READING 3

PART A
Ectopic pregnancy
TEXT A
Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside
the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding.
Fewer than 50 percent of affected women have both of these symptoms. The pain may
be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding
into the abdomen has occurred. Severe bleeding may result in a fast heart rate, fainting,
or shock. With very rare exceptions the fetus is unable to survive.
• Risk factors for ectopic pregnancy include
• Pelvic inflammatory disease, often due to chlamydia infection
• Tobacco smoking
• Prior tubal surgery
• History of infertility
• Use of assisted reproductive technology
• Those who have previous history ectopic pregnancy
• Previous exposure to DES
• Endometriosis
• Tubal ligation
Most ectopic pregnancies (90%) occur in the fallopian tube, which are known as tubal
pregnancies Implantation can also occur on the cervix, ovaries, or within the abdomen.
Detection of ectopic pregnancy is typically by blood tests for human chorionic
gonadotropin (hCG) and ultrasound. This may require testing on more than one
occasion
 TEXT B

Signs and symptoms

Up to 10% of women with ectopic pregnancy have no symptoms, and one third have no
medical signs. In many cases the symptoms have low specificity, and can be similar to
those of other genitourinary and gastrointestinal disorders, such as
appendicitis, salpingitis, rupture of a corpus luteum cyst, miscarriage, ovarian torsion or
urinary tract infection. Clinical presentation of ectopic pregnancy occurs at a mean ofweeks
after the last normal menstrual period, with a range of four to eight weeks. Later
presentations are more common in communities deprived of modern diagnostic ability.
Signs and symptoms of ectopic pregnancy include increased hCG, vaginal bleeding (in
varying amounts), sudden lower abdominal pain, pelvic pain, a tender cervix, an adnexal
mass, or adnexal tenderness. In the absence of ultrasound or hCG assessment,
heavy vaginal bleeding may lead to a misdiagnosis of miscarriage. Nausea, vomiting and
diarrhea are more rare symptoms of ectopic pregnancy.

TEXT C

Complications
The most common complication is rupture with internal bleeding which may lead to
hypovolemic shock. Death from rupture is the leading cause of death in the first
trimester of the pregnancy. Rupture of an ectopic pregnancy can lead to abdominal
distension, tenderness, peritonism and hypovolemic shock. A woman with ectopic
pregnancy may be excessively mobile with upright posturing, in order to decrease
intrapelvic blood flow, which can lead to swelling of the abdominal cavity and cause
additional pain.

Causes
There are a number of risk factors for ectopic pregnancies. However, in as many as one
third to one half no risk factors can be identified. Risk factors include: pelvic
inflammatory disease, infertility, use of an intrauterine device (IUD), previous exposure
to diethylstilbestrol (DES), tubal surgery, intrauterine surgery (e.g. D&C), smoking,
previous ectopic pregnancy, endometriosis, and tubal ligation. A previous
induced abortion does not appear to increase the risk. The intrauterine device (IUD)
does not increase the risk of ectopic pregnancy, but with an IUD if pregnancy occurs it is
more likely to be ectopic than intrauterine. The risk of ectopic pregnancy after
chlamydia infection is low. The exact mechanism through which chlamydia increases
the risk of ectopic pregnancy is uncertain, though some research suggests that the
infection can affect the structure of Fallopian tubes.
 Text D
Treatment
Unfortunately, the fetus (the developing embryo) cannot be saved in an ectopic
pregnancy. Treatment is usually needed to remove the pregnancy before it grows too
large
The main treatment options are;
• Expectant management –your condition is carefully monitored to see whether
treatment is necessary
• Medication – a medicine called methotrexate is used to stop the pregnancy
growing.
• Surgery –surgery is used to remove the pregnancy, usually along with the
affected fallopian tube.
These options each have advantages and disadvantages that your doctor will discuss
with you. They’ll recommend what they think is the most suitable option for you,
depending on factors such as your symptoms ,the size of the fetus and the level of
pregnancy hormone (human chorionic gonadotropin or hCG)in your blood.

QUESTIONS 1-7
For each question, 1-7 decide which text (A,B,C,OR D)the information comes
from .you may use any letter more than one

In which text can you find information about?

1) Different sites of implantation in pregnancy?

2) Treatment usually requires to terminate pregnancy?

3) Characteristics of pain in ectopic pregnancy?

