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December 23, 2003

Dear Nurse Nancy,

I just graduated in May and failed the NClex the first time. I did great in school and had a 99.99 percent on the HESI exam, but I had so much anxiety when I took the exam. I feel as though I knew the material but if you have any suggestions they would be greatly appreciated.

Thank you,

GP

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Dear GP,

Well, first of all - welcome to nursing. I know you know the material, you just need some tips on test taking. It is likely not all that unusual to be so anxious that you make the wrong decisions. What you might need at this point is to enroll in a review course, to convince yourself that you know the material, and also to get the valuable insight most of them offer on how to take a test. This will include some common sense ideas like:

• At some point, stop studying
• Go to the test site the day before at the same time you plan to go on the "real" date. Get a feel for the traffic, how long it will take, etc.
• Stay healthy. Eat well, drink water, go to bed early
• Try deep breathing - it will relax you
• Trust yourself. Vision a passing grade, and think positive.

Most of this is common sense. You have to be positive. Good luck - I know you will pass and be a great nurse!

Please note that Dear Nurse Nancy will not be published online from Dec. 24, 2003 to Jan. 6, 2004. Have a happy holiday and check out the Nurse Nancy archives for questions and answers you may have missed in 2003!

Nurse Nancy

December 22, 2003

Dear Nurse Nancy,

What can you tell me about administering the drug ketamine to patients in the PACU for pain relief? I am unsure if RN's can even administer this drug...I cannot find information about it in the PDR.

HP

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Dear HP,

Ketamine HCl is a non barbiturate rapid acting dissociative anesthetic used for short term procedures, like changing burn dressings, in dentistry, specifically for procedures that do not require skeletal muscle relaxation. It is also indicated for the induction of anesthesia prior to the administration of other anesthetic agents, or to supplement low potency agents such as nitrous oxide.

According to McCaffery & Pasero (1999) in Pain:Clinical Manual - Second Edition published by Mosby, (pp.336-337) it does have some indication for acute pain management in subanesthetic doses. The advantage is that it does not suppress the cardiovascular function, laryngeal protective reflexes, and it causes less respiratory depression than opioids. They warn that tolerance can occur, and adverse effects include dizziness, frightening dreams and possibly hallucinations. They give several references which might interest you.

And speaking of hallucinations, ketamine is now used as an illicit drug, in the clubs where raves are held. The street name is Vitamin K, Special K, and Kit Kat.

I agree with your concern about RNs administering it in the PACU. You need to have the correct information about dosing, side effects and patient monitoring, just as you would with any new drug. Hopefully that will be provided to you - it is a patient safety (and a nurse safety!) issue.

Nurse Nancy

December 19, 2003

Dear Nurse Nancy,

I am an RN who may have a complainant filed against me with our state Board of Nurse Examiners. Can you recommend good legal counsel? Thank you

SS

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Dear SS,

While I don't recommend specific attorneys, I will say that I would interview several attorneys who have done work with RNs, who knows what the regulations are in your state, and who understands the professional practice of nursing. Hopefully you will find someone who has done similar work, and who is familiar with nursing issues, our malpractice, etc. You need to have faith in this person and tell him/her the truth.

I wish you luck. Think positive!

Nurse Nancy

December 18, 2003

Dear Nurse Nancy,

Can you please tell me the pros and cons of a Bachelors degree in Nursing vs. a Bachelors degree in Health Care Administration? I am an RN and midwife trained in England and I have an associate degree in Management from the U.S. I would like to have a Bachelor degree in something. Thanks.

PG

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Dear PG,

Well, I suppose it all depends on what you want to do. Certainly a BSN will open more doors for you than one in Health Care Administration. We have a science in nursing which is not in the curricula of the Health Care Administration, and I must admit my bias is in getting a BSN. If you plan to stay in nursing, I would say go for the BSN.

If you plan to be an administrator, however, you might want to do the Health Care Administrator degree. Both certainly have value - just depends on what you want to do with it.

