Medical CCRN : Critical Care Register Nurse Exam Dumps

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Exam Number : CCRN
Exam Name : Critical Care Register Nurse
Vendor Name : Medical
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CCRN Exam Format | CCRN Course Contents | CCRN Course Outline | CCRN Exam Syllabus | CCRN Exam Objectives

A criterion-referenced standard setting process, known as the modified Angoff, is used to establish the passing point/cut score for the exam. Each candidates performance on the exam is measured against a predetermined standard.

The passing point/cut score for the exam is established using a panel of subject matter experts, an exam development committee (EDC), who carefully reviews each exam question to determine the basic level of knowledge or skill that is expected. The passing point/cut score is based on the panels established difficulty ratings for each exam question.

Under the guidance of a psychometrician, the panel develops and recommends the passing point/cut score, which is reviewed and approved by AACN Certification Corporation. The passing point/cut score for the exam is established to identify individuals with an acceptable level of knowledge and skill. All individuals who pass the exam, regardless of their score, have demonstrated an acceptable level of knowledge.

I. CLINICAL JUDGMENT (80%)

A. Cardiovascular (17%)

1. Acute coronary syndrome:

a. NSTEMI

b. STEMI

c. Unstable angina

2. Acute peripheral vascular insufficiency:

a. Arterial/venous occlusion

b. Carotid artery stenosis

c. Endarterectomy

d. Fem-Pop bypass

3. Acute pulmonary edema

4. Aortic aneurysm

5. Aortic dissection

6. Aortic rupture

7. Cardiac surgery:

a. CABG

b. Valve replacement or repair

8. Cardiac tamponade

9. Cardiac trauma

10. Cardiac/vascular catheterization

11. Cardiogenic shock

12. Cardiomyopathies:

a. Dilated

b. Hypertrophic

c. Idiopathic

d. Restrictive

13. Dysrhythmias

14. Heart failure

15. Hypertensive crisis

16. Myocardial conduction system abnormalities

(e.g., prolonged QT interval, Wolff-ParkinsonWhite)

17. Papillary muscle rupture

18. Structural heart defects (acquired and congenital, including valvular disease)

19. TAVR

B. Respiratory (15%)

1. Acute pulmonary embolus

2. ARDS

3. Acute respiratory failure

4. Acute respiratory infection (e.g., pneumonia)

5. Aspiration

6. Chronic conditions (e.g., COPD, asthma, bronchitis, emphysema)

7. Failure to wean from mechanical ventilation

8. Pleural space abnormalities (e.g., pneumothorax, hemothorax, empyema, pleural effusions)

9. Pulmonary fibrosis

10. Pulmonary hypertension

11. Status asthmaticus

12. Thoracic surgery

13. Thoracic trauma (e.g., fractured rib, lung contusion, tracheal perforation)

14. Transfusion-related acute lung injury (TRALI)

C. Endocrine/Hematology/Gastrointestinal/Renal/Integumentary (20%)

1. Endocrine

a. Adrenal insufficiency

b. Diabetes insipidus (DI)

c. Diabetes mellitus, types 1 and 2

d. Diabetic ketoacidosis (DKA)

e. Hyperglycemia

f. Hyperosmolar hyperglycemic state (HHS)

g. Hyperthyroidism

h. Hypoglycemia (acute)

i. Hypothyroidism

j. SIADH

2. Hematology and Immunology

a. Anemia

b. Coagulopathies (e.g., ITP, DIC, HIT)

c. Immune deficiencies

d. Leukopenia

e. Oncologic complications (e.g., tumor lysis syndrome, pericardial effusion)

f. Thrombocytopenia

g. Transfusion reactions

3. Gastrointestinal

a. Abdominal compartment syndrome

b. Acute abdominal trauma

c. Acute GI hemorrhage

d. Bowel infarction, obstruction, perforation (e.g., mesenteric ischemia, adhesions)

e. GI surgeries (e.g., Whipple, esophagectomy, resections)

f. Hepatic failure/coma (e.g., portal hypertension, cirrhosis, esophageal varices, fulminant hepatitis, biliary atresia, drug-induced)

g. Malnutrition and malabsorption

h. Pancreatitis

4. Renal and Genitourinary

a. Acute genitourinary trauma

b. Acute kidney injury (AKI)

c. Chronic kidney disease (CKD)

d. Infections (e.g., kidney, urosepsis)

e. Life-threatening electrolyte imbalances

5. Integumentary

a. Cellulitis

b. IV infiltration

c. Necrotizing fasciitis

d. Pressure injury

e. Wounds:

i. infectious

ii. surgical

iii. trauma

D. Musculoskeletal/Neurological/

Psychosocial (14%)

