MAC.DIALYSIS: June 2012

Saturday, 30 June 2012

Hand Hygiene Saves Lives

✅ Hand Hygiene Saves Lives – MCQs

1. What is the most effective way to prevent the spread of infections in healthcare settings?
A. Proper hand hygiene
B. Wearing gloves only
C. Using antibiotics routinely
D. Avoiding patient contact
➡️ Answer: A. Proper hand hygiene

2. According to WHO, how long should you rub your hands with alcohol-based hand rub to effectively clean them?
A. 20-30 seconds
B. 5 seconds
C. 1 minute
D. 10 seconds
➡️ Answer: A. 20-30 seconds

3. When should healthcare workers perform hand hygiene?
A. Before and after touching a patient
B. Only after touching bodily fluids
C. Only at the start of the shift
D. Only after removing gloves
➡️ Answer: A. Before and after touching a patient

4. What is the recommended method for hand hygiene if hands are visibly soiled?
A. Washing with soap and water
B. Alcohol-based hand rub
C. Using gloves only
D. Rinsing with water only
➡️ Answer: A. Washing with soap and water

5. Which of the following is NOT a common source of contamination in healthcare settings?
A. Healthcare workers’ hands
B. Clean linens
C. Medical equipment
D. Patient environment surfaces
➡️ Answer: B. Clean linens

6. Why is hand hygiene especially critical in hemodialysis units?
A. To prevent bloodstream infections and cross-contamination
B. To reduce needle pain
C. To improve dialysis adequacy
D. To decrease treatment time
➡️ Answer: A. To prevent bloodstream infections and cross-contamination

7. What is the minimum time recommended for handwashing with soap and water?
A. At least 40-60 seconds
B. 10 seconds
C. 5 minutes
D. 20 seconds
➡️ Answer: A. At least 40-60 seconds

8. What should be done after removing gloves to maintain hand hygiene?
A. Perform hand hygiene immediately
B. Wait until the end of the shift
C. Use hand lotion only
D. No action needed if gloves were used
➡️ Answer: A. Perform hand hygiene immediately

9. What is the key advantage of alcohol-based hand rubs over soap and water?
A. Faster and more effective at killing many pathogens if hands are not visibly soiled
B. Cheaper
C. Less effective but convenient
D. Removes dirt better than soap
➡️ Answer: A. Faster and more effective at killing many pathogens if hands are not visibly soiled

10. Which of the following can compromise hand hygiene effectiveness?
A. Wearing artificial nails or jewelry during patient care
B. Using alcohol-based hand rub correctly
C. Washing hands for 20 seconds
D. Using disposable gloves
➡️ Answer: A. Wearing artificial nails or jewelry during patient care

11. Which organization developed the “5 Moments for Hand Hygiene” concept?
A. World Health Organization (WHO)
B. Centers for Disease Control and Prevention (CDC)
C. Food and Drug Administration (FDA)
D. Occupational Safety and Health Administration (OSHA)
➡️ Answer: A. World Health Organization (WHO)

12. Which of the following is NOT one of the WHO’s “5 Moments for Hand Hygiene”?
A. Before touching a patient
B. After touching a patient
C. Before moving to a clean body site on the patient
D. Before eating lunch in the staff room
➡️ Answer: D. Before eating lunch in the staff room

13. What is the primary reason gloves do NOT replace hand hygiene?
A. Gloves can have micro-tears and hands can become contaminated during removal
B. Gloves kill all bacteria automatically
C. Gloves prevent all infections
D. Gloves are reusable
➡️ Answer: A. Gloves can have micro-tears and hands can become contaminated during removal

14. Which of the following hand hygiene practices is recommended after contact with patient surroundings?
A. Perform hand hygiene
B. Gloves only, no hand hygiene needed
C. Washing hands once a day
D. Use hand lotion only
➡️ Answer: A. Perform hand hygiene

15. What is a common barrier to proper hand hygiene compliance among healthcare workers?
A. Time constraints and skin irritation
B. Lack of knowledge about germs
C. No availability of gloves
D. No patient cooperation
➡️ Answer: A. Time constraints and skin irritation

16. How can healthcare facilities improve hand hygiene compliance?
A. Provide easy access to hand hygiene stations and regular training
B. Punish staff for non-compliance without education
C. Only provide soap without hand rubs
D. Limit use of gloves
➡️ Answer: A. Provide easy access to hand hygiene stations and regular training

17. When hands are NOT visibly soiled, what is the preferred hand hygiene method?
A. Alcohol-based hand rub
B. Soap and water washing
C. Use gloves only
D. No action needed
➡️ Answer: A. Alcohol-based hand rub

18. Which of the following can help prevent skin damage from frequent hand hygiene?
A. Using moisturizing lotions compatible with gloves
B. Avoiding hand hygiene
C. Using harsh soaps frequently
D. Wearing jewelry during hand hygiene
➡️ Answer: A. Using moisturizing lotions compatible with gloves

19. Hand hygiene compliance is especially important in which patient care area?
A. Dialysis units
B. Administrative offices
C. Hospital cafeterias
D. Parking lots
➡️ Answer: A. Dialysis units

20. Which is NOT an effective hand hygiene agent?
A. Plain water without soap
B. Alcohol-based hand rub
C. Antimicrobial soap
D. Chlorhexidine gluconate
➡️ Answer: A. Plain water without soap

21. Which of the following hand hygiene methods is most effective against Clostridium difficile spores?
A. Washing hands with soap and water
B. Alcohol-based hand rub
C. Using hand lotion
D. Wearing gloves without handwashing
➡️ Answer: A. Washing hands with soap and water

22. What is the minimum alcohol concentration recommended in hand sanitizers for effective microbial killing?
A. 60% to 95% alcohol
B. 20% alcohol
C. 40% alcohol
D. 10% alcohol
➡️ Answer: A. 60% to 95% alcohol

23. Which of the following is an important step after applying hand sanitizer?
A. Rub hands until dry
B. Rinse hands with water
C. Wipe hands on clothing
D. Wait 5 minutes before touching anything
➡️ Answer: A. Rub hands until dry

24. Which of the following is TRUE regarding hand hygiene compliance monitoring?
A. Direct observation is commonly used but can lead to the Hawthorne effect
B. Compliance cannot be monitored
C. Electronic monitoring is inaccurate
D. Compliance is not important to patient outcomes
➡️ Answer: A. Direct observation is commonly used but can lead to the Hawthorne effect

