STUJDY OF THE BASIC KNOWLEDGE LEVEL

OF CRITICAL CARE NURSES

A Thesis Presented to the Division of Nursing

College of Pharmacy and Health Sciences Drake University

In Partial Fulfillment of the Requirements for the Degree

Master of Science in Nursing

by Suzanne Tovz

November 1994

DRAKE UNIVERSITY DIVISION OF NURSING

APPROVAL OF THESIS PROPOSAL

Student Suzanne Baifd Tovar

Title of Thesis Proposal

Approved by:

Thomas S. Westbrook, PhD. Date

ABSTRACT

This remspective data analysis was completed to determine if there is a

relationship between the nurse's level of basic critical care nursing knowledge and

the following variables: basic educational preparation, critical care nursing

experience, cumulative nursing experience, specific critical care unit experience,

and ~ e ~ c a t i o n in critical care nursing. A convenience sampling technique was

used at one midwestern hospital. The sample was comprised of I f 1 subjects who

had completed the BKAT, a 100 question tool by Toth utilized to assess basic

critical care knowledge. The sample was categorized by basic educational

preparation, specific critical care unit, CCRN status, and years of nursing

experience. Results indicated that nurses with more critical care experience had

significantly higher B U T scores than nurses with less critical care experience.

Nurses with CCRN certification had significantly higher BKAT scores than nurses

without certification. Nurses with more cumulative nursing experience also had

significantly higher BKAT scores than nurses with less experience. When

comparing basic educational preparation, nurses with a BSN had significantly

higher BKAT scores when compared to nurses with a diploma or associate degree.

However, when comparing each basic educational group separately, there was not a

significant difference between the three educational groups. When comparing

BKAT scores by specific critical care unit, a significant difference between the ICU

and CSICU BKAT scores was found.

TABLE OF CONTENTS

m s m m TABLE OF C O r n N T S LIST OF FIGURE AND TABLES ACKNOWLEDGEMENTS

I;"(STTIODUCllON Overview of the problem Overview of the conceptual basis Purpose of the study Definition of terms Hypotheses Assumptions of study Significance of study to nursing

11. LI3ERATURE REVIEW Conceptual Framework Studies of critical care nursing competencies Summary of Iiterature review

111. METHODOLOGY Subjects and Setting Procedure for Assessment of Learning Needs Protection of Human Subjects Instrumentation Data Analysis

IV. ANALYSIS Descriptive Statistics Inferential Statistics Additional Analyses

V. DISCUSSION AND RECOWhDATIONS Discussion of findings Limitations of study Implications for nursing practice Recommendations for further research Conclusion

REFERENCES

APPENDICES

Figure 1

Table 1

Table 2

Table 3

Table 4

Table 5

Table 6

Table 7

Table 8

Table 9

Table 10

Table 11

Table 12

LIST OF FIGURE Ahm TABLES

Mean Yem of Nursing Experience of AU Subjects

Educational Background of Subj jects by Critical Care Unit

CCRN Certification of Subjects in each Critical Care Unit

Years of Nursing Experience by Unit

B U T Scores for Subjects Based on Education

BKAT Scores Based on Critical Care Unit

1-test Results for Critical Care Experience

L-test Results for CCRN Status

1-test Results for Cumulative Experience

1-test Results for Education

ANOVA Results for Education

ANOVA Results for Specific Critical Care Unit

Tukey-HSD Results for Critical Cure Units

ACKNOWhEDGEhENTS

I would like to thank all of the individuals who were instrumental in helping me

complete this study. Without their assistance, it would have been an impossible

task. To my husband, Jose, for his patience, support and encouragement through

this entire process, thank you. I would not have been able to complete this project

without his confidence in me and support with family activities. To t l ~ e critical care

managers at Mercy Hospital Medical Center for having the insight to use the BKAT

for identifying individual learning needs, thank you. Thank you to my colleagues

for their advice, encouragement, and support during my academic pursuits. To

Sandy Chacko for assisting me on the statistical analysis, thank you. Finally, thank

you to my thesis committee members: Deb Delong for her encouragement and

professional expertise; Dr. Tom Westbrook for teaching me the importance of adult

learning theory; Dr. Mary Hansen for her assistance throughout my graduate

studies and during the final days of thesis preparation.

Over ihc past few desarles, the nursing profession hes by r~r.

explssi~n sf scientific Biswvmies md technofogicd adssnna. \Vigh &e adveaa crf

~ritical care uniry, a highly skilled and &reeraad n h n g sgf is mersrM far the

provision of quality care (Houser, 1999). To g~3tcrlce eomprentiiy irz &*id cape

requires not ady the mastery of technical skills but $so ehe u ~ m g ~ . ~ ofmgk6ve

skiIls (Hughes, 1987).

In the midst of technological advances md budget mns@&&, instim~ons m

faced with the challenges of preparing nurses to fmctioa cEwGveiy in eiliPia1 care

units and retaining experienced nurses in these. units @a&&n & Greg; f 9861%

This need for a consistent level of clinical expdse, coupled ~5th &e vdanee in

nurses' educational backgrounds and experience, requires institutions to assess the

knowledge base of staff nurses. By doing this assessment, institutions would be

aware of their staffs basic knowIedge and fearning needs and educational programs

could be deveIoped to meet these learning needs. Staff nurses wouId, therefore, be

better prepared to provide high quality care for critically ill patients.

It is imperative for institutions to have a means of assessing knowledge levels

of critical care nurses to ensure this quality care. Since resources are limited,

institutions need to use their orientation and educational dollars wisely. With cost-

effective orientation p r o w s and programs designed to meet the learning needs of

staff, the amount of dollars spent on recruitment could be decreased with a

concomitant increase in retention and quality of care (Hamilton & Gregor, f 986). %

Changes in health care delivery are leading to increased competition in

providing cost-effective care and quality outcomes. Therefore, institutions need

competent staff to provide this care. One tool that is being used to assess

competency of critical care nursing staff is the Basic Knowledge Assessment Tool

(BKAT) (Toth, 1984).

One aspect of competency is educational preparation. The issue of what basic

educational preparation is needed for nursing has never been resolved. For an

institution, the basic educational preparation has not been the issue. The issue has

been what does the new staff nurse know. In this study, a comparison between

basic educational preparation and knowledge levels could provide data regarding the

reIationship of educational preparation and the knowledge level of a staff nurse.

Another way to measure competency is the use of certification examinations.

Nurses who have obtained Certification in Critical Care Nursing (CCRN) status

have been promoted in several institutions as experts in providing critical care. The

CCRN status is obtained by completion of a national certification examination,

prepared by the American Association of Critical Care Nurses (AACN).

Approximately 50,000 critical care nurses are certified in neonatal, pediatric, and

adult critical care nursing by AACN (Niebuhr, 1993). Supporters of this

certification believe it provides a means for recognizing those with specialized

knowledge and experience while assuring the public that they are receiving care

from nurses who have met a defined level of competence (Niebuht, 1993). In this

study, the knowledge levels of CCRNs will be compared to the knowledge level of

staff not certified as CCRNs in an attempt to determine whether or not the CCRN

status validates basic critical care knowledge.

cherview of the Conceptual Basis

According to Brookfield (l986), adults learn throughout their lives and use

experience as a resource. When learning, adults prefer that the content and process

have a perceived and meaningful relationship to past experiences. These life

experiences have the potential to enhance or interfere with new learning. Therefore,

if the adult learner experiences educational success early in life, learning is

enhanced.

When adults are gathered in a classroom, learning may or may not be occurring

(Brookfield, 1986). During formal educational preparation, the majority of

teaching may be done in the classroom environment. Therefore, adults who

complete the majority of their educational studies in the classroom environment may

or may not have attained knowledge applicable to clinical practice.

Adults develop into critical thinkers by identifying and challenging assumptions

as well as exploring alternative ways to complete tasks (Brookfield, 1987). Adults

explore the feasibility of these alternatives and question ideas that claim to be the

answer for all problems.

Adults must participate in learning voluntarily and be self-directed if meaningful

learning is to occur (Brookfield, 1987). Identifying learning needs and

encouraging adults to identify ways for these needs to be met assists in learning.

External sources and stimuli also play an important part in an adult's movement

towards independence and self-directed learning (Brookfleld, 1986). These

extrinsic and intrinsic motives include patient care situations requiring knowledge

the adult does not possess and/or internal realization of Iack of knowledge .

Purpose of the Study

The purpose of this study was to determine if there is a relationship between the

level of basic critical care nursing knowledge and the following variables: basic

educational preparation, critical care nursing experience, cumulative nursing

experience, specific critical care unit experience, and certification in critical care

nursing.

Definition of Terns

Critical care nurse was operationally defined as a registered nurse in a critical

care unit. The sample for this study consisted of critical care nurses in a selected

private non-profit hospital.

Critical Care Unit was operationally defined as a nursing area with monitoring

equipment where critically ill patients are admitted. The units, in this study,

included the Coronary Care Unit, Intensive Care Unit, Surgical Intensive Care

Unit, and Cardiac Surgical Intensive Care Unia.

was ~pmtion&iily defined as the highest level of

nursing education completed, This incf uded assmiate degree &AD). &pl~ma, or

baccalaureate (BSN). This was obtained by self-report.

was operabonafly defined as the ntmmkr of

years spent working as a nurse, as a Iiccnsd practical nurse (LPN), maor

registered nurse (Rn) in a c r i ed cart: nuning area, This was o b h h d by self-

report.

was pera at ion ally defined m the n m k r of years

spent working as a nurse, as a licensed pracdcaE nurse (LPN), andlor registered

11rarse (RN). This was obtained by self-report.

was opera~onally defined as the number of

years spent working as a nurse, as a licensed practical ntnrse (LPN), and or

registered nurse (RN) in the present critical care unit. This was obtained by self-

report.

was operationally defined as having passed

the American Association of Critical Care Nwses (AACN) cedfieahon examination

and having maintained CCRN status at the rime data was collectedi. This was

obtained by seE-report.

was &eoreticdly defined as a body of

knowledge that a critical care nurse applies in order to provide safe nursing care to

the patient (Toth & Ritchey, 1984). Basic knowledge in critical care nursing was

operationally defined as scores on the fourth version of the BKAT (Toth & Ritcbey,

1984).

Hypotheses

The first research hypothesis for this study was: Nurses with more years of

experience in critical care nursing will have higher B D T scores &an nurses with

less years of experience. The null hypothesis stated: Nurses with more y e a of

experience in critical care nursing will have the same or lower BKAT scores than

nurses with less years of experience.

The second research hypothesis for this study was: Nurses with certification in

critical care nursing will have higher BKAT scores than nurses without

certification. The null hypothesis stated: Nurses with certification in critical care

nusing will have the same or lower BKAT scores than nurses without certification.

The third research hypothesis for this study was: Nurses with more cumulative

nursing experience will have higher BKAT scores than nurses with less experience.

The null hypothesis stated: Nurses with more cumulative nursing experience wil l

have the same or lower BKAT scores than nurses with less experience.

The fourth research hypothesis for this study was: Nurses with a baccalaureate

degree will have higher BKAT scores when compared to nurses with a diploma or

assmiate degree. The null hypothesis stated: Nurses with a baccalaureate degree

will have the same or lower BKAT scores when compared to nurses with a diploma

or associate degree.

Assumption of Study

The main assumption of this study was that basic knowledge in critical care

nursing is required for safe practice in critical care.

Significance of Study to Nursing

Health care is changing and the quality of care provided is being defined in t e r n

of outcomes. Exploring the relationship between basic critical care nursing

knowledge and selected demographics of critical care nurses can provide insight

into the learning needs of these nurses. This information could be used by

managers, educators, and professional organizations to examine the strategies

needed to prepare nurses for the critical care role. In addition, individual learning

needs could be identilied and cost-effective education could be provided rather than

giving the same education to all.

CP-L4PrER I1

1,ITTRAWRE W E W

TPhis l i t @ E i t ~ review begins wish a p ~ s e n ~ t i o n d the coneeptud f m ~ e ~ ~ r k fw

this study. This is followed by a discussion of inxdividud studies relatd $0 mitical

care ~lursing competencies in regards to ducaGon, experience, and CCWM

certification.

Concepnaal Fsansework

Brooldeld (1 986) believes that when adt~its are in the clas eavimnmen t,

leaning may or may not occur. In formal educational pmmms, the m j o ~ t ~ f of

teaching is completed in the classroom environment. &+my of these f m d

programs are organized in orderly sequences witfa p&ete&n& edetca~onnl

objectives: and activities. By focusing on a t ~ n i n g the predetem~ined objec~ves,

incidental learning is discouraged and lemirtg may m10t occur. TI& applic~hon has

been frequently observed in nursing (Brookfield, 1991). The objectives are

specified in terms of observable behavioral outcomes and are used in task-oriented

instrumental learning. This type of learning does not encourage learners to develop

critical thinking skills and find meaning within their experience. To build on this

type of teaching, the facilitator should build on teachable moments (BrooHield,

1991).

Brookfield (1986) stresses that adult groups prefer to change directions and

revise original purposes and plans of learning programs. By changing direction,

unmricipatd insights can occur. Therefore, this incidental learning and unplanned

aquisition should not be regarded by the participants or facilitators as being of

less value than the previously specified learning outcomes.

Teaching d~ould be a transactional process (Brookfield, 1986). In an effective

teaching-learning ramaction, participants need to be self-directed for meaningful

learning to occur. By encouraging adults to participate in heir educational

endeavours, leaming is enhanced. Identifying individual leaming needs and

enmuraging adults to identify ways for these needs to be met assists in learning.

However, asking adults to take responsibility for their own learning and

independence can be anxiety-producing. Therefore, these adults will need

encouragement from their facilitators to participate in this process.

Adults are encouraged by their external sources and stimuli to become self-

directed learners @rookfield, 1986). The extrinsic and intrinsic motives may

include patient care situations requiring knowledge the adult does not possess and

an internal realization of lack of knowledge. Therefore, experience is a major

motivator for learning.

Experience is an important resource for adults (Brookfield, 1986). Adults learn

throughout their lives and their experiences have the potential to enhance or interfere

with new learning. If the adult learner experiences educational success early in life,

the potential for future learning to occur is enhanced. Also, the adult reflects on

these experiences, gaining knowledge and insight on how to react in situations if

they occur again. This incidental leaming should be valued as highly as the

learning that occurs in the classroom.

