Certification examination questions may ask the nurse to choose which treatment, medication, or intravenous fluid should be administered to a patient, even though the nurse’s role does not include initiating these orders. It is accurate but oversimplistic to say that the nurse “follows” orders from the physician or advanced practice provider. It is easy to hear the word follower and picture someone passive and unquestioning, but there are various types of followers. Effective followers are not dependent or submissive; they display a high level of independent discernment.1 An effective follower critically evaluates the direction of a leader and actively engages in adding input to further the team’s goals. For example, a physician or nurse practitioner places an order to obtain blood cultures for a patient with sepsis. The competent nurse shows effective followership by prioritizing the blood cultures before antibiotic administration and additionally suggesting a culture of the exudative wound on the patient’s foot. Performing well in the role of a follower involves engagement, critical thinking, and initiative, all important leadership qualities.Nurses move between leadership and followership roles in various situations depending on their position, knowledge, and experience.2 A nurse manager may support and add input from a followership role when a staff nurse leads the unit-based council, and a staff nurse may direct a code response in a leadership role until the code team arrives. Achieving certification is one way to demonstrate that the nurse has the knowledge and skills necessary for effective leadership and followership.Administration of 30 mL/kg of an isotonic crystalloid solution within the first 3 hours of treatment is recommended to stabilize a patient with sepsis-induced hypoperfusion. Ongoing fluid administration may be needed but should be balanced with the risk of fluid overload. Albumin (A) is a colloid solution that is not recommended for initial fluid resuscitation but can be used to support perfusion after crystalloid administration. Use of norepinephrine (C) before adequate fluid resuscitation will not improve mean arterial pressure and perfusion. After adequate fluid administration, norepinephrine should be the first vasopressor used. Vasopressin (D) is recommended as a second-tier medication to improve mean arterial pressure after administration of fluids and norepinephrine.Electrocardiographic changes in leads II, III, and aVF are consistent with an inferior wall myocardial infarction. Nearly 50% of inferior wall myocardial infarctions include subsequent right ventricular infarction. Infarctions of the right ventricle impact forward flow from the right heart to the left heart and may cause decreased stroke volume and cardiac output. The right ventricle is often preload dependent, so fluid administration should be initiated to maintain cardiac output. Additional vasodilation from further nitroglycerin administration (A) may further lower blood pressure by decreasing preload in the presence of an inferior wall myocardial infarction with right ventricular involvement. Atropine (C) causes the sinoatrial node to increase the heart rate and could be indicated if the patient developed symptomatic bradycardia with a heart rate of less than 50/min. Dopamine (D) can be used in instances of cardiogenic shock. However, for patients who present with signs and symptoms of right ventricular failure without pulmonary congestion, a fluid challenge should be performed before initiation of an inotrope.Devices that measure exhaled carbon dioxide are considered the diagnostic standard for immediate evaluation of ETT placement. The patient is demonstrating signs of ineffective ventilation, and ETT placement should be assessed immediately. A chest radiograph (A) provides definitive confirmation of ETT placement but will take time to obtain. Without ensuring effective ETT placement, placing the patient on a ventilator (B) will not be beneficial because the ETT may be placed incorrectly into the esophagus or placed too low so that it is ventilating only 1 lung. If breath sounds and chest rise are found on only 1 side, the ETT may need to be slightly withdrawn until signs of ventilation in both lungs are present. Manual ventilation using the bag-valve mask (D) will need to be continued but the higher priority is evaluating ETT placement because ventilating through a misplaced ETT will be ineffective.The nurse’s first intervention should be to evaluate correct functioning of the suction through the nasogastric tube to ensure it is providing effective gastric decompression. Management of intra-abdominal hypertension regardless of cause includes evacuation of intraluminal contents via nasogastric tube and/or enemas. Avoidance of excessive fluid resuscitation (A) is another essential component of intra-abdominal hypertension management. Although a fluid bolus may temporarily improve mean arterial pressure, the mean arterial pressure in this patient is adequate for perfusion, and additional intravenous fluid would increase the risk of increased intra-abdominal pressure. A diuretic (B) may be indicated to reduce intra-abdominal pressure if the patient has a positive fluid balance, but assessing the nasogastric tube should be the first intervention because it can be accomplished more quickly. The Trendelenburg position (C) is not indicated. This position can produce lower bladder pressure readings if indirect intra-abdominal pressure measurements are obtained with the urinary catheter, but this position