25. Which hand hygiene moment is crucial immediately after removal of gloves?
A. Perform hand hygiene immediately
B. Wait 10 minutes before washing hands
C. No need for hand hygiene after glove removal
D. Only perform hand hygiene if hands look dirty
➡️ Answer: A. Perform hand hygiene immediately

26. Which hand hygiene product is recommended if hands are visibly dirty or contaminated with proteinaceous material?
A. Soap and water
B. Alcohol-based hand rub
C. Hand lotion
D. Plain water
➡️ Answer: A. Soap and water

27. What should healthcare workers do if they experience skin irritation from frequent hand hygiene?
A. Use moisturizers compatible with hand hygiene products
B. Stop hand hygiene practices
C. Use harsh soap to clean skin better
D. Wear gloves at all times without hand hygiene
➡️ Answer: A. Use moisturizers compatible with hand hygiene products

28. Which of these is a key benefit of alcohol-based hand rubs over soap and water?
A. They are faster to use and less irritating to skin
B. They remove dirt better than soap
C. They require water for rinsing
D. They are less effective against most pathogens
➡️ Answer: A. They are faster to use and less irritating to skin

29. When should healthcare workers wash their hands with soap and water instead of using an alcohol-based hand rub?
A. When hands are visibly soiled or contaminated with spores
B. Before every patient contact
C. After every glove use regardless of contamination
D. Only at the end of a shift
➡️ Answer: A. When hands are visibly soiled or contaminated with spores

30. What is the best way to educate healthcare workers about hand hygiene?
A. Regular training sessions combined with reminders and feedback
B. Only initial training when hired
C. Written policies without education
D. Punishments for non-compliance only
➡️ Answer: A. Regular training sessions combined with reminders and feedback

31. Which hand hygiene step helps remove transient microorganisms most effectively?
A. Friction during handwashing or rubbing with sanitizer
B. Rinsing with water only
C. Drying hands with a towel only
D. Wearing gloves without hand hygiene
➡️ Answer: A. Friction during handwashing or rubbing with sanitizer

32. Why is hand drying important after handwashing?
A. Wet hands transfer germs more easily than dry hands
B. It helps preserve skin moisture
C. It removes soap residue
D. It is not important
➡️ Answer: A. Wet hands transfer germs more easily than dry hands

33. Which of the following is the least effective way to remove germs from hands?
A. Rinsing hands with plain water only
B. Handwashing with soap and water
C. Using alcohol-based hand rub
D. Scrubbing hands with soap and water for at least 20 seconds
➡️ Answer: A. Rinsing hands with plain water only

34. Which of these is NOT recommended during hand hygiene practices?
A. Wearing artificial nails
B. Using alcohol-based hand rub
C. Washing hands with soap and water when visibly soiled
D. Using moisturizer compatible with gloves
➡️ Answer: A. Wearing artificial nails

35. When performing hand hygiene, which surfaces must be cleaned thoroughly?
A. All hand surfaces including between fingers and under nails
B. Only the palms
C. Only the fingertips
D. Only the back of hands
➡️ Answer: A. All hand surfaces including between fingers and under nails

36. In the healthcare setting, when is the best time to perform hand hygiene?
A. Before and after patient contact, before aseptic tasks, after exposure to bodily fluids, and after contact with patient surroundings
B. Only at the start and end of shift
C. Only after touching bodily fluids
D. Only when hands look dirty
➡️ Answer: A. Before and after patient contact, before aseptic tasks, after exposure to bodily fluids, and after contact with patient surroundings

37. Which type of hand sanitizer is preferred in most healthcare settings?
A. Alcohol-based hand rub with 60%-95% alcohol content
B. Water-based hand gel
C. Lotion without alcohol
D. Plain water
➡️ Answer: A. Alcohol-based hand rub with 60%-95% alcohol content

38. What should be avoided to prevent interference with hand hygiene effectiveness?
A. Wearing rings, watches, and bracelets during patient care
B. Using hand sanitizer regularly
C. Frequent handwashing
D. Using gloves appropriately
➡️ Answer: A. Wearing rings, watches, and bracelets during patient care

39. What is the purpose of the “5 Moments for Hand Hygiene”?
A. To remind healthcare workers of key times to perform hand hygiene to reduce infections
B. To list all patient care tasks
C. To limit hand hygiene to 5 times a day
D. To specify when gloves should be used
➡️ Answer: A. To remind healthcare workers of key times to perform hand hygiene to reduce infections

40. Which of the following is NOT true about hand hygiene in dialysis units?
A. Hand hygiene is critical to prevent bloodstream infections in dialysis patients
B. Hand hygiene should be performed before touching the patient and dialysis equipment
C. Gloves alone can replace hand hygiene during dialysis
D. Hand hygiene facilities should be readily accessible in dialysis units
➡️ Answer: C. Gloves alone can replace hand hygiene during dialysis

41. Which is the primary goal of hand hygiene in healthcare settings?
A. To reduce transmission of healthcare-associated infections
B. To improve patient satisfaction scores
C. To shorten treatment times
D. To reduce healthcare costs only
➡️ Answer: A. To reduce transmission of healthcare-associated infections

42. Which of the following is true about the use of gloves in infection prevention?
A. Gloves do not replace the need for hand hygiene
B. Gloves can be worn for multiple patients without changing
C. Gloves sterilize hands
D. Gloves prevent all infections without hand hygiene
➡️ Answer: A. Gloves do not replace the need for hand hygiene

43. What should healthcare workers do if their hands are visibly soiled or contaminated?
A. Wash with soap and water before using hand rub
B. Use alcohol-based hand rub immediately
C. Wipe with a dry cloth
D. Wear gloves only
➡️ Answer: A. Wash with soap and water before using hand rub

44. Which of the following is recommended to maintain skin health in healthcare workers?
A. Use of compatible hand moisturizers regularly
B. Avoid hand hygiene to prevent dryness
C. Frequent use of harsh antiseptics
D. Wearing rings and bracelets to protect skin
➡️ Answer: A. Use of compatible hand moisturizers regularly

45. What is a key feature of effective hand hygiene agents?
A. Broad-spectrum antimicrobial activity
B. Pleasant scent only
C. Ability to clean hands without friction
D. Colorless and odorless only
➡️ Answer: A. Broad-spectrum antimicrobial activity