According to Brooldeld (1986), the most fundamental flaw with educational

programs developed with predetermined objectives is the tendency to focus on one

form of adult leaming. It does not take into account the most significant type of

personal learning, which is the reflection on experiences. In this type of learning,

the adults reflect on their self-image, change their self-concepts, question meir

behavioral and moral norms, and develop a new perspective. By encouraging this

we of learning, criticill thinking is enhanced. Critical hblkess understand &e

importance of identifying and challenging assumptions, as well as, exploring

alternative ways of thinking and acting (Brookfield, 1987)-

When adults reflect on their experiences, they may identify byearning nee& and

educational programs which would enhance their knowledge. Adults prefer that ffie

content and process of the educational program has a perceivd and n~emin@etl

relationship to past experiences (Brookfield, 1986). Therefore, educaaisnd

programs need to be individualized to assist k the leanring of dl ghcipants

(Brookfield, 1990). No one can predict the range of learning ouzomes that. may

result from this type of program development. In this process, the learners and

facilitators negotiate objectives and methods of Ieaming. Assump~ons of this

teaching practice are that the learners are the best judges of their own needs and the

facilitator should meet these needs as requested. However, this may not always be

the case. Therefore, facilitators and learners should discuss individual learning

needs and develop programs based on input from both. Facilitators may be able to

provide insight on individual learning needs that the learner does not identify

(Brookfield, 1990).

S tu&es of critical care nursing competencies

Critical care nurses must make effective clinical decisions on a daily basis,

therefore, clinical decision making is a highly desirable skill (del Bueno, 1983). TO

make these clinical decisions, critical care nurses must possess a well-develop&

critic& care knowledge base (Oermann & Pmvenzano, 1992). The possession of

critical care howledge does not guarantee effective clinicaf decision

however, clinical decision making cannot occur without this knowledge (Toth &

Ritchey, 1984).

Fagin and Lynaugh (1992) stated that the majority of critical care howledge is

obtained through nursing experts teaching novices the skiils and rationde behind

nursing cares. The theoretical knowledge, taught during educational preparation, is

relevant only to the extent in which it is used in patient care activities (del Bueno,

1983). Students may have demonstrated skills as isolated tasks without emphasis

on performance speed and with minim& environmental sti-essors (Hughes, 1987).

Therefore, clinical experience combined with theoretical knowledge is essential for

the development of clinical decision-making skills (Hughes, 1987).

Fagin and Lynaugh (1992) believe a common responsibility for all to share is

how nurses are prepared for nursing. These authors state that nurses need to be

prepared at the baccalaureate level to ensure quality patient care due to the need for

in-depth arts and science education and clinical experience. According to these

authors, only 22% of registered nurses complete their basic education in

baccalaureate programs and less than a third possess a baccalaureate degree. To

ensure safe patient care, these authors believe the proportion of nurses prepared at

the baccalaureate level must exceed those prepared at the lower levels. They found

that the basic educational nursing programs range from two to four yeas, with

varying content and clinical experiences. To further complicate issues, associate

degree program faculty rarely meet faculty in baccalaureate programs, creating

minimal collaboration between the two faculty groups on educational decisions.

Jackle, Ceronsky, and Petersen (1977) sent questionnaires to elicit information

about students' critical care experience in school to a random sample of 104

applicants for the Mnnesora State Board Examinations. The rerum rate w u 89%

and the sample consisted of 36% baccalaureate, 35% associate degree, and 29%

diploma graduates, representing 32 schools of nursing. Approximately 75% of the

students had experience in critical care, ranging from 6 - 320 hours with an average

of 46 hours. The students reported caring for 1- 6 acutely 31 patients by observing,

completing selected procedures, or helping a staff nurse provide cares. Of these

students, 58% considered themselves unprepared to work in critical care with 37%

citing the reason as not enough practice. Interestingly, the baccaluareate and

diploma graduates were more likely to consider themselves capable of working in

critical care.

Reynolds, Wood, and Garnero (1991) evaluated critical care educational

preparation by sending questionnaires to 455 NLN accredited baccalaureate nursing

programs. There was a 65.1% return rate, with 75% indicating their undergraduate

curriculum incorporates critical care concepts. However, these concepts were

incorporated in a variety of ways with two to twenty-one clinical days reported. In

39% of the programs, the critical care experience was limited to observation rather

than direct patient care. The student-to-faculty ratio varied from 3-12 students per

faculty person. The majority of programs used the adult critical care environment

for these clinical experiences.

Oermann and Provenzano (1992) utilized the BKAT to study the effects of a

critical care nursing course for nursing students. The sample consisted of 46 senior

nursing students in a baccalaureate nursing program. The expesimentd group

comprised of 3 1 students, six attended lecture while 25 attended lecture and clinical.

The control group consisted of 15 senior nursing students not ykdclp~ting in the

critical care nursing course. Smdents enmIfed in the lecture scored i8t man of &,7

on the BKAT at pretest and 72.2 at pstaest. This was zfot statis~cdly sigt~iEcant

The students em1led in the kctm and clinical showed a s~~s t i cs l iy signscant

difference (g < .UQl) between pretest and posrtest scores. M e n cQrnp&ng B U T

posttest scores for iecture, lm~reiclinical, and mntml p u p s , M 8 V R ~ v e d e d a

significant difference ( p = -087) across the gmups In this study, the hands-on

experience made a difkrence. However, due to the d i spa r i~ of goup si~es, theses

findings have limited generafizability.

Scheqe and Rompre (1985) reported that nurses fro111 aapprenrice-t_we iflplma

programs, based in hospital settings, were better prepmed for the red world, The

majority of leaning revolved around hands-on skill acquisidon. By slaoving

nursing education to the university setthg and the focus on the theomticd

component, the skill acquisition has k e n 10s t. This has left the college-bas&

nursing graduate unprepared for the red world of nursing.

To deal with the disparity between education and the red world, a profiferation

of nurse internship programs were developed over the years (Schempe Br Rompre,

1986). These hospital internship programs were devebged to bridge the gap

between education and service. The programs were designed as an extended

training period for new nurses. According to Gibbons and Lewison (1980), many

of the nurse internship programs were required for the associate degree graduate.

The diploma graduate was rarely required to participate in the program. However,

due to restructuring in the hospital setting, these programs have lost popularity

today. Nursing staffing patterns have changed and the cost-effectiveness of these

programs have not always been proven.

DeBack and Mentkowski (1986) studied nursing performance based on

education and experience. These authors identified nursing competencies in three

midwestern health care settings: acute care, long-term care, and a community

agency. Eighty-three nurses were interviewed, using the Job Competence

Assessment. Of these subjects, 38 were associate degree and diploma nurses while

45 possessed a baccalaureate or higher degreee. Nurses with five or more years of

experience (n = 29) were contrasted with nurses with less than five yeas of

experience (n = 54). The findings showed that nurses with more education acted

more independently, responsibly, or took an advocacy role for another (p < .05).

This group also influenced others by attempting to change behaviors and coached to

increase the responsibility of others (p < .08). Conceptualization was positively

associated with experience (p < .05), showing that this group supported their

actions with relationship between information. Interestingly, the more experienced

nurses exhibited less helping skills, including Iess active listening, rapport,

empathy, and provision of information (p < .01).

Most educators agree that the learning needs of experienced registered nurses

differ from those of the novice nurse (Barrows, f 983). Education combined with

experience influence what and how much nurses know, and that makes a difference

in the health and well-being of patients (Fagin & Ly naugh, 1992). Oemann and

Provenzano (1992) feel that prior experience in nursing is a significant factor in

terms of job performance. This prior experience enables the nurse to acquire the

knowledge and skills needed for data interpretation md interventions.

del Bueno (1983) believed the understanding of an actual nursing situation

occurs only though experience and analysis of similar and contrasting situations.

This author completed a study where she provided experienced and inexperienced

nurses with twelve video-simulated patient situations and asked nurses to choose

actions. The simulations consisted of common physiological problems.

In this study, the inexperienced nurse group consisted of 14 baccalaureate, 27

a~sociate degree, and 3 diploma graduates. Experienced was defined as having

seven months or more of nursing experience. The experienced group consisted of

15 baccalaureate nurses, 12 associate degree nurses, and 14 diploma nurses. The

majority of the nurses worked with adult medical-surgical patients in critical care

units or general units. The results showed that the experienced nurses made fewer

decision errors in problem identification and subsequent action than those in the

inexperienced group. Seventeen percent of the experienced group and nineteen

percent of the inexperienced group labeled the problem incorrectly. Twenty-two

percent of the experienced nurses and twenty-nine percent of the inexperienced

nurses chose the wrong action. However, the experienced diploma nurses and

inexperienced associate degree nurses made the most unacceptable decisions while

the experienced baccalaureate nurses performed best. Forty-seven percent of the

experienced baccalaureate nurses appropriately identified the problem and

subsequent action.

McCloskey and McCain (1988) exmined job performances of nurses in critical

care units. Tfie sample consisted of 320 nurses who joined a midwesrern university

in a 16-month period. The breakdown of the sample was 70 associate degree

nurses, 5 1 dlploma nurses, 188 baccalaureate nurses, and 10 master's degree

nurses. Of this sample, 150 completed the study by completing self-reports at 1,6,

and 12 month intervals. Addtiorsal data was collected Mrn perfommce

evaluations and the S h Dimension Scale of Nursing PerBorn~nce. With regessim

analysis, years of IW experience was relatehi sighrificme y to criticaI c m

performance (r = -24) and leadaship skills (r = -1 5). The years of toad experience,

including LPN and aide expefience, was the best p~&ctor of cni6caH care &ills

(r = -25). Continuing education was significantdy related (I- = -18) to the Scde of

Nursing Perfomance, however, fomd &education was not.

According to Barrows f 1983), experienced nurses develop specialties in their

area of practice and it is difficult to assess heir basic knowi&ge level. These

experienced nurses are regarded by others as knowledgeable and assessment of

basic knowledge may not be considered However, it is imperative that knowledge

levels and lack of knowledge be recognized in all levels of critical care nursing

practice.

Fmdson (1 980) felt that periodic checking of competence was one way to

assure competency and that this can be accomplished though examinations,

performance evaluations, or other measurements. The use of examinations is a

nonthreatening means of identifying a nurse's learning needs (Barrows, 148T),

Whittaker and Henker (1 987) agree that an examination may show that a nurse has

adequate knowledge but it cannot always measure the ability to apply this

knowledge in a clinical situation. However, the examinations may identify those

nurses possessing the knowledge for safe practice and those without adequate

knowledge levels. This type of assessment may be used to plan educational

programs for staff or to identify the basic knowledge level of cri~cal care nurses.

The result can be increased competency level of staff and decreased potential of

malpractice c h h s against a hospital (%%ittaker & Henker, 1987).

Houser (1977) studied 50 newly employed nurses in thee chiticat care units and

two post-acute units in a 1000 bed hospital. The purpose of &e study was to

identify the predictive factors of successfuI job performance, based on perlbmance

evaluations. She found a correlation between prior ciinical experience, high post

orientation test scores, educational background, and job performance. 'Fhe

performance level of all associate degree graduates, at six months, was below the

minimal expectations. The educational background of the nurse (with OF without

clinical experience) was not as significant a factor in test scores as it was in

performance levels. The majority of the subjects tmk six months to adapt to the

intensive care unit role. Prior clinical experience in any area was a significant

predictor of successful job performance. Those with critical care experience scored

higher on performance evaluations than those with other clinical experiences.

However, lack of experience was not a significant predictor of low performance

evaluations.

Toth (1984) administered the BKAT to a sample of 100 critical care nurses,

including 18 new graduates with less than one month critical care experience.

The sample included 6 1 baccalaureate nurses, 20 diploma nurses, 12 associate

degree nurses, and 7 master's degree nurses. Scores ranged from 50 - 8 1, with an

average of 75.5 and mean of 67.9. The length of critical care experience was found

to be the best explanation and predictor of basic knowledge (p < 0.00 1). A

statistically significant difference was found between the new graduates with less

&an one month of critical care experience and those nurses with greater than six

months to greater than five years of critical care experience (p = 0.01). In addition,

a statistically significant difference was found between nurses certified in critical

care nursing (CcRN) and those not certified (p = 0.01). Neither the basic

ducational preparation or the type of critical care unit the nurse worked in was

statistically related to the B U T scores (p = 0.24). Also, whether the test was

talcen on a supeNised or unsupervised basis was not statistically refated to the

BKAT scores (p = 0.77). Toth concluded that as the nurse gained critical care

experience, basic knowledge increased.

Toth (1986) repeated the study by contacting 152 critical care nurses fmrn

among critical care nurses belonging to the American Association of Critical Case

Nursing. Eighty-four nurses participated by completing the BKAT. The results

showed that nurses with more experience in critical care nursing have more basic

knowledge than do nurses with less experience (p < .0l). In addition, CCRNs had

more basic knowledge than non-CCRNs (p < .01). The length of experience in

non-critical care nwsing was not a significant predictor of basic knowledge

(p > .05). The results showed there was no significant difference in basic

knowledge among nurses with an associate degree, a diploma, or a baccalaureate

degree (p > .05).

In studying utilization of the BKAT to assess knowledge levels, Toth and

Dennis (1993) completed a study using a national sample of 93 nurses who

requested copies of the BKAT over a period of 12 months. Of this sample, 58.1%

completed and returned the questionnaire. Two-thirds of the sample used h e

BKAT during the orientation of nurses to the critical care unit Other uses of the

BKAT included placement of nurses with previous experience and evaluation of

cwen t staff. The BKAT scores were usually reviewed with the individual staff

nurse by the inservice educator. The nunes completing the study provided

information regarding their orientation programs and w a e using as many as five

written tests for orientation. These tests included the B U T as well as EKlj and

medication tests.

