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Davita practice exam
Practice Exam
| Question | Answer |
|---|---|
| Ultrafiltration: | Fluid pushed through the semipermeable membrane (SPM) |
| Convection: | Solutes dragged across SPM along with fluid |
| Diffusion: | Particles move from an area of high concentration to low concentration |
| Osmosis: | Fluid moves from an area of low concentration to high concentration |
| What are the kidneys' excretory functions? | To normalize electrolytes, remove wastes, provide fluid and acid base balance. |
| How do we replace normal excretory kidney functions? | By normalizing electrolytes through the use of acid concentrate and providing fluid balance through ultrafiltration. |
| What is the function of acid concentrate? | Provides the concentration gradient for diffusion to take place and helps normalize electrolytes |
| What is the function of bicarbonate? In the Dialysate solution? | Buffers the acid concentrate |
| What is the function of bicarbonate? When it diffuses into the patient's blood? | Normalizes body pH |
| Signs and symptoms of: Hyperkalemia: | >5.5 mEq Symptoms: extreme muscle weakness, abnormal heart rhythm, and possible cardiac arrest |
| Signs and symptoms of: Hypokalemia: | <3.5 mEq Symptoms: extreme muscle weakness, paralysis, and respiratory failure, cardiac instability, arrythmias, cardiac arrest |
| Normal blood pH range is? | 7.35 - 7.45 |
| What are the kidneys' endocrine functions? | Renin secretion, Erythropoietin secretion, Vitamin D activation |
| How do we replace normal endocrine kidney functinos? | Provide medications |
| How much of normal kidney function is replaced by hemodialysis? | 15% |
| What is uremia and how does it affect the body? | Uremia is buildup of wastes in the blood due to kidney failure and affects all body systems. |
| What are the most common causes of CKD in the USA? | Diabetes, Hypertension, Polycystic Kidney Disease |
| Outline the treatment goals for a patient with CKD: | Slowing the progression of CKD, Managing comorbidities and complications, Controlling symptoms, Minimizing the effects of CKD on patients' lifestyles, Kidney replacement therapy modality education, Encouraging patients to actively participate in healthcar |
| Why it is important to know what caused your patient's CKD? | So the nurse and PCT can inquire about possible problems during data collection and assessment |
| Signs & Symptoms of fluid imablance | Hypertension, Edema, Shortness of Breath |
| Why is sodium balance important? | This leads to volume expansion, increased cardiac output, increased peripheral vascular resistance, and increased blood pressure. |
| Systemic effects of CKD-what would you advise for a patient who complains of: Dry, itchy skin: | Use hyper-fatted soaps and lotions |
| Systemic effects of CKD-what would you advise for patient who complains of: Peripheral Neuropathy (nerve pain in the extremities): | Monitor patient for changes in motor function, decreased strength in legs, complaints of restless legs, burning feet. Advise patients not to walk barefoot, have good foot care practices. |
| Systemic effects of CDK-what would you advise for patient who complains of: GI problems (i.e. nausea/vomiting): | Inform RN & physician of any bleeding problems/constipation/diarrhea/ER visits, take medications as ordered... i.e.... stool softeners/Imodium |
| Systemic effects of CDK-what would you advise for patient who complains of: Psychological Problems (i.e. anxiety/depression): | Verbalize struggles to IDT (core team) especially the social worker |
| What is a consequence of prolonged fluid overload and hyertension? | Left Ventricular Hypertrophy |
| What is pericarditis? | Inflammation of the membrane (Pericardial Sac) Surrounding the heart |
| What is the treatment for pericarditis? | Decrease or stop heparin, more frequent dialysis |
| What is a common cause of hypertension in dialysis patients? | Fluid overload |
| Left Ventricular Hypertrophy leads to: | Ischemic heart disease, arrhythmia, myocardial infarction, and sudden death |
| Why are dialysis patients anemic? Red Blood Cells in patients with end-stage kidney disease have a shorter life span than healthy people. The life span of a red blood cell is 60 days for a patient with ESKD or approximately 1/2 of normal 120 days. | Primary cause: Lack of the hormone erythropoietin (EPO) Secondary causes: Inadequate Iron stores, inadequate dialysis, malnutrition, blood loss during treatment |
| What can you do to avoid contributing to lower hemoglobin and blood loss in dialysis patients? | Verify correct Erythropoietin Stimulating Agent does is administered, rinse back until venous line is pink tinged, and avoid repeat lab draws |