46. What action is recommended if hand hygiene products cause skin irritation?
A. Switch to a different compatible product and use moisturizers
B. Stop all hand hygiene temporarily
C. Use harsher soaps to clean skin better
D. Avoid gloves to reduce irritation
➡️ Answer: A. Switch to a different compatible product and use moisturizers

47. The “Five Moments for Hand Hygiene” includes which of the following?
A. Before aseptic task
B. Only at shift start
C. Only after glove removal
D. Once daily before lunch
➡️ Answer: A. Before aseptic task

48. What is the effect of poor hand hygiene compliance in healthcare?
A. Increased healthcare-associated infections and patient morbidity
B. Reduced healthcare costs
C. Decreased antibiotic resistance
D. Improved patient outcomes
➡️ Answer: A. Increased healthcare-associated infections and patient morbidity

49. Which of the following best describes the hand hygiene technique recommended by WHO?
A. Cover all hand surfaces and rub hands together until dry
B. Wash hands quickly for 5 seconds
C. Only clean palms and fingertips
D. Use gloves without hand hygiene
➡️ Answer: A. Cover all hand surfaces and rub hands together until dry

50. Which of the following is a recommended step to improve hand hygiene practices in a healthcare facility?
A. Regular training and audit with feedback
B. No enforcement or reminders
C. Only written policies without education
D. Limited access to hand hygiene supplies
➡️ Answer: A. Regular training and audit with feedback

Saturday, 23 June 2012

Buttonhole Cannulation--What do we know

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Buttonhole Cannulation – What Do We Know? (MCQs)

1. What is Buttonhole Cannulation?
A. A technique for peritoneal dialysis
B. A method for repeated cannulation at the same site in AV fistula
C. A type of vascular access surgery
D. A dialysis catheter placement method
✅ Correct answer: B

2. What is formed at the cannulation site during Buttonhole technique?
A. Thrombosis
B. Hematoma
C. Scar tissue
D. Epithelialized track (tunnel)
✅ Correct answer: D

3. What type of needle is used for cannulation in a mature Buttonhole track?
A. Blunt needle
B. Sharp needle
C. Butterfly needle
D. Central venous catheter
✅ Correct answer: A

4. Which of the following is an advantage of the Buttonhole technique?
A. Higher infection rate
B. Reduced pain during cannulation
C. Increased bleeding
D. Greater use of sharp needles
✅ Correct answer: B

5. During the track creation phase of Buttonhole cannulation, which type of needle is used?
A. Blunt needle
B. Catheter needle
C. Sharp needle
D. Arterial needle
✅ Correct answer: C

6. Which of the following patients is most suitable for Buttonhole technique?
A. Patients with AV graft
B. Patients with central line
C. Patients with newly created fistula
D. Patients with matured AV fistula with limited cannulation sites
✅ Correct answer: D

7. What is a key requirement to maintain a Buttonhole track?
A. Use different cannulators every time
B. Cannulate at random angles
C. Use of the same angle and depth consistently
D. Cannulate at a different site daily
✅ Correct answer: C

8. A potential complication of Buttonhole cannulation is:
A. Pneumothorax
B. Peritonitis
C. Localized infection or abscess
D. Cardiac tamponade
✅ Correct answer: C

9. Why is scab removal important before Buttonhole cannulation?
A. To reduce bleeding
B. To reduce infection risk and allow proper needle insertion
C. To promote scar formation
D. To avoid using blunt needles
✅ Correct answer: B

10. How often should the initial track (tunnel) be cannulated by the same person ideally?
A. Once only
B. By different staff for experience
C. By the same cannulator to maintain consistency
D. Randomly to avoid favoritism
✅ Correct answer: C

11. How many successful cannulations using a sharp needle are typically required to form a mature Buttonhole track?
A. 1–2 times
B. 3–5 times
C. 6–10 times
D. 15 times
✅ Correct answer: C

12. In Buttonhole cannulation, a key technique is to:
A. Rotate the needle to widen the tunnel
B. Insert the needle at a different angle each time
C. Maintain the same angle, direction, and depth
D. Use higher pressure to insert the needle faster
✅ Correct answer: C

13. The Buttonhole technique is NOT recommended in which of the following access types?
A. AV fistula
B. AV graft
C. Radiocephalic fistula
D. Brachiocephalic fistula
✅ Correct answer: B

14. Which factor is associated with a higher risk of infection in Buttonhole cannulation?
A. Daily use of antiseptic
B. Improper scab removal
C. Use of blunt needles
D. Rotating cannulation sites
✅ Correct answer: B

15. What is one of the most critical infection control practices before Buttonhole cannulation?
A. Soaking needles in alcohol
B. Applying a warm compress
C. Removing the scab using a sterile technique
D. Wiping with tissue paper
✅ Correct answer: C

16. Which of the following is a contraindication for Buttonhole technique?
A. Patient prefers self-cannulation
B. AV graft use
C. Mature fistula with limited sites
D. Stable AV fistula in use for over 6 months
✅ Correct answer: B

17. Which personnel are best to perform the initial Buttonhole track formation?
A. New trainees
B. Any rotating staff
C. Consistent, trained staff members
D. Patient only
✅ Correct answer: C

18. Which is a common misconception about Buttonhole technique?
A. It reduces pain
B. It decreases aneurysm formation
C. It increases needle dislodgement risk
D. It is suitable for all access types
✅ Correct answer: D

19. When cannulating a mature Buttonhole track, resistance is usually felt when:
A. The needle hits a valve
B. The needle is inserted too deep
C. The scab is not removed
D. The angle or direction is incorrect
✅ Correct answer: D

20. What is the primary goal of the Buttonhole technique in long-term dialysis patients?
A. Promote graft use
B. Reduce cost
C. Preserve access longevity and reduce trauma
D. Increase blood flow
✅ Correct answer: C

21. A patient using Buttonhole cannulation reports pain and swelling at the site. What should you suspect?
A. Proper cannulation
B. Track maturity
C. Local infection or abscess
D. Dehydration
✅ Correct answer: C

22. Which of the following is not a benefit of Buttonhole cannulation?
A. Easier self-cannulation
B. Reduced aneurysm formation
C. Reduced risk of local infection
D. Decreased infiltration
✅ Correct answer: C

23. One disadvantage of the Buttonhole technique is:
A. Inability to reuse needles
B. Increased rate of hematoma
C. Higher risk of infection if hygiene is poor
D. Need for general anesthesia
✅ Correct answer: C

