Sara Knippa, MS, RN, ACCNS-AG, CCRN, PCCN, is the content advisor of the column. Sara is a clinical nurse specialist/educator in the cardiac intensive care unit at University of Colorado Hospital, Aurora, Colorado. She welcomes feedback from readers and practice questions from potential contributors at sara.knippa.cns@gmail.com. Sara wrote the introduction.KNIPPAKristin Sollars, MSN, RN, CCRN-K, and Marci Ebberts, MSN, RN, CCRN-K, are clinical education specialists at Saint Luke’s Hospital, Kansas City, Missouri. Marci and Kristin wrote the adult CCRN practice questions.SOLLARSEBBERTSKatherine M. Sabin, DNP, APRN, AGACNP-BC, CCRN, is a cardiology nurse practitioner fellow at Mayo Clinic Arizona, Phoenix, Arizona. Katherine wrote the CMC practice questions.SABINThis holiday season I am reflecting on the gift of being mentored and what a gift it is to mentor others. These 2 types of mentoring are happening in my life at the same time. I feel like I am the middle link in a chain of mentorship: I am being pushed and encouraged by a few wise women and I am also paying it forward by helping others step into opportunities that are new for them. I call it double mentoring.For me, it started with someone offering to mentor me on a small evidence-based practice project in my unit. After I grew comfortable with the process, I supported a more novice nurse doing another project while I was being encouraged to take the next step to present my project outcomes. The mentorship chain continued to grow from there!Even a brand-new nurse can mentor a student or someone considering nursing as a career. I encourage you to consider, in this season of giving, looking for someone to provide you with mentorship and someone you can mentor.Members of the lesbian, gay, bisexual, transgender, and queer community are at risk for health disparities. Critical care nurses should always provide sensitive and culturally competent care. Using a patient’s preferred pronouns demonstrates respectful communication. Making assumptions about the patient’s relationships (A) should be avoided. Name changes are common among transgender persons and asking, “Could your medical record be under another name?” conveys less judgment than referring to the given name as the “real” name (B). Using patients’ preferred terms to describe them demonstrates respect (D).Prone positioning may improve oxygenation and reduce ventilator-induced lung injury but can be quite challenging to perform. All of these preparatory actions may be appropriate, but the greatest risk is dislodgment of the endotracheal tube, so securement needs to be the highest priority. Patients generally mobilize excessive oral secretions when first positioned prone, but this is not a threat to the airway because the drainage flows away from the mouth (B). Preventing pressure injuries (C) is a serious consideration but not the highest priority. Although studies have shown the best outcomes when prone positioning is paired with neuromuscular blockade, neuromuscular blockade (D) may not always be necessary with prone positioning.Amniotic fluid embolism is the mobilization of amniotic fluid and fetal debris into the maternal systemic circulation during or just after delivery. It most often causes hemodynamic collapse and disseminated intravascular coagulopathy. Eclampsia is another obstetrical emergency characterized by seizures in women with preeclampsia/gestational hypertension (A). Maternal sepsis is a concern for patients who develop hypotension after delivery but would most likely be accompanied by hypothermia or hyperthermia (B). HELLP syndrome is another serious obstetric condition. Although the low platelet count does align with this diagnosis, HELLP syndrome most commonly resolves with delivery (D).Vascular complications such as hematomas and pseudoaneurysms are the most common postprocedural complications of transcatheter aortic valve replacement. Large-bore sheaths are used to deliver the new valve through peripheral vessels that may be atherosclerotic. Pulmonary edema (A) is not a common complication; although these cases may be lengthy, patients are not likely to have volume overload. Acute kidney injury is possible with transcatheter aortic valve replacement but is relatively rare, with a 2.5% overall risk (C). Heart tones will change following the implantation of a new valve, but a pansystolic murmur is unlikely (D).Haloperidol is a psychotropic medication that may prolong the QT interval, which could lead to the lethal arrhythmia torsades de pointes. Low serum potassium level (A) may also contribute to an irregular cardiac rhythm, but given this