Toth (1994) completed mother study using a purposive, stratified national

sample of I06 critical care nurses from seven midwestem and eastern states. The

dependent variable was basic knowledge. The independent variables were

experience in criticd care nursing and C C W certification. Other data collected

included years of experience in non-critical care nursing, educational preparation,

critical care unit, job status, tyjx of hospital, and size of unit Experience in criticd

care ranged from new hire to 25 years. The results supprted the theory that nurses

with more critical care nursing experience have more basic knowledge than nurses

with less experience. The findings also revealed that nurses with CCRN

certification have more basic knowledge than non-CCRNs. Variables that were

unrelated to basic knowledge included years worked in a nm-critical care unit,

educational preparation, type of critical care unit, job status, type of hospital, and

size of critical care unit.

Ressler, h g e r , and Herb (1991) used the BKAT to evaIuate new critical care

hires. They compared criticd care nurse interns, experienced critical cue nurses,

and medical-surgical nmes. The convenience sample consisted of 24 critical care

interns, 35 experienced critical care nurses, and 25 experienced medical-surgical

nurses. Tfie intern group consisted of 18 baccalaureate graduates, 4 associate

degree graduates, and 2 diploma graduates. The experienced critical care gorap

consisted of 13 baccalaureate nurses, 10 assmiale degree nurses, and 12 diploma

nurses with years of experience in criticai care ranging from 0.3 - 11 years (average

2.99 years). The 25 experienced medical-surgical group consisted of 12

baccalaureate nurses. 6 associate degree nurses, and 7 diploma nurses with

medical-surgical experience ranging from 0.5 - 9 years (average 2.93 years). After

6 months of employment, there was a statistically significant difference between the

groups'scores (p < .05). The interns had the highest BKAT mean score (88.25)

while the medical-surgical group had the lowest. After one year. the interns

maintained the highest mean but it was not significantly different fiom the other

groups.

Hartshorn (1942) evaluated a critical care nursing internship program by

administering the BKAT to critical care interns and preceptcars. The 33 nurses in

the intern group consisted of 19 baccalaureate graduates, 9 associate degree

graduates, and 5 diploma graduates. The number of preceptors involved was not

given. The average score was 83 for the preceptors while the average intern score

was 75. For the intern group, the mean score on the BKAT prior to the internship

program was 75, while the BKAT score after the internship program was 82. This

was statistically significant. In five of the cases (33.3%), the interns scored higher

on the BKAT than their preceptors. According to Hartshorn (1992), the

preceptors' low scores may suggest that their knowledge of crirical care nursing

may be limited in some areas and a study should be developed to specifically assess

the preceptors' knowledge base.

Henry and Waltmire (1992) used the BKAT, a Cardiovascular Self-Evaluation

T d , and four computerized cIinical simulations to discriminate between nurses

with varied levels of knowledge and experience. The convenience sample consisted

of 23 inexperienced Oess than 1 year) critical care nurses and 119 experienced (1 or

more years) critical care nurses. Of this sample, 53.5% were prepxed at the

baccalaureate level- The experienced critical care nurses had significantly higher

(p < .001) BKAT scores than the less experienced nurses, Also, current and

previous ~ ~ v m c e d ~ardiac life support (ACLS) certified nurses scored significantly

higher (p < ,001) on the BKAT than the nurses who had not been ACLS certified.

The authors concluded that the BKBT discriminated between

experiencdinexperienced nurses and ACLS-certified/non ACLS-cedfied critical

care nurses.

To explore the relationship between the B U T md computer-based clinicd

simulation performance, Henry and Holzerner (1993) completed a study of 68

critical care nurses. The majority of the sampIe consisted of nurses educated at the

baccalaureate level. The subjects completed the BKAT and four computer

simulations of EKG interpretation and appropriate intewentions. Two of the

simulations significantly correlated (p = -001) with knowledge as measured by the

BKAT. However, the other two computer simulations significantly correlated ody

with self-evaluation of expertise (p = .W) and nor with BKAT scores.

Certification in critical case nursing (CCRN) has been promoted as a means of

verifying competency. Therefore, it is poseuIated that nurses with CCRN

certification have attained the basic knowledge required for critical care nursing

practice. Supporters of certification believe it is a mechanism to assist practitioners

in validating competence in practice while patients and families can be confident that

a knowledgeable nurse is providing safe care @unbar, 1985; Johnson, 1985;

Coleman et al, 1988). However, those against certification believe there are nurses

that are able to perform nursing skills and provide high-quality patient care but are

unable to become certified due to poor test-taking skills (Johnson, 1988).

Therefore, the success on a written examination for certification documents the

possession of a theory base. but does not document competent practice (Johnson,

1988). Also, it cou1d be possible that an individual would continue to be certified

by completing continuing education to obtain recertification but would be unable to

pass the original test (del Bueno, 1988). Therefore, employers and consumers

could have a false sense of security by thinking a recertified individual possessed

the current basic knowledge relevant to the profession (del Bueno, 1988).

Walthall et a1 (1993) investigated CCRN status and knowledge with a sample of

212 nurses at five Detroit institutions. The participants were asked if digitalis

should be withheld for a heart rate less than 60 katslmin and to provide the

rationale for their answer. Forty percent of the respondents held a baccalaureate

degree, 14 percent were CCRN certified, and over half of the respondents worked

in a critical care unit. Eighty-one percent of the total respondents inappropriately

withheld digitalis or administered it without appropriate rationale. CCIW nurses

were three times more likely than non-CCRN nurses to respond correctly. After

multivariate analysis, CCRN certification was the only statistically significant

predictor of correct responses,

Summary

Based on the literature review, additional research is needed in this area, There

is a need to examine this relationship at one institution, utilizing demographic

variables similar to Toth's study. If research can show a correlation between

critical care nursing knowledge and other variables, assumptions could be made and

expectations outlined when hiring and opienrlng critical cape sauhsing s~aff, regip%d;d~g

the. possession of basic cfitical care nusing howIedge.

CHAPTER I11

METHODOLOGY

Subjects and Setting

This study was a reEospecrive data analysis, utilizing infomadon previously

collected by this investigator as part of the hospital's plan to identify the educational

needs of critical care staff. A convenience sampling technique was used with

critical care staff nurses at one midwestem hospital. The total population of critical

care nurses in this hospital was 180 registered nurses. Subjects consisted of

registered nurses working in the critical care units in this hospital who have taken

the BKAT.

The setting for the study was a 550-bed private non-profit hospitd. The critical

care units where the sample was employed were the Cardiac Srsrgicd Intensive Care

Unit, Surgical Intensive Care Unit, Medical Intensive Care Unir, and Coronary

Care Unit. The Cardiac Surgical Intensive Care Unit consisted of 14 beds with a

patient population primarily consisting of pediatric and adult open heart surgical

patients and heart transplant patients. The Surgical Intensive Care Unit consisted of

eight beds with a patient population primarily consisting of adult general surgical

patients, adult trauma patients, and kidney transplant patients. The Medical

Intensive Care Unit consisted of 16 beds with a patient population primarily

consisting of neurosurgical patients, neurotraurna patients, chronic obstructive

pulmonary disease patients, and patients without surgical intervention. The

Coronary Care Unit consisted of 33 beds with a patient popdation primarily

consisting of acute myocardial infarction patients, coronary angioplasty patients,

and cardiac arrest patients.

Procedure for Assessment of Learning Needs

deal care nursing division identified the need to assess staff learning

w o r t 0 the assessment, permission to collect demographic data and

administer the BKAT to critical care registered nurses in the hospital was obtained

from the critical cue unit nursing directors and the administrative director of

nursing for critical care (Appendix A). This assessment was done to assist the

critical care educators in identifying learning needs and planning educational

programs.

Critical care staff lists were obtained from each criticd care unit nursing director.

A memo explaining the BKAT, demographic data collection tool, and purpose of

collecting this information was hsmbuted to each critical care department for

posting (Appendix B). The investigator, in her role as a clinical educator, met with

the clinical educators from each Mitical care unit to discuss the process. The

investigator attended individual unit meetings, as needed, for further clarification to

staff. The staff were reminded that their participation and scores on the BKAT

would remain confidential and would not affect their job status or performance

appraisal. A time period of at least 45 minutes was set for completion of the

BKAT. However, individual subjects were allowed more time for BKAT

completion if needed.

The BKAT was initidly distributed at unit department nXetingS, allowing

subjects the time to complete the BKAT at the department meeting. After initial

dispiburion, copies of the BKAT were distributed to unit educators to administer to

the who were not present at the department meeting- Completion of the

BUT was unsupenrised. According to T ~ t h (19841, the B U T has been

administered in a supewised and unsupenrised manneb with no statisiticd

difference. After completing the BKAT, ihc subject could return the BKAT to the

unit educator or send it to the investigator through the hospital mail system. ?*he

official answers to the BKAT were kept by the investigator and all BKATs were

scored by the investigator,

hotection of Human Subjects

Based on staffs input and to assure confidentiality, the last four digits of each

staff nurse's social security number was used to code the answer sheet and

demographic form. Anonymity was maintained during scoring by the investigator.

The individual resuits and originai answer sheet were returned to the staff nurse by

the educator. In one critical care unit, the staff requested anonymity and this was

assured by using random numbers to cade answer sheets. Results were disn-ibuted

by leaving answer sheets in the area and individual staff members retrieving their

answer sheet.

Data was coded by the invesaigatrrrr, using the last four digits of the social

security number or random numbers. The completed forms were stored in a locked

b x in the investigator's home. The data were reported in the aggregate f o m and

individual results were not reported.

Instnrmentation

A demographic form (Appendix C) was utilized to gather data on the following

v&ables: criticd c m nursing experience, years in presen t critical care unit,

cumulative nursing experience, basic nursing education, and CCRN status. The

BKAT, Version 4, (Appendix D) was utilized to assess basic knowledge.

Permission to use the BKAT in this study was obtained by the inves@alor

El- This tool consisted of 100 multiple choice and fill-in-the-blak

~tems- These items measured recall and application of basic knowledge in h e

following areas: cardiovascular, pulmonary, neurology, endocrine, renal, and

gastrointestinal systems and invasive line monitoring. The possible score range

was 0 - IOo. For scoring purposes, there was a breakdown of items relating to

each content area (Appendix F) and a score sheet developed to tally the scores in

each area (Appendix G).

Content for the BKAT was determined through a literature review, interviews

with head nurses and critical care nurses, and suggestions from two critical cafe

physicians and a nine-member panel of expats in critical care nursing practice and

education (Toth, 1984). Toth and Ritchey (1984) tested BKAT Version 1 on a

sample of 100 critical care nurses, including 18 new graduate nurses with less than

one month experience in critical care nursing. Reliability was established by

Cronbach's coefficient alpha result of 0.86. Revisions of the tool were made using

item analysis results. The original panel of experts and two additional nurse experts

were consulted to ensure content validity for the revised tool (Version 2). Version

2 was evaluated on data from a sample of 38 baccalaureate nursing students and 92

critical care nurses who had not previously answered the B U T (Toth, 1984).

Gronbach's coefficient alpha result of Version 2 was 0.83 - 0.86. Item analysis

was completed and the panel of experts were consulted to verify content validity for

the revised tool (Version 3) (Toth, 1984). BKAT Version 3 was studied by Toth

(1986) using a sample of 84 rritical care nurses. Cronbach's coefficient alpha was

0.73 on Version 3. Version 3 was revised and Version 4 has shown Cronbach's

coefficient alpha of 0.88 (Toth & Dennis, 1993).

Data Analysis

The demographic data included registered nursing experience. critical care

experience, yeas in specific critical care unit, cumulative nursing

experience, basic nursing educational preparation, and CCRN status, Basic

nursing educational preparation was categorized as 1) diploma 2) associate degree

3) baccalaureate degree in nursing. The breakdown of basic nursing educational

preparation and CCRN status for nurses in each area were displayed in a table.

Also, CCRN status was categorized as 1) yes 2) no and reported as percentages.

Descriptive statistics were used to summarize the data. The means and standard

deviation for registered nursing experience, critical care nursing experience,

cumulative nursing experience, and years in present unit were presented in a table

and graph. The BKAT score was reported as a mean and standard deviation by

basic nursing educational preparation and by specific critical care unit. In addition,

the range of BKAT scores were reported in each critical care area. These results

were presented in a table.

Inferential statistics were used to determine if there was a relationship between

the study variables, as hypothesized by the researcher. One tailed t-test, with alpha

level of .05, was used to test the hypotheses. To differentiate the nurses with more

years of experience from the nurses with less years of experience, the subjects were

divided based on the cumulative nursing experience median. TO differentiate the

nurses with more years of experience in critical care nursing from the nurses with

less y e m of experience, the subjects were divided based on the critical care nursing

experience To test the hypothesis based on education, the subjects were

divided into two groups of baccalaureate prepared nurses and no~-baccalaureate

prepared nurses.

One-way ANOVA was used to test for a significant relationship between BKAT

scores and the following variables: critical care nursing experience, cumulative

nursing experience, specific critical care unit, and basic nursing educational

preparation. Multifactor analysis was completed to test relationships between

variables.

CMPTER IV

ANALYSIS

Descriptive Statistics

The critical care nurse population at the time of data colIection was 180

registered nurses. A total of 114 subjects completed the BKAT and demogaphic

form. Three of the subjects returned incomplete demographic foms and their data

was no? included in the study. The return rate of usable data was 1 1 I subjects

(61%).

To analyze the data, the subjects were categorized by basic educationaI

preparation, specific critical care unit, and years of nursing expe~ence. The 1 1 1

subjects consisted of 47 diploma nurses, 28 associate degree nurses, and 36

baccalaureate nurses. The number of subjects for each area was: 23 subjects from

the Medical Intensive Care Unit (ICU); 19 subjects from the Surgical Intensive Care

Unit ; 34 subjects from the Cardiac Surgical Intensive Care Unit (CSICU); md 35

subjects from the Coronary Care Unit (CCU).

Basic educational preparation for each of the critical care units varied by the

individual area. As can be seen in Table I , the majority of the ICU nurses were

diploma prepared (52%). In the SICU area, the educational background was

equally disnibuted among the subjects between a11 three educational progms, In

the CSICU afea, the majority of nwses were baccalaureate (44%) or diploma

graduates (40%). In the CCU area, the majority d nurses were associate degree

(34%) or diploma (4%) prepared.

Table l

ICU SICU CSICU CCU

Diploma 12 7 H 4 1 4

BSN 6 6 15 9

Of the total sample, 13% of the nurses were CCW certified. As can be seen in

Table 2, the number of subjects with CCTRN certification varied by areas. Of these

CCRN certified nurses, 64% were from the CSICU area, 21% from the CCU area,

7% from the ICU area, and 7% from the SICU area.

