? - VERIFIED ANSWER✔✔-• If required by state law

  • If there were abnormal findings What are the 6 "W"s to be used when completing a REM? - VERIFIED ANSWER✔✔-• What
  • When
  • Where
  • Why
  • Witness
  • Who

What are the 3 things you should not include in a REM? - VERIFIED ANSWER✔✔-• Personal opinions

  • Speculation
  • Vendettas - Remember include only the facts!!! What is the target weight - VERIFIED ANSWER✔✔-TW is the physician prescribed weight post-dialysis that the patient can safely and reasonably achieve TW should be modified by the physician based on patient's tolerance, ongoing signs of fluid overload, and changes in fluid status What is target weight determined by? - VERIFIED ANSWER✔✔-Physician order How must the target weight be adjusted? - VERIFIED ANSWER✔✔-Must be adjusted in a timely manner so that the physician's most recent order is taken into account for each treatment. You may not adjust the TW retroactively. Interdialytic Weight Gain (IDWG)Calculation: - VERIFIED ANSWER✔✔-Pre-weight - Last post weight UF Goal Calculation: - VERIFIED ANSWER✔✔-Pre-weight
  • Target weight
  • NS prime & rinseback
  • Oral intake, infusions = UF Goal UFR Calculation: - VERIFIED ANSWER✔✔-UF Goal / Tx hours=UFR The maximum ultra-filtration (UF) rate should not exceed (unless ordered by the physician)? - VERIFIED ANSWER✔✔-13 mL/kg/hr What are the four consequences of sodium loading during dialysis? - VERIFIED ANSWER✔✔-• Increased thirst
  • Large fluid gains
  • More hypotension
  • and ischemic events during treatment State 3 ways we can contribute to sodium loading during dialysis - VERIFIED ANSWER✔✔-• Give broth
  • Normal saline, hypertonic saline
  • Increased sodium in dialysate (high setting in machine or sodium modeling) What are the consequences if a patient is consistently fluid overloaded (hypervolemia)? - VERIFIED ANSWER✔✔-LVH, increased CVP, hypertension, increased mortality, pulmonary edema, increased hospitalization rate What are the consequences and risks of hypovolemia/hypotension during the treatment? - VERIFIED ANSWER✔✔-Attempting to remove large amounts of fluid can lead to hypovolemia during tx which increases mortality, ischemia and damage to vital organs (organ stunning) - loss of residual kidney function What is the difference between an AVF and an AVG? - VERIFIED ANSWER✔✔-• AVF - connection of the patient's native artery to native vein
  • AVG - uses artificial or biological material & requires 2 connections What is the connection point called of the artery and vein for the creation of an AVF? - VERIFIED ANSWER✔✔-Anastomosis Describe the four AVF evaluations for maturation based on the KDOQI Rule of 6's. - VERIFIED ANSWER✔✔-• 600 ml flow through access (on Doppler)
  • 0.6 cm in depth under the skin
  • 0.6 cm diameter (width of pencil eraser)
  • 6-8 weeks post op maturation (some AVF will take longer- however notifying vascular surgeon is essential if access in not maturing)

Describe the teammate's cannulation level: beginner - VERIFIED ANSWER✔✔-Less than 6 months experience or less than 10 successful cannulations. Describe the teammate's cannulation level: intermediate - VERIFIED ANSWER✔✔-6 months experience cannulation of AVF & 10 successful cannulations Describe the teammate's cannulation level: advanced - VERIFIED ANSWER✔✔-Has completed all the competencies for NFACT training, expert cannulation skills documented and can determine if rule of 6's have been met What is the difference between a tunneled and a non-tunneled CVC? - VERIFIED ANSWER✔✔-• Tunneled CVC has a cuff that the skin grows to for anchoring to the patient - it is kept in place longer. Sutures used at placement- but can be removed after site healed.