patient’s presentation, it is not a likely cause. Haloperidol may lower the seizure threshold (C), but in this situation the risk for arrhythmias is greater given the new onset of premature ventricular contractions. Oral haloperidol (D) has less effect on the QTc and is usually safe at therapeutic doses, so this option may also be a consideration, but the immediate best action is to calculate the current QTc.Patients with constrictive pericarditis often have chronic symptoms that develop over months to years. Venous pressure is elevated, a Kussmaul sign (in which venous pressure fails to decrease with inspiration) is present, and blood pressure is typically normal. A pericardial knock is often present. Patients with restrictive cardiomyopathy (A) will typically have increased arterial blood pressure with additional signs and symptoms of heart failure in the absence of cardiomegaly, and a pericardial knock would not be expected. Signs of hypertrophic cardiomyopathy (B) include an enlarged cardiac silhouette and a displaced apical pulse, and chest pain and shortness of breath are experienced only with activity. Cardiac tamponade (C) will often present with acute chest pain, not chronic chest pain. In cardiac tamponade, the Kussmaul sign is rare, a pericardial knock would not be present, and the patient would have muffled heart sounds.The best option to treat hypotension in a patient with cardiogenic shock is to discontinue the nitroprusside (a vasodilator). Nitroprusside has a short half-life, so the hypotension should resolve quickly if the medication is discontinued. Titrating down the dobutamine (B), a positive inotrope, may cause further hypotension. Increasing the dose of norepinephrine (C), a vasopressor with positive inotropy, may be useful but the nitroprusside should be discontinued first. Giving fluids (D) may help increase blood pressure in many situations, but in cardiogenic shock the cause of hypotension is not hypovolemia.Patients should have uninterrupted anticoagulation for 3 weeks before cardioversion and 4 weeks after cardioversion. If a patient has not received continuous anticoagulation for 3 weeks before cardioversion, a transesophageal echocardiogram is recommended to rule out left atrial thrombus. Continuing with the scheduled cardioversion (A) would not be appropriate because the patient is at greater risk of stroke. Canceling the cardioversion and rescheduling it for a different day (B) would be appropriate if the option to obtain a transesophageal echocardiogram was unavailable. Initiating a heparin infusion and then immediately proceeding with a cardioversion (C) would not ensure that the patient has adequate anticoagulation and would put the patient at greater risk for complications.A patient who has had a heart transplant is at risk for developing infective endocarditis because of being immunocompromised. A patient with a congenital bicuspid heart valve (A) is not at increased risk for developing infective endocarditis, although patients with prosthetic heart valves or implants should receive antibiotics before a dental appointment. Medical issues such as diabetes (A), atrial fibrillation, ejection fraction of 52%, hypertension, and sleep apnea (C) are not risk factors for infective endocarditis. Patients with a known history of illicit intravenous drug use (D) do not require antibiotics before dental work unless they have a history of infective endocarditis. Those with a history of infective endocarditis are at high risk for developing infective endocarditis again.Patients with hemodynamically significant mitral stenosis (or mechanical heart valves) should be treated with warfarin. Direct-acting oral anticoagulants are effective and do not require routine monitoring (A), but they are not approved for use in patients with severe mitral stenosis. The use of a DOAC is reasonable in a patient with native aortic valve disease (B). Many clinical trials have demonstrated that DOACs are very effective compared with warfarin and often cause less major bleeding as an adverse effect (D), but DOACs are much more expensive than warfarin and cost can be limiting for patients.AACN Certcorp publishes a study bibliography that identifies the sources from which items are validated. The document may be found in the AACN certification examination handbook. The contributor of each question written for this column has listed the source used in developing each item. Clinical practice should be based on primary sources of evidence when possible; this column will also include secondary sources to help nurses become aware of available resources for certification review.