ICU SICU CSICU CCU

CCRN 1 1 9 3

In analyzing years of nursing experience, 75% of the respondents had greater

than two years of FW experience with 30% of the respondents having nine or more

years Rlcd experience. Cumulative experience was based on the total of RRN and

LPN experience reported for each individual. Seventy-six percent (n = 87) of the

respondents reported no prevbus LPN experience. Of the nurses that reported

LPN experience, 93% reported one year or less of LPN experience. Therefore,

there is a minimal difference between the cumulative years of experience and RN

experience alone.

As can be seen in Figure 1, the highest mean nursing experience was cumulative

experience. Oi?icaI care experience was differentiated from specific unit critical

care experience with fifty percent of the respondents having more than three years

of critical care experience. The total years of critical care experience ranged from

new graduates to 27 years of critical cwe experience. Forty percent of the nurses

had 2 - 6 years of critical care experience.

The years of nursing experience varied by the type of experience. Years of

specific critical care unit experience ranged from new graduates to 27 years of

experience in the specific unit. Fifty percent of the respondents had more than two

years of experience in the specific unit. One-third of the nurses reported 2 - 6 yeas

of experience in the specific unit. Based on self-report, one nurse had worked in

critical care and the same unit during her entire RN experience (27 years).

P) 0 c Unit QI .- L Critical a x Care

W *C 0 RN 6.82

0 2 4 5 8

Mean Years of Nursing Experience

Figure 1, Mean years of nursing experience of all subjects.

As can be seen in Table 3, the years of nursing experience varied for subjects

in each of the mas. In the ICU area, 50% of the subjects possessed two or less

years of critical care experience. In the SlCU area, 50% of the subjects possessed

four or more years of critical care experience. In the CSICU area, 50% of the

subjects possessed 6.5 or more years of critical care experience. In the CCU area,

50% of the subjects possessed two or less years of critical care nursing experience.

The CSICU area maintained the highest mean years of nursing experience in each

of the caregories. For the total sample the mean yeas of critical care nursing

experience was 5.21 years (Mdn = 5.1).

Table 3

Years of nursing experience bv unit

ICU srcu CSICU ccu

M - - SD M - SD - M - SD SD -

Cumulative 5.61 7.84 6.40 3.90 9.58 6.79 7.43 5.91

RN 4.80 7.09 6.31 4.00 9.25 6.83 6.59 5.63

Criticalcare 4.06 5.87 4.57 3.91 7.68 5.50 4.53 4.40

Unit 3.79 5.94 3.76 3'01 5.55 4.75 2.80 2.94

As can be seen in Table 4, scores on the BKAT varied by educational background

with the BSN goup scoring the highest mean, The overall mean BKAT score for

all subjects was 82.1 (Se = 7.00).

Table 4

Education - n - M SD -

ADN 28 81.6 6.33

Diploma 47 81.7 7256

BSN 3 6 84.3 6.56

The BKAT scores varied according to the critical care unit of employment (see

Table 5). Subjects in the CSICU and CCU area scored the highest with a score of

94 points. In the ICU and CCU areas, 40% of the nurses scored greater than 85.

In the SICU area, 40% of the nurses scored greater than 82. In the CSICU area,

40% scored greater than 86.

Table 5

BKAT Scores based on Critical Care Unit

Unit tl range - M SD

ICU 23 65 - 91 79.78 8.38

SICU 19 70 - 93 80.84 7.16

CSICU 34 73 - 94 85.03 5.40

CCU 3 5 70 - 94 82.80 6.68

Inferential Stagsrim

A t=test and alpha level of .05 was ussd ro study the hypoxheses. The Erst

hypothesis tested was: Nurses with mom years of experiesce in critical csre

nursing will have higher BKAT scores than nurses with less years of expe~ence.

?he niaicd care nursing experience group was divided iedinro two groups by rhose

subjects above the median years of cfilic~l ca-e expeTlttl?ce ( > 5-21 for me &mup

and those subjects below the median yeas of crilicai G=. exp&e.ace 4 5 5 2 ) for the

second egoup. As can be seen in TabIe 6, the nurses with mare cfiaicai tare

experience had significmnly higher BKAT scores timn mmw with less ch&cd

experience.

Table 6

More CC exper. 37 86.59

Less CC exper. 73 80.53 108 4.67 O.OOO***

*** g < .OOl.

The second hypothesis tested was: Nurses with certification in chitical care

nursing will have higher BKAT scores than nurses without certification. As can be

seen in Table 7, the nurses with certification in critical care nursing had significantly

higher BKAT scores than nurses without certification.

CCRN 14 86.93

non-CCRN 97 $1.89 IW 2.58 Q.W55** - - -- ----- -- -

**p < .Q I.

The third hypothesis tested was: N~vses with more curnsrlagve expe~ence \4fi11

have higher B U T scores than nurses with less ex~fi-ieacc, The cumda~ve

nursing experience group was divided into two goups by $hose subjects abve the

median years of cumulative experience f > 6.8) far sne p u p and those ssubjects

below the median years ( 5 6.8) for the other group. As can be seen in Table 8, the

nurses with more cumulative experience had significmtl y higher BKAT scores t b

rimes with less cumulative experience.

'Fable 8

t-test Results far Cumulative Experience

More experience 47 85.94

Less experience 64 80.16 109 4.5 4 0.W1 -

fad hypothesis tested was: Nurses with a baccalaureate degree wilt have

higher BKAT scores when compated ro nunes with a diploma or associate degree.

As can be seen in Table 9, the nurses with a baccalaureate degree had significmlly

higher BKAT scores when compared to the p u p of nurses with a diploma m

associate degree.

Table 9

1-

BSN 36 84.3 1

Non-BSN 7 5 8 1.67 109 1.88 0.03 1 *

Note: Non-BSN group consisted of associate degree and diploma subjects.

*p < .05.

Additional Ai~aiyses

One-way ANOVA was completed to see if there was a difference between

BKAT scores and each educational group: associate degree, diploma, and

baccalaureate degree. As can k seen in Table 10, no statistically significant

difference was seen.

Table 10

ANOVA results for Education

Source of Variance SS d f - MS E 2

Between Groups 169.55 2 84.77 1.75 0.178

Within Groups 5222.15 108 48.35

One-way ANOVA was conducted to see if there was a difference in BKAT

scores based on employment in specific critical care unit. As can be seen in Table

11. there was a statisdcally significant difference in the scores by critical care units.

Table 11

ANOVA Results for Specific Critical Care Units

Source ss d f MS - E P.

Between Groups 442.68 3 147.56 3.19 -027 * Within 0 s 4949.01 107 46.25

Note: Analysis of Variance was completed to compare the 4 critical care units.

*E< .u5.

A post-hoc test, the Tukey-HSD procedure, was completed to test the difference

between individual units. As can be seen in Table 12, there was a stadsfically

significant difference between the ECU BKAT scores and CSICU BKAT score.

The mean ICU score was 79.78 while the CSICU mean score was 85.03.

Table 12

Tukev-HSD Results for Critical Care Units

Group

Group 1 Group 2 Grouu 4

Note: Group 1 = ICU; Group 2 = SICU; Group 3 = CSICU; Group 4 = CCU.

Tvlultifactor malysis was completed to test for additional significant

relationships. There was not a statisticafly significant interaction between basic

education and area with regard to influence on BKAT score. There was not a

staristically sipificant interaction between education and W experience with regard

to influence on BKAT score. No statistically significant interaction between

education and CCRN certification with regard to influence on BKAT score was

found. No statistically significant interaction was found between RN experience

and CCRN certification with regard to influence on BKAT score.

In checking all variables, no statisticalIy significant interaction was found

between education, CCRN certification, and critical care area with regatd to

influence on B U T score. No statisticalIy significant inremction was found

between RN experience, CCRN cehtifrcacion, and Mitical care area with regard to

influence on B U T score. No statistically significant inresaction was found

between basic education, CCRN certification, RN experience with regard to

influence on B U T score.

CPiAPTER V

DISCUSSION AND RECOMMENDATlONS

lhis chapter begins with a discussion of this study's findings. An idenefica~on

and discussion of limitations in this study as well as implications of h i s study for

nursing practice is presented. Lastly, recommendations for fwther resea& are

outlined.

Discussion of Findings

The PWose of this study was to examine variables that may affect the nurse's

level of critical care nursing knowledge. When comparing nurses' B U T scores

between critical care units, here was a statistically significant difference found

between the ICU nurses' scores and CSICU nurses' scores. This may be due to

the difference between the groups in years of cumulative experience. The ICU

subjects were the least experienced (5.6 years) while the CSICU subjects were the

most experienced (9.6 years). The majority of CCRN subjects were from the

CSICU area while only one subject was from the ICU area. Also, this researcher

postulates that the difference between scores may be due to the type of questions on

the BKAT and the patient care provided in these two units. This researcher has

reviewed the types of patients, equipment, and crirical care knowledge utilized in

these specific units. The ICU is a medical unit caring for neurological patients,

pulmonary patients, and patients without surgical intervention. In the ICU, there is

a s ~ o n g focus on pulmonary and neurological knowledge and equipment related to

these systems. The ICU nurses have a limited exposure to pulmonw xtery lines

and hemodynadc monitoring. In the CSZCU, the patient popul3tion consists of

pediatric and adult open heart surgical patients and heart transplant patients. 73ere

is a Strong focus on cardiac and pulmonary knowledge and equipment related to

these SYstems, including a strong knowledge level of hemodynamics. When

reviewing the BKAT content, 3 1 questions are related to cardiovascular concepts

and 11 questions are related to monitoring lines. These two areas would focus on

knowledge the CSICU nurse would use frequently. For the ICU nurse, ten

questions are related to pulmonary knowledge and ten questions related to

neurology knowledge. Therefore, this researcher postulates that the CSICU nurses

should have higher scores based on the BKAT content and experience level of the

staff.

Based on Brookfield's conceptual framework, adults learn throughout their lives

and they use experience as a resource (Brookfield, 1986). In this study, experience

became an important factor in regard to the possession of basic critical care

knowledge. Brookfield has also addressed formal education and the way adults

learn, implying that learning may or may not occur in this milieu. In this study, the

basic education was not a crucial factor in regards to the possession of basic critical

care knowledge.

Several studies have been completed regarding critical care nursing competencies

and the ways critical care knowledge is obtained (Reynolds, Wood, & Gamero,

1991; McCloskey & McCain, 1988). Educational preparation that includes critical

care content and skill development has been encouraged, however, a standard

educational program across all nursing schools has not been developed. Therefore,

the amount of critical care knowledge obtained through formal education varies by

the type of basic educational preparation (diploma, ADN, and BSN) and by the

individual schools of nursing. Studies have linked more nursing education with

h-mxised independency, responsibility, and coaching capabilities of the individual

nurse (DeBack Mentkowski, 1986). Generally, when comparing different

eduf ational programs, these studies showed that baccalaureate nurses performed

better in actual nursing practice, simulations, and tests of basic critical care nursing

knowledge. In this study, analysis showed there was a difference between the

basic criticd care knowiedge of BSN nurses when compared to non-BSN nurses.

When comparing each educational group (diploma, ADN, and BSN) individually, a

significant difference was not found. However, the years of cumulative nursing

experience for each educational group varied. The diploma soup possessed the

highest years of experience (8.4) followed by the baccalaureate group with 6.9

years, and the associate degree group with the least years of experience (4.7)

After completing basic educational preparation, there remains a disparity

between education and practice. What is taught in nursing school does not equate

to what is expected for performance as a critical care nurse. Further education in

the practice area is required for the new graduate to function competently. En this

study, those nurses who became CCRN certified possessed more basic critical care

knowledge than those nurses without CCRN certification. Nurses prepare for the

CCRN examination by completing coursework, attending seminars, and reviewing

the literature. Therefore, additional education is completed to obtain this critical

care knowledge.

Several studies have been done to identify whether basic educational preparation

andfor nursing experience were valid predictors of critical care nuning knowledge

the individual nurse possessed (Houser, 1977; det Bueno, 1983; Toth, 1986;

McCloskey & McCain, 1988). Of these studies, nursing experience continued to

prove as a valid predictor of critical care nursing knowledge. As a nurse gained

experience, critical cue nursing knowledge was obtained. This wns supponed in

this study by the significant difference in BKAT scores when comparing nurses

with more critical care experience to those nurses with less critical care experience.

Toth completed several studies, udlizing the BKAT, to explore relationships

between basic critical care nursing knowledge and the following: education,

expe~ence, and CXRN certification. The results of these studies demonssated that

CCRN certification and critical care nursing experience were significant predictors

of basic critical care nursing knowfedge. Educational preparation was not a

significant predictor of basic critical care nursing knowledge. Other variables

unrelated to basic knowledge attainment induded years worked in a non-critical care

unit, type of critical care unit, job status, type of hospital, and size of criticd care

unit.

The sample size of this study was 11 1 critical care nmes, similar to Toth's

1994 study consisting of 106 nurses. However, the sample of this study was

obtained from one institution compared to Toth's sample from seven midwestern

and eastern states. Also, there were four critical care units in this study compared

to eleven types of units identified in Toth's study.

Regatding educational preparation in this study, 42% of the subjects were

diploma prepared, 25% ADN prepared, and 32% BSN prepared. In Toth's study,

19% were diploma prepared, 18% ADN prepared, 58% BSN prepared, 2.9%

master's prepared, and 1.9% doctorate prepwed. However, CCRN certification

was 13 % of the subjects CCRN certified in this study and 1 8.4%

certified in Tothb study.

care nursing experience was similar with zero (new to &tical care) to 27

Y e a n of experience in this study while Toth's study included subjects with up to 25

yean of critical care nursing experience. The average length of experience i n this

study was 5-21 y e m compared to Torh's average of 5.4 years.

BKAT score ranges also differed. In this study, scores ranged from 65 - 94

points, with an overall mean of 82.1. In Toth's study, the mean score was 80.2.

Based on analysis in this study, critical care experience significantly positively

affected B U T scores and CCRN certification significantly positively affected

B U T scores. These findings were congruent with Toth's findings.

