Sara Knippa, MS, RN, ACCNS-AG, CCRN, PCCN, is the contributing editor of the column. Sara is clinical nurse specialist/educator in the cardiac intensive care unit at University of Colorado Hospital, Aurora. She welcomes feedback from readers and practice questions from potential contributors at sara.knippa.cns@gmail.com. Sara wrote the introduction.KNIPPACarol Ann Rauen, MS, RN-BC, CCRN, PCCN, CEN, TCRN, is an independent clinical nurse specialist and education consultant in St Augustine, Florida. She works in the trauma intensive care unit at Orange Park Medical Center, Orange Park, Florida. Carol Ann wrote the adult CCRN questions.RAUENLaura Ullery, MSN, RN, CCNS, ACNS-BC, PCCN, SCRN, is a clinical nurse specialist at Sutter Roseville Medical Center, Roseville, California. She works with the cardiac-monitored units, inpatient diabetes mellitus/glycemic management program, and stroke program. Laura wrote the PCCN review questions.ULLERYAs I write this, my niece is a week away from finishing her orientation in her first job as a new graduate nurse in a progressive care unit in Texas. I want to share a few things with her and all new nurses.All people who require a splenectomy must have up-to-date vaccinations because they are immunosup-pressed; therefore, a pneumococcal vaccine should be given postoperatively. Digestive enzyme production (A) is the function of the pancreas, not the spleen. Standard precautions (B) are needed for this patient. Routine crossmatching (D) is adequate if this patient requires a blood transfusion.Obese patients require high protein intake during critical illness because they are at risk for protein-energy malnutrition. Their bodies may have trouble using lipid metabolism for energy and may instead metabolize protein to meet a higher percentage of their energy needs. The timing (A) of beginning nutrition support (as soon as clinically possible) is the same for all critically ill patients regardless of body mass index. Checking gastric residual volume (B) is not an evidence-based method for routinely assessing feeding tolerance, but if gastric residual volume is used, there is no evidence for allowing greater volumes in obese patients. The increased insulin levels (D) caused by insulin resistance in obese individuals make them hungrier and increase their risk of developing type 2 diabetes mellitus and therefore hyperglycemia, not hypoglycemia.The insertion of an indwelling urinary catheter and the number of days it remains in place can both increase the likelihood a patient will get a urinary tract infection. Removing the catheter as early as possible (within 24 hours) can mitigate the risk. Removing the catheter might improve ambulation (B) but ambulation is not the primary indication to decrease its use. Measuring weight daily and measuring intake and output (C) are both important for assessing fluid balance, and the need for accurate measurement of urine output may be an indication for urinary catheter placement in some situations. The Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention have guidelines related to preventing catheter-associated urinary tract infection (D), but patient safety is the reason for early removal and decreased use.Transfusion-related acute lung injury is noncardiogenic pulmonary edema (acute lung injury/acute respiratory distress syndrome) caused by blood transfusion. The inflammatory response is activated by a reaction to the donor blood product. A restrictive alveolar response causes a decrease in the Pao2 to Fio2 ratio to 300 mm Hg or less (C, D) and an elevation in PIP (reference value is below 35 cm H2O) (B, C, D). Fluid accumulates in the alveoli, leading to bilateral opacities, not effusions, on chest radiographs (B, C).Patients with cervical spine injuries at or above C4 will not be able to breathe on their own because the diaphragm is innervated at that level. A patient with a C5 injury must be monitored very carefully for adequate airway and ability to breathe. Monitoring arm perfusion (A) in a shoulder dislocation and stabilizing the pelvis (B) in a fracture are very important but are not more important than airway assessment. Establishing intravenous access is essential in all critically ill patients, especially trauma patients, but maintaining an airway and ventilation is the highest priority.When a patient is taking nothing by mouth, contacting the physician to review the patient’s basal insulin dose is important. The general recommendation is to reduce the basal insulin dose by 20% to 50% to decrease the risk for hypoglycemia (A). Long-acting basal insulin should not be withheld (C) in a patient with type 1 diabetes mellitus. Because these patients produce little or no insulin, a patient who does not receive basal insulin will be at risk for developing severe hyperglycemia and diabetic ketoacidosis. A correctional sliding scale (D) involves administering a fast-acting insulin but it does not provide a patient with necessary long-acting basal insulin coverage.A bedside swallow screen is an evidence-based way for the nurse to assess a patient’s ability to swallow after a stroke. Guidelines for the management of patients with acute ischemic stroke recommend a bedside swallow screen before any oral intake, including medications. Withholding the aspirin (B) is inappropriate because it is important that the patient receive aspirin within the first 24 to 48 hours after an acute ischemic stroke. Aspirin can be given rectally if the patient cannot swallow safely. A swallow screen should be performed before any oral intake, even if the intake is compatible with a dysphagia diet (C). If the patient passes the bedside swallow screen a speech therapy evaluation (B, D) is likely not necessary.A 1-way speaking valve requires that the tracheostomy cuff be deflated. The valve covers the end of the tracheostomy tube, opening during inspiration so that air can be inhaled through the nose, mouth, and tracheostomy. The valve closes during exhalation, which forces air up the sides of the tracheostomy tube past the vocal cords to the nose and mouth so the patient can speak. The patient is unable to exhale if the cuff is not deflated. Patients with tracheostomies may or may not require oxygen therapy (A), and the valve itself does not require oxygen delivery. Thinning and managing secretions is important, but oxygen does not always need to be humidified (A), and routinely suctioning a tracheostomy every 2 hours (B) is unnecessary unless clinically indicated for mucus and/or secretions. Some patients may require continuous pulse oximetry monitoring (D), but the frequency of monitoring depends on the patient and the current respiratory assessment.Patients with a history of intravenous heroin use are at risk for right-sided (tricuspid valve) infective endocar-ditis. The most common sign of endocarditis is fever, but the shortness of breath and back pain may indicate an embolus that has traveled to the lungs from the right-sided infective endocarditis. Patients with bacterial pneumonia (A) may have fever, chills, malaise, shortness of breath, and chest discomfort. However, in this case the patient’s history of intravenous heroin use points to endocarditis as the more likely condition. Although intravenous heroin use also puts patients at risk for HIV infection (B) and hepatitis C (C), HIV causes a higher risk for infection but not these acute symptoms. Symptoms consistent with hepatitis C (C) would include abdominal bloating, nausea, weight loss, fatigue, and jaundice.The nurses may be experiencing burnout, a state of emotional exhaustion related to chronic interpersonal stressors. The best initial action is to contact the unit manager to discuss ways to assess and intervene. This approach promotes collaboration and strong communication with the unit clinical manager. Once the nurse meets with the manager, it may be appropriate to use a survey for assessment, but the stressors described indicate burnout rather than moral distress (A). A plan to address burnout may include organizing a unit-based committee (C), but a staffing problem is likely only one of the contributing factors. Meeting individually with nurses (D) may help identify those experiencing burnout, but the focus should be on support and not only on job longevity.AACN Certcorp publishes a study bibliography that identifies the sources from which items are validated. The document may be found in the AACN Certification exam handbook. The contributor of each question written for this column has listed the source used in developing each item.
Search from 250 M+ research papersSearch from 250 M+ research papers
Open Access
Just Published
Apr 5, 2024
Ahmed Mohammed Shennawy + 4