| What are the four key elements contributing to CKD-Mineral Bone Disorder? | Calcium, Phosphorus, PTH, Vitamin D (Calcitriol)- All lead to CKD-MBD when they are abnormal |
| What are symptoms of CKD-MBD in addition to bone disease? | Soft tissue calcification, itching, muscle weakness, pathological fractures, tendon ruptures, compression of vertebrae, atherosclerosis, heart disease |
| What is your role in CKD-MBD Management? | Report symptoms, urge patients to take medications (home and incenter) Report problems related to nonadherence |
| Define the term AKI | Term incorporates a wide spectrum of kidney issues, Includes acute kidney failure as well as less catastrophic kidney function changes, May dialyze in an out-patient facility until kidney function recovers |
| Give 3 examples of pre- causes of AKI | Pre: Obstruction, Volume Depletion, Impaired Cardiac Function-decreased cardiac output |
| Give 3 examples of intra- causes of AKI | Intra: Ischemic ATN, Sepsis, Acute Interstitial Nephritis, Septic Shock, Anaphylaxis, Drugs, Goodpasture Syndrome, Acute Glomerulonephritis, Trauma, Open Heart Surgery |
| Give 3 examples of post-renal causes of AKI | Post: Obstruction, Bladder Rupture, Pregnancy |
| Explain the difference between AKI and CKD | 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) |
| Outline the treatment goals for a patient with AKI dialyzing in the out patient facility: How do you help in restoring kidney function? | Find the cause of the AKI |
| Outline the treatment goals for a patient with AKI dialyzing in the out-patient facility: What do you need to consider in regard to their vascular access? | Patients will typically have a dialysis catheter, be careful to avoid catheter related infections |
| Outline the treatment goals for a patient with AKI dialyzing in the out-patient facility: How do you protect kidneys from further injury? | 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? | Keep a little extra fluid on the patient 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? | Hypovolemia and hypotension |
| What is the difference between OSHA and CMS infection control requirements? | 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? | 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 # |
| Explain the acceptable hand hygiene technique when caring for a patient with active Clostridioides difficile infection (C diff): | Handwashing with soap and water per policy is the only acceptable hand hygiene |
| What is the most common infectious complication in hemodialysis patients? | Bacterial vascular access infections are the most frequent infectious complication |
| What organism causes the most common infections in hemodialysis patients? | Methicillin-resistant Staphylococcus aureus (MRSA) - Must pay attention to infection control. Proper hand hygiene, cleaning and disinfecting procedures to prevent the spread of infection (viable on surfaces for days) |
| What is the importance of wearing gloves? | Reduces the risk of hand contamination and prevents the transfer of organisms already on hands to a patient |
| Why do you need to perform hand hygiene before and after wearing gloves? | Gloves are not impervious and have microscopic pores |
| Who can use clean sinks for hand washing? | Teammates and patients |
| Is a cleaned dialysis machine considered a 'clean' area? | No |
| How can you tell when an area or sink is clean or dirty in your facility? | It is clearly labeled with a 'clean' or 'dirty' sign |
| What is "strikethrough" of an external pressure transducer and why is it of concern? | 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 |
| When should sharps containers be removed from the treatment floor? | When they are 3/4 full |
| Explain the HBV classification and state which test is performed monthly on HBV susceptible patients. | HBsAg: Hepatitis B surface Antigen-tested monthly for susceptible pts and non-responders HBsAb (anti-HBs): Hepatitis B Surface Antibody HBcAb (anti-HBc): Hepatitis B Core Antibody |
| How do surveyors verify teammates have completed infection control training and education? | Documentation of infection control training in the teammate's file or transcript |
| Which patient care assignments are appropriate when caring for Hepatitis B patients? | Caring for HBsAg positive and Hep B immune patients at the same time Caring for Hep B susceptible patients and those in the process of receiving the vaccination at the same time Caring for Hep B immune and susceptible patients at the same time |
| State the 3 strategies recommended to decrease the risk of infection when working with CVC. | 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 |
| What is the most common transmission route for HAIs? | Contact transmission |
