CNL Certification Exam Review

1. CNL Certification Exam Review

2. Systems • Macro vs. Micro systems • Microsystems • Assess, Diagnose, Treat, Evaluate • All players including patient

3. Health Care Improvement • Quality Improvement( CQI, QA) • Risk Management • Sentinel events • Patient injury • Outcomes Management

4. Advanced Med Surg • Key populations • Safety • Meds • Emergency/critical thinking • Vaccines • Chronic illness • Gerontology

5. Care Issues- Vulnerable Populations Groups of persons who may be compromised in their ability to give informed consent, who are frequently subjected to coercion in their decision making, or whose range of options is severely limited, making them vulnerable to health care quality problems. • Children • All infants, children, and adolescents, i.e., all individuals who have not reached the legal age for consent. • Disabled • Persons with physical or mental disabilities that affect or limit their activities of daily living and that may require special accommodations. These include cognitively disabled, communicatively disabled, mentally disabled, and physically disabled • Frail Elderly • Older adults or aged individuals who are lacking in general strength and are unusually susceptible to disease or to other infirmity

6. Homeless • Persons who have no permanent residence, including children and adolescents with no fixed place of residence. • Illiterate/Low-literate Populations • Persons with low levels of education. • Immigrants • Persons coming into a country of which he or she is not a native for the purpose of setting up residence. This category is also defined to include refugees, asylees, and undocumented aliens or immigrants. • Medically Uninsured • Mentally Ill • Minority Groups

7. Non-English Speaking Populations • Poverty Populations • Prisoners • Rural Populations • Terminally Ill • Transient/Migrants • Urban Populations • Women

8. IOM Care Issues • Frailty associated with old age - preventing falls and pressure ulcers, maximizing function, and developing advanced care plans • Hypertension - focus on appropriate management of early disease • Asthma - appropriate treatment for persons with mild/moderate persistent asthma • Cancer screening that is evidence-based - focus on colorectal and cervical cancer • Care Coordination (cross cutting)

9. Immunization - children and adults • Ischemic heart disease - prevention, reduction of recurring events, and optimization of functional capacity • Major depression - screening and treatment • Medication management - preventing medication errors and overuse of antibiotics • Nosocomial infections - prevention and surveillance • Obesity (emerging area) • Pain control in advanced cancer

10. Pregnancy and childbirth - appropriate prenatal and intrapartum care • Self-management/health literacy (cross-cutting) • Severe and persistent mental illness - focus on treatment in the public sector • Stroke - early intervention and rehabilitation • Tobacco dependence treatment in adults • Children with special health care needs • Diabetes - focus on appropriate management of early disease • End of life with advanced organ system failure - focus on congestive heart failure and chronic obstructive pulmonary disease

11. Exam Content • Illness/Disease Management • Knowledge Management • Health Promotion and Disease Prevention & Injury Reduction/Prevention Management • Evidence-Based Practice

12. Exam Content • Uses clinical judgment and decision-making skills to make clinical decisions regarding patient care decisions, delegation of patient care activities, and nursing care outcomes • Uses care management skills and principles to provide and supervise client care within specific episodes and across episodes of illness and disease

13. Illness/Disease Management 1. Assumes responsibility for the provision and management of care at the point of care in and across all environments 2. Provides care at the point of service to individuals across the lifespan with particular emphasis on health promotion and risk reduction services 3. Performs a comprehensive health assessment, including a comprehensive history and physical assessment 4. Identifies patient problems that require intervention, with special focus on those problems amenable to nursing intervention 16. Uses advanced knowledge of pathophysiology and pharmacology to anticipate illness progression, response to therapy and to guide/teach patients and families regarding care

14. CHF • Treatment goals: • Prevent initial cardiac injury • Prevent further injury; aggressive tx post MI • Prevent post injury deterioration( ACE) • General tx • Prevent life threatening complications: PE

15. COPD • Stop smoking • Bronchodilators; short term, long term • Steroids • Antimicrobials • Oxygen- acute and chronic • Vaccines • Pulm rehab • Surgery