Generd nursing experience correlated with significantly higher B U T ' scores in

this study. Toth's study showed that the years working in a non-critical care unit

was unrelated to basic critical care knowledge.

In this study, nurses with a baccalaureate degree had significantly higher B U T

scores when compared to the diploma and associate degree group. This

significance was found when comparing two educational groups: BSN nurses and

non-BSN nurses. Toth's study does not support this finding. However, in this

study, when the educational groups were analyzed separately, comparing BSN

nurses, ADN nurses, and diploma nurses as three separate groups, a significant

difference was not found.

Limitations of Study

Several limitations of this study can 'be identified. As mentioned previously, the

that cardiac-surgical intensive care nurses possess more basic critical

care nursing knowledge than medical intensive care nurses cannot be made based

on be different levels of experience and the BKAT content in relation to the

required by Rurses in these meas. If the B U T inrPcIud& more

neurology and pulmonq questions, perhaps this significance would not have k e n

obtained in this study. Also, if the experience levei between the groups was equal.

perhaps his significance would not have ken found,

In this study, the initial orienfafion of the critical care nurses was assumed to be

homogenous for the group. However, orientation time h m e s have varied at this

institution since previously the institution a~lized a critical w e internship program

for new graduates that is no longer offered. Therefore, cvrientntion programs and

times did vary.

In regard to collection of demographic information, the demographic data was

collected by self-report. No attempt was made by this researcher to verify this data

by reviewing individual personnel files.

For the subjects with baccalaureate preparation, no attempt was made to

differentiate between the generic BSN graduates and graduates of BSN completion

progarns. This differenriation could possibly provide additional information.

Also, demographic data on the subject's age and nursing experience when

compiethg basic educational preparation may have been helpful. According to

B r ~ ~ e l d , adults use experience as a resource and those adults working while

completing their basic educational program would have experience as a resource,

assisting &em with retention of h e nursing information received.

r or the C C ~ cdficarion, it was not identified when this certification was

&titin&. For the initial cercifcation, the staff nurse must successfully complete a

critical care certification examination. For recertification, AACN offers successful

completion as an option but it is not required. The AACN does require

evidence ~f~r i t icd-care related continuing education, documenmion of criricd care

hours worked, and types of critical care experiences. It has been

speculated that if a nurse was CCRN certified ten years ago, this might affect

suc~t%sful completion of the current critical care certification examination.

hplications for Nursing Practice

Several implications for nursing practice arise based on the results of this study.

The has been used, by hospital educators, as an assessment tool of basic

critical care knowledge. Critical care managers could also utilize this to assess the

basic critical care knowledge of nurses hired into their department. After

assessment, orientation and learning experiences could be planned based on this

assessment. Orientation could then be focused on weak aeas identified by this

assessment and enable the manager or educator to plan a cost-effective orientation

program for the individual nurse while ensuring quality care.

Second, critical care experience has k e n identified as a valid predictor of basic

critical care knowledge. Critical care managers should administer the BKAT to all

experienced nurses to assess their previous knowledge and verify competency of

these nurses upon hire. With this assessment, orientation programs could be

tailored to the experienced critical care nurses and educational money could be spent

on advmced programs for these experienced nurses. Therefore, less funds would

be used to assist nurses in obtaining basic critical care knowledge and more spent

on advancing knowledge.

Third, regarding the CCRN certification as a valid predictor of basic critical care

howledge, institutions should regard this certification as an indicator of basic

critical care knowledge. These nurses should be rewarded in some manner for

being motivated to obtain this certification. Rewards could be monetary but should

be related to additional responsibilities given to these motivated nurses including

additional decision-making responsibilities and involvement in the organization.

Also, the institution could benefit by marketing that their patients are cared for by

CCRN certified staff.

Fourth, basic educational preparation did not show a difference in possession of

critical care nursing knowledge when each group was analyzed separately. The

baccalaureate degree has been promoted as the professional degree. However, in

this smdy, the baccalaureate degree did not make a significant difference in BKAT

scores when compared to the ADN group and with the diploma group. There are a

variety of curricuIurns in each of these basic educational programs, Uniformity of

each of these programs would assist in identifying which program makes a

difference in possession of critical care knowledge. If this is not done, should an

educational program be developed at the basic preparation levef specifically for

critical care nursing? After obtaining a nursing license, should nurses interested in

critical care nursing be required to complete an intensive critical care educational

program prior to employment in critical care nursing?

Recommendations for Further Research

Further research should examine more homogenous groups when comparing

CCRN certified nurses to non-CCRN certified nurses. This could be accomplished

with a stratified random sampling. By contacting the AACN association, the

researcher could obtain a list of CCRN certified nurses to create homogenous

groups.

A longitudinal study, comparing educational background and experience with

of basic howledge over time, could be completed to see if the basic

knowledge scores are stable over time. This could be accomplished by

administering the BKAT to the same subjects at different time intervals and testing

for the significance of experience and educational background (BSN vs. nun-BSN)

over time.

A research study with a revised BKAT, inciuding more equivalent numbers of

questions in each of the content areas of cardiovascular, pulmonary, neurofogy, and

renal, would assist in comparing nurses from different criticai care units. This

could be completed by analyzing content included on the CCW certification

examination and sampling different types of critical care units to exmine what is

required for the knowledge base in each of the critical care units.

No attempt was made by this researcher to identify the actual numkr of days the

individual staff nurse worked (prn vs. part-time vs. full-time). If this infomation

was collected, comparisons could be made between full-time staff md pm staff.

An investigation of BKAT scores comparing full-time to part-time and pm status

nurses would assist in verifying possession of basic criticai care nursing knowledge

and possibly assist in defining the competency of these nurses with vlirying work

patterns.

Additional demographic data could be included to compare nurses working

different shifts. Do night shift nurses, evening shift nurses, and day shift nurses

possess the same amount of basic critical care nursing knowledge? This could be

by utilizing a larger sample and including demographic data on shift

work. A~SQ, a snatified random sample could be completed by identifying nurses

who work only one shift.

Demographic data could include the subjects' preceptor experience. Analysis

he completed to compare preceptors to non-preceptors in regards to basic

knowledge levels.

Another area needing to be explored is the CCRN cekfication and if the

possession of basic critical care nursing knowledge is related to CGRN certification

over time. Does a nurse CCRN certified in 1986 have the same BKAT scores as a

nurse CCRN certified in 1994? This could be accomplished by obtaining a list of

nurses CCRN certified in 1986 and comparing the BKAT results to nurses certified

in 1994. The researcher could contact the AACN association to verify how the

previously certified nurses recertified (by examination or continuing education) or

ask this question on the demographic data collected.

Conclusion

This study supported Toth's and others' previous studies showing previous

critical care nursing experience does make a difference. Therefore, it is imperative

that assessments are completed in the critical care units regarding possession of

basic critical care knowledge. Competencies of the nurses in these critical care units

must be assessed and verified. The BKAT is a cost-effective tool that could be

utilized in this competency assessment to assure the quality of care provided to the

patients in an institiution. This smdy offers some initial data that serves to stimulate

further inquiry into this important professional issue. For institutions to survive in

today's changing health care environment, critical care managers must consider

cost-effective oprions in verifying and reverifying the competency of the critical care

staff to ensure the knowledge level of the staff and quality of care provided.

References

Bm~kfield, S . (1991). Grwnding teaching in learning. In M. W. Galbraith (pp. 33-55). Malabar* FL: E e g r Ptrblishing

B ~ o o ~ e I d , S. (1990). Facilitating adult iesning, In S. Merrim & P. Cunningham (Eds.), Adultand S~dtrcmrion, F~ranciso, CAI Jossey-Bass Publishers.

BsooSiefd, S. (1987). Developin 9: critical thinkers. San Francisco, CA: Josse y-Bass,

B m K e l d , S. (1986). San Francisco, CA: Jossey-Bass.

Coco, C . (1976). A report on nurse internship programs. Supervisor Nurse, 7. (121, 12-16.

Coleman, B., Stanley, M,, Cfienevey, B,, Sullivan, S., & Cmdin, S. (1988). CCRN certification: Exclusive or expensive? Focus on Cri ticat Care, 15(5), 23- 27.

DeBack, V. & Mentkowski, M (1986). Dms the baccalaureate make: a difference? Differentiating nurse performance by education and experience.

(71,275-285.

dd Bueno, D. L. (1988). The promise and the reality of certification. Journal of Wursin g Scholarship, 20 (41, 208-21 1.

deI Bueno, D. L. (1983). Doing the right thing: Nurses' ability to make clinical decisions. (3),'?- 11

Dunbar, S. (1985). Should CCRN nurses receive a salary differential? (6). 361-364.

Fagin, C.M. & Lynaugh, J.E. (1992). Reaping the rewards of radical change: A new agenda for nursing education. Nursin P Outlook. 40 (5),2 13-220.

Frandson, P.E. (1980). Continuing education for the professions. In E.3. Bosne, E.E. White, & Associates (Eds.), throtgh adult education (pp. 61-81). San Francisco, CA: Jossey-Bass.

Gibbons, L.K, & Lewison, D. (1980). Nuniog internships: A tri-state survey and model for evaluation. The Journal of Nursing Administration. 10 (2), 31 -36.

Hamilton. L. & Gregor, F. (1986). Self-directed learning in a criricd care nursing program. The lonrnal of Continuinp Edacarion in Nunin?. 17 (3). 94-99.

Hartshorn, J. (1992). Evaluation of a critical c z e nursing internship program. f % ), 42-48.

Henry, S.B. & Holzerner, W.L. (1993). The relationship between perfomance on computer-based clinical simulations md two w~ften methds of evaluation: Cognitive examination and self-evaluation of expertise. C ~ m ~ u r e ~ s in Nursing, I I ( I ) , 29-34.

Henry, S.B. & Waltmire 11, D, (1992). Cornputetdzed clinical simulations: A strategy for staff development in critical care. (2), 99-107.

Houser, D. (1977). A study of nurses new to special care units. Supewisor Nurse. 8 (15), 15-22.

Hughes, L. (1987). Employment of new graduates: Implications fur critical care nursing practice. -(4), 0,- 15.

Jackle, M., Ceronsky, C., & Petersen, J, (1977). Nursing students' experience in critical care: Implications for staff development. (4),685-690.

Johnson, I.R. (1988). CCRN: A validation of competence. Focus ar~t Critical (6), 12-16.

McCloskey, J.C. & McCain, B. (1988). Variables related to nurse performance. Image. 2Q (4), 203-207.

Niebuhr, B.S. (1493). Credentialing of critical care nurses. AACN Clinical Issues of Critical Care Nurses, 4 (41, 61 1- 61 6.

Oermann, M.H. & Provenzano, L.M. (1992). Students' knowledge and perceptions of critical care nursing. Critical Care Nurse. 12 (I), 72-77.

Ressler, K.A., Kruger, N.R., &( Herb, T.A. (1991). Evaluating a critical care internship program. Dimensions of Critical Care Nursing. 1 Q (3), 176- 184.

Reynolds, A., Wood, S.G., & Gamero, M.L. (1991). Critical care concepts in baccalaureate nursing education. Critical Care Nurse, 1 (7), 12- 16.

Schempp, C.M. & Rompre, R.M. (1986). Transition programs for new graduates -- How effective are they? Journal of Nursing Staff Development. 2, (4). 150- 156.

Toth, J.C. (1994). Basic knowledge assessment tool fcrr critical care nursing, version four (BKAT-4): Validiry, reliability, and replication. 14 (3)& 111-117. -

Toth, J.C. (1986). The basic knowledge assessment tool fBKAT)--validi~ and reliability: A national study of critical care nursing knowledge. fiursiny Research, 8 (21, 18 1-196.

Toth, J.C. (1984). Evaluating the use of the basic knowledge assessment too1 (BKAT) in cxiticd care nursing with baccalaureate nursing students. Image; The JJof 31, 67-7 1.

Toth, J.C. & Dennis, M.M. (1993). The basic knowledge assessment tool (BKAT) for critical care nursing: Its use and effect on orientation programs. Critical Care Nurse, 13 (2),98-105.

Toth, J.C. & Ritchey, K.A. (1984). New from nursing research: The Basic Knowledge Assessment Tool for critical care nursing. Heart & Lung. 13 (31,272- 279.

US Public Health Service. (1990). Nursing -Sevennh report to the President. b R Codstheington: U, S , Public Health Service.

Wdthall, S.A., Odtohan, B., McCoy, M.A., Fromrn, B., Frankovich,. D. & Lehmann, M.H. (1993). Routine withholding of digitalis for heart rate below 60 beats per minute: Widespread nursing misconceptions. Heart 8r Lung, 22 (61, 472-476.

Whittaker, A. & Nenker, R. (1987). Critical care orientation examinations: A basis for employment? Dimensions of Critical Care Nursinp. 6 (I), 47-52.

July 19, 1494

Human Subjects Research Review Committee Drake University 25th and University Ave. Des Moines, IA 50311

Dear Committee Members:

Suzanne Tovar has my permission to utilize data collected for the Study of Basic Know1 edge Level o f Critical Care Nurses. This data was collected to assess the knowledge level of critical care nurses at our institution, identify learning needs, and plan educational programs based an the data col 1 ected.

Suzanne does not need to obtain further approval from the Institutional Review Board.

Sin

Sha Administrative irkt tor o f Nursing Nursing Administration

: jyd

Appendix B

Menlo explaining the B U T

l3ASIC KNOWLEDGE ASSESShENT TOOL ( B U T )

FOR CmnCAB, CARE hVRSING

7''he B U T is a 100 item tool, which measures basic knowledge in critical care

nursing in the following areas: cardiovascular, pulmonary, neurology, endocrine.

rend and gastrointestinal systems and invasive line ~~~onirohng.

The BKP;T takes approximateIy 30-45 minutes to complete. it conmins mul&ple

choice and fill-in-the-bfmk questions that measure the recall of b a ~ c infoma~on

and applicarion of basic knowledge in practice situa6ons.

This tool1 will be administered at the unit d e p m e n t meeting. Tfne following

demographic data will also be collected: yews of clinical experience as a RN years

of clinical experience as a LPN; years working in critical care; years working in

present unit; basic nursing educational preparation; CCRN status.