1. Musculoskeletal

a. Compartment syndrome

b. Fractures (e.g., femur, pelvic)

c. Functional issues (e.g., immobility, falls, gait disorders)

d. Osteomyelitis

e. Rhabdomyolysis

2. Neurological

a. Acute spinal cord injury

b. Brain death

c. Delirium (e.g., hyperactive, hypoactive, mixed)

d. Dementia

e. Encephalopathy

f. Hemorrhage:

i. intracranial (ICH)

ii. intraventricular (IVH)

iii. subarachnoid (traumatic or aneurysmal)

g. Increased intracranial pressure (e.g., hydrocephalus)

h. Neurologic infectious disease (e.g., viral, bacterial, fungal)

i. Neuromuscular disorders (e.g., muscular dystrophy, CP, Guillain-Barré, myasthenia)

j. Neurosurgery (e.g., craniotomy, Burr holes)

k. Seizure disorders

l. Space-occupying lesions (e.g., brain tumors)

m. Stroke:

i. hemorrhagic

ii. ischemic (embolic)

iii. TIA

n. Traumatic brain injury (TBI): epidural, subdural, concussion

3. Behavioral and Psychosocial

a. Abuse/neglect

b. Aggression

c. Agitation

d. Anxiety

e. Suicidal ideation and/or behaviors

f. Depression

g. Medical non-adherence

h. PTSD

i. Risk-taking behavior

j. Substance use disorders (e.g., withdrawal, chronic alcohol or drug dependence)

E. Multisystem (14%)

1. Acid-base imbalance

2. Bariatric complications

3. Comorbidity in patients with transplant history

4. End-of-life care

5. Healthcare-associated conditions (e.g., VAE, CAUTI, CLABSI)

6. Hypotension

7. Infectious diseases:

a. Influenza (e.g., pandemic or epidemic)

b. Multi-drug resistant organisms (e.g., MRSA, VRE, CRE)

8. Life-threatening maternal/fetal complications (e.g., eclampsia, HELLP syndrome, postpartum hemorrhage, amniotic embolism)

9. Multiple organ dysfunction syndrome (MODS)

10. Multisystem trauma

11. Pain: acute, chronic

12. Post-intensive care syndrome (PICS)

13. Sepsis

14. Septic shock

15. Shock states:

a. Distributive (e.g., anaphylactic, neurogenic)

b. Hypovolemic

16. Sleep disruption (including sensory overload)

17. Thermoregulation

18. Toxic ingestion/inhalations (e.g., drug/alcohol overdose)

19. Toxin/drug exposure (including allergies)

II. PROFESSIONAL CARING 7 ETHICAL PRACTICE (20%)

A. Advocacy/Moral Agency

B. Caring Practices

C. Response to Diversity

D. Facilitation of Learning

E. Collaboration

F. Systems Thinking

G. Clinical Inquiry

CLINICAL JUDGMENT

General

• Recognize normal and abnormal:

o developmental exam findings and provide developmentally appropriate care

o physical exam findings

o psychosocial exam findings

• Recognize signs and symptoms of emergencies, initiate interventions, and seek assistance as needed

• Recognize indications for, and manage patients requiring:

o capnography (EtCO2)

o central venous access

o medication reversal agents

o palliative care

o SvO2 monitoring

• Manage patients receiving:

o complementary/alternative medicine and/or nonpharmacologic interventions

o medications (e.g., safe administration, monitoring, polypharmacy)

• Monitor patients and follow protocols for pre- and postoperative care

• Assess pain

• Evaluate patients response to interventions

• Identify and monitor normal and abnormal diagnostic test results

• Manage fluid and electrolyte balance

• Manage monitor alarms based on protocols and changes in patient condition Cardiovascular

• Apply leads for cardiac monitoring

• Identify, interpret and monitor cardiac rhythms

• Recognize indications for, and manage patients requiring:

o 12-lead ECG

o arterial catheter

o cardiac catheterization

o cardioversion central venous pressure monitoring

o defibrillation

o IABP

o invasive hemodynamic monitoring

o pacing: epicardial, transcutaneous, transvenous

o pericardiocentesis

o QT interval monitoring

o ST segment monitoring

• Manage patients requiring:

o endovascular stenting

o PCI Respiratory

• Interpret blood gas results

• Recognize indications for, and manage patients requiring:

o modes of mechanical ventilation

o noninvasive positive pressure ventilation (e.g., BiPAP, CPAP, high-flow nasal cannula)

o oxygen therapy delivery devices

o prevention of complications related to mechanical ventilation (ventilator bundle)

o prone positioning

o pulmonary therapeutic interventions related to mechanical ventilation: airway clearance, extubation, intubation, weaning

o therapeutic gases (e.g., oxygen, nitric oxide, heliox, CO2 )

o thoracentesis

o tracheostomy Hematology and Immunology

• Manage patients receiving transfusion of blood products

• Monitor patients and follow protocols:

o pre-, intra-, post-intervention (e.g., plasmapheresis, exchange transfusion, leukocyte depletion)

o related to blood conservation Neurological

• Recognize indications for, and manage patients requiring neurologic monitoring devices and drains (e.g., ICP, ventricular or lumbar drain)

• Use a swallow evaluation tool to assess dysphagia

• Manage patients requiring:

o neuroendovascular interventions (e.g., coiling, thrombectomy)

o neurosurgical procedures (e.g., pre-, intra-, post-procedure)

o spinal immobilization Integumentary

• Recognize indications for, and manage patients requiring, therapeutic interventions (e.g. wound VACs, pressure reduction surfaces, fecal management devices, IV infiltrate treatment) Gastrointestinal