negatively affects respiratory function. Reverse Trendelenburg positioning is a measure to improve abdominal wall compliance, decrease abdominal pressures, and improve lung recruitment in patients receiving mechanical ventilation.Hypertensive urgency is a blood pressure of greater than 180/120 mm Hg or markedly elevated compared with the patient’s baseline blood pressure without signs of impending organ damage. A gradual reduction in blood pressure is indicated to prevent low blood pressure and complications that can occur from low blood flow, especially to the brain, kidneys, or heart. This patient does not have signs of imminent organ damage along with the hypertension, which would be classified as a hypertensive emergency, and there is no indication (such as eclampsia or aortic dissection) for a more aggressive reduction in blood pressure (A, B). There is no need for an additional agent (C) if order parameters allow for upward titration of the nicardipine.To achieve safe and gradual correction of hyperglycemia, the addition of dextrose to the intravenous fluids is indicated to avoid subsequent hypoglycemia when the blood glucose level falls below 250 mg/dL. A goal serum potassium level of 4.0 to 5.0 mEq/L is appropriate during diabetic ketoacidosis management (A). Additional intravenous potassium may be necessary even if the serum potassium level is within this range during insulin therapy because potassium shifts out of the serum, but even during potassium repletion it would be appropriate to monitor the serum potassium every 2 hours or less frequently. When glucose levels fall below 250 mg/dL, continuing to increase the rate of the insulin infusion (B) would put the patient at risk for hypoglycemia. If the patient had hypernatremia, 0.45% saline solution (D) could be appropriate, but in this situation, using 0.45% saline solution would put the patient at risk for hyponatremia and hypoglycemia.Sevelamer hydrochloride is a non–calcium-containing phosphate binder prescribed to help lower phosphorus levels in patients with end-stage renal disease treated with hemodialysis. It is important to monitor phosphorus levels to make sure that levels stay within the goal range to further reduce the risk for hyperphosphatemia. Potassium (A) is an important electrolyte to monitor in patients with end-stage renal disease receiving hemodialysis, but it is not directly impacted by the intake of sevelamer hydrochloride. Sevelamer hydrochloride does not directly impact magnesium (B) levels. Sevelamer hydrochloride is a non–calcium-containing binder, so it does not directly increase calcium (C) levels.Epicardial pacing should be initiated promptly for postoperative open heart surgery patients who experience symptomatic bradycardia dysrhythmias such as third-degree heart block. Patients undergoing valvular surgery are at risk for bradycardia and heart blocks because of the location of the suture lines near the cardiac conduction system, which may cause swelling or edema near the conduction site. The swelling may cause the patient to experience a heart block. The intraoperative placement of epicardial wires allows for postoperative epicardial pacing if a patient exhibits bradycardia or heart blocks. Atropine (A) is typically not successful in treating a wide-complex bradycardic dysrhythmia like third-degree heart block. Metoprolol (B) is contraindicated in patients with third-degree atrioventricular heart block. Synchronized cardioversion (C) may be used to treat some tachydysrhythmias but not bradydysrhythmias.Research studies have shown that administering aspirin within the first 48 hours after an acute ischemic stroke helps reduce the risk of early, recurrent stroke. If a patient with ischemic stroke is not a candidate for fibrinolytic therapy, the patient should receive aspirin within the first 48 hours after stroke onset. This patient has facial palsy, which may indicate a risk for impaired swallowing, so while waiting for a speech therapy swallow evaluation the nurse can administer aspirin rectally. Fibrinolytic therapy including intravenous alteplase (A) is recommended for the treatment of acute ischemic stroke when a patient presents within 4.5 hours of symptom onset. Intensive statin therapy (C) is recommended for secondary prevention of stroke in patients with a diagnosis of ischemic stroke and a low-density lipoprotein cholesterol level of greater than 70 mg/dL, but it is not time sensitive compared with initiating aspirin therapy. Heparin (D) is not indicated for the treatment of acute ischemic stroke.A patient experiencing acute dyspnea needs a fast-acting bronchodilator. Albuterol is a short-acting β2-agonist bronchodilator that provides relief for dyspnea. Chest radiography (B) is an important diagnostic evaluation of the lungs, but it is not an urgent intervention because exertion likely caused the dyspnea. Once the patient receives the short-acting bronchodilator, a posttreatment respiratory assessment can help determine if the patient improved or requires further clinical studies. A 12-lead ECG (C) is not the priority intervention, but it may be considered if the patient has a change in cardiac rhythm or continues to report chest pain after the short-acting bronchodilator treatment. Tiotropium bromide (D) is a once-daily, long-acting anticholinergic bronchodilator used for maintenance treatment of chronic obstructive pulmonary disease. It is not used for the quick relief of acute symptoms of dyspnea or bronchospasm.AACN Certification Corporation 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.