16. High Alert Medications • Insulin, Oral hypoglycemics • Anticoagulants-Heparin... • Thrombolytics • Chemo agents • Adrenergic agonists- epinephrine, norepinephrine • Adrenergic antagonists- Beta blockers • Antiarrythmics- Lidocaine • Anesthetic agents • Dextrose, hypertonic- >20% • Epidural agents • Sedatives • Opiates • TPN Source: www.ismp.org

17. Medications • Antihypertensives • (il) ACE inhibitors Lisinopril • Ol) Beta blockers Metaprolol • (tan) Aldosterone II receptor blockers • (ine) Ca Channel Blockers Nifedipine • Antiadernergics ( dilation) Aldomet/Methyldopa • Vasoldilators • Human B-type natriuretic peptides • Diuretics • K, K K!!!! • Fluid balance

18. Anticoagulants • Antithrombin ( newer drugs) • Platelet inhibitors : clopidogrel, ticlopidine • Heparin • Coumarins( Warfarin) • Insulin control • Hypoglycemic agents

19. Emergency • Prevent sentinel events • RRT • Principles of Triage • Critical lab values

20. Pain management • When and how much???

21. Case 1: Mrs. S was diagnosed with Type II Diabetes 6 months ago. She has been admitted twice with HHNKC. This admission she came in with a BG of 650, and was barely conscious. Her English is limited and she has few financial resources.

22. Case 2 Mr. J is receiving palliative care for terminal cancer of the stomach. His pain meds do not seem to be effective. He is somewhat confused but moans constantly. The nurses on the unit seem reluctant to give him the prescribed medication. You have noticed that the nurses do not medicate unless the patient asks for the pain meds

23. Case 3 The patient, Mrs. B, in room 12 is complaining of tightness in her chest; she is pale and diaphoretic. Her VS are as follows: (98/54, 103, 24, SaO2 89%.She has an IV at kvo rate. You have left another RN in the room with her and you now have to reach the MD..

24. What do you suggest be done to solve this problem? • Who should be involved in the problem solving? • What are the important considerations during the problem solving process? • What CNL roles and competencies apply to this scenario

25. Case 4 • A nurse working on a medical nursing unit during an external disaster is called to assist with care for clients coming into the emergency room. Using principles of triage, the nurse initiates immediate care for a client with which of the following injuries? • bright red bleeding from a neck wound • b. penetrating abdominal injury • c. fractured tibia • open massive head injury in deep coma

26. Case 5 Furosemide( Lasix) 40 mg po has been prescribed for a client. The nurse administers 80mg at 10:00 am. Following discovery of the error, the nurse completes an incident report. Which of the following would be documented on the report? a. Lasix 80mg was given instead of 40mg b. The wrong dose of medication was given to the client at 10 am c. Lasix 80 mg administered at 10am d. I meant to give 40mg but I was rushed to help another patient and I gave the wrong dose This has been the 4th Lasix error on the unit this month

27. Case 6 The physician’s order reads heparin sodium 25,000 units in 250ml, 5% Dextrose in water to run continuously at a rate of 800 units per hour by IV, The nurse sets the pump to how many ml per hour? a. 8 b. 32 c. 40 d. 80 What is the significant problem with Heparin that led to use of Lovenox? What are the nursing issues if the patient is going to take Lovenox at home?

28. Case 7 The mouth care measure that should be used with caution by the nurse when the client has a nasogastric tube is: a. regularly brushing teeth and tongue with a soft brush b. sucking on ice chips to relieve dryness c. occasionally rinsing mouth with a nonastringent solution and massaging gums d. application of lemon swabs and glycerin to the lips. What other complications may occur when a patient has a NG tube ? How do you prevent these?

29. Case 8 Forty-eight hours after a nephrectomy, a client complains of increasing nausea and abdominal pressure. The nurse’s first nursing action is: a. change the client’s position to relieve pressure b. ausculatate bowel sounds c. administer a rectal tube to relieve flatus d. administer 6mg Morphine SO4 as ordered for the relief of discomfort You also find that he has a rigid abdomen and is diaphoretic. What will you do now?

30. You have patient who is being treated for clinical depression while he is on the Med-Surg unit for exacerbation of his liver disease and GI bleeding What are the issues?