• Monitor patients and follow protocols for procedures pre-, intra-, post-procedure (e.g., EGD, PEG placement)

• Intervene to address barriers to nutritional/fluid adequacy (e.g., chewing/swallowing difficulties, alterations in hunger and thirst, inability to self-feed)

• Recognize indications for, and manage patients requiring:

o abdominal pressure monitoring

o GI drains

o enteral and parenteral nutrition Renal and Genitourinary

• Identify nephrotoxic agents

• Monitor patients and follow protocols pre-, intra-, and post-procedure (e.g., renal biopsy, ultrasound)

• Recognize indications for, and manage patients requiring, renal therapeutic intervention (e.g., hemodialysis, CRRT, peritoneal dialysis)

Musculoskeletal

• Manage patients requiring progressive mobility

• Recognize indications for, and manage patients requiring, compartment syndrome monitoring

Multisystem

• Manage continuous temperature monitoring

• Provide end-of-life and palliative care

• Recognize risk factors and manage malignant hyperthermia

• Recognize indications for, and manage patients undergoing:

o continuous sedation

o intermittent sedation

o neuromuscular blockade agents

o procedural sedation - minimal

o procedural sedation - moderate

o targeted temperature management (previously known as therapeutic hypothermia)

Behavioral and Psychosocial

• Respond to behavioral emergencies (e.g., nonviolent crisis intervention, de-escalation techniques)

• Use behavioral exam tools (e.g., delirium, alcohol withdrawal, cognitive impairment)

• Recognize indications for, and manage patients requiring:

o behavioral therapeutic interventions

o medication management for agitation

o physical restraints

I. CLINICAL JUDGMENT (80%)

A. Cardiovascular (14%)

1. Cardiac infection and inflammatory diseases

2. Cardiac malformations

3. Cardiac surgery

4. Cardiogenic shock

5. Cardiomyopathies

6. Cardiovascular catheterization

7. Dysrhythmias

8. Heart failure

9. Hypertensive crisis

10. Myocardial conduction system defects

11. Obstructive shock

12. Vascular occlusion

B. Respiratory (18%)

1. Acute pulmonary edema

2. Acute pulmonary embolus

3. Acute respiratory distress syndrome (ARDS)

4. Acute respiratory failure

5. Acute respiratory infection

6. Air-leak syndromes

7. Apnea of prematurity

8. Aspiration

9. Chronic pulmonary conditions

10. Congenital airway malformations

11. Failure to wean from mechanical ventilation

12. Pulmonary hypertension

13. Status asthmaticus

14. Thoracic and airway trauma

15. Thoracic surgery

C. Endocrine/Hematology/Gastrointestinal/Renal/Integumentary (20%)

1. Endocrine

a. Adrenal insufficiency

b. Diabetes insipidus (DI)

c. Diabetic ketoacidosis (DKA)

d. Diabetes mellitus, types 1 and 2

e. Hyperglycemia

f. Hypoglycemia

g. Inborn errors of metabolism

h. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

2. Hematology and Immunology

a. Anemia

b. Coagulopathies (e.g., ITP, DIC)

c. Immune deficiencies

d. Myelosuppression (e.g., thrombocytopenia, neutropenia)

e. Oncologic complications

f. Sickle cell crisis

g. Transfusion reactions

3. Gastrointestinal

a. Abdominal compartment syndrome

b. Abdominal trauma

c. Bowel infarction, obstruction and perforation

d. Gastroesophageal reflux

e. GI hemorrhage

f. GI surgery

g. Liver disease and failure

h. Malnutrition and malabsorption

i. Necrotizing enterocolitis (NEC)

j. Peritonitis

4. Renal and Genitourinary

a. AKI

b. Chronic kidney disease (CKD)

c. Hemolytic uremic syndrome (HUS)

d. Kidney transplant

e. Life-threatening electrolyte imbalances

f. Renal and genitourinary infections

g. Renal and genitourinary surgery

5. Integumentary

a. IV infiltration

b. Pressure injury

c. Skin failure (e.g., hypoperfusion)

d. Wounds

D. Musculoskeletal/Neurological/Psychosocial (15%)

1. Musculoskeletal

a. Compartment syndrome

b. Musculoskeletal surgery

c. Musculoskeletal trauma

d. Rhabdomyolysis

2. Neurological

a. Acute spinal cord injury

b. Agitation

c. Brain death

d. Congenital neurological abnormalities

e. Delirium

f. Encephalopathy

g. Head trauma

h. Hydrocephalus

i. Intracranial hemorrhage

j. Neurogenic shock

k. Neurologic infectious disease

l. Neuromuscular disorders

m. Neurosurgery

n. Pain: acute, chronic

o. Seizure disorders

p. Space-occupying lesions

q. Spinal fusion

r. Stroke

s. Traumatic brain injury (TBI)