After completion of the tool, it will be scored by Suzanne Tovar, RN, Clinical

Educator, CSICU. Learning needs for each individual will be identified based on

the results and given to the clinical educator in your area.

Your actual score on the BKAT will remain confidenrial. Suzanne Tovar will be

available to discuss any questions you have about your results, You may contact

her at Extension 417 1.

This is not a test. There isn't a pass-fail score. The results of this tool wit1

not be used for performance appraisals. This tool is being utilized to identify

individual staff Jearrting needs and identify content for inservice education.

Appendix C

DEMOGRAPHIC FORM FOR BMAT

ID Number

Clinical experience as a LPN yews

Clinical experience as a RN years

Clinical experience in critical care years

Years working in present unit y e u s

Basic nursing educational preparation A D - Diploma - BSW

CCRN certified Yes no

BASIC ENOWLEDGE ASSESSMENT TOOL CBIAT) IN CBITICBL CARE H U R S f R G

Version Hour

D i p e c t i a a s : C i r c l e the beat answer or fill in t h e b l a n k .

I , I n i t i a l measures f o r t h e t r e a t m e n t of a n g i n a pectaris i n c l u d e a l l o f the f o l l o w i n g EXCEPT:

1) r e s t 2 ) m o r p h i n e 3) o x y g e n 4 ) n i t r o g l y c e r i n e

2 , T h e c l a s s i c a l ECG c h a n g e i n n y s c a r d i a l infarction (MI) I s a:

1) n o r m a l Q wave 2 ) ST segment e l e v a t i o n 3 ) p r o l o n g e d Q-T d u r a t 9 o n 4 ) p r o l o n g e d P-R i n t e r v a l

3 . E l e v a t e d c a r d i a c i so -enzymes g e n e r a l l y accur i n a l l of the f o l l o w i n g EXCEPT:

I ) . c o n g e s t i v e h e a r t f a i l u r e 2 ) . p e r i c a r d i t i s 3 ) c l o s e d c h e s t i n j u r y - 4 ) c a r d i a c s u r g e r y

4 . T h e m a j o r t h e r a p e u t i c g o a l i n t h e t r e a t m e n t o f c a r d i o g e n i c s h o c k (8) i s t o :

1) i n c r e a s e a f t e r l o a d 2 ) l o w e r t h e B U N 3 ) i n c r e a s e c a r d i a c o u t p u t 4 ) d e c r e a s e e x t r a c e l l u l a r f l u i d v o l u m e

5. H r . H a r t i s two d a y s p o s t M I . D u r i n g h i s f i r s t t ime g e t t i n g o u t ( 9 ) o f b e d h i s p u l s e i n c r e a s e s f r o m 86/min t o , 9 6 / m i n . B a s e d o n this r e s p o n s e t h e n u r s e s h o u l d :

1) a s k h i m t o slow h i s pace 2 ) a l l o w h im t o c o n t i n u e 3) h a v e h im l i e down i m m e d i a t e l y 4 ) c h e c k h i s v i t a l s i g n s

6. I n d e a l i n g w i t h a d e p r e s s e d p a t i e n t d u r i n g t h e f i r s t days p o s e M I the m o s t a p p r o p r i a t e n u r s i n g a c t i o n would b e :

1) e n c o u r a g e t h e p a t i e n t t o v e n t i l a t e h i s c o n c e r n s 2 ) r e s t r i c t v i s i t s f r o m t h e f a m i l y members 3 ) p r o v i d e f o r p r i v a c y b y l e a v i n g t h e p a t i e n t a l o n e 4 ) p r o v i d e a q u i e t e n v i r o n m e n t f o r t h e p a t i e n t

7 . T h e following m o n i t o r p a t t e r n w o u l d i n d i c a t e t h a t t h e Swan G a n z (11) c a t h e t e r i s i n w h i c h p o s i t i o n ?

1) r i g h t a t r i u m 2) r i g h t v e n t r i c l e 3 ) p u l m o n a r y a r t e r y 4 ) p u l m o n a r y a r t e r y w e d g e

8. T h e u s e o f a n a r t e r i a l l i n e w o u l d b e i n d i c a t e d f o r a l l o f t h e f o l l o w i n g c o n d i t i o n s EXCEPT:

1) s h o c k w i t h b l o o d p r e s s u r e t o o l o w t o b e d e t e r m i n e d b y c u f f 2 ) p a t i e n t s b e i n g t r e a t e d w i t h I V n i t r o p r u s s i d e 3 ) m e c h a n i c a l v e n t i l a t i o n r e q u i r i n g f r e q u e n t a r t e r i a l b l o o d g a s e s 4 ) f o r t h e a d m i n i s t r a t i o n of i n t r a v e n o u s d r u g s

9 . W h i c h o f t h e f o l l o w i n g wave p a t t e r n s i n d i c a t e s i d e a l f u n c t i o n i n g (13 ) o f a n a r t e r i a l l i n e ?

10. A f t e r a n a r t e r i a l c a t h e t e r i s r e m o v e d , d i r e c t p r e s s u r e s h o u l d p e n e r a l l y b e a p p l i e d t o t h e a r t e r y :

1) f o r 2 f u l l m i n u t e s 2 ) f o r 5 t o 10 m i n u t e s 3 ) u n t i l t h e o o z i n g o f b l o o d f r o m t h e p u n c t u r e s i t e s l o w s 4 ) u n t i l a p r e s s u r e d r e s s i n g i s a p p l i e d

11. A c e n t r a l v e n o u s p r e s s u r e (CVP) r e a d i n g d i r e c t l y r e f l e c t s p r e s s u r e i n t h e :

1 ) l e f t a t r i u m 2 ) r i g h t a t r i u m 3 ) l e f t v e n t r i c l e 4 ) p u l m o n a r y a r t e r y

12. An e l e v a t e d C v p r e a d i n g m a y i n d i c a t e :

1 ) r i g h t h e a r t f a i l u r e 2 ) a f a l l i n h e m a t o c r i t 3 ) a c u t e d e h y d r a t i o n 4 ) p e r i p h e r a l v a s o d i l i a t i o n

13. I f t h e m o n i t o r s h o w s a p u l m o n a r y c a p i l l a r y w e d g e p r e s s u r e (PCWP) ( 1 7 ) p a t t e r n , a l l o f t h e f o l l o w i n g a c t i o n s a r e a p p r o p r i a t e EXCEPT:

1 ) r e l e a s i n g a i r f r o m t h e b a l l o o n 2 ) r e p o s i t i o n i n g t h e p a t i e n t 3 ) f l u s h i n g t h e l i n e 4 ) k e e p i n g t h e p a t i e n t immo 'b i l e

1 4 . T h e PCWP r e f l e c t s p r e s s u r e i n t h e :

1 ) r i g h t v e n t r i c l e 2 ) l e f t v e n t r i c l e 3 ) r i g h t a t r i u m 4 ) v e n a c a v a

15. T h e n o r m a l p u l m o n a r y a r t e r y p r e s s u r e i s :

1 ) 1 0 - 2 0 mean 5-10 0-4

2 ) 2 1 - 3 0 mean 1 1 - 2 0 5-1 5

3 ) 3 1 - 3 5 mean 2 1 - 3 0 1 6 - 2 0

4 ) 3 6 - 4 5 mean 3 1 - 3 5 2 1 - 2 5

1 6 . Wow many m m Hg i s t h e n o r m a l PCWP?

1 7 . An e l e v a t e d PCWP may i n d i c a t e :

1 ) h y p o v o l e m i a 2 ) p e r i p h e r a l b l o o d p o o l i n g 3 ) s y s t e m i c h y p o t e n s i o n 4 ) l e f t v e n t r i c u l a r f a i l u r e

18. T h e w a v e i n t h e c a r d i a c c y c l e t h a t r e p r e s e n t s a t r i a l d e p o l a r i z a t i o n i s t h e :

A QRS complex wider t h a n 0.12 seconds most l i k e l g i n d i c a t e s :

I ) n o r m a l ventricular conduction 2 ) b u n d l e branch block 3 ) s e c o n d d e g r e e h e a r t block 4 ) myocard ia l infarction

How many seconds is the normal P-W fnterval?

The f o l l o w i n g rhythm strip represents : (Zf)

The ventricular rare in question 2 1 is a p p r o x i m a t e l y how many b e a t s per m i n u t e ?

The dysrhythmia in the following strip is: ( 2 7 )

A strong ventricular stimulus is potentially dangerous in which (28)

p e r i o d of the cardiac cycle?

1 ) U wave 2 ) P wave 3 ) T wave 4 ) QRS c o m p l e x

. -

2 6 . The m a i n p u r p o s e o f e n c l o s i n g a pacemaker g e n e r a t o r i n a r u b b e r g l o v e o r s im i l a r a p p a r a t u s i e t o p r e v e n t :

1) t h e p a c e m a k e r f r o m g e t t i n g d i r t p 7 m o i s t u r e f r o m c o r r o d i n g t h e p a c e m a k e r - / - 3) a c c i d e n t a l c h a n g e i n s e t t i n g s 4 ) e l e c t r i c a l i n t e r f e r e n c e w f t h t h e p a c e m a k e r

2 7 . I n t h e f o l l o w i n g r h y t h m s t r i p the p a c e m a k e r i s e x h i b i t i n g :

1) f a i l u r e t o s e n s e 2 ) f a i l u r e t o c a p t u r e 3 ) n o r m a l f u n c t i o n L\ demand f u n c t i o n

2 8 . The i n i t i a l d r u g t r e a t m e n t f o r v e n t r i c u l a r t a c h y c a r d i a i s :

1) I s u p r e l 1 . 0 rng i n 250 m l D5W d r i p 2 E p i n e p h r i n e 1 : 1 0 , 0 0 0 1 . 0 mg IV bolus 3 ) A t r o p i n e 0 . 6 mg I V bolus 4 ) L i d o c a i n e 50-100 mg IV b o l u s

2 9 . T h e r h y t h m s t r i p b e l o w s h o w s :

( 3 4 ) 30. The cardiac r h y t h m o f a t r i a l f l u t t e r 5s:

1) a b e n i g n c o n d i t i o n i n m o s t p e o p l e 2 ) normal f o l l o w i n g myocardial i n f a r c t i o n 3 ) h a z a r d o u s , a s t h e v e n t r i c u l a r r a t e may suddenly i n c r e a s e 4 ) h a z a r d o u s , a s i t may progress to complete h e a r t b l o c k

31. Upon r e c o g n i z i n g v e n t r i c u l a r f i b r i l l a t i o n , t h e n u r s e s h o u l d f i r s t :

1 ) p e r f o r m a p r e c o r d i a l t hump 2 ) e s t a b l i s h u n r e s p o n s i v e n e s s 3 ) g i v e L i d o c a i n e I V push 4 ) c h e c k t h e EGG leads

3 2 , One o f t h e f i r s t d r u g s t o b e a d m i n i s t e r e d in t h e treatment of c o m p l e t e heart b l o c k w o u l d be:

1) A t r o p i n e 2 ) L i d o c a i n e 3 ) Q u i n T d i n e 4 ) D i g o x i n

3 3 . Your p a t i e n t h a s a t r i a l f l u t t e r w i t h a v e n t r i c u l a r r e s p o n s e of ( 3 7 ) 150 b e a t s p e r m i n u t e . Therapy f o r t h i s rhythm includes:

1 ) D i g o x i n , V e r a p a m i l , c a r d i o v e r s i o n 2 ) L i d o c a i n e , s o d i u m bicarb, c a r d i o v e r s i o n 3 ) L i d o c a i n e , p o t a s s i u m c h l o r i d e , pacemaker 4 ) I s o r d i l , N i t r a p a s t e , P r o n e s t y l

3 4 . T h e c o r r e c t e n e r g y s e t t i n g f o r d e f i b r i l l a t i o n is how many w a t t / s e c o n d s ?

35. S i g n s o f c a r d i a c t a m p o n a d e may i n c l u d e a l l o f t h e f o l l o w i n g (39) EXCEPT :

I ) d i s t e n d e d n e c k v e i n s 2 3 p u l s u s p a r a d o x u s 3) d e c r e a s e d s y s t o l i c p r e s s u r e 4 ) b r a d y c a r d i a

36. A p a t i e n t b e c o m e s a p n e i c a n d pulseless. T h e m o n i t o r s h o w s a s y s t o l e . T h e d r u g t h a t w o u l d m o s t l i k e l y b e u s e d i n i t i a l l y i s :

I ) C a l c i u m G l u c o n a t e 2) A t r o p i n e 3 ) E p i n e p h r i n e 4 ) L i d o c a i n e

3 7 . T h e m o s t i m p o r t a n t s t e p i n p r e v e n t i n g c e n t r a l v e n o u s c a t h e t e r ( 4 1 )

r e l a t e d s e p s i s i s :

1 ) u s i n g a n o c c l u s i v e d r e s s i n g 2 ) t h o r o u g h h a n d w a s h i n g 3 ) c h e c k i n g t h e p a t i e n t ' s t e m p e r a t u r e q 6 h 4 ) a s e p t i c c a r e o f t h e c a t h e t e r

38. A n e x c e s s i v e a m o u n t o f c h e s t t u b e d r a i n a g e i n t h e f f r s t f e w ( 4 2 )

I h o u r s f o l l o w i n g t h o r a c i c s u r g e r y i s how many cc's p e r h o u r ?

39. A r o u t i n e c h e c k of y o u r p a t i e n t ' s b l o o d gas v a l u e s show a I

P H o f 7-40. o f 100 m a Hg. pCOZ of 38 mrn Hg, a n d HCU3 I o f 2 5 mEq. T h e s e r e s u l t s r e f l e c t :

1) m e t a b o l i c a c i d o s i s 2 ) m e t a b o l i c a l k a l o s i s 3) n o r m a l v a l u e s 4 ) r e s p i r a t o r y a l k a l o s i s

40 . B e f o r e s u c t i o n i n g a p a t i e n t , you adjust t h e p r e s s u r e s o t h a t i t is:

1 ) 1 2 0 m m Hg of vacuum 2 ) a s h i g h a s n e c e s s a r y 3 ) 40 m m Hg o f v a c u u m 4 ) 1 0 mm W g b e l o w t h e s y s t o l i c b l o o d p r e s s u r e

41. P r i o r t o s t a r t i n g c h e s t p h y s i c a l t h e r a p y (BT) o n a p o s t - o p e r a t i v e ( 4 5 ) p a t i e n t w i t h a l e f t a n t e r i o r c h e s t t u b e , you a u s c u l t a t e t h e l u n g f i e l d s b i l a t e r a l l y a n d n o t e t h a t you h e a r diminf i shed b r e a t h s o u n d s i n t h e r i g h t p o s t e r i o r b a s e . T h i s w o u l d mast l i k e l y b e d u e t o :

I) p l e u r i t i s 2 ) c o n s o l i d a t i o n 3 ) a t e l e c t a s i s 4 ) t h e c h e s t t u b e

4 2 . C h e s t p e r c u s s i o n w o u l d g e n e r a l l y b e c o n t r a i n d i c a t e d f o r w h i c h o f t h e f o l l o w i n g c o n d i t i o n s ?