Nurse Nancy

December 17, 2003

Dear Nurse Nancy,

I am a RN with an ASN degree. I have not worked for several years so I would appreciate your opinion. My daughter, who will be a senior in high school and has excellent grades would also like to be an RN. I have been trying to encourage her to get her BSN in nursing....but she is interested only in an ASN degree. I must confess that I want her to go to a 4-year college instead of a community college. She is primarily interested in bedside nursing, preferably neonatal. What would be your recommendation? Thank you.

ZG

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Dear ZG,

I could not agree with you more! Getting a BSN the first time will open doors for her. Neonatal nursing is a tough area to break into, and I know that in most places, a BSN will be required to even be considered. Tell her that openings in that area are far and few between (those nurses are very devoted to the neonates) and if a position opens up, having a BSN will help her immensely. It will open doors, help her in so many ways. And yes, she can remain a bedside nurse with a BSN.

I would encourage you to have her speak to young BSN nurses and perhaps her guidance counselor. Sometimes being her mother gets in the way.

Good luck to you both.

Nurse Nancy

December 16, 2003

Dear Nurse Nancy,

This question refers to a job interview, after finding one of interest or seeking to attain a promotion within your current organization. I was wondering if you had any pointers regarding interviewing for a supervisor position, going from a non-exempt staff nurse. I am not sure of what reading I should do and how in depth I should be with responses to whatever questions that may be asked.

I am sincerely interested in this position and want to make sure that I can not only answer the committee relevantly, coherently and succinctly but I also want to show enthusiasm and make a good impression. Any help or insight would be very much appreciated and welcomed. Thanks.

ND

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Dear ND,

Congratulations on your professional growth. Interviewing for a supervisory position is a great beginning. Your letter shows how much you really want this position, and my guess is that the people who interview you will pick up on that. That is a great asset already.

What I have found from internal candidates I have interviewed over the years is that sometimes treat it less formally than external candidates. I would encourage you to do this on a day when you are off, come in dressed professionally and not feeling rushed to go back to work. As far as the interview goes, I would practice this with someone if you are nervous. Most skilled interviewers will not ask tough questions or ones you can't answer; they are looking to see if your skills match their needs. This is the time to speak up about what you do, talk about yourself in a positive (but not boastful) manner. Don't tell them what you don't know; ask what the orientation plan for this position is. If you don't know an answer, say so. That says a lot about you - that you are honest, and you won't make bad choices to save face.

Good luck on the interview!

Nurse Nancy

December 15, 2003

Dear Nurse Nancy,

I graduated from a 3 year nursing program. Graduates from a two
year program use the initials ADN, and four year nurses use BSN, what initials can I use. I have a Diploma.

Thanks

CL

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Dear CL,

Your question points out one of the main issues in nursing education. Unlike any other profession, nursing does not have a standardized way to enter the field. And it is something we have been debating among ourselves - unsuccessfully - for as long as I can remember.

Your colleagues have academic credentials because they have attended college, for either 2 or 4 years. Diploma graduates have a different kind of education, with emphasis placed on clinical practice. As a diploma graduate myself, I know we took coursework in science and pharmacology, but the faculty I had did not have the academic credentials required of a university setting. That is not to say that they were not good teachers; I had a fabulous education, but it was not sanctioned by any university. When I did go back to get my BSN, I had to start all over, as I had no college credit.

Thanks for your question.

Nurse Nancy

December 12, 2003

Dear Nurse Nancy,

I have just recently become and RN. I was an LPN for 5 years and wanted to do more for my patients and went back to school. Now I am wondering if I made the right choice. I work in a medical/Surgical ICU and my problem is the Doctors. I work night shift and they just don't want to be called. I find myself hoping nothing goes wrong so I won't have to pick up the phone. I keep telling my self that I need to become one of those nurses who just don't care, but that is just not me. How do you make your job enjoyable when those you depend on for help are critical and very nasty on the other end? I have discussed this with the night shift coordinator and my manager. Nothing has changed. I need advice or maybe a new position in the hospital. I just don't seem to be able to handle the stress or rude and uncaring doctors. If you have and suggestions I would love to hear it.