3. Behavioral and Psychosocial

a. Abuse and neglect

b. Post-traumatic stress disorder (PTSD)

c. Post-intensive care syndrome (PICS)

d. Self-harm

e. Suicidal ideation and behavior

E. Multisystem (13%)

1. Acid-base imbalance

2. Anaphylactic shock

3. Death and dying

4. Healthcare-associated conditions (e.g., VAE, CAUTI, CLABSI)

5. Hypovolemic shock

6. Post-transplant complications

7. Sepsis

8. Submersion injuries (i.e. near drowning)

9. Hyperthermia and hypothermia

10. Toxin and drug exposure

II. Professional Caring & Ethical Practice (20%)

A. Advocacy/Moral Agency

B. Caring Practices

C. Response to Diversity

D. Facilitation of Learning

E. Collaboration

F. Systems Thinking

G. Clinical Inquiry

CLINICAL JUDGMENT

General

• Manage patients receiving:

o continuous sedation

o extracorporeal membrane oxygenation (ECMO)

o nonpharmacologic interventions

o pharmacologic interventions

o intra-procedural and post-procedural care

o post-operative care

o vascular access

• Conduct physical exam of critically ill or injured patients

• Conduct psychosocial exam of critically ill or injured patients

• Evaluate diagnostic test results and laboratory values

• Manage patients during intrahospital transport

• Manage patients undergoing procedural sedation

• Manage patients with temperature monitoring and regulation devices

• Provide family-centered care Cardiovascular

• Manage patients requiring:

o arterial catheterization (e.g., arterial line)

o cardiac catheterization

o cardioversion

o CVP monitoring

o defibrillation

o epicardial pacing

o near-infrared spectroscopy (NIRS)

o umbilical catheterization (e.g., UVC, UAC)

• Manage patients with:

• cardiac dysrhythmias

• hemodynamic instability Respiratory

• Manage patients requiring:

o artificial airways (e.g., endotracheal tubes, tracheotomy)

o assistance with airway clearance chest tubes

o high-frequency oscillatory ventilation (HFOV)

o mechanical ventilation

o noninvasive positive-pressure ventilation (e.g., CPAP, nasal IMV, high-flow nasal cannula)

o prone positioning

o respiratory monitoring devices (e.g., SpO2, SVO2, EtCO2)

o therapeutic gases (e.g., oxygen, nitric oxide, heliox, CO2)

o thoracentesis

Hematology and Immunology

• Manage patients receiving:

o plasmapheresis, exchange transfusion or leukocyte depletion

o transfusion

Neurological

• Conduct pain exam of critically ill or injured patients

• Manage patients with seizure activity

• Provide end-of-life and palliative care

• Manage patients requiring:

o neurologic monitoring devices and drains (e.g., ICP, ventricular drains, grids)

o spinal immobilization Integumentary

• Manage patients requiring wound prevention and/or treatment (e.g., wound VACs, pressure reduction surfaces, fecal management devices, IV infiltrate treatment)

Gastrointestinal

• Manage patients with inadequate nutrition and fluid intake (e.g., chewing and swallowing difficulties, alterations in hunger and thirst, inability to self-feed)

• Manage patients receiving:

o enteral and parenteral nutrition

o GI drains

o intra-abdominal pressure monitoring Renal and Genitourinary

• Manage patients requiring:

o electrolyte replacement

o renal replacement therapies (e.g., hemodialysis, CRRT, peritoneal dialysis)

Multisystem

• Manage patients requiring progressive mobility

Behavioral and Psychosocial

• Conduct behavioral exam of critically ill or injured patients (e.g., delirium, withdrawal)

• Manage patients requiring behavioral and mental health interventions

• Respond to behavioral emergencies (e.g., nonviolent crisis intervention, de-escalation techniques)

I. CLINICAL JUDGMENT (80%)

A. Cardiovascular (5%)

1. Acute pulmonary edema

2. Cardiac surgery (e.g., congenital defects, patent ductus arteriosus)

3. Dysrhythmias

4. Heart failure

5. Hypovolemic shock

6. Structural heart defects (acquired and congenital, including valvular disease)

B. Respiratory (21%)

1. Acute respiratory distress syndrome (ARDS)

2. Acute respiratory failure

3. Acute respiratory infection (e.g., pneumonia)

4. Air-leak syndromes

5. Apnea of prematurity

6. Aspiration

7. Chronic conditions (e.g., chronic lung disease/bronchopulmonary dysplasia)

8. Congenital anomalies (e.g., diaphragmatic hernia, tracheoesophageal fistula, choanal atresia, tracheomalacia, tracheal stenosis)

9. Failure to wean from mechanical ventilation

10. Meconium aspiration syndrome

11. Persistent pulmonary hypertension of the newborn (PPHN)

12. Pulmonary hemorrhage

13. Pulmonary hypertension

14. Respiratory distress (RDS)

15. Thoracic surgery

16. Transient tachypnea of the newborn

C. Endocrine/Hematology/Gastrointestinal/Renal/Integumentary (27%)

1. Endocrine

a. Adrenal insufficiency

b. Hyperbilirubinemia

c. Hyperglycemia

d. Hypoglycemia

e. Inborn errors of metabolism

2. Hematology and Immunology

a. Anemia

b. Coagulopathies (e.g., ITP, DIC)