24. What should be done immediately before cannulation with blunt needles in Buttonhole?
A. Massage the fistula
B. Apply alcohol swab only
C. Remove scab using sterile forceps or pick
D. Use heparin lock
✅ Correct answer: C

25. Why is consistent staff assignment important in Buttonhole cannulation?
A. Reduces salary cost
B. Ensures correct use of different tracks
C. Maintains consistency in angle, depth, and site
D. Avoids patient complaints
✅ Correct answer: C

26. During the healing phase of a Buttonhole track, what should NOT be done?
A. Keep using sharp needles
B. Allow the track to rest for a few days
C. Use blunt needles
D. Reinsert at the exact site and angle
✅ Correct answer: C

27. What is the minimum number of successful cannulations usually required to create a usable Buttonhole tunnel?
A. 2
B. 5
C. 6–10
D. 12–15
✅ Correct answer: C

28. Which of the following is true regarding blunt needles?
A. They are used to create new tunnels
B. They have a higher risk of infiltration
C. They are used only after tunnel formation
D. They are used in AV grafts
✅ Correct answer: C

29. Which infection prevention strategy is most critical with Buttonhole cannulation?
A. Rotating cannulation sites
B. Using antibiotics after dialysis
C. Strict aseptic technique and scab removal
D. Using only new gloves per shift
✅ Correct answer: C

30. Which patient education point is most essential for self-cannulating using Buttonhole technique?
A. Use new site every time
B. Use sharp needles always
C. Use same angle and depth every time
D. Alternate arms every week
✅ Correct answer: C

31. Which of the following is used to clean the Buttonhole site before scab removal?
A. Sterile water
B. Alcohol swab
C. Normal saline
D. Betadine or antiseptic solution (e.g., chlorhexidine)
✅ Correct answer: D

32. What is the risk if a non-mature track is cannulated with a blunt needle?
A. Aneurysm formation
B. Successful track formation
C. Bleeding and infiltration
D. Reduced infection risk
✅ Correct answer: C

33. During cannulation, you notice resistance at the usual angle. What is the correct action?
A. Apply force to insert the needle
B. Use a sharp needle to force entry
C. Withdraw and reassess angle and site
D. Push deeper
✅ Correct answer: C

34. How should scabs at the Buttonhole site be removed?
A. With gloved fingers
B. With sterile tweezers or pick under aseptic technique
C. With gauze soaked in alcohol
D. With water pressure
✅ Correct answer: B

35. Which of the following can help minimize pain during cannulation?
A. Using a larger gauge needle
B. Changing site frequently
C. Application of topical anesthetic (e.g., EMLA cream)
D. Using non-sterile gloves
✅ Correct answer: C

36. Which patient behavior increases risk of Buttonhole site infection?
A. Adherence to hand hygiene
B. Consistent cannulation technique
C. Touching scab or site with bare hands
D. Daily use of antiseptic
✅ Correct answer: C

37. What is the appropriate gauge size of blunt needles typically used for mature Buttonhole tracks?
A. 14G
B. 15G
C. 16G or 17G
D. 20G
✅ Correct answer: C

38. What should be done if a Buttonhole site becomes infected?
A. Continue using the same site
B. Skip dialysis
C. Stop using the site, start antibiotics, consider new site
D. Increase dialysate flow
✅ Correct answer: C

39. Buttonhole cannulation should ideally be done by:
A. Trainee staff only
B. The same few experienced cannulators
C. A different person daily
D. Patient relatives
✅ Correct answer: B

40. Why should cannulation be done at exact same angle each time in Buttonhole technique?
A. To make the tunnel wider
B. To reduce infection
C. To maintain the epithelial track and prevent trauma
D. To reduce the number of needles used
✅ Correct answer: C

41. Which of the following best describes the main difference between Buttonhole and rope-ladder cannulation techniques?
A. Buttonhole uses rotating sites; rope-ladder uses same site
B. Rope-ladder uses sharp needles only
C. Buttonhole uses same site, angle, and depth every time
D. Rope-ladder has higher infection risk
✅ Correct answer: C

42. The Buttonhole technique can help reduce which of the following complications?
A. Central line infections
B. Hemodialysis catheter blockage
C. Aneurysm and pseudoaneurysm formation in fistula
D. Hypertension
✅ Correct answer: C

43. What is the correct management if bleeding continues longer than usual after removing needles from Buttonhole site?
A. Re-cannulate immediately
B. Apply light pressure only
C. Apply firm pressure and monitor bleeding time
D. Leave site open
✅ Correct answer: C

44. Which of the following is true about epithelialization of Buttonhole tracks?
A. It refers to muscle thickening
B. It makes the tunnel softer
C. It forms a stable, scar-lined path for the needle
D. It prevents fistula maturation
✅ Correct answer: C

45. What does increased resistance or pain during blunt needle insertion into a Buttonhole site most likely indicate?
A. The tunnel is clear
B. A sharp needle is needed
C. Improper alignment with the track
D. The patient has low blood pressure
✅ Correct answer: C

46. If a Buttonhole site becomes too inflamed or infected, what is the next best step?
A. Ignore and proceed with cannulation
B. Switch to rope-ladder at same site
C. Stop using the site, allow healing, monitor and treat
D. Use a central venous catheter immediately
✅ Correct answer: C

47. Which of the following materials is preferred for scab removal before Buttonhole cannulation?
A. Cotton ball
B. Non-sterile gauze
C. Sterile pick or sterile forceps
D. Alcohol-soaked paper towel
✅ Correct answer: C

48. One reason some centers are cautious about using Buttonhole technique is:
A. Requires less staff
B. Lower blood flow rates
C. Risk of increased bloodstream infection if protocol is not followed
D. It’s more painful than sharp-needle cannulation
✅ Correct answer: C

49. How can facilities reduce infection rates in Buttonhole cannulation?
A. Avoid blunt needles
B. Switch to AV graft
C. Use strict antiseptic protocol, hand hygiene, and limit staff handling
D. Use warm compress before every dialysis
✅ Correct answer: C

50. What is the purpose of marking the Buttonhole site on the skin?
A. Cosmetic reasons
B. To reduce patient anxiety
C. To assist with consistent angle and location for cannulation
D. To show fistula location to new staff
✅ Correct answer: C

51. What is a primary reason for track loss in Buttonhole cannulation?
A. Using topical anesthetic
B. Daily use of blunt needles
C. Changing cannulation angle or depth
D. Applying antiseptic too early
✅ Correct answer: C

