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Have you ever considered certification from the perspective of patients and their family members? Although certification provides many benefits to nurses, it also exists to protect and enhance patient health and safety.1 Nurses who hold a certification demonstrate achievement of patient care knowledge and clinical judgment according to a national standard. The certification credential communicates this achievement not only to the nurse's colleagues and professional networks but also to patients and families. When my father was a patient in an intensive care unit after major surgery, in a hospital I was unfamiliar with, knowing that he was being cared for by CCRN-certified nurses gave me peace of mind and comfort. A certification credential is a quick way to send a message that the nurse possesses knowledge of practice consistent with evidence-based standards.1 Certification is one of many ways to convey excellence. My father was also cared for by several outstanding nurses who did not display a certification credential, and their words and actions demonstrated their high-quality practice. Caring for patients who do not follow recommendations can be challenging. Seeking more information about the circumstances in which the patient lives can build a collaborative relationship with the patient and help identify and address drivers of health, including employment, financial resources, residence, and transportation. Labeling patients "noncompliant" can be detrimental to the health care professional–patient relationship (A). Social services consultation (C) may be helpful, but first the assessment must be completed. Mental health services (D) may be indicated, but making assumptions about the reason for the missed appointments and medication nonadherence is not holistic care.The data obtained from a pulmonary artery catheter can guide diagnosis and treatment for complicated hemodynamic scenarios such as concurrent heart failure and sepsis. Pulmonary artery catheters provide real-time information about cardiac output and pulmonary artery pressure, allowing clinicians to evaluate the need for and effectiveness of inotropes, fluids, and vasoactive therapies. Pulmonary artery catheter placement is contraindicated in patients with right-sided thrombus (A), tricuspid valve endocarditis (C), or recent insertion of pacemaker leads (D). Pulmonary artery catheters can measure cardiac output but they do not independently improve low cardiac output (C).Assessing a patient who may have Guillain-Barré syndrome involves a thorough pulmonary and neurologic examination. Assessment of cerebrospinal fluid is important for diagnosis, and measurements of vital capacity and negative inspiratory force are essential to identify respiratory muscle weakness. A neurologic examination is necessary, but cardiac stress testing is not (B). Echocardiography is not indicated, but deep tendon reflexes would be notably reduced or absent (C). Computed tomography of the head is not indicated when Guillain-Barré syndrome is suspected, but extremity strength examination is appropriate (D).Placement of a new invasive device carries a risk of trauma to the surrounding tissues. When inserting an indwelling urinary catheter, a nurse uses cleaning, patient positioning, and lubrication to cause the least possible amount of tissue trauma. Despite all efforts, some tissue trauma can occur, so the nurse should anticipate next steps to prevent further patient harm. If a patient sustains significant trauma during a urinary catheter insertion, the nurse should anticipate continuous bladder irrigation to ensure patency of the catheter and prevent further bladder damage due to obstruction. Although a clinician may request computed tomography of the pelvis (A), it is not a high priority because the bleeding has an obvious cause. Imaging of the abdomen would not be necessary (A). Although manual irrigation of the catheter could immediately ensure patency, with extremely bloody output the risk of new clot formation is significant, warranting constant irrigation rather than intermittent flushing (B). Expert opinion may be needed if the urine does not clear, but consultation would not be the first anticipated intervention (D).Sepsis is an independent risk factor for acute kidney injury requiring renal replacement therapy. When a patient with sepsis decompensates to the point of requiring continuous renal replacement therapy, filters will frequently clog with cytokines, the byproducts of active infection and inflammation. Although patients with renal failure often have volume overload as a result of their illness, their intravascular fluid is frequently depleted, so this volume status does not impact the filter pressures (A). A patient's hypotension could impact the access pressures or the nurse's ability to remove prescribed volume but would not impact the filter pressures (B). Although large molecules like cytokines can clog renal replacement filters, smaller particles like electrolytes do not cause filter clogging (C).Many premature newborns have apnea of prematurity, resulting in irregular respiratory effort with respiratory pauses that can lead to bradycardia. The suck, swallow, and breathing reflexes are often not coordinated until approximately 34 to 35 weeks of gestation. Sucking on the pacifier can cause apnea if the newborn does not pause to breathe occasionally. The nurse should stimulate the newborn to breathe by rubbing the feet. If bradycardia had not occurred, it would be safe to observe the newborn for spontaneous resolution of apnea (A). A newborn with a heart rate of less than 100 beats/min would need positive pressure ventilation if the newborn had no response to stimulation (C). The newborn would be placed back on continuous positive airway pressure only if these episodes were frequent and required intervention (D).Hypotonia at birth can have many causes, including hypoglycemia, bacterial infection, heart defects, neuromuscular disorders, or genetic disorders. The nurse's priority after delivery is to assess the newborn for abnormal behavior, tone, and reflexes. Although hypoglycemia could cause low tone, feedings should not be given until the nurse assesses the baby's suck, swallow, and gag reflexes (B). Some hypotonic conditions, like hypoxic-ischemic encephalopathy or neuromuscular disorders, could cause choking and lack of a gag reflex, so feedings should be delayed until after assessment of reflexes. Contractures could occur in newborns with arthrogryposis or other skeletal abnormalities (C) but would not occur in a newborn with shoulder dystocia at birth. Passive range-of-motion manipulation could help improve tone in some situations but is not the highest priority at this time (D).Newborns at birth have amniotic fluid on their skin and are prone to heat loss. The main method of heat loss in a cold delivery room is by evaporation of fluid from the skin. Therefore, all newborns need to be dried with a warm blanket after delivery to prevent additional heat loss. Taking a temperature (A), measuring heart rate (B), and computing and reporting the Apgar scores (D) to the obstetrician and entering results in the medical record are secondary responses if an newborn is active and breathing well after birth.Pain assessment of an newborn involves physiologic indicators (elevated heart rate and blood pressure and decreased oxygen saturation) and behavioral indicators (crying, postural indicators, and facial expressions). Compared with term newborns, premature newborns with pain demonstrate less crying and less movement with arm extensions and finger splays. Newborns exhibiting behavioral indicators of pain require more pain medications. Therefore, this newborn is not tolerating pain well (A). A newborn who has undergone a surgical procedure and is lying in bed not moving is not ready for extubation and may still be under the effects of the anesthesia (C). The oxygen desaturation episodes could be due to an increased need for ventilation support (D), but this finding along with the other signs indicates a newborn pain response.A patent urachus is a channel that allows urine to travel to the umbilicus from the bladder. This channel usually closes in utero. Signs of a urachus that remains patent include clear urine drainage from the umbilicus or a wet umbilicus that does not dry out and fall off by 10 days of age. Urine output of greater than 5 mL/kg/h is polyuria, which is unrelated (A). A serum sodium level of 130 mEq/L is hyponatremia, which in neonates is usually due to water retention (B). A reddened streak surrounding the base of the umbilical cord can result from infection of the umbilicus, or omphalitis (D).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.
Knippa et al. (Mon,) studied this question.