c. Immune deficiencies

d. Leukopenia

e. Polycythemia

f. Rh incompatibilities, ABO incompatibilities, hydrops fetalis

g. Thrombocytopenia

3. Gastrointestinal

a. Bowel infarction/obstruction/perforation (e.g., mesenteric ischemia, adhesions)

b. Feeding intolerance

c. Gastroesophageal reflux

d. GI abnormalities (e.g., omphalocele, gastroschisis, volvulus, imperforate anus, Hirshsprung disease, malrotation, intussusception, hernias)

e. GI surgeries

f. Hepatic failure (e.g., biliary atresia, portal hypertension, esophageal varices)

g. Malnutrition and malabsorption

h. Necrotizing enterocolitis (NEC)

i. Pyloric stenosis

4. Renal and Genitourinary

a. Acute kidney injury (AKI)

b. Chronic kidney disease

c. Congenital genitourinary conditions (e.g., hypospadias, polycystic kidney disease, hydronephrosis, bladder exstrophy)

d. Genitourinary surgery

e. Infections

f. Life-threatening electrolyte imbalances

5. Integumentary

a. Congenital abnormalities (e.g., epidermolysis bullosa, skin tags)

b. IV infiltration

c. Pressure injury/ulcer (e.g., device, incontinence, immobility)

d. Wounds:

i. non-surgical

ii. surgical

D. Musculoskeletal/Neurological/Psychosocial (13%)

1. Musculoskeletal

a. Congenital or acquired musculoskeletal conditions

b. Osteopenia

2. Neurological

a. Agitation

b. Congenital neurological abnormalities (e.g., AV malformation, myelomeningocele, encephalocele)

c. Encephalopathy

d. Head trauma (e.g., forceps and/or vacuum injury)

e. Hemorrhage:

i. intracranial (ICH)

ii. intraventricular (IVH)

f. Hydrocephalus

g. Ischemic insult (e.g., stroke, periventricular leukomalacia)

h. Neurologic infectious disease (e.g., viral, bacterial, fungal)

i. Neuromuscular disorders (e.g., spinal muscular atrophy)

j. Neurosurgery

k. Pain (acute, chronic)

l. Seizure disorders

m. Sensory impairment (e.g., retinopathy of prematurity, hearing impairment, visual impairment)

n. Stress (e.g., noise, overstimulation, sleep disturbances)

o. Traumatic brain injury (e.g., epidural, subdural, concussion, physical abuse)

3. Behavioral and Psychosocial

a. Abuse and neglect

b. Families in crisis (e.g., stress, grief, lack of coping)

E. Multisystem (14%)

1. Birth injuries (e.g., hypoxic-ischemic encephalopathy, brachial plexus injury, lacerations)

2. Developmental delays

3. Failure to thrive

4. Healthcare-associated conditions (e.g., VAE, CAUTI, CLABSI)

5. Hypotension

6. Infectious diseases (e.g., influenza, respiratory syncytial virus, multidrugresistant organisms)

7. Life-threatening maternal/fetal complications (e.g., eclampsia, HELLP syndrome, maternal-fetal transfusion, placental
abruption, placenta previa)
8. Low birth weight/prematurity

9. Sepsis

10. Terminal conditions (e.g., end-of-life, palliative care)

11. Thermoregulation

12. Toxin/drug exposure (e.g., neonatal abstinence syndrome, fetal alcohol syndrome, maternal or iatrogenic).

II. Professional Caring & Ethical Practice (20%)

A. Advocacy/Moral Agency

B. Caring Practices

C. Response to Diversity

D. Facilitation of Learning

E. Collaboration

F. Systems Thinking

G. Clinical Inquiry

CLINICAL JUDGMENT

General

• Assess pain considering patients gestational age

• Follow protocol for newborn car seat testing, hearing and congenital heart disease screening

• Follow protocol for feeding and supplementation

• Identify and monitor normal and abnormal diagnostic test results

• Implement interventions to keep neonates safe (e.g., transponder use, safe sleep)

• Manage monitor alarms based on protocol and change in patient condition

• Manage patients receiving complementary alternative medicine and/or nonpharmacologic interventions

• Manage patients receiving medications (e.g., safe administration, monitoring, polypharmacy)

• Monitor patients and follow protocols for pre- and postoperative care

• Recognize indications for, and manage patients requiring, central venous access

• Recognize normal and abnormal:

o developmental exam findings and provide developmentally appropriate care

o family psychosocial exam findings

o physical exam findings

• Recognize signs and symptoms of emergencies, initiate interventions, and seek assistance as needed

Cardiovascular

• Apply leads for cardiac monitoring

• Identify, interpret and monitor cardiac rhythms

• Monitor hemodynamic status and recognize signs and symptoms of hemodynamic instability

• Recognize early signs of decreased cardiac output

• Recognize normal fetal circulation and transition to extra-uterine life

Recognize indications for, and manage patients requiring:

o 12-lead ECG

o arterial catheter

o cardioversion

o invasive hemodynamic monitoring Respiratory

• Interpret blood gas results

• Manage medications and monitor patients requiring rapid sequence intubation (RSI)