52. Which patient population may not be suitable for Buttonhole cannulation?
A. Pediatric patients with small fistulas
B. Adults with matured AVF
C. Patients performing home hemodialysis
D. Stable, long-term dialysis patients
✅ Correct answer: A

53. What is a recommended method to assess track readiness for blunt needle use?
A. Patient report of pain reduction
B. Formation of consistent scab
C. At least 6 successful sharp cannulations with same technique
D. Random attempt with blunt needle
✅ Correct answer: C

54. Buttonhole cannulation is especially helpful for patients who:
A. Require short-term access
B. Have poor hygiene practices
C. Need frequent catheter replacements
D. Have limited cannulation sites on the AVF
✅ Correct answer: D

55. Which step should immediately follow scab removal?
A. Apply gauze
B. Re-clean site with antiseptic
C. Start dialysis
D. Insert sharp needle
✅ Correct answer: B

56. If Buttonhole track is misaligned due to poor technique, what complication is most likely?
A. Hematuria
B. Thrombocytopenia
C. Infiltration and bruising
D. Seizures
✅ Correct answer: C

57. Which of the following statements is true regarding infection prevention in Buttonhole technique?
A. Scab removal can be skipped if the area looks clean
B. Hand hygiene is optional if gloves are worn
C. Antiseptic must be reapplied after scab removal
D. Patients should self-cannulate to prevent infection
✅ Correct answer: C

58. Why is it important to avoid “track switching” in Buttonhole sites?
A. It causes skin discoloration
B. It affects blood pressure
C. It may result in new tunnel formation or infiltration
D. It helps maintain symmetry
✅ Correct answer: C

59. A blunt needle should glide smoothly into a mature track. If resistance occurs, what’s the best step?
A. Force the needle
B. Ask another nurse to try
C. Withdraw, reassess angle, and reinsert gently
D. Switch to a larger gauge
✅ Correct answer: C

60. What is a best practice for tracking and maintaining Buttonhole cannulation quality?
A. Avoid documentation to reduce workload
B. Record cannulator, angle, depth, needle type daily
C. Rotate sites weekly to rest the area
D. Change antiseptic brand weekly
✅ Correct answer: B

Thursday, 14 June 2012

Hand Hygiene In Healthcare Settings

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Wednesday, 6 June 2012

Management Of Dialysis Complication

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✅ Management of Dialysis Complications – MCQs

1. What is the first step in managing intradialytic hypotension?
A. Increase ultrafiltration rate
B. Stop ultrafiltration and lay patient flat with legs elevated
C. Increase dialysate temperature
D. Administer intravenous calcium
➡️ Answer: B. Stop ultrafiltration and lay patient flat with legs elevated

2. Which medication is commonly used to treat muscle cramps during haemodialysis?
A. Intravenous calcium gluconate
B. Oral potassium
C. Intravenous magnesium sulfate
D. Intravenous sodium bicarbonate
➡️ Answer: A. Intravenous calcium gluconate

3. What is the appropriate action if a patient develops chest pain during dialysis?
A. Continue dialysis as usual
B. Stop dialysis immediately and assess for cardiac causes
C. Increase ultrafiltration rate
D. Ignore if mild pain
➡️ Answer: B. Stop dialysis immediately and assess for cardiac causes

4. What is the most common cause of dialysis-related fever?
A. Dialysis membrane reaction
B. Infection, such as catheter-related bloodstream infection
C. Fluid overload
D. Electrolyte imbalance
➡️ Answer: B. Infection, such as catheter-related bloodstream infection

5. How should dialysis disequilibrium syndrome be managed?
A. Increase dialysis duration and ultrafiltration rate
B. Slow dialysis rate and manage symptoms conservatively
C. Administer high doses of diuretics
D. Ignore symptoms and continue usual dialysis
➡️ Answer: B. Slow dialysis rate and manage symptoms conservatively

6. What is the first line treatment for hyperkalemia in a haemodialysis patient?
A. Immediate dialysis
B. Oral potassium supplements
C. Intravenous calcium gluconate and insulin with glucose
D. No treatment required
➡️ Answer: C. Intravenous calcium gluconate and insulin with glucose

7. How is an air embolism during haemodialysis best managed?
A. Place patient in Trendelenburg and left lateral decubitus position
B. Increase blood flow rate
C. Administer intravenous fluids rapidly
D. Ignore if no symptoms
➡️ Answer: A. Place patient in Trendelenburg and left lateral decubitus position

8. What is the management for severe hypotension unresponsive to initial treatment during dialysis?
A. Continue dialysis without changes
B. Discontinue dialysis and provide intravenous fluids and vasopressors if needed
C. Increase ultrafiltration rate
D. Administer oral antihypertensives
➡️ Answer: B. Discontinue dialysis and provide intravenous fluids and vasopressors if needed

9. What should be done if a patient develops signs of anaphylaxis during dialysis?
A. Continue dialysis and monitor closely
B. Stop dialysis immediately and administer intramuscular epinephrine
C. Increase dialysate sodium concentration
D. Administer oral antihistamines only
➡️ Answer: B. Stop dialysis immediately and administer intramuscular epinephrine

10. How is clotting in the dialysis circuit usually managed?
A. Increase blood flow rate
B. Administer anticoagulants such as heparin
C. Decrease ultrafiltration rate
D. Ignore if mild
➡️ Answer: B. Administer anticoagulants such as heparin

11. What is the recommended treatment for Dialysis Disequilibrium Syndrome (DDS)?
A. Increase blood flow rate rapidly
B. Shorten dialysis sessions
C. Slow or shorten dialysis and manage symptoms with anticonvulsants if needed
D. Ignore symptoms and continue as usual
➡️ Answer: C. Slow or shorten dialysis and manage symptoms with anticonvulsants if needed

12. During dialysis, a patient develops sudden shortness of breath and hypotension. What is the likely complication?
A. Dialysis disequilibrium syndrome
B. Air embolism
C. Muscle cramps
D. Fever
➡️ Answer: B. Air embolism

13. Which of the following is a common cause of intradialytic muscle cramps?
A. Hypokalemia
B. Excessive ultrafiltration leading to hypovolemia
C. Hypernatremia
D. Hypercalcemia
➡️ Answer: B. Excessive ultrafiltration leading to hypovolemia