  • Non-tunneled CVC (often referred to as temporary) are held in place by only sutures- no cuff present Once the heparin loading dose is administered, when can the hemodialysis treatment be initiated? - VERIFIED ANSWER✔✔-Minimum of 3-5 minutes after heparin administration Vascular Access steps: LOOK - VERIFIED ANSWER✔✔-Entire access from inflow back to the heart, observe for healing at sites, observe skin for cleanliness and intactness and drainage, new AVF for signs of maturation Vascular Access steps: LISTEN - VERIFIED ANSWER✔✔-for bruit- inflow stenosis (water hammer pulse) or outflow stenosis (whistling sound) Vascular Access steps: FEEL - VERIFIED ANSWER✔✔-Thrill (vibration) both AVF & AVG should be soft & compressible not hard and raised Definition of newly mature AVF - VERIFIED ANSWER✔✔-New fistula has post op surgical exam, meets the rules of 6's, can be cannulated by NFACT trained teammates Definition of mature AVF - VERIFIED ANSWER✔✔-Intermediate teammate can cannulate, AVF is at prescribed BFR matching needle gauge size

Definition of established AVF - VERIFIED ANSWER✔✔-Prescribed BFR and max needle size for 2 months Recommended needle gauge and max BFR for new AVF initial cannulation - VERIFIED ANSWER✔✔- 17 gauge & BFR not to exceed 250 ml/min Needle gauge and suggested BFR - VERIFIED ANSWER✔✔-17: 200- ml/min

  • 16: 250-350 ml/min
  • 15: 350-450 ml/min
  • 14: not to exceed 450 ml/min without physician prescription Use of one needle - VERIFIED ANSWER✔✔-Per physician order, used for arterial pull Use of tourniquet - VERIFIED ANSWER✔✔-Used to help engorge fistula and stabilize vessel for cannulation - it should not impede overall blood flow to limb and take care when using on individuals with compromised or thinner skin Evaluation of blood flow: - VERIFIED ANSWER✔✔-Thrill/bruit; look/listen/feel Site rotation / healing time - VERIFIED ANSWER✔✔-14 days- 'rope ladder method' rotation of sites needed to promote healing Needle insertion: - VERIFIED ANSWER✔✔-o AVF: 25 degrees o AVG: 45 degrees Flipping the needle / complications: - VERIFIED ANSWER✔✔-Flipping needles not necessary because arterial needle has back eye- flipping needles causes coring of access and can lead to increased bleeding and damage to access (scarring)

Distance from anastomosis: - VERIFIED ANSWER✔✔-1.5 inches Distance between needle tips: - VERIFIED ANSWER✔✔-1.5 inches Needle Removal - VERIFIED ANSWER✔✔-• Angle: same angle as insertion (also follow manufacturer recommendations)

  • When to apply pressure: when needle is completely removed
  • Use of clamps: Need physician order, one clamp at a time, and must verify blood flow
  • Use of hemostatic sponges: require order and must be removed prior to patient discharge BEST TIPS Complications and Prevention - VERIFIED ANSWER✔✔-B: Bleeding E: Erosion S: Stenosis T: Thrombosis I: Infection P: Pseudoaneurysm/aneurysms S: Steal syndrome PPE Requirements: - VERIFIED ANSWER✔✔-Gowns, gloves, face shield are required when drawing pre- dialysis labs through the VA needle; if CVC add mask to teammate and patient Successful lab draws: Familiarize yourself with the 20 tips (Job Aid) - VERIFIED ANSWER✔✔-No handwritten or double label - will be rejected and order of lab draw is important to follow because of additives in tubes that will affect other tubes Clotting time - VERIFIED ANSWER✔✔-Follow requisition label Rules for spinning samples - VERIFIED ANSWER✔✔-Follow requisition - must balance centrifuge When to refrigerate - VERIFIED ANSWER✔✔-Follow requisition (some are immediate and not spun)