| What is the reason that dialysis patients are at increased risk for acquiring a HAI at the facility? | Chronic Kidney Disease patients are immunosuppressed and more vulnerable to infection. Infection is the second most common cause of death in dialysis patients. |
| What contributes to hemodialysis patients being placed at increased risk for acquiring an HAI at the facility? | Kidney failure weakens the immune system, making patients more vulnerable to infection. Dialysis patients often have multiple comorbid conditions that further compromise the immune system. The dialysis procedure requires prolonged access to the patient's |
| What is the correct procedure for your hands when you have casual contact with a patient? | Gloves are unnecessary for casual social contact, but hand hygiene is required after every direct contact with a patient and between patient contacts, even if the contact is casual. |
| What is the most important intervention to prevent HAIs? | Performing hand hygiene |
| What is the total proportion of dialysate used at DaVita?(Mixture of specific proportions of acid, bicarbonate, and dialysis quality water) | 45x |
| What are the two most frequent physician prescribed potassium strengths of dialysate concentrate used at DaVita? | 2.0 K+ and 3.0 K+ |
| Which part of the kidney functions similarly to the dialyzer's semi-permeable membrane to provide filtration and removal of fluids and toxins? | Glomerulus |
| What are the two waste products removed by dialysis that are monitored with monthly labs? | Blood Urea Nitrogen (BUN) and Creatinine |
| What is the safe dialysate pH range? | Between 6.9 and 7.6 |
| How often are dialysis machine alarm tests performed? | Before the initiation of each patient treatment |
| Why is it important for patient care teammates to know when the water treatment system disinfection was performed? | Because the end-to-end disinfection process will also introduce the disinfectant solution to the dialysis deliver systems through their water inlet lines |
| Following recirculation, how long can a dialyzer and blood lines be set up? | 6 hours |
| Why are the dialyzer and blood lines not used for a dialysis treatment once recirculating for longer than six hours? | Because of the potential for bacterial growth |
| What is the correct procedure for residual bleach testing after the chemical disinfection of loops and equipment fluid pathways? | Residual bleach testing should be performed after bleach disinfection and prior to equipment use |
| Who established the Standards of Care for Nephrology Nursing and for what purpose? | 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 |
| What are three considerations when delegating nursing care activities? | Must be within the nurse's scope of practice Must be delegable by State Board of Nursing Personnel must be adequately trained to perform the activity |
| What role does DaVita's P&P play? | Provides evidenced-based guidance Meets CMS' Conditions for Coverage (CfC) Complies with state & federal laws |
| What are the risks of performing activities your way? | Not providing safe evidence-based care can lead to Civil Liability |
| What are the four reasons that we document in the medical record? | Proof that care was rendered Provides data continuity Communication tool Permanent legal record |
| List six occurrences when to document: | Change from baseline assessment Change in patient's condition Procedure performed or treatment provided Medication given and patient response Patient teaching Care plan review and interventions |
| What does SMART communication stand for? | S: Simple: Keep message clear & 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 are the possible consequences of not using SMART communication? | Exposes you and DaVita to liability Reputational injury Jeopardizes the recipient Potentially career threatening |
| How do you document late entries? | If unable to chart immediately after rending 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 entries? Electronic: | If documenting within the electronic medical record, the notation will automatically contain your electronic signature, date and time |
| How do you document late entries? Paper Chart: | The late entry must be signed by the person making the late entry The late entry must be timed and dated at the time it is entered |
| How do you document charting errors? | 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 procedure for that sytem. |
| What is the difference between data collection and assessment and who is responsible for each? Assesslment-Nurse: | Determining the depth of edema Heart rate, rhythm, quality of heart sounds Respiration rate, rhythm, effort being put into breathing, identifying unusual lung sounds |
| What is the difference between data collection and assessment and who is responsible for each? Data Collection-PCT: | Noting presence of edema Counting the patient's heart rate Respiration rate, recognizing unusual breath sounds Machine parameters, safety checks |