14. What immediate action should be taken if a patient develops a seizure during dialysis?
A. Increase dialysate flow rate
B. Stop dialysis, protect airway, and manage seizure
C. Continue dialysis with slower blood flow
D. Administer oral sedatives and continue
➡️ Answer: B. Stop dialysis, protect airway, and manage seizure

15. How should hypotension during dialysis be prevented?
A. Rapid ultrafiltration rate
B. Monitor dry weight and adjust ultrafiltration accordingly
C. Use cold dialysate always
D. Increase dialysate sodium concentration drastically
➡️ Answer: B. Monitor dry weight and adjust ultrafiltration accordingly

16. What is the most effective way to manage access site bleeding during dialysis?
A. Apply firm pressure over the site
B. Increase blood flow rate
C. Use anticoagulants immediately
D. Ignore if minor bleeding
➡️ Answer: A. Apply firm pressure over the site

17. If a patient experiences a dialysis reaction with fever and chills, what should be the initial step?
A. Stop dialysis and assess for infection or reaction
B. Continue dialysis and give antipyretics
C. Increase ultrafiltration rate
D. Administer antihypertensives
➡️ Answer: A. Stop dialysis and assess for infection or reaction

18. What electrolyte abnormality is commonly corrected by haemodialysis?
A. Hyperkalemia
B. Hypernatremia
C. Hypocalcemia
D. Hyponatremia
➡️ Answer: A. Hyperkalemia

19. What is the best approach to managing dialysis-associated hypotension refractory to fluids?
A. Use vasopressor support and review dialysis prescription
B. Increase ultrafiltration rate
C. Discontinue dialysis permanently
D. No intervention required
➡️ Answer: A. Use vasopressor support and review dialysis prescription

20. How should dialyzer clotting during dialysis be prevented?
A. Maintain adequate anticoagulation with heparin or alternatives
B. Reduce blood flow rate only
C. Increase ultrafiltration rate
D. No prevention needed
➡️ Answer: A. Maintain adequate anticoagulation with heparin or alternatives

21. What is the first step when a patient experiences severe hypotension during dialysis?
A. Increase ultrafiltration rate
B. Stop ultrafiltration and lay patient flat with legs elevated
C. Administer intravenous antibiotics
D. Increase dialysate temperature
➡️ Answer: B. Stop ultrafiltration and lay patient flat with legs elevated

22. Which of the following is a common cause of fever during dialysis?
A. Dialysis membrane reaction
B. Catheter-related bloodstream infection
C. Electrolyte imbalance
D. Dialysis disequilibrium syndrome
➡️ Answer: B. Catheter-related bloodstream infection

23. How is dialysis-related muscle cramping best managed?
A. Decrease ultrafiltration rate and provide supportive care
B. Increase ultrafiltration rate
C. Administer intravenous potassium
D. Increase dialysate sodium
➡️ Answer: A. Decrease ultrafiltration rate and provide supportive care

24. What is the immediate management of suspected air embolism during dialysis?
A. Place patient in Trendelenburg and left lateral decubitus position
B. Increase blood flow rate
C. Increase ultrafiltration
D. Administer intravenous calcium
➡️ Answer: A. Place patient in Trendelenburg and left lateral decubitus position

25. What complication should be suspected if a patient develops chills and fever midway during dialysis?
A. Hypotension
B. Dialysis reaction or infection
C. Muscle cramps
D. Air embolism
➡️ Answer: B. Dialysis reaction or infection

26. Which intervention is critical when managing severe bleeding from the vascular access site?
A. Apply direct pressure immediately
B. Increase blood flow rate
C. Remove vascular access
D. Administer anticoagulants
➡️ Answer: A. Apply direct pressure immediately

27. How can dialysis disequilibrium syndrome be prevented?
A. Use high-efficiency dialysis from the start
B. Initiate dialysis slowly with shorter and lower blood flow sessions
C. Increase ultrafiltration rate quickly
D. Ignore and continue dialysis as usual
➡️ Answer: B. Initiate dialysis slowly with shorter and lower blood flow sessions

28. What is the typical cause of hypotension during dialysis?
A. Fluid overload
B. Excessive ultrafiltration causing hypovolemia
C. Hyperkalemia
D. Infection
➡️ Answer: B. Excessive ultrafiltration causing hypovolemia

29. What is the best way to manage dialyzer clotting?
A. Ensure adequate anticoagulation during dialysis
B. Increase ultrafiltration rate
C. Reduce blood flow rate
D. Stop dialysis immediately
➡️ Answer: A. Ensure adequate anticoagulation during dialysis

30. What should be done if a patient develops chest pain and shortness of breath during dialysis?
A. Continue dialysis and observe
B. Stop dialysis and evaluate for cardiac or pulmonary complications
C. Increase dialysate sodium concentration
D. Administer oral analgesics and continue
➡️ Answer: B. Stop dialysis and evaluate for cardiac or pulmonary complications

31. Which electrolyte imbalance is a common cause of cardiac arrhythmias during dialysis?
A. Hypokalemia
B. Hyperkalemia
C. Hypocalcemia
D. Hypernatremia
➡️ Answer: B. Hyperkalemia

32. What is the recommended action if a patient develops dialysis access thrombosis?
A. Increase ultrafiltration rate
B. Immediate referral for vascular surgery or interventional radiology
C. Stop dialysis permanently
D. Continue dialysis without intervention
➡️ Answer: B. Immediate referral for vascular surgery or interventional radiology

33. Which complication is characterized by sudden hypotension, chest pain, and respiratory distress during dialysis?
A. Dialysis disequilibrium syndrome
B. Air embolism
C. Muscle cramps
D. Infection
➡️ Answer: B. Air embolism

34. How should intradialytic hypertension be managed?
A. Decrease ultrafiltration rate
B. Review dry weight and adjust antihypertensive medications
C. Ignore if asymptomatic
D. Increase dialysate sodium concentration
➡️ Answer: B. Review dry weight and adjust antihypertensive medications

35. What is a common cause of dialysis-related fever without chills?
A. Dialysis membrane reaction
B. Bacterial infection
C. Hypotension
D. Air embolism
➡️ Answer: A. Dialysis membrane reaction

36. How can dialysis access infection be prevented?
A. Proper aseptic technique during cannulation
B. Reuse of catheters without sterilization
C. Ignoring skin disinfection
D. Sharing dialysis machines between patients
➡️ Answer: A. Proper aseptic technique during cannulation