When not to refrigerate - VERIFIED ANSWER✔✔-Culturettes/swabs/ occult stool - follow directions Training requirements for shipping - VERIFIED ANSWER✔✔-IATA What is the goal for Single Pool (spKt/V) for 3x/week frequency of dialysis treatments? - VERIFIED ANSWER✔✔-Greater than or equal to 1. What is 'K' in Kt/V? - VERIFIED ANSWER✔✔-Clearance of urea What treatment factors decrease K? - VERIFIED ANSWER✔✔--Inadequate coagulation, -decreased BFR, -poor priming, -not following P&P, -patient not staying on tx as prescribed What treatment factors increase K? - VERIFIED ANSWER✔✔--Increased BFR, -correct DFR, -correct dialyzer, -correct target weight -amputation factor What is the goal for the urea reduction ratio (URR) lab result? - VERIFIED ANSWER✔✔-Greater than or equal to 65% What is 't' in Kt/V? - VERIFIED ANSWER✔✔-Time of dialysis session What factors influence 't'? - VERIFIED 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' in Kt/V? - VERIFIED ANSWER✔✔-Volume of urea distribution/volume of pts body water in which urea is distributed What factors influence 'V'? - VERIFIED ANSWER✔✔--Amputation, -height, -sex, -age, -and type of access (less efficient access reduces the volume process of a patient's blood) Procedure for Post BUN lab draw - VERIFIED ANSWER✔✔-• Turn off UFR or decrease it to 50 ml/hr

  • Decrease DFR to 300 or put in bypass
  • Decrease BFR to 100 ml/min
  • Wait 15 secs for all access types and draw post Lab draws mistakes that would falsely increase Kt/V - VERIFIED ANSWER✔✔-• BFR not reduced
  • Waiting only 5 secs
  • Drawing post BUN from venous line Lab draws mistakes that would falsely decrease Kt/V - VERIFIED ANSWER✔✔-Accidently diluting pre tx arterial BUN blood sample with saline, waiting longer than 15 seconds to draw blood sample What 2 steps are preformed to replace fluid removed and prevent clotting during the recirculation of blood in the extracorporeal circuit when there has been a treatment interruption (i.e. the patient using the restroom)? - VERIFIED ANSWER✔✔-The saline infusion line is opened and if the patient is receiving an intradialytic heparin infusion via the dialysis machine, the heparin pump remains on. Pre-pump arterial pressure that becomes too negative can cause hemolysis. The arterial pressure may not exceed: - VERIFIED ANSWER✔✔--260 mmHg

A sudden decrease in blood pressure can be an indication that the patient is losing intravascular fluid too quickly, this can be seen with a change in blood pressure equal to or greater than: - VERIFIED ANSWER✔✔-20 mmHg What are the four meds PCTs can administer per DaVita P&P? - VERIFIED ANSWER✔✔-• Normal Saline

  • Heparin (if allowed per state regulations)
  • Lidocaine
  • Topical Anesthetic Spray What are the six items included in documenting administered medications? - VERIFIED ANSWER✔✔-• Time and date
  • Route of administration
  • Reason for giving
  • Medication dosage
  • Reason for Administering
  • Patient Response At what time are medications containing a preservative discarded? - VERIFIED ANSWER✔✔-28 days (except when the manufacturer specifies differently such as Epogen MDV at 21 days) What size needle with the appropriately sized syringe should be used when drawing up heparin? - VERIFIED ANSWER✔✔-21g x 1 inch What is the time frame during which single use medications should be prepared and administered? - VERIFIED ANSWER✔✔-4 hours (unless your state specifies another time limit) How do you verify your needle is not in the access when administering Lidocaine? - VERIFIED ANSWER✔✔-Aspiration (pull back) of syringe plunger How do you administer Topical Anesthetic Spray? - VERIFIED ANSWER✔✔-• Wash arm
  • Clean site per P&P
  • Spray for 4-10 seconds from a distance of 3-7 inches
  • Don't frost the skin - numbing effect occurs with blanching Why would the nephrologist order a formulary exception of Citrasate or CitraPure dialysate concentrate? - VERIFIED ANSWER✔✔-To use as part of anticoagulation therapy during the dialysis treatment when heparin is contraindicated. Regarding multi-dose medication vials: Labeling & Expiration: - VERIFIED ANSWER✔✔-Must be labeled with the initials of the person opening the vial and the date it was opened (must be discarded within 28 days except when the manufacturer specifies differently such as Epogen at 21 days) Regarding multi-dose medication vials: Needle/syringe/vial: - VERIFIED ANSWER✔✔-The vial may be entered more than once but requires a new sterile needle and syringe to puncture each medication vial to avoid pooling of medication from different vials. Regarding single-dose medication vials: - VERIFIED ANSWER✔✔-• Must be used for only one patient.
  • Each vial should only be entered once and then discarded.
  • The same syringe may be used to enter up to two single use vials of the same medication and concentration to constitute the prescribed patient dose What does TRAMP stand for? (Note there is often a 6th one-documentation - VERIFIED ANSWER✔✔-T: Time R: Route A: Amount M: Medication P: Patient What are the two reasons for water treatment? - VERIFIED ANSWER✔✔-• Prevent equipment damage
  • Patient safety