• Recognize indications for, and manage patients with, tracheostomy

• Recognize indications for, and manage patients requiring:

o assisted ventilation

o bronchoscopy

o chest tubes

o endotracheal tubes

o non-invasive positive pressure ventilation (e.g., bilevel positive airway pressure, CPAP, high-flow nasal cannula)

o oxygen therapy delivery device

o prone positioning (lateral rotation therapy)

o rescue airways (e.g., laryngeal mask airway [LMA])

o respiratory monitoring devices (e.g., SpO2, EtCO2) and report values

o therapeutic gases (e.g., oxygen, nitric oxide, heliox, CO2)

o thoracentesis

Hematology and Immunology

• Manage patients receiving transfusion of blood products

• Monitor and manage patients with bleeding disorders

• Monitor patients and follow protocols:

o pre-, intra-, post-intervention (e.g., exchange transfusion)

o related to blood conservation

Neurological

• Manage patients with congenital neurological abnormalities

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Medical Nurse study help

Study seeks to raise awareness for leading non-genetic cause of infant hearing loss

Two years ago, Michelle Zappas, director of the Department of Nursing at the USC Suzanne Dworak-Peck School of Social Work, noticed developmental delays and language regression in her two-year-old daughter Margot. Her little girl had even stopped responding to her own name.

Zappas, a family nurse practitioner with experience in community healthcare settings, suspected early on that the cause might be the result of congenital cytomegalovirus (CMV) infection, the most common viral infection and leading non-genetic cause of hearing loss in infants born in the United States. For the next 24 months she fought for Margot's doctors to consider this, and along the way realized there was a significant gap in knowledge among medical professionals—and the general public—about the potential effects of CMV.

She consulted with colleagues Sharon P. O'Neill, clinical associate professor at the Rory Meyers College of Nursing at New York University, and Courtney Rotz, adjunct professor in the Department of Nursing at USC Social Work, to help research and document a case report. The three nurse practitioners recently published their findings, "Congenital Cytomegalovirus Infection: A Case Report," in The Journal of Nurse Practitioners.

"The fact that as a healthcare professional I went through this, and was dismissed by quite a few medical professionals, has made me very passionate about spreading the word about CMV," Zappas said. "Not only to the public, but also to the medical community."

Awareness not proportional to prevalence

Through their research, and Zappas' personal experience, the authors discovered that the medical community mostly looks for CMV only in very extreme cases in newborns. But symptomatic newborns only account for 10% of CMV cases. Often, as in Margot's case, newborns may be asymptomatic or have only one or two slight symptoms, and it is not unusual in these cases for newborns to have delayed or progressive hearing loss.

Zappas, O'Neill and Rotz explain in the case report that CMV is a relatively common illness. Many people are exposed to it, and those with robust immune systems do not experience much more than common cold-type symptoms. If a woman acquires CMV during pregnancy, she may be unaware of it. However, if it affects the fetus in utero, it can have neurodevelopment consequences, including hearing loss.

Women who are primarily infected during pregnancy are more likely to give birth to neonates who are symptomatic and suffer long-term effects. The authors also point out that CMV is one of the leading causes of childhood disabilities, yet the awareness is not proportional to the prevalence.

There were signs of potential CMV that many of Margot's doctors missed. Zappas had intrauterine growth restriction causing her daughter to be born very small. Margot also experienced slight delays in her gross motor skills, had some hearing and words early on but then regressed. Even with a medical background and the ability to navigate the health care system, Zappas was often dismissed as a "hysterical mom," causing the eventual diagnosis for her daughter to be delayed.

"We, as medical personnel, need to be aware that the family may have a bigger insight into what's going on," Zappas said. "And the family needs to advocate for themselves and their children for whatever those needs are. We can all support that, even for people who do not have as many resources as I did."

Zappas hopes the case report will also bring more awareness of CMV to the Deaf and Hard of Hearing (DHH) community.

Changing the conversation

Zappas joined the National CMV Foundation and its fight for education, research funding and implementation of a national program to screen every newborn for congenital CMV. Only seven states require CMV education for pregnant women and targeted newborn screening. Only Minnesota has enacted universal newborn CMV screening.

According to Zappas, while a vaccine is in the works, that should not preclude patient education of how CMV is spread and what the symptoms are during pregnancy or in a young infant or toddler. If caught early enough, anti-virals may delay or decrease hearing loss as well as other sequelae such as cerebral palsy and retinitis.

"It needs to be on people's radar for any child that is having some speech and language delay, lagging in some of their gross motor or fine motor skills, or had a complicated birth or prenatal history," Zappas said. "This case report is really for nurse practitioners to make this a part of our differential."

More information: Michelle P. Zappas et al, Congenital Cytomegalovirus Infection, The Journal for Nurse Practitioners (2023). DOI: 10.1016/j.nurpra.2023.104563

Citation: Study seeks to raise awareness for leading non-genetic cause of infant hearing loss (2023, June 12) retrieved 13 June 2023 from https://medicalxpress.com/news/2023-06-awareness-non-genetic-infant-loss.html

This document is subject to copyright. Apart from any fair dealing for the purpose of private study or research, no part may be reproduced without the written permission. The content is provided for information purposes only.