| What is the role of the licensed nurse prior to treatment initiation? | 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? For a CKD hemodialysis patient: | Based on state law (may be before treatment initiation or within an h our of treatment initiation) or if data collection has abnormal finidings |
| What is a pre-treatment assessment by the licensed nurse required? For patients with AK: | a pre-treatment assessment is ALWAYS required |
| What is the role of the PCT prior to treatment initiation? | Complete data collection and PCT must notify the RN if there are any abnormal findings prior to initiation of treatment |
| What are the appropriate times for documentation? Pre-treatment safety checks: | Prior to treatment initiation |
| What are the appropriate times for documentation? Pre-treatment patient data collection: | Completed 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? Observations during treatment: | Document Assessment pre-treatment, continuous monitoring during treatment, as they occur |
| What are the appropriate times for documentation? Post treatment data collection/assessment: | Must be done after treatment is complete-some of the things needed post treatment: Documentation of clearance of dialyzer after rinse back. Blood pressure. Heart Rate. Temperature. Respiratory rate. Weight |
| What is the preferred location for taking a blood pressure? | Upper, non-vascular access arm |
| What BP reading error can be caused by an incorrect cuff size? | Cuff to small, reading may be higher than actual bp Cuff too large, reading may be lower than actual bp |
| What is a normal pre-treatment blood presure? | Systolic equal to or less than 180 mm/Hg or equal to or greater than or equal to 90 mm/Hg and Diastolic less than 100mm/Hg or greater than or equal to 50 mm/Hg |
| What is the normal heart rate range? | 60-100 beats/minute |
| What is the normal respiratory range? | 12-20 breaths/minute |
| What is a normal temperature? | Less than 100 degrees Fahrenheit or 37.8 Celsius or less than 2 F of baseline (pre-treatment temperature reading) |
| The three words DaVita uses to easily recall the pre-treatment AVF/AVG access evaluation are: | LOOK LISTEN FEEL |
| When is post-treatment assessment by the licensed nurse required? | If required by state law If there were abnormal findings |
| What are the 6 "W"s to be used when completing a REM? | What When Where Why Witness Who |
| What are the 3 things you should not include in a REM? | Personal opinions Speculation or Theories Vendettas-Remember to include only the facts! |
| Target Weight: | is determined by physician order |
| The maximum ultra-filtration rate should not exceed (unless ordered by the physician)? | 13 mL/kg/hr |
| Interdialytic Weight Gain (IDWG) Calculation: | Pre-weight-(minus) Last post weight |
| UF Goal Calculation: | Pre-weight -Target weight +NS prime & rinseback +Oral intake, Infusions -UF Goal |
| UFR Calculation: | UF Goal/Tx hours=UFR |
| What are the four consequences of sodium loading during dialysis? | Increased thirst Large fluid gains More hypotension Ischemic events during the hemodialysis treatment |
| State 3 ways we can contribute to sodium during dialysis: | Giving patient broth Administering 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)? | LVH, increased Central Venous Pressure (CVP), hypertension, increased mortality, pulmonary edema, increased hospitalization rate |
| What are the consequences and risks of hypovolemia/hypotension during the treatment? | Attempting to remove large amounts of fluid can lead to hypovolemia during the treatment which increases mortality, ischemia and damage to vital organs (organ stunning) including the loss of residual kidney function |
| What is the difference between an arteriovenous fistula (AVF) and an arteriovenous graft (AVG)? | AVF- Connection of the patient's native artery to native vein AVG- Uses artificial or biological material & requires 2 connections |
| What is the point where an artery and vein are connected to create an AVF? | The anastomosis |
| Describe the four AVF evaluations for maturation based on the KDOQI Rule of 6's: | >600 ml flow through access <0.6 cm in depth under the skin >o.6 cm diameter 6-8 weeks post op maturation (some AVF will take longer-however notifying vascular surgeon is essential if access is not maturing) |
| What is the difference between a tunneled and a non-tunneled CVC? | Tunneled CVC has a cuff that the skin grows for anchoring to the patient- it is kept in a place longer, Sutures used at placement-but can be removed after site healed. Non tunneled CVC, temp. held in place by sutures only-no cuff present |
