Trustworthy Nurses

Nursing consistently earns recognition in annual Gallup polls as the most trusted profession,1 highlighting nurses’ high ethical standards and dedication. Patients are often at their most vulnerable when needing nursing care, and we earn their trust by practicing with expertise, clear communication, and kindness.Some patients with knowledge of health care trust nurses because they understand our years of formal preparation, educational requirements, and high ethical standards. Others may have had previous experiences that shaped their trust of nurses. But many patients with low health literacy or lack of personal experience with the medical system may trust nurses out of necessity, hoping their confidence is not misplaced. Nurses consistently step up to this challenge, advocating for those in our care and earning the trust of our patients and their families.Earning trust does not stop with our patients. We are trusted by the clinicians on our team and our fellow nurses, and perhaps best of all, we trust ourselves. Specialty certification may add distinction to our credibility as nurses, increasing the value of trust from all angles and firmly establishing our place as the most trusted profession. A lumbar drain may be placed in the epidural space of the lumbar spine to obtain intraspinal pressure measurements and drain cerebrospinal fluid. Severe complications of lumbar drain placement may include intracranial hemorrhage or meningitis, and a severe headache may be a symptom of either of these. Intracranial hemorrhage should be ruled out with a computed tomography scan. Clamping the drain to stop cerebrospinal fluid drainage prevents overdrainage, which could also lead to severe headache (A). Although a neurologic examination is indicated, the drainage rate should not be increased without more information and a physician’s order (B). Raising the head of the bed will change the rate of drainage and may worsen the headache if it is caused by overdrainage. Although pain medication may be indicated, finding the cause is more important (C). Ensuring that the level of the lumbar drain is at the prescribed height is important because the drainage occurs by gravity, and an inappropriately high or low drain position will affect drainage. Lumbar drains are not connected to a pressurized flush bag like other hemodynamic devices and are not flushed for a square-wave test (D). Patients with adrenal insufficiency may experience a life-threatening adrenal crisis when the adrenal glands do not produce enough cortisol. This failure of the adrenal glands must be treated with intravenous corticosteroids (D). Antibiotics may be indicated but only after an infectious disease workup (A). Dopamine infusion may need to be considered but would not address the cause (B). Phentolamine is used to treat high blood pressure associated with pheochromocytoma (C). An ST-segment elevation in the contiguous leads II, III, and aVF indicates an inferior wall injury, which must be treated on an emergency basis. The coronary artery usually responsible for circulation to the inferior wall is the right coronary artery (B). Typical coronary blood flow originates from the left main artery (D). The left main artery branches into the left anterior descending artery, which delivers blood to the anterior wall (C), and the left circumflex artery, which delivers blood to the lateral wall (A). Anterior wall ST-segment changes generally indicate an obstruction in the left anterior descending artery, whereas the lateral wall is perfused by the left circumflex artery. Table When dealing with angry patients, nurses have several roles. Nurses must protect their own safety while allowing dialogue that will de-escalate heated situations. Asking patients questions that allow them to talk about their feelings can create a safe space for nurses to hear about patients’ worries about their current situation (D). When a nurse uses a calm tone of voice and models appropriate behavior, the patient has an opportunity to mirror these back to the nurse. Chastising an angry patient does not show professionalism or caring (A). Although the social services team has many resources to offer patients, especially those with health-related social needs, these staff members do not necessarily have the skills to de-escalate this situation (B). Using restraints should be a last resort for patients who exhibit behaviors that could physically harm themselves or others (C). Postoperative pain is distressing and can hinder the healing process. Multimodal pain control after surgical procedures has become standard of care. Teaching patients about layered medications to ensure adequate relief can encourage them to take more than just narcotics for pain control. Explaining the reasons for decisions encourages a partnership between the nurse and the patient (A). Increasing the dose of narcotics should be considered, but multimodal medications can allow lower doses of narcotics to be used (B). Nonmedication approaches to pain control are helpful, but discussing them in the situation described here may seem dismissive to the patient (D). Protamine sulfate is used in cardiothoracic surgery to reverse the anticoagulant effect of heparin. Adverse reactions to protamine, including hemodynamic effects and anaphylaxis, have been reported. Patients at risk for a reaction to protamine may benefit from a test dose before administration of the full prescribed dose. Those at highest risk include patients previously exposed to protamine, those who take NPH (neutral protamine Hagedorn) insulin, and those who have undergone vasectomy (A) because they may have developed antibodies to sperm (protamine is a product of salmon sperm). Obesity, heparin-induced thrombocytopenia (B), aspirin allergy, and cesarean delivery (C) do not increase the risk for a protamine reaction. Prior open-heart surgery may indicate previous exposure to protamine, and shellfish allergy may slightly increase the risk of allergy to protamine (D), but the risk is not as high as that of the combination of factors in answer option A. Pericardial window, or partial pericardiectomy, may be indicated in patients with recurrent pericardial effusion, often due to cancer. The removal of a small portion of the pericardium allows fluid to drain either directly into the mediastinum or into the peritoneal cavity (C) but not directly into the cardiac circulation (B). This procedure does not prevent fluid from forming (A) or stretch the pericardium (D). Perioperative hyperglycemia is associated with an array of poor outcomes, including an increased risk of surgical site infections (C). Hypoglycemia is less likely than hyperglycemia to occur but would be treated with glucose administration (A). Blood glucose levels should be assessed in patients with diabetes and in those without diabetes because surgical stress may cause hyperglycemia even in patients without a previous diagnosis of diabetes (B, D). Intra-aortic balloon pump timing should be assessed with the frequency set to the every-other-beat assistance setting (1:2). The dicrotic notch represents the closure of the aortic valve and beginning of diastole. This is the point at which the balloon should inflate (A), displacing the volume of blood in the aorta proximally into the coronary arteries and distally into the peripheral circulation. Deflation should occur just before the opening of the aortic valve and systolic ejection, which decreases afterload (B). Ideally, assisted end-diastolic pressure should be the lowest point on the tracing, representing afterload reduction (C). The R wave, indicating ventricular depolarization, not the P wave, is commonly used as the trigger source for balloon pump timing (D). Extracorporeal membrane oxygenation supports oxygenation by pumping venous (dark red) blood out of the body through an oxygenator and returning bright red blood to the body (A). Hypercarbia, or a Paco2 of greater than 45 mm Hg, could cause an acid-base imbalance and should be corrected, but a Paco2 of 42 mm Hg is normal (C). Patients are at risk for hypothermia due to the large volume of blood outside of the body (B), but this possibility is not as concerning as air bubbles in the circuit (D). Air bubbles in the tubing may lead to air embolism, obstructing blood flow and gas exchange. Air bubbles in the tubing would prompt the nurse to immediately clamp the lines and notify the physician. 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.