New study may help improve diagnosis of cognitive disability in Parkinson's disease

A few minutes of data recorded from a single electrode placed on top of the head may be sufficient to predict thinking problems, including dementia, in patients with Parkinson's disease (PD). The finding from a new University of Iowa study might help improve diagnosis of cognitive disability in PD and develop new biomarkers and targeted therapies for cognitive symptoms of the disease.

"Cognitive decline, including dementia, is a significant and underappreciated symptom of Parkinson's disease. Around 30% of patients can have cognitive symptoms at the beginning of the disease, and up to 80% will have cognitive problems at some point in their disease," says Nandakumar Narayanan, MD, PhD, associate professor of neurology at the UI Carver College of Medicine and senior author of the new study, which is published in the Journal of Neurology, Neurosurgery & Psychiatry. "Furthermore, although we have quite a few effective treatments for the motor symptoms of Parkinson's, including medical therapies and deep brain stimulation, we have very few treatments for the cognitive aspects of Parkinson's disease."

EEG: a potential tool for predicting cognitive function in Parkinson's

The brain recordings were made using a very old, widely available technology called electroencephalography (EEG), which measured low-frequency brain waves, known as delta and theta waves, in the frontal region of study participants' brains. The UI team found that reduced strength of these specific brain waves when a patient is required to engage in thinking is strongly linked to cognitive dysfunction in PD. The findings suggest that EEG, which is also inexpensive and non-invasive, might be useful for diagnosing cognitive impairment in PD patients.

"Traditional methods for diagnosing cognitive problems often involve time-consuming pen and paper tests and require a neurologist to administer and interpret the tests. In addition, because these traditional tests can be 'learned,' they cannot be used repeatedly over time for the same patient," says Narayanan, who also is a neurologist with UI Health Care and a member of the Iowa Neuroscience Institute. "In contrast, EEG can be done continuously over several hours or days. It can be applied in nursing homes, or patient's homes, and it gives you a richly featured description of a patient's cognitive status."

The EEG measurements might also be useful for monitoring and fine tuning the cognitive side effects of medications and brain simulation used to treat for Parkinson's disease. Eventually, EEG could even provide a basic assay to determine whether new treatments for PD are effective at improving cognitive function.

Diminished brain signal linked to cognitive problems in Parkinson's

Lastly, the study, which is one of the largest to date, involving 100 PD patients across the full spectrum of cognitive function from healthy to dementia, and 49 demographically similar control participants, reveals a fundamental insight into the role of the brain signal being measured by the EEG electrode.

All the participants completed three different tasks that are commonly used to assess cognitive control, and while they were doing the task, a single EEG electrode measured the strength of the low frequency delta and theta brain waves from their frontal cortex.

Narayanan's team found that diminished cognitive function was correlated with diminished strength of low frequency brain waves while the patient was doing a task. Importantly, it did not matter which cognitive task the patient was doing during the measurement.

Surprisingly, the effect was seen simply because the patient was required to pay attention to a cue and respond. I think this is the deep insight into why Parkinson's patients have cognitive problems: they fail to engage these basic response processes in the brain."

Nandakumar Narayanan, MD, PhD, associate professor of neurology at the UI Carver College of Medicine and senior author of the new study

"That was very surprising to us, and it's helpful because it means we might be able to get information about cognitive function using the simplest version of this task where there's a cue, and the patient has to engage and respond. That process-; cue, engage, respond-;might be enough to determine where patients are on the cognitive status scale and whether they have the potential to improve."

Narayanan says this insight might also be an opportunity to help patients. Potentially "cueing" Parkinson's patients to engage in a task-; whether it's walking, talking or thinking, might improve how well they perform the task. If this is true, it would have important implications for the way rehabilitation, occupational, and speech therapists help patients with PD.

The next steps for Narayanan's team are to investigate the mechanisms that link diminished delta and theta brain waves to worse cognition in PD, and to better understand how EEG technology might be used to improve diagnosis or even treatment of cognitive dysfunction in patients with PD.

In addition to Narayanan, the research team included Arun Singh, PhD, at University of South Dakota; Rachel Cole, Arturo Espinoza, and Jan Wessel at the UI; and James Cavanagh at the University of New Mexico. The research was funded in part by grants from the National Institute of Neurological Disorders and Stroke.

Source:

Journal reference:

Singh, A., et al. (2023) Evoked mid-frontal activity predicts cognitive dysfunction in Parkinson's disease. Journal of Neurology Neurosurgery & Psychiatry. doi.org/10.1136/jnnp-2022-330154.

Global study highlights deaths from neonatal sepsis and steps to improve treatment

image: Newborn with sepsis view more

Credit: GARDP

A global observational study co-led by UCL (University College London), which involved more than 3,200 newborn babies suffering from sepsis in 19 hospitals in 11 countries, has shown that many newborns are dying because the antibiotics used to treat sepsis are losing their effectiveness.

The study, conducted from 2018 to 2020, found there was high mortality among infants with culture-positive sepsis (almost 1 in 5 across the hospital sites), and a significant burden of antibiotic resistance. The study has provided a wealth of high-quality data aimed at improving the treatment of newborn babies with sepsis.