1) a t e l e c t a s i s 2 ) t h i c k s p u t u m 3 ) p u l m o n a r y h e m o r r h a g e 4 ) l o b e c t o m y

4 3 . Your p a t i e n t i s o n a v e n t i l a t o r . T h e l o w v o l u m e a l a r m s o u n d s . ( 4 7 ) T h i s may b e d u e t o :

I) p u l m o n a r y e d e m a 2 ) d e c r e a s e d s e c r e t i o n s 3 ) a d i s c o n n e c t e d t u b e 4 ) b i t i n g t h e t u b e

4 4 . To a s s e s s p r o p e r p o s i t i o n i n g o f a n e n d o t r a c h e a l t u b e , t h e m o s t ( 4 8

a p p r o p r i a t e n u r s i n g a c t i o n w o u l d b e t o :

1) l i s t e n f o r m i n i m a l l e a k o f t h e c u f f 2 ) l i s t e n f o r b i l a t e r a l b r e a t h s o u n d s 3 ) c h e c k f o r c h e s t e x p a n s i o n 4 ) c h e c k t h e t i d a l v o l u m e i n d i c a t o r o n t h e v e n t i l a t o r

* -3 2 ; f a t embolas 2 ) a t e l e c t a s i s 3 ) p l e u r a l e f f u s i o n 4 ) p u l m o n a r y e d e m a

4 9 . A s e v e r e l y b u r n e d patient i s admitted t o p o u r u n i t . T h e most ( 5 3 ) i m p o r t a n t t r e a t m e n t d u r i n g t h e f i r s t 2 4 h o u r s a f t e r i n j u r y i s :

1 ) wound c u l t u r e s 2 ) a n t i b i o t i c p r o p h y l a x i s 3) n u t r i t i o n a l s u p p o r t 4 ) f l u i d r e p l a c e m e n t

SO. A d a n g e r o u s e f f e c t o f r e - w a r m i n g a h y p o t h e r r n i c patient i s :

1) a n i n c r e a s e i n e x t r a v a s c u l a r f l u i d 2 ) a d e c r e a s e i n c a r d i a c o u t p u t 3 ) a d e c r e a s e i n d r u g u t i l i z a t i o n 4 ) a s u d d e n r i s e i n b l o o d pressure

51. N u r s i n g c a r e o f a p a t i e n t o n s h y p o t h e r m i a b l a n k e t i n c l u d e s : (55)

1 ) a d m i n i s t e r i n g v a s o d i l a t o r s to p r e v e n t s h i v e r i n g 2 ) a v o i d i n g m o v i n g t h e p a t i e n t t o p r o v i d e maximum c o o l i n g 3 ) r e m o v i n g t h e h y p o t h e r m i a b l a n k e t q 2 h t o p r e v e n t o v e r c o o l i n g 4 ) m a k i n g f r e q u e n t o b s e r v a t i o n s of t h e s k i n to p r e v e n t t i s s u e i n j u r y

52. T h e m o s t i m p o r t a n t n u r s i n g m e a s u r e f o r a p a t i e n t a d m i t t e d w i t h t h e d i a g n o s i s o f c e r v i c a l s p i n a l c o r d i n j u r y i s :

1 ) k e e p i n g t h e p a t i e n t f l a t 2 ) i m r n o b o l i z i n g t h e h e a d 3 ) a s s e s s i n g t h e r e f l e x e s 4 ) m o n i t o r i n g f o r d y s r h y t h m i a s

5 3 . I n a p a t i e n t w i t h c e r v i c a l s p i n e i n j u r y , t h e m o s t i m p o r t a n t o b s e r v a t i o n s t h e n u r s e makes d e a l w i t h w h i c h b o d y s y s t e m ?

1 ) c a r d i o v a s c u l a r 2 ) r e s p i r a t o r y 3 ) r e n a l 4 ) g a s t r o i n t e s t i n a l

5 4 . T h e e a r l i e s t s i g n o f i n c r e a s e d i n t r a c r a n i a l p r e s s u r e g e n e r a l l y (58) i n v o l v e s c h a n g e s i n :

1) r e s p o n s e t o p a i n 2 ) l e v e l o f c o n s c i o u s n e s s 3 ) e q u a l i t y o f p u p i l l a r y r e a c t i o n 4 ) r e s p i r a t o r y r a t e

5 5 . I n c r e a s e d i n t r a c r a n i a l p r e s s u r e i s c h a r a c t e r i z e d b y a l l o f t h e ( 5 9 ) f o l l o w i n g EXCEPT:

1 ) d e c r e a s e i n b r i s k n e s s o f p u p i l l a r y r e a c t i o n 2 ) i n c r e a s e i n b l o o d p r e s s u r e 3 ) d e c r e a s e i n p u l s e p r e s s u r e 4 ) d e c r e a s e i n l e v e l o f c o n s c i o u s n e s s

5 6 . A d r u g u s e d s p e c i f i c a l l y t o r e d u c e i n c r e a s e d i n t r a c r a n i a l p r e s s u r e i s :

1 ) A l d o m e t 2 ) P h e n o b a r b i t a l 3) M a n n i t o l 4 ) D i l a n t i n

5 7 . A p o s i t i v e B a b i n s k i r e s p o n s e i n a n a d u l t :

1 ) i n d i c a t e s l o w e r m o t o r d i s e a s e 2 ) i s a n o r m a l f i n d i n g 3 ) i s a n a b n o r m a l f i n d i n g 4 ) i s a s s o c i a t e d w i t h f l e x i o n o f t h e f o e s

58. T h e n u r s i n g c a r e o f a p a t i e n t d u r i n g t h e a c u t e p e r i o d a f t e r a s t r o k e i n c l u d e s a l l o f t h e f o l l o w i n g EXCEPT:

1) p r o v i d i n g a q u i e t e n v i r o n m e n t 2 ) c o n t r o l o f s e c r e t i o n s 3) p r e v e n t i n g i n j u r y 4 ) i n c r e a s i n g s e n s o r y i n p u t

5 9 . A l l o f t h e f o l l o w i n g a r e i n c l u d e d i n a n h o u r l y n e u r o c h e c k EXCEPT:

1) m o t o r s t r e n g t h 2 ) u r i n a r y o u t p u t 3 ) r e s p o n s e t o s t i m u l a t i o n 4 ) p u p i l l a r y r e s p o n s e t o l i g h t

60. S i g n s a n d s y m p t o m s o f d i a b e t i c k e t o a c i d o s i s i n c l u d e :

1 ) d r y w a r m s k i n , f r u i t y b r e a t h , d e e p a n d r a p i d b r e a t h i n g 2 ) v o m i t i n g , h y p e r a c t i v i t y , d i a p h o r e s f s 3 ) s l o w a n d s h a l l o w b r e a t h i n g , p a l l o r , h e e d a c h e 4 ) d i l a t e d p u p i l s , coma, f l u s h e d s k i n

61 . I m p e n d i n g i n s u l i n s h o c k s h o u l d b e s u s p e c t e d when t h e d i a b e t i c patient c o m p l a i n s o f o r m a n i f e s t s :

1 ) d e c r e a s e d s k i n t u r g o r , a b d o m i n a l p a i n , f e v e r 2 ) f l u s h e d s k i n , t a c h y c a r d i a , K u s s m a u l b r e a t h i n g 3 ) t h i r s t , h y p o t e n s i o n , f r u i t y o d o r t o t h e b r e a t h 4 ) w e a k n e s s , h e a d a c h e , d i a p h o r e s i s

62. M e a s u r e s t h a t w o u l d b e t a k e n t o t r e a t a p a t i e n t i n d i a b e t i c k e t o a c i d o t i c c o m a w o u l d i n c l u d e a l l o f t h e f o l l o w i n g EXCEPT:

1 ) d e x t r o s e 50% I V i n f u s i o n 2 ) i n s u l i n IV i n f u s i o n 3) p o t a s s i u m r e p l a c e m e n t 4 ) s o d i u m b i c a r b o n a t e a d m i n i s t r a t i o n

6 3 . A n e w l y d i a g n o s e d d i s b e t i c p a t i e n t who i s o n a s l i d i n g s c a l e o f R e g u l a r i n s u l i n c o n p l a i n s of f e e l i n g v e r y n e r v o u s a n d a f r a i d t h a t s h e i s g o i n g t o f a i n t . N u r s i n g a c t i o n s m i g h t i n c l u d e a l l o f t h e f o l l o w i n g EXCEPT:

1 ) t a k i n g t h e b l o o d p r e s s u r e 2 ) a d m i n i s t e r i n g t h e PRN o r d e r f o r R e g u l a r i n s u l i n 3 ) c h e c k i n g a b l o o d s a m p l e f o r g l u c o s e 4 ) g i v i n g h e r a g l a s s o f j u i c e t o d r i n k

6 4 . P a t i e n t s w i t h d i a b e t e s m e l l i t u s who a r e a c u t e l y ill g e n e r a l l y r e q u i r e a :

1 ) h i g h e r d o s e o f i n s u l i n 2 ) l o w e r c a l o r i c i n t a k e 3 ) h i g h e r f a t i n t a k e 4 ) l o w e r d o s e o f i n s u l i n

6 5 . T h e p s y c h o p h y s i o l o g i c s t ress r e s p o n s e o f a c u t e i l l n e s s g e n e r a l l y ( 6 9 ) r e s u l t s i n t h e f o l l o w i n g c h a n g e s i n h e a r t r a t e ( H R ) , b l o o d p r e s s u r e ( B P ) , a n d u r i n e o u t p u t :

1 ) i n c r e a s e d HR, i n c r e a s e d BP, i n c r e a s e d u r i n e output

2 ) d e c r e a s e d HR, d e c r e a s e d BP, d e c r e a s e d u r i n e o u t p u t

3 ) i n c r e a s e d HR, d e c r e a s e d BP, i n c r e a s e d u r i n e o u t p u t 4 ) i n c r e a s e d H R , i n c r e a s e d B P , d e c r e a s e d u r i n e o u t p u t

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T h e f o l l o w i n g l a b t e s t s a r e good i n d i c e s o f r e n a l f u n c t i o n (76) EXCEPT:

1 ) c a t e c h o l a m i n e s 2 ) e l e c t r o l y t e s 3 ) c r e a t i n i n e 4 ) o s m o l a l i t y

Your p a t i e n t h a s a c u t e r e n a l f a i l u r e . M e d i c a t i o n s t h a t a r e n o r m a l l y e x c r e t e d t h r o u g h t h e k i d n e y s w i l l p r o b a b l y b e :

I ) d e c r e a s e d i n d o s a g e 2 ) a d m i n i s t e r e d as u s u a l 3 ) i n c r e a s e d i n d o s a g e 4 ) i n c r e a s e d i n f r e q u e n c y

E n t e r a l f e e d i n g i n a c u t e r e n a l f a i l u r e commonly i n c l u d e s : (78) ( I ) h i g h p r o t e i n , l o w p o t a s s i u m , low s o d i u m 2 ) r e s t r i c t e d p r o t e i n , h i g h p o t a s s i u m , low s o d i u m 3 ) h i g h p r o t e i n , h i g h p o t a s s i u m , h i g h s o d i u m 4 ) r e s t r i c t e d p r o t e i n , l o w p o t a s s i u m , low s o d i u m

S u d d e n d e v e l o p m e n t o f d y s p n e a , s i n u s t a c h y c a r d i a , a n d r a l e s i n a n a c u t e r e n a l f a i l u r e p a t i e n t wou ld m o s t l i k e l y i n d i c a t e which of the f o l l o w i n g ?

1 ) f l u i d o v e r l o a d 2 ) i n f e c t i o n 3 ) h y p e r k a l e m i a 4 ) p e r i c a r d i t i s

ECC c h a n g e s commonly seen i n h y p e r k a l e m i a a r e :

1 ) n a r r o w QRS, i n v e r t e d T wave 2 ) n a r r o w QRS, f l a t t e n e d P wave 3 ) w i d e QRS, i n v e r t e d T wave 4 ) w i d e QRS, t a l l p e a k e d T wave

Code No. (1-3) C a r d No . ( 4 )

G e n e r a l l y , p e r i t o n e a l d i a l y s i s s o l u t i o n s d o NDT c o n t a i n : ( 5 )

1) c h l o r i d e 2 ) g l u c o s e 3 ) c r e a t i n i n e 4 ) s o d i u m

C o m p l i c a t i o n s o f p e r i t o n e a l d i a l y s i s i n c l u d e a l l o f t h e f o l l o w i n g EXCEPT:

1 ) h y p o t e n s i o n 2 ) r e s p i r a t o r y d i s t r e s s 3 ) p e r i t o n i t i s 4 ) h y p e r k a l e m i a

I 79. F o l l o w i n g t h e f i r s t exchange of p e r i t o n e a l d i e l y s e t e s o l u t i o n , ( 7 ) t h e o u t f l o w d r a i n a g e r e t u r n i s b r o w n i s h I n c o l o r . Which of t h e f o l l o w i n g o b s e r v a t i o n s i s c o r r e c t ?