DN

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Dear DN,

Well, first of all - congratulations on becoming an RN! That is great. Your problem is nothing new, and I worked nights for 10 years, and have been a night supervisor, so I can relate. You have already spoken to your supervisors, and good for you.

Waking people up is what night nurses do. Hopefully, you organize your calls so you are not calling frequently. I would suggest that you have the physician review the patients' orders before they leave. Make sure you have orders for things that might come up - pain medications, sleeping pills, and so forth. If you anticipate some of this, the calls should decrease.

Bottom line - you are there advocating for your patient, and if it involves waking someone up, that is your job. They can yell - if you need their assistance, you have a professional responsibility to do that. I would remain calm and professional. This is what we do best, and I am glad you are there to advocate for your patients.

Nurse Nancy

December 11, 2003

Dear Nurse Nancy,

I am looking into the legal nurse role. I live in Hartford County, in Connecticut. Can you tell me more about this part of the nursing profession and how I can find a job in my area. I am currently in dialysis and have experience in emergency medicine. I recently received my BSN and not sure what I want to do in the near future. Thanks.

GG

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Dear GG,

There are several courses available to become a Legal Nurse Consultant. Part of the coursework is teaching nurses how to do a business plan (not something taught in nursing programs) and marketing skills. The most successful LNCs that I know have a very strong professional resume, including a master's degree, certification, publications and presentations. This establishes you as an expert. You certainly are off to a great start - I would continue to build on your professional development.

I know several nurses who have been through the Legal Nurse Consultant education, only to find they really did not have that entrepreneurial spirit to make it work for them. It requires selling yourself, developing new skills of marketing, developing a brochure, having business cards, networking among professional and non professional colleagues to make sure people know who you are and how you can help them.

Nurse Nancy

December 10, 2003

Dear Nurse Nancy,

I am a Director of Nursing in a LTC facility and need to in-service my staff on proper documentation in medical record. I am leaning toward focus charting. What is your preferred method of charting? My nursing staff is currently wasting a lot of time documenting the same info in numerous places. Please help. Also what info is would be deemed inappropriate on a incident and accident report. What is the needed info and what exactly should be stated in the medical record when an incident report is filed? Thanks.

CS

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Dear CS,

There are so many types of documentation systems, and I find that no one system works for everyone. My suggestion would be to get a small representative group of your staff together, have them look into what is out there, and have the group make a recommendation to you. I have used this method many times in my career, and it has been successful. By including them, you empower them to be part of the selection, and hopefully will have the buy-in for the success of the project.

As for incident reports, they should have as many details as is possible so that you can track and trend the issues in your institution. Staff needs to realize that these are not used in a punitive manner, but are used to look at recurrent issues, and to improve processes. Details matter - AM or PM, exactly what happened, where, etc. The completion of an incident report should not be documented in the medical record, as the incident report is not discoverable (by an attorney) but the medical record is. This is not to say that if a patient has an adverse reaction you should not chart it, but just state the patient data, not that an incident report was completed.

Good luck in your new documentation system.

Nurse Nancy

December 9, 2003

Dear Nurse Nancy,

I was just promoted this week to staff developer and I need to take a class to become a certified staff developer. I've been looking in the Internet for classes and I'm so lost and I need help in order to attend a class to be certified. I live in Los Angeles CA.

Thanks. Help!

DA

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Dear DA,

Congratulations on your promotion! This is a great role for nurses, as you have the opportunity to influence so many new (and experienced) nurses. I would suggest that one of the first things you do is to join the National Nurse Staff Development Organization.

This group has a whole selection of publications which I believe will help you in your transition to staff developer, as well as the Core Curriculum for Staff Developers. And they are having their national meeting in San Diego next summer - July 29 to August 1. Their site will tell you more about this group. I know if there is a class to take near your area, they can help you find it.

Good luck!

