AACN CCRN-Adult - CCRN (Adult) - Direct Care Eligibility Pathway

The patient has thrombocytopenia, which is a low platelet count that increases the risk of bleeding. Heparin is an anticoagulant that prevents clotting, but also increases the risk of bleeding. Therefore, heparin should be avoided in patients with thrombocytopenia. Hemodialysis can be performed without heparin by using alternative methods such as saline flushes, blood predilution, or specialized dialyzers that reduce clotting. Transfusing platelets during hemodialysis is not recommended, as platelets may be damaged by the extracorporeal circuit. Rescheduling hemodialysis may not be feasible, as the patient may have fluid overload, electrolyte imbalance, or uremia that require urgent dialysis.

References:

Use and safety of heparin-free maintenance hemodialysis in the USA

Anticoagulation for the hemodialysis procedure

Dialysis without anticoagulation (Heparin Free Dialysis)

Acute peripheral arterial insufficiency typically presents with sudden, severe pain at rest, which may be accompanied by other signs such as pallor, paresthesia, paralysis, pulselessness, and poikilothermia (the six P's). This condition indicates a critical reduction in blood flow to the affected extremity, requiring immediate medical attention. References: AACN Adult CCRN Certification Review Course, AACN CCRN Exam Handbook.

Crush injuries can lead to significant muscle damage and rhabdomyolysis, resulting in the release of intracellular potassium into the bloodstream, causing hyperkalemia. Tall peaked T waves are a classic sign of hyperkalemia, which needs to be closely monitored in these patients. References: = CCRN Exam Handbook and AACN's Certification Review Course materials.

Sequential compression devices (SCDs) are not recommended for patients receiving therapeutic hypothermia (TH) post-cardiac arrest, because they may interfere with the cooling process and increase the risk of skin injury. SCDs are used to prevent deep vein thrombosis (DVT) by applying intermittent pneumatic pressure to the lower extremities, but they may also increase peripheral blood flow and heat exchange, which can counteract the effects of TH. SCDs may also cause skin breakdown, blisters, or burns in patients with impaired sensation and reduced perfusion due to TH. Therefore, a nurse should clarify the order for SCDs and consider alternative methods of DVT prophylaxis, such as pharmacological agents or early mobilization.

References:

Therapeutic Hypothermia (TH) Education Components: This document states that “Avoid use of sequential compression devices (SCDs) during cooling phase as they may interfere with cooling process and increase risk of skin injury.”

Sequential Compression Devices: Clinical Effectiveness, Cost- Effectiveness and Guidelines: This document states that “One evidence-based guideline from the American Heart Association (AHA) and the American Stroke Association (ASA) recommended against the use of SCDs in patients undergoing therapeutic hypothermia after cardiac arrest, as they may interfere with the cooling process and increase the risk of skin injury.”

This response is the most appropriate because it acknowledges the family’s concern, invites them to share their perspective, and opens up a dialogue about the patient’s condition and comfort. Communication with patients and families about illness progression and end of life requires sensitivity, empathy, and respect. The nurse should avoid making assumptions, giving false reassurance, or dismissing the family’s emotions. Instead, the nurse should explore the family’s understanding, expectations, and needs, and provide information and support accordingly12. Answer A is not appropriate because it does not address the family’s emotional distress or their perception of the patient’s suffering. Answer C is not appropriate because it may contradict the family’s observation or belief, and it may imply that the patient is not aware of their presence or care. Answer D is not appropriate because it may seem like the nurse is avoiding the issue or imposing a religious intervention that the family may not want or need.

Hypoperfusion is a condition in which the blood flow to the organs and tissues is insufficient to meet their metabolic demands. Hypoperfusion can result from third-degree AV block, which is a complete loss of communication between the atria and the ventricles. This causes the ventricles to beat very slowly or not at all, leading to a low cardiac output and reduced blood pressure. Hypoperfusion can cause symptoms such as dizziness, fainting, confusion, chest pain, shortness of breath, and shock12. Heart failure, hypoxia, and chest pain are possible complications of hypoperfusion, but they are not the most common problem in patients with third-degree AV block.

The signs and symptoms described in the patient post-bariatric surgery, including anxiety, restlessness, increased abdominal pain, and subcutaneous crepitus over the neck, suggest a potential anastomotic leak, which is a surgical emergency. Given the vital signs indicating possible sepsis or shock (elevated heart rate, increased respiratory rate, and fever), immediate surgical intervention is likely required to repair the leak and prevent further complications. References: CCRN Exam Handbook, AACN, page 30, section on GI surgical emergencies.

Haloperidol

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Haloperidol has a known side effect of prolonging the QT interval, which can lead to cardiac dysrhythmias123. Therefore, after the administration of haloperidol, it is important for a nurse to monitor for a prolonged QT interval and cardiac dysrhythmias123. This is why continuous cardiac monitoring is recommended if repeated doses are given1.

Kernig's and Brudzinski's signs are classic clinical indicators of meningeal irritation, commonly associated with conditions such as meningitis. Kernig's sign is positive when there is resistance and pain upon extending the knee from a flexed position, and Brudzinski's sign is positive when flexion of the neck causes involuntary flexion of the hips and knees. These signs are not indicative of autonomic hyperreflexia, adrenal insufficiency, or increased intracranial pressure. References: = CCRN Exam Handbook, AACN Adult CCRN Certification Review Course