37. What is the appropriate management of hypotension due to excessive ultrafiltration?
A. Increase fluid removal
B. Stop or reduce ultrafiltration and provide fluid replacement if necessary
C. Ignore and continue dialysis
D. Increase blood flow rate
➡️ Answer: B. Stop or reduce ultrafiltration and provide fluid replacement if necessary

38. What complication might arise from rapid changes in plasma osmolality during dialysis?
A. Dialysis disequilibrium syndrome
B. Hypotension
C. Muscle cramps
D. Access infection
➡️ Answer: A. Dialysis disequilibrium syndrome

39. What is the treatment for suspected anaphylactic reaction during dialysis?
A. Administer epinephrine immediately and stop dialysis
B. Continue dialysis and observe
C. Administer antihypertensives
D. Increase ultrafiltration rate
➡️ Answer: A. Administer epinephrine immediately and stop dialysis

40. What is the best preventive measure against clotting in the dialysis circuit?
A. Regular anticoagulation with heparin or alternatives
B. Increase dialysate temperature
C. Decrease blood flow rate
D. Ignore minor clotting
➡️ Answer: A. Regular anticoagulation with heparin or alternatives

41. What is the initial management step for a patient who develops severe chest pain and hypotension during dialysis?
A. Continue dialysis and monitor
B. Stop dialysis, assess airway and circulation, and prepare for emergency treatment
C. Increase ultrafiltration rate
D. Administer oral painkillers and continue
➡️ Answer: B. Stop dialysis, assess airway and circulation, and prepare for emergency treatment

42. Which complication is suggested by the presence of blood leaking from the dialysis machine circuit?
A. Dialyzer clotting
B. Circuit disconnection or rupture
C. Access infection
D. Dialysis disequilibrium syndrome
➡️ Answer: B. Circuit disconnection or rupture

43. How should hypotension unresponsive to fluids be managed during dialysis?
A. Increase ultrafiltration
B. Use vasopressors and reassess dialysis prescription
C. Ignore and continue dialysis
D. Decrease blood flow rate only
➡️ Answer: B. Use vasopressors and reassess dialysis prescription

44. What is the recommended treatment if a patient has severe allergic reaction to the dialyzer?
A. Continue dialysis with same dialyzer
B. Stop dialysis immediately and provide supportive treatment including antihistamines and steroids
C. Increase dialysate sodium
D. Ignore and continue
➡️ Answer: B. Stop dialysis immediately and provide supportive treatment including antihistamines and steroids

45. What is a common cause of muscle cramps during haemodialysis?
A. Hypovolemia due to excessive ultrafiltration
B. Hyperkalemia
C. Hypercalcemia
D. Infection
➡️ Answer: A. Hypovolemia due to excessive ultrafiltration

46. What is the MOH recommended action if total chlorine levels in dialysis water exceed limits?
A. Continue dialysis with caution
B. Stop dialysis until water treatment is corrected
C. Dilute water with untreated water
D. Ignore if patient is asymptomatic
➡️ Answer: B. Stop dialysis until water treatment is corrected

47. How should bleeding from a vascular access site be managed during dialysis?
A. Apply direct pressure and consult vascular team if needed
B. Increase anticoagulation
C. Continue dialysis as usual
D. Remove vascular access immediately
➡️ Answer: A. Apply direct pressure and consult vascular team if needed

48. What is the main treatment for hyperkalemia in an acute dialysis setting?
A. Immediate dialysis combined with medical treatment like calcium gluconate and insulin/glucose
B. Increase potassium intake
C. Decrease dialysis duration
D. Ignore if asymptomatic
➡️ Answer: A. Immediate dialysis combined with medical treatment like calcium gluconate and insulin/glucose

49. What is the primary cause of dialysis disequilibrium syndrome?
A. Rapid removal of urea and solutes causing cerebral edema
B. Infection
C. Excessive ultrafiltration
D. Electrolyte imbalance
➡️ Answer: A. Rapid removal of urea and solutes causing cerebral edema

50. Which of the following is a key preventive measure for infection in haemodialysis patients?
A. Routine hand hygiene and aseptic technique during access manipulation
B. Sharing equipment between patients without cleaning
C. Avoiding vaccination
D. Ignoring early signs of infection
➡️ Answer: A. Routine hand hygiene and aseptic technique during access manipulation

51. What is the recommended initial management for a patient experiencing severe muscle cramps during dialysis?
A. Increase ultrafiltration rate
B. Decrease or stop ultrafiltration and stretch the affected muscles
C. Administer intravenous potassium
D. Increase dialysate sodium
➡️ Answer: B. Decrease or stop ultrafiltration and stretch the affected muscles

52. Which of the following is an indication of air embolism during dialysis?
A. Sudden hypotension, dyspnea, and chest pain
B. Gradual onset fever
C. Muscle cramps
D. Gradual rise in blood pressure
➡️ Answer: A. Sudden hypotension, dyspnea, and chest pain

53. How should an anaphylactic reaction to dialysis membrane be treated?
A. Administer intramuscular epinephrine and stop dialysis
B. Continue dialysis and monitor
C. Administer oral antihistamines only
D. Increase dialysate temperature
➡️ Answer: A. Administer intramuscular epinephrine and stop dialysis

54. What is the first action if a dialysis patient develops sudden hypotension and loss of consciousness?
A. Continue dialysis
B. Stop dialysis, secure airway, and initiate resuscitation
C. Increase ultrafiltration
D. Administer oral fluids
➡️ Answer: B. Stop dialysis, secure airway, and initiate resuscitation

55. Which of the following can cause dialysis-related fever?
A. Bloodstream infection
B. Allergic reaction to dialyzer membrane
C. Both A and B
D. None of the above
➡️ Answer: C. Both A and B

56. What is the best way to prevent vascular access infections?
A. Routine hand hygiene and aseptic cannulation technique
B. Use same needle for multiple patients
C. Ignore skin antisepsis
D. Delay catheter replacement indefinitely
➡️ Answer: A. Routine hand hygiene and aseptic cannulation technique

57. How should hypotension during dialysis be prevented?
A. Avoid excessive ultrafiltration and monitor patient’s dry weight closely
B. Use rapid fluid removal
C. Increase dialysate sodium concentration indiscriminately
D. Ignore symptoms and continue dialysis
➡️ Answer: A. Avoid excessive ultrafiltration and monitor patient’s dry weight closely

