Carol Rauen, rn-bc, ms, ccrn, pccn, cen, the department editor, is an independent clinical nurse specialist from St Augustine, Florida. She wrote the CCRN review questions. Carol welcomes feedback from readers and practice questions from potential contributors at rauen.carol104@gmail.com.RAUENSara Knippa, rn, ms, cns, ccrn, pccn, accns-ag, the department co-editor, is clinical nurse specialist/educator in the cardiac intensive care unit at University of Colorado Hospital. Sara co-wrote the CCRN review questions.KNIPPAMary Beth Flynn Makic, rn, phd, cns, ccns, is an associate professor at the University of Colorado College of Nursing, Anschutz Medical Campus, Aurora, Colorado. She wrote the PCCN questions.MAKICNavigating the 7 Cs of certified practice1 is difficult even with fair winds and clear skies. Competence, critical thinking, collaboration, consultation, communication, continuity, and compassion are challenging even in healthy work environments with strong teams. It takes an additional boost of courage to step to the helm, take the wheel of one’s professional practice, and achieve certification. The hallmark of a strong clinical nurse is to be courageous rather than compliant.A diagnosis of pancreatitis, like many gastrointestinal (GI) disorders, is primarily made with laboratory results. Because the low calcium, potassium, and magnesium levels common in pancreatitis occur in so many disorders, these levels are not a sensitive indicator. Elevations of amylase and lipase are more specific to the pancreas and increase rapidly with pancreatitis. During times of inflammation, the pancreas releases less insulin so the serum glucose level tends to be elevated.Monitoring and surveillance of indwelling urinary catheter use revealed that more catheters were inserted and stayed in longer than was clinically necessary, negatively affecting quality patient care and safety. The Centers for Disease Control and Prevention (CDC) guidelines on catheter-associated urinary tract infections (CAUTIs) outline evidence-based recommendations for the safe use of catheters. It is not catheter use that is an issue for insurance companies and the Centers for Medicare and Medicaid Services (CMS) (A), it is the CAUTI. Research studies have shown several practices that might decrease complications of urinary catheter use (B), but have not found that the catheter use causes more harm than good. The length of time a catheter is in place may increase the incidence of postuse incontinence (D), but is the not the primary reason use has decreased recently in the ICU.When information exists that the patient’s injuries might be intentional, the ICU nurse should complete the assessment and share the conversation and results of the assessment with the team. Documenting the conversation (A) does not guarantee the team is aware of the situation in a timely fashion. Restraining the patient (B) without more information would be inappropriate. Communicating with the team (C) is important, but there will be more to communicate once the assessment is completed.Diabetes insipidus can be neurogenic, when the pituitary does not release enough antidiuretic hormone (ADH), or nephrogenic, when the kidneys do not respond to ADH and continue to release water. In both cases the patient releases an excess of water causing severe dehydration. The serum sodium and osmolarity are high so hypotonic fluids, not isotonic or hypertonic (B) fluids, would be indicated. Dialysis (C) is not indicated in DI because the kidneys are working but not regulating water loss appropriately. Intranasal ADH might be administered in neurogenic DI (D) but would not be indicated in nephrogenic DI, in which ADH is available, but the target organ is not responding appropriately to it.The blood gas assessment reveals the patient is hyperoxygenating and hyperventilating. The 22 spontaneous breaths will receive the entire set TV of 450 mL in an AC mode. The patient is not hyperventilating because of hypoxia because the Pao2 is high. The patient should be assessed for anxiety or pain and treated accordingly. Hyperoxygenation can be treated by lowering the Fio2, which needs to be done to avoid oxygen toxicity complications. The patient might be extubated (A) soon, but the assessment data list does not allow readiness to be determined. Decreasing the TV (C) would help some-what with the hyperventilation and the antianxiety agent might also help treating the cause (if anxiety is the cause and not pain), but would not help treat the hyper-oxygenation. Increasing the mandatory breaths (D) could make the hyperventilation worse and does not treat the hyperoxygenation.Adequate hydration and volume expansion are the key interventions to reduce the risk for CI-AKI. A minimum of 500 mL intravenous fluid should be infused before a patient is exposed to contrast media. Hydration during and after (B) the procedure is also important but not more important than preprocedure hydration. NPO status (C) is only necessary if sedation will be required as part of the procedure; but in the event of NPO status, intravenous hydration is essential to prevent risks for CI-AKI. Sodium bicarbonate infusion (D) may be prescribed, but it should be initiated before the procedure and continued for 6 hours after the procedure is completed.Symptoms of alcohol withdrawal are associated with abrupt withdrawal of alcohol, a sedating agent, which results in unopposed autonomic hyperactivity. Sedation with benzodiazepine agents (B), specifically rapid-acting benzodiazepines such as diazepam, lorazepam, and alprazolam, is considered the first-line therapy in the treatment of acute alcohol withdrawal syndrome (AWS). The goal is to treat the patient’s withdrawal symptoms to avoid progression to delirium tremens. Opioid analgesics such as fentanyl (A) will not address the unopposed receptors in the brain that are reacting to the lack of alcohol. Metoprolol (C) may be prescribed to affect hypertension associated with worsening withdrawal cardiovascular reactions, but not to alleviate the other symptoms caused by autonomic hyperactivity associated with AWS. Phenytoin (D) may be prescribed if seizures develop but will not treat all of the symptoms seen in patients with AWS.The core of all ethical patient decisions has to do with the concept of autonomy. When patients are unable to make decisions for their care and exercise autonomy, surrogates make these decisions. It is best for the surrogate decision maker to have legal documents such as advanced directives or living wills to guide decisions that represent the patient’s preferences. If those documents are absent, the surrogate is asked to make the decision based on his or her understanding of the patient and what the patient would decide for herself if she were able (C). Referring the patient to the physician (A) is not assisting the surrogate in thinking about the patient’s wishes. Inviting a hospital ethicist (B) and discussing with siblings (D) may assist the surrogate in decision making but the same question will be asked about understanding the patient’s wishes. The best action is to ask the surrogate what information is known about the patient’s health care wishes to guide decisions.In the absence of patient ability to self-report pain, behavior scales/assessment tools should guide nurses’ assessment of pain. Facial grimacing is often a behavioral sign associated with discomfort and pain. Vital signs should never be used as the sole indicator of pain because research has consistently found that vital signs alone do not accurately reflect response to pain sensation. Vital signs should be considered cues to begin further pain assessment and to avoid potential adverse effects of untreated pain. Pain frequently stimulates a sympathetic response increasing the BP, HR, and RR.It can be difficult to identify sepsis in patients with cirrhosis. However, when an infection such as pneumonia presents a risk and the patient demonstrates signs of sepsis, change in mentation, tachycardia, and hypotension (quick Sepsis-Related Organ Failure Assessment [qSOFA] score), the nurse should anticipate implementing the sepsis bundle. Priorities in the first 3 hours of suspected sepsis include restoring tissue perfusion with intravenous fluid (A), obtaining blood cultures followed by antibiotics (B) after fluid resuscitation, and possibly measuring the serum lactate level (C) to assess the patient’s response to intravenous fluids. Dynamic assessments such as passive leg raise are recommended to monitor the patient’s response to intravenous fluid challenge rather than measuring hourly urinary output (D).
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Sep 2, 2023
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