Aluminum in water used for dialysis causes - VERIFIED ANSWER✔✔-• Anemia • Bone disease • Nausea • Vomiting Chlorine in water used for hemodialysis causes - VERIFIED ANSWER✔✔-Hemolysis Excess calcium and sodium in water used for dialysis causes - VERIFIED ANSWER✔✔-Hypertension Excess calcium and magnesium in water used for dialysis causes - VERIFIED ANSWER✔✔-Muscle Weakness What does the RO remove? - VERIFIED ANSWER✔✔-Organic and inorganic materials, bacteria and endotoxins What are two concerns with using DI Tanks? - VERIFIED ANSWER✔✔-• Exhaust quickly

  • When exhausted they dump/release previously removed ions back into water Response to Final Water Quality Alarm - VERIFIED ANSWER✔✔-• Bypass
  • Notify Charge nurse/FA/Biomed/ Medical Director
  • If not restored must terminate treatments and complete REM Water/Dialysate culture results - VERIFIED ANSWER✔✔-• Acceptable level: below 50 cfu/ml
  • Action level: 50-99 cfu/ml
  • Unacceptable level: 100 cfu/ml or > Water endotoxin testing results - VERIFIED ANSWER✔✔-• Acceptable level: below 0.12 EU/ml
  • Action level: 0.12 to < 0.25 EU/ml
  • Unacceptable level: 0.25 EU or >

Dialysate endotoxin testing results - VERIFIED ANSWER✔✔-• Acceptable level: <0.25 EU/ml

  • Action level: 0.25 to < 0.50 EU/ml
  • Unacceptable level: 0.50 EU/ml or > How often are water and dialysate cultures drawn and monitored for bacteria and endotoxins? - VERIFIED ANSWER✔✔-Monthly What removes chlorine/chloramines? - VERIFIED ANSWER✔✔-Carbon Tanks WHEN: Chlorine/Chloramine testing - VERIFIED ANSWER✔✔-Always test while the RO is actively supplying water: After the RO has operated for at least 15 minutes, before the first shift of patients, and every 4 hours. WHERE: Chlorine/Chloramine testing - VERIFIED ANSWER✔✔-After Primary carbon tank sample port Acceptable result for chlorine/chloramine testing - VERIFIED ANSWER✔✔-0.1 mg/L or less Action if results are too high post primary tank for chlorine/chloramine testing - VERIFIED ANSWER✔✔- Repeat the test- if still too high - move onto secondary port and test, remember to notify biomed and FA F/U if secondary test results are within limits for chlorine/chloramine testing - VERIFIED ANSWER✔✔- Every 30 minutes F/U if secondary test results are too high for chlorine/chloramine testing - VERIFIED ANSWER✔✔-Stop dialysis by placing dialysis delivery system into bypass-do not rinse patients' blood back What is removed during hardness testing - VERIFIED ANSWER✔✔-Calcium and Magnesium Why is hardness testing important - VERIFIED ANSWER✔✔-For RO protection