58. What complication is associated with rapid reduction in serum osmolality during dialysis?
A. Dialysis disequilibrium syndrome
B. Muscle cramps
C. Access thrombosis
D. Infection
➡️ Answer: A. Dialysis disequilibrium syndrome

59. Which intervention is appropriate for management of clotting in the dialysis circuit?
A. Increase anticoagulation dosing
B. Reduce blood flow rate only
C. Stop dialysis permanently
D. Ignore minor clotting
➡️ Answer: A. Increase anticoagulation dosing

60. What is the appropriate treatment for access site bleeding during dialysis?
A. Apply direct pressure and hold until bleeding stops
B. Increase anticoagulation
C. Continue dialysis without intervention
D. Remove access immediately
➡️ Answer: A. Apply direct pressure and hold until bleeding stops

61. What is the common cause of chest pain during haemodialysis?
A. Myocardial ischemia due to hypotension
B. Muscle cramps
C. Electrolyte imbalance only
D. Air embolism only
➡️ Answer: A. Myocardial ischemia due to hypotension

62. What is the main cause of intradialytic hypotension?
A. Excessive ultrafiltration causing hypovolemia
B. Hyperkalemia
C. Hypercalcemia
D. Infection
➡️ Answer: A. Excessive ultrafiltration causing hypovolemia

63. How is dialysis-related muscle cramps best prevented?
A. Avoid rapid fluid removal and maintain adequate hydration
B. Increase dialysate potassium
C. Decrease dialysate sodium
D. Increase ultrafiltration rate
➡️ Answer: A. Avoid rapid fluid removal and maintain adequate hydration

64. What is the immediate treatment for anaphylactic reaction during dialysis?
A. Stop dialysis and administer intramuscular epinephrine
B. Continue dialysis with antihistamines
C. Increase dialysate sodium concentration
D. Administer oral corticosteroids only
➡️ Answer: A. Stop dialysis and administer intramuscular epinephrine

65. Which complication can be caused by rapid removal of urea during dialysis?
A. Dialysis disequilibrium syndrome
B. Infection
C. Access thrombosis
D. Muscle cramps
➡️ Answer: A. Dialysis disequilibrium syndrome

66. What is the appropriate response to access site bleeding during dialysis?
A. Apply firm pressure and monitor
B. Increase anticoagulation
C. Continue dialysis without intervention
D. Remove the access immediately
➡️ Answer: A. Apply firm pressure and monitor

67. What is a typical sign of dialysis-associated infection?
A. Fever and chills during or after dialysis
B. Hypotension only
C. Muscle cramps
D. Hypertension
➡️ Answer: A. Fever and chills during or after dialysis

68. What is the recommended management of air embolism during haemodialysis?
A. Place patient in Trendelenburg and left lateral decubitus position
B. Increase ultrafiltration
C. Continue dialysis as usual
D. Administer oral fluids
➡️ Answer: A. Place patient in Trendelenburg and left lateral decubitus position

69. What is a preventive strategy for dialysis disequilibrium syndrome?
A. Initiate dialysis with low blood and dialysate flow rates
B. Use high-efficiency dialysis immediately
C. Increase ultrafiltration rate
D. Ignore symptoms
➡️ Answer: A. Initiate dialysis with low blood and dialysate flow rates

70. Which of the following is the most effective way to prevent infection in dialysis patients?
A. Proper hand hygiene and aseptic technique
B. Reuse needles between patients
C. Avoid vaccination
D. Ignore early signs of infection
➡️ Answer: A. Proper hand hygiene and aseptic technique

71. Which electrolyte disturbance is most commonly corrected by dialysis?
A. Hyperkalemia
B. Hyponatremia
C. Hypocalcemia
D. Hypermagnesemia
➡️ Answer: A. Hyperkalemia

72. What is the first step when a patient develops sudden shortness of breath and chest pain during dialysis?
A. Stop dialysis and assess for complications such as air embolism or myocardial ischemia
B. Continue dialysis and monitor
C. Increase dialysate temperature
D. Administer intravenous calcium
➡️ Answer: A. Stop dialysis and assess for complications such as air embolism or myocardial ischemia

73. Which condition is characterized by rapid onset of fever, chills, and hypotension during dialysis?
A. Dialysis reaction (pyrogenic reaction)
B. Muscle cramps
C. Hypotension due to ultrafiltration
D. Dialysis disequilibrium syndrome
➡️ Answer: A. Dialysis reaction (pyrogenic reaction)

74. What is the most effective way to prevent vascular access thrombosis?
A. Regular monitoring and anticoagulation as appropriate
B. Avoid dialysis altogether
C. Increase ultrafiltration rate
D. Use high dialysate sodium concentration
➡️ Answer: A. Regular monitoring and anticoagulation as appropriate

75. Which complication is best managed by slowing dialysis blood flow rate and duration?
A. Dialysis disequilibrium syndrome
B. Access thrombosis
C. Infection
D. Muscle cramps
➡️ Answer: A. Dialysis disequilibrium syndrome

76. What is the best initial treatment for muscle cramps during dialysis?
A. Decrease ultrafiltration rate and stretch muscles
B. Increase blood flow rate
C. Increase dialysate potassium
D. Administer oral potassium supplements
➡️ Answer: A. Decrease ultrafiltration rate and stretch muscles

77. What should be done if the dialysis circuit becomes clotted?
A. Administer anticoagulants and assess dialysis prescription
B. Ignore and continue dialysis
C. Increase ultrafiltration rate
D. Stop dialysis permanently
➡️ Answer: A. Administer anticoagulants and assess dialysis prescription

78. Which of the following is the initial treatment of anaphylaxis during dialysis?
A. Administer intramuscular epinephrine and stop dialysis
B. Continue dialysis and monitor symptoms
C. Administer oral antihistamines only
D. Increase dialysate sodium concentration
➡️ Answer: A. Administer intramuscular epinephrine and stop dialysis

79. What is the cause of dialysis disequilibrium syndrome?
A. Rapid removal of urea causing cerebral edema
B. Infection
C. Excessive ultrafiltration
D. Air embolism
➡️ Answer: A. Rapid removal of urea causing cerebral edema

80. How can infection risk be minimized in dialysis patients?
A. Strict hand hygiene, aseptic technique, and vaccination
B. Sharing dialysis equipment between patients
C. Avoiding vaccinations
D. Ignoring minor infections
➡️ Answer: A. Strict hand hygiene, aseptic technique, and vaccination

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