Nurse Nancy

December 8, 2003

Dear Nurse Nancy,

I work in a juvenile correctional facility undergoing management turnover. Our new nurse manager is stating that when Ritalin orders are discontinued the pills are put in our sharp containers and when picked up by our biowaste company the manifest serves as the proof of destruction of controlled substance. I have never seen this done and was wondering if it is acceptable practice. We are in the state of Florida.

LW

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Dear LW,

This is an interesting question, as I see nurses in the hospital setting putting all sorts of items in the systems where I work that I question. That box should be used for sharps only, not as a waste basket. I know there has been a big issue with the disposal of Duragesic (fentanyl patches) in the sharps containers. Their have been incidences of tampering with the boxes to get to the residual medication by individuals trying to get to the drug. The manufacturers insert informs the nurse to flush the patch down the toilet - it is biodegradable, and then no one can get to the residual medication.

I would feel better if the medications were flushed down the toilet for the same reason. I would have a witness and have both of you sign somewhere on your client's record. I would also seek the advice of the Florida Drug Enforcement Agency for their procedure.

Thanks for the question.

Nurse Nancy

December 5, 2003

Dear Nurse Nancy,

I am a travel RN working a 6 month assignment. I do not want to finish this assignment and want to return home. Can I legally do this? Help??

SS

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Dear SS,

Well, certainly being a travel nurse is not a prison sentence! This is a contractual agreement between you and the Travel Nurse Agency, who in turn contracts with the hospital for your services. I would suggest you take a look at your contract; it likely spells out what you would have to do to sever the contract, which is likely to repay the expenses paid for you to go there.

Before you do this, I wonder if you have spoken with your advisor at the Agency, as well as the Nursing Management people where you are. Sometimes things can be fixed, given a chance for them to be aware of your issues. I would encourage you to complete your assignment; I know six months sounds like a long time, but it will go by quickly. Good luck!

Nurse Nancy

December 4, 2003

Dear Nurse Nancy

I have asked this question to many other nurses and cannot seem to get a sure answer. Can a LPN/LVN give push medication legally? At the hospital I work they do. I was a LPN/LVN for 7 years before becoming a RN and was instructed I could not give push meds, nor did I feel comfortable doing so. Thank you.

EF

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Dear EF,

Well, I agree that I am not used to LPNs pushing IV meds. There are several places to look to see if this is within the scope of practice of the LPN. Having been an LPN yourself, you know that LPNs work under their own practice act; I would start looking there. It is generally mandated by the state what licensed practical nurses and registered professional nurses are allowed to do by practice act (look for your state Board of Nursing's information on our site - click here!

The other place to look is your hospital policy and procedure manual. This generally spells out who can perform what skill, and it is based on the practice acts for your state along with regulatory agencies.

Thanks for the question. Good luck!

Nurse Nancy

December 2, 2003

Test your knowledge on Alzheimer's with Nurse Nancy's trivia quiz. Answers are in red.

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Alzheimer's is a progressive, neurological disorder that attacks the brain and results in cognitive problems. Test your knowledge of this chronic condition. Good luck!

1. What year did German psychologist Alois Alzheimer first describe this disease?

A. 1896
B. 1906
C. 1916
D. 1926

2. Which one of the following medications is NOT approved by the Food and Drug Administration for Alzheimer's?

A. Aricept
B. Cognex
C. Exelon
D. Mentax

3. How many Americans over the age of 85 does the Alzheimer's Association suggest have Alzheimer's Disease?

A. One fourth
B. One third
C. Two thirds
D. Half

4. Which group of 687 individuals agreed to periodic memory tests, examination of earlier writings and autopsies of the brain to further the study of Alzheimer's?

A. Farmers
B. Librarians
C. Nuns
D. Students

5. Which movie star, who died of Alzheimer's Disease, has this on the tombstone: "To Yesterday's Companionship and Tomorrow's Reunion"?

A. Jackie Coogan
B. Bing Crosby
C. Rita Hayworth
D. Heddy Lamar