The findings of the observational study have been published in a paper in PLOS Medicine co-authored by a global team of over 80 researchers spanning four continents. https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004179

The study was conducted by the Global Antibiotic Research and Development Partnership (GARDP) in collaboration with the Medical Research Council Clinical Trials Unit at UCL, whose research team led in analyzing the data; St George’s, University of London (SGUL); Penta – Child Health Research; and the University of Antwerp.

“It was very important to undertake this study to get a better understanding of the kind of infections we’re seeing in newborns in hospitals, the bugs causing them, the treatments that are being used and why we are seeing more deaths. The study has given us vital information which will help us to better design clinical trials and ultimately improve the care and outcome of babies with neonatal sepsis,” said Manica Balasegaram, Executive Director of GARDP.

Sepsis is a life-threatening bloodstream infection which affects up to 3 million babies a year globally. Every year, 214,000 newborn babies, mostly in low- and middle-income countries (LMICs), die of sepsis that has become resistant to antibiotics. Newborn babies are particularly at risk of severe infection because of their underdeveloped immune systems.

Findings

There was extensive variation in mortality between the 19 hospitals in the study, ranging from 1.6% to 27.3%, with markedly higher rates in LMICs. Leading clinicians in hospitals in Bangladesh, Brazil, China, Greece, India, Italy, Kenya, South Africa, Thailand, Vietnam and Uganda took part in the study.

“The study exposed the glaring reality of antibiotic-resistant infections, especially in hospitals in LMICs, where we are often faced with a shortage of nurses, beds and space. The risk of infections is very high and most infections are resistant to antibiotics. If an antibiotic doesn’t work, the baby often dies. This urgently needs to change. We need antibiotics that will cover all bacterial infections,” said Sithembiso Velaphi, head of paediatrics at Chris Hani Baragwanath Academic Hospital in Johannesburg, South Africa.

The study highlights a worryingly wide variation in treatment. More than 200 different antibiotic combinations were used by hospitals in the study, with frequent switching of antibiotics due to high resistance to treatments.

Many physicians were forced to use antibiotics such as carbapenems due to the high degree of antibiotic resistance to the recommended treatments in their units. These are classified by the World Health Organization as “Watch” antibiotics. They are recommended only for specific, limited indications as they need to be preserved. However, these were often the only antibiotics available to treat the infection.

Last-line antibiotics were prescribed to 15% of babies with neonatal sepsis enrolled in the study. Klebsiella pneumoniae was the most common pathogen isolated. It is usually associated with hospital-acquired infections.

Future steps to improve treatment and survival

Using the data collected, the team developed two tools that could be used in clinical trials and in any neonatal intensive care unit worldwide. The NeoSep Severity Score, based on 10 clinical signs and symptoms, could be used by clinicians to identify newborns who have a high risk of dying, and ensure they get special attention more quickly. The NeoSep Recovery Score uses many of the same clinical signs and symptoms and could provide clinicians with key information on whether to escalate treatment.

“The observational study has been instrumental in providing the high-quality data that we need to design trials of appropriate treatments for sepsis in newborn babies. It has been a huge collaborative effort by researchers and clinicians in Africa, Asia, Latin America and Europe,” said Neal Russell, Principal Investigator for the neonatal sepsis study at SGUL.

The study also aims to inform WHO guidelines on treatment for newborn babies with sepsis.

“Organisms evolve, drug resistance changes; that is why clinical guidelines for neonatal sepsis need constant adaptation. Updating guidelines relies on recent and good evidence, so this observational study is a significant step towards better treatment,” said Wolfgang Stöhr, statistician for the observational study at the MRC Clinical Trials Unit at UCL.

The results of the study have been used to design a pivotal strategic public health clinical trial to find better treatments for newborn infections in the context of increasing resistance to existing treatments.

The neonatal sepsis trial (NeoSep1) is led by GARDP together with SGUL and the MRC CTU at UCL and is being conducted at Chris Hani Baragwanath Academic Hospital in Soweto, Johannesburg, Tygerberg Hospital in Cape Town and Kilifi County Hospital in Kenya. The trial will also look at appropriate formulations and dosages for newborn babies. The trial will be expanded to other countries and regions from 2024, with a target of recruiting up to 3000 newborns overall.

“Work in formulation and dose appropriateness is imperative. Children are not small adults. Drugs must be formulated to meet their needs in a safe and effective manner,” said Alessandra Nardone, Clinical Project Manager at Penta – Child Health Research.

The new trial will benefit from vital laboratory work carried out during the observational study.

“The Laboratory of Medical Microbiology (LMM LAB-Net) functioned as the central laboratory, supporting local lab analysis for the observational study. We also performed an in-depth molecular analysis on the collected pathogens. Together, these results provide valuable information for the NeoSep1 trial,” said Surbhi Malhotra-Kumar, head of the Laboratory of Medical Microbiology at the University of Antwerp.

Method of Research

Observational study

Subject of Research

People

Article Title

Patterns of antibiotic use, pathogens and prediction of mortality in hospitalized neonates and young infants with sepsis: a global neonatal sepsis observational cohort study (NeoOBS)

Article Publication Date

8-Jun-2023

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