1) c o m m o n l y s e e n f o l l o w i n g t h e f i r s t e x c h a n g e 2 ) characteristic f i n d i n g i n peritonitis 3 ) i n d i c a t e s p o s s i b l e b o w e l p e r f o r a t i o n 4 ) i n d i c a t e s p o s s i b l e a b d o m i n a l b l e e d i n g

80. N u r s i n g c a r e m e a s u r e s f o r t h e p a t i e n t r e c e i v i n g peritoneal d i a l y s i s i n c l u d e a l l of t h e following EXCEPT:

1) c a r e f u l i n t a k e a n d o u t p u t 2 ) w a r m i n g t h e d i a l y s i s s o l u t i o n 3 ) m a i n t a i n i n g s t e r i l i t y af t h e d i a l y e a t e 4 ) m a i n t a i n i n g i m m o b i l i t y

81. When f e e d i n g a p a t i e n t u s i n g c o n t i n u o u s t u b e f e e d i n g s , t h e m o s t i m p o r t a n t i n t e r v e n t i o n i n p r e v e n t i n g a s p i r a t i o n i s t o :

1 ) k e e p the h e a d o f t h e b e d e l e v a t e d 2 ) d o f r e q u e n t c h e s t PT 3 ) c h e c k t h e p o s i t i o n of t h e f e e d i n g t u b e q 4 h 4 ) a s p i r a t e s t o m a c h c o n t e n t s q4h

8 2 . H y p e r o s m o l a r , n o n - k e t o t i c d e h y d r a t i o n and coma c a n b e easily p r e v e n t e d i n t o t a l p a r e n t e r a l n u t r i t i o n t h e r a p y i f d e t e c t e d e a r l y . A m e t h o d o f e a r l y d e t e c t i o n i e checking:

1 ) C P K , SGOT, LDH 2 ) t h e b l o o d s u g a r 3) f o r a b n o r m a l p u p i l l a r y r e s p o n s e

- 4 ) f o r a d e c r e a s e i n u r i n a r y o u t p u t

8 3 . M s . P h i l l i p s h a s a B l a k e m o r e t u b e i n p l a c e f o r t h e c o n t r o l o f a c t i v e b l e e d i n g f r o m h e r esophageal v a r i c e s . T h e m o s t i m p o r t a n t a s p e c t o f h e r a c u t e n u r s i n g c a r e i s :

I

I I ) p e r i o d i c a l l y r e l e a s i n g t h e p r e s s u r e i n t h e b a l l o o n s 2 ) m a i n t a i n i n g t h e p r e s s u r e i n t h e b a l l o o n s 3 ) a c c u r a t e l y c h e c k i n g i n t a k e a n d o u t p u t 4 ) e n c o u r a g i n g t h e p a t i e n t t o v e r b a l i z e h e r f e e l i n g s

84 . Low i n t e r m i t t e n t s u c t i o n o f g a s t r i c c o n t e n t s i s g e n e r a l l y u s e d in a l l o f t h e f o l l o w i n g s i t u a t i o n s EXCEPT:

1) t o r e d u c e a b d o m i n a l d i s t e n t i o n 2 ) t o p r e v e n t a s p i r a t i o n 3 ) w h e n b o w e l s o u n d s a r e a b s e n t 4 ) t o c o n t r o l b l e e d i n g

85. A c u t e g a s t r o i n t e s t i n a l b l e e d i n g i n c r i t i c a l l y i l l p a t i e n t s may ( 1 3 ) o c c u r a s a r e s u l t o f :

1) a d e c r e a s e i n c a t e c h o l a m f n e s 2 ) t h e b o d y ' s r e s p o n s e t o s t r e s s o r s 3 ) d e c r e a s e d g a s t r i c m o t i l i t y 4 ) a l t e r a t i o n i n e a t i n g p a t t e r n s

8 6 . N u r s i n g a c t i v i t i e s f o r p a t i e n t s r e c e i v i n g g a s t r i c l a v a g e t o c o n t r o l a c u t e g a s t r o i n t e s t i n a l b l e e d i n g i n c l u d e a l l o f t h e f o l l o w i n g EXCEPT:

1 ) o b s e r v a t i o n f o r a b d o m i n a l d i s t e n t i o n 2 ) a c c u r a t e i n t a k e a n d o u t p u t 3 ) u s i n g d i s t i l l e d water f o r the l a v a g e 4 ) m o n i t o r i n g o f h e m o g l o b i n a n d h e m a t o c r i t

8 7 . W h i l e c a r i n g f o r a c h o l e c y s t e c t o m y p a t i e n t p o s t - o p e r a t i v e l y , y o u (15) n o t i c e " c o f f e e g r o u n d " m a t e r i a l c o m i n g f r o m h e r n a s o g a s t r i c t u b e . You s h o u l d :

1 ) know t h i s i s a n o r m a l f i n d i n g 2 ) i r r i g a t e t h e t u b e 3 ) t e s t t h e d r a i n a g e f o r b l o o d 4 ) l i s t e n f o r b o w e l s o u n d s

88. Y o u r p a t i e n t , who i s a c t i v e l y b l e e d i n g f r o m t h e g a s t r o i n t e s t i n a l ( 1 6 ) t r a c t a n d i s r e c e i v i n g a b l o o d t r a n s f u s i o n , h a s a s u d d e n i n c r e a s e i n b o d y t e m p e r a t u r e . Y o u r f i r s t r e s p o n s e i s t o :

1 ) n o t i f y t h e p h y s i c i a n 2 ) c h a r t t h e f i n d i n g 3 ) c h e c k f o r a r a s h 4 ) s t o p t h e t r a n s f u s i o n

89 . W h i c h o f t h e f o l l o w i n g m e a s u r e s g e n e r a l l y r e s u l t s i n t h e e a r l i e s t d e t e c t i o n o f g a s t r i c b l e e d i n g i n p a t i e n t s w h o h a v e g a s t r i c t u b e s ?

1) t e s t i n g t h e g a s t r i c c o n t e n t s f o r m i c r o s c o p i c b l o o d 2 ) o b s e r v i n g t h e c o l o r o f t h e g a s t r i c a s p i r a t e 3 ) n o t i n g t h e p r e s e n c e o f a b d o m i n a l d i s t e n t i o n 4 ) n o t i c i n g a s l o w f a l l i n b l o o d p r e s s u r e

90. S p e c i a l c a r e s h o u l d b e e x e r c i s e d when a d m i n i s t e r i n g I 1 D o p a m i n e b e c a u s e :

1) i n f i l t r a t i o n l e a d s t o t i s s u e n e c r o s i s 2 ) h i g h d o s e s c a u s e a b r a d y c a r d i a 3 ) p r e c i p i t a t i o n c a n o c c u r when u s e d i n a d e x t r o s e s o l u t i o n 4 ) l o w d o s e s d e c r e a s e r e n a l p e r f u s i o n

91. D i l a n r i n w i l l c r y s t a l l i z e when g i v e n I V i n a l l o f t h e f a l l o w i n g ( 1 9 ) s o l u t i o n s EXCEPT:

1 ) d e x t r o s e i n w a t e r 2 ) d e x t r o s e i n s a l f n e 3 ) n a r m a l s a l i n e 4 ) r i n g e r ' s l a c t a t e

92. P r e c a u t i o n s i n u s i n g IV n i t r o p r u s s i d e i n c l u d e a l l o f t h e f o l l o w i n g EXCEPT:

1 ) p r o t e c t i o n o f t h e s o l u t i o n f r o m l i g h t 2 ) c a r e f u l m o n i t o r i n g f o r a s u d d e n i n c r e a s e i n h e a r t r a t e 3 ) a l e r t n e s s t o t h e d e v e l o p m e n t of h y p e r t e n s i v e c r i s i s 4 ) u s e o f a f r e s h m i x t u r e a t a p p r o p r i a t e i n t e r v a l s

9 3 . T h e d a s a g e o f w h i c h d r u g m u s t b e t a p e r e d o f f s l o w l y t o p r e v e n t ( 2 1 ) a c u t e a d r e n a l i n s u f f i c i e n c y ?

1 ) n i t r o p r u s s i d e 2 ) c o r t i s o n e 3 ) s t r e p t o k i n a s e 4 ) p i t r e s s i n

9 4 . A l l o f t h e f o l l o w i n g may b e m a n i f e s t a t i o n s o f d i g i t a l i s t o x i c i t v EXCEPT:

1 ) r a p i d A-V c o n d u c t i o n 2 ) p r e m a t u r e v e n t r i c u l a r c o n t r a c t i o n s 3 ) n a u s e a 4 ) y e l l o w v i s i o n

95. The m o s t common s y m p t o m o f a t o x i c b l o o d l e v e l o f L i d o c a i n e i s : ( 2 3 )

1 ) e l e v a t e d b l o o d p r e s s u r e 2 ) c o n f u s i o n 3 ) a b n o r m a l c l o t t i n g t i m e 4 ) m e t a l t a s t e

96 . I f t h e p h y s i c i a n d i d n o t u s e A t r o p i n e f o r a b r a d y c a r d i a , w h i c h ( 2 4 ) o f t h e f o l l o w i n g c o u l d b e u s e d t o i n c r e a s e t h e h e a r t r a t e :

1) I n d e r a l 2 ) Q u a b a i n 3 ) I s u p r e l 4 ) V e r a p a m i l

9 7 . When a d m i n i s t e r i n g L i d o c a i n e t o B p a t i e n t , t h e p r o p e r ( 2 5 ) f u n c t i o n i n g o f w h i c h o f t h e f o l l o w i n g b o d y s y s t e m s w o u l d b e m o s t u s e f u l t o know t o d e t e r m i n e t h e c o r r e c t d o s a g e ?

1 ) h e p a t i c 2 ) g a s t r o i n t e s t i n a l 3 ) r e s p i r a t o r y 4 ) e n d o c r i n e

99. In c a r i n g f o r a p a t i e n t in w h i c h t h e n u r s e w o u l d b e e x p o s e d t o ( 2 7 ) b o d y f l u i d s , i t i s i m p o r t a n t t o o b s e r v e w h i c h o f t h e f o l l o w i n g ?

1 ) r e s p i r a t o r y p r e c a u t i o n s 2 ) r e v e r s e i s o l a t i o n 3 ) u n i v e r s a l p r e c a u t i o n s 4 ) u r i n e i s o l a t i o n

100. I n c a r i n g f o r a n i n t u b a t e d a d u l t p a t i e n t on 8 cm of PEEP who ( 2 8 ) r e q u i r e s f r e q u e n t a u c t i o n i n g , a p p r o p r i a t e p r e c a u t i o n s would i n c l u d e t h e u s e o f :

I ) g o w n s , g l o v e s , a n d m a s k s 2 ) g l o v e s , a n d m a s k s 3 ) g o w n s , e y e c o v e r i n g s , and g l o v e s 4 ) g l o v e s , eye c o v e r i n g s , a n d m a s k s .

THIS IS THE END OF THE TEST *

BKAT-4: C o p y r i g h t , 1990

K a t h l e e n A . R i t c h e y , R . N . , M.S.N. V e t e r a n s A d m i n i s t r a t i o n M e d i c a l C e n t e r

W a s h i n g t o n , D . C . 20422

J e a n C . T o t h , R.N., D.N.Sc. The C a t h o l i c U n i v e r s i t y o f A m e r i c a

W a s h i n g t o n , D . C. 2 0 0 6 4

This t e s t may b e r e p r o d u c e d r o y a l t y - f r e e f o r U n i t e d S t a t e s Government P u r p o s e s

Appendix E

School of Nursing Werhington, D. C. 20064

202-3 19-5400

Suzanne B. T o w , BSN, C W U n i t Nursing Manager, CSICU Mercy osp i t a l Medial Center 6th and University Des Moines, Iowa 50314.

Replying to your recent l e t t e r , I an enclosing a copy of a l e t t e r of information regarj lag BUT& together with an Agreement Form to be signed and returned to me.

I would be most interested i n receiving a copy of your r e s u l t s .

Sincerely,

P 3 4 ,,, ean C.Toth, R.N., D.N.Sc.

Associate Professor of Cardiovasculaz NursFng

The Catholic University of America Washington, D. C . 20064

Appendix F

SCORE SHEET

BIAT-4 Content Area Ques t ions

f 1. Cardiovaacular

a. Myocardial ischemia -- 01,03,04,05,06 5 b. EKG interpretation 02,18,19,20,21,22,23,24,

25,27,29,30 1 2 c , / Electrical cardiac - stimulation 26,34

I 2

d. Emergency situations 31,35,36 3 e. Drugs 28,32,33,90.92.94.

2. Monitoring l i n e s

i 3. Pulmonary a. Ventilators 43,46 2 b. Pulmonary assessment

& care 38,39,40,41,42,44,45,47 8 (10 1

4 . Neurology a. Assessment & care 52,53,54,55,57,59,69 7 b. C V A 58 1 c. Drugs 56,91 2

(10)

5. Endocrine a. Diabetes Mellitus 60,61,62 3 b. Thyroid 68 1

- c. Drugs 63,64,66,67,93 5 d. Stress 65 1

(10)

6. Renal - h - a. Assessment & care 70,71,72,73,75,76 6

b. Peritoneal dialysis 77,78,79,80 4 (10)

7 - Gastrointestinal/parenteral 74,81,82

I a. Nutrition 3 6. GI bleeding 83,84,85,86,87,89 6

(9)

8. Other a. Blood transfusion 88 1

b. Burns 49 1

c. i ~ r u ~ n a t i 2 3 1 98) 1

d. fiothermia r/ m , 5 1 2

e. Infection control 37,99,100 3

f. Trauma 48 1

f n \

Appendix G

Score Sheet

NAME BKAT SCORE (Total possible 100)

I . Cardiovascular a. MI

Total possible 31 / C \

b. EKG interpretation c. EIectricaI cardiac stimulation d. Emergency situations e. Drugs

2. Monitoring Lines Total possible 11 a. l'ntra-cardiac b. Arterial-venous

(6) (5 1

3. Pulmonary Total possible 10 a. Ventilators b. Pulmonary care

(2) (8)

4. Neurology a. Assessment & care b. CVA c. Drugs

5. Endocrine a. Diabetes b. Thyroid c. Drugs d. Stress

6. Renal a. Assessment & care b. Peritoneal Dialysis

7. GVParenteral a. Nutrition b. GI bleeding

8. Other a. Blood transfusion b. Burns c. Drug calculation d. Hypothermia e. Infection control f, Trauma

Total possible 10 (7)

Total possible 10

Total possible 10 (6) (4)

Total possible 9 (3) (6)

Total possible 9 (1 1 (1) (1) (2) (3) (1)