| Describe the teammate's cannulation level based on Cannulator Competency Classifications. Beginner Cannulator: | Less than 6 months experience and less than 10 successful cannulations on established vascular accesses. |
| Describe the teammate's cannulation level based on Cannulator Competency Classifications: Proficient Cannulator: | Greater than 6 months experience and cannulation of greater than 10 successful cannulations |
| Describe the teammate's cannulation level based on Cannulator Competency Classifications: Expert Cannulator: | Experienced and skilled teammate. Has completed all the Expert Cannulation Program training, expert cannulation skills documented. |
| Needle insertion for AVF: | 25 degrees |
| Needle insertion for AVG: | 45 degrees |
| Site rotation/healing time is: | 14 days-'rope ladder method' rotation of sites needed to promote healing |
| Flipping the needle/ complications: | Flipping needles is 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). Not a recommended practice. |
| Distance from anastomosis: | 1.5 inches |
| Distance between needle tips: | 1.5 inches |
| Use of clamps: | Require a physician order. Use ONLY ONE clamp at a time. |
| Use of hemostatic sponges: | require order and must be removed prior to patient discharge |
| What is the goal for Single Pool (spKt/V) for 3x/week frequency of dialysis treatments? | Greater than or equal to 1.2 |
| What is 'K'? | Clearance of urea |
| What treatment factors decrease K? | Inadequate coagulation, decreased BFR, poor priming, not following P&P, patient not staying on treatment as prescribed, |
| What treatment factors increase K? | Increased BFR, Correct DFR, Correct dialyzer, correct target weight-amputation factor |
| What is the goal for the urea reduction ratio (URR) lab result? | Greater than or equal to 65% |
| What is 't'? | Time of dialysis session |
| What factors influence 't'? | Running prescribed treatment time, follow physician orders-encourage patient to run entire treatment. Getting off early will impact time |
| What is 'V'? | Volume of urea distribution/volume of pts body water in which urea is distributed |
| What factors influence 'V'? | Amputations, height sex, age, and type of access |
| Procedure for Post BUN lab draw: | Verify that dialysis has been initiated for approximately 30 mins with blood flow rate set as prescribed Turn off UFR or decrease it to 50ml/hr Decrease DFR to 300 or put in bypass Decrease BFR to 100 ml/min Wait 15 secs for all access types and draw |
| Lab draw mistakes that would falsely increase Kt/V: | BFR not reduced Waiting only 5 secs Drawing post BUN from venous line |
| Lab draw mistakes that would falsely decrease Kt/V | Accidently diluting pre-treatment arterial BUN blood sample with saline, waiting longer than 15 seconds to draw blood sample |
| Regarding multi-dose medication vials: Labeling & Expiration: | Must be labeled with the initials of person opening the vial and the date it was opened (must be discarded within 28 days after opening except when the manufacturer specifies differently such as Epogen at 21 days) |
| Regarding multi-dose medication vials: Needle/syringe/vial: | 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: | 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 singe use vials of the same medication and concentration to constitute the prescribed patient dose |
| What are the six rights of medication administration? | Time Route Amount Medication Patient Documentation |
| What are the four medications that PCTs can administer per DaVita P&P? | Normal Saline (o,9% Sodium Chloride) Heparin 1000u/mL (if allowed per state regulations) Lidocaine (1% intradermal) Topical Anesthetic Spray |
| At what time are medications containing a preservative discarded? | 28 days except when the manufacturer specifies differently such as Epogen multidose vial (MDV) at 21 days) |
| What size needle with the appropriately sized syringe should be used when drawing up 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 the dialysis treatment when heparin is contraindicated |
| How do you verify your needle is not in the access when administering Lidocaine? | Aspiration (pull back) of syringe plunger and you do not see blood in the syringe |
| How do you administer Topical Anesthetic Spray? | Wash access site Clean site per P&P Spray topical anesthetic to reach cannulation site for 4-10 seconds from a distance of 3-7 inches. The skin will begin to turn white. Don't frost the skin-numbing effect occurs with blanching |
| What is the time frame during which single use medications should be prepared and administered? | Within 4 hours |
| What are the six items included in documenting administered medications? | Time and date Route of administration Reason for giving Medication dosage Reason for administering Patient response |
Created by:
Villaneday