4) Cause of death during a certain period of pregnancy?

 5) Percentage of women with ectopic pregnancy who are asymptomatic?

6) Causes of ectopic pregnancy?

7) Unusual manifestations of ectopic pregnancy?

Questions 8-13
Answer each question 8-13 with a word or short phrase from one of the texts. Each
answer may include words, numbers or both

8) What is the most common complication noted when embryo attaches outside
the uterus?

9) What is the percentage of ectopic pregnancies which occurs in the fallopian

tube?

10) A medication which used to cease the gestation

11) What can cause abnormal enlargement of the abdominal cavity?

12) What is the percent of woman who have both abdominal pain and vaginal
bleeding?

13) Which management requires careful monitoring of the condition?

14) Which sign in ectopic pregnancy can present in varying amount?

 Questions 15-20
Complete each of the sentences, 14-20 with a word or a short phrase from one
of the texts. Each answer may include words, number or both.

15) of an ectopic pregnancy may cause hypovolemic shock

16) Woman with ectopic pregnancy are asymptomatic and _have no
medical signs
17) Detection of ectopic pregnancy may require testing more than .
18) The use of technology is a risk for ectopic pregnancy.
19) will suggest the most appropriate treatment option.
20) Massive vaginal bleeding may misdiagnose in the absence of HCG assessment
or
 PART B

TRENDS IN ONCOLOGY NURSING

As a result of the growing number of anticancer agents delivered orally and the shift of
responsibility from inpatient to outpatient settings, patients are increasingly expected
to control their treatment by themselves. Since patients generally stay at home during
therapy, the completion of the therapy depends on whether or not the patients
themselves adhere to the treatment regimen. A research that evaluated whether or not
nursing intervention improved patients' QOL using treatment adherence as the outcome
indicator is currently attracting attention.
What the manual says about?
a) Changes in the field of cancer treatment
b) Role of nursing intervention in cancer treatment
c) Importance of patient in cancer treatment.

NUCLEAR MEDICINE

In Nuclear Medicine Departments (NMDs), nurses care for patients undergoing

diagnostic or therapeutic treatments. This involves patient preparation, administering
radioactive and non-radioactive medications, explaining the procedure, comforting and
ensuring patient safety. These nurses are vulnerable to the damaging effects of ionizing
radiation. However, they can reduce the risks of radiation by using different principles of
radiation protection such as ALARA and the 10-day-rule. In addition, they may use the
principles of time, distance, and shielding as well as various monitoring devices such as
Geiger Muller (GM) counter and Thermoluminescent Dosimeters (TLDs). ALARA refers to
As Low as Reasonably Achievable, in other words, to receive the maximum benefits by
using the minimum of radiation dose to avoid its risks. The 10-day-rule on the other
hand recommends that in women of child bearing age, non-urgent examinations that
involve pelvic radiation should be limited to the first 10 days of the menstrual cycle.
Time refers to the length of exposure to radiation, in that short exposures will produce
less radiation dose. Distance refers to the distance between an individual and the
radiation source. Increase in distance can result in dose reduction. Shielding refers to
both fixed protective barriers and personal protective equipment such as lead aprons.

2) How nurses should reduce damaging effect of ionizing radiation?

a) By using different principles of radiation protection such as ALARA and the 10 day
rule.
b) By administering radioactive medicines.
c) Should maintain less distances between individual and radiation sources.

Nurse Involvement in End-of-Life Decision Making.

In the critical care setting, nurses often feel the stress of working with patients and
family members who are facing end-of-life decisions. Traditionally, the responsibility for
end-of-life discussion belongs to the physician. Nurses often feel ill-prepared and
awkward in addressing the topic with the patient and family. As patient advocates,
nurses should be more actively involved with facilitating end-of-life decision-making
process for critically ill patients and their families. Advocating for patients is an ethical
imperative for nurses

3) Who is the main person involved in end of life discussion

a) physician
b) Nurse
c) Both physician and nurse.

Patient safety is one of the nation's most pressing health care challenges, which are in
the domain of clinical risk management; in fact clinical risk management is a principal
element of clinical governance. In other words, besides error detection capabilities,
establishing effective clinical risk management depends on institutionalizing the culture
of error reporting based on trust. Reducing the probability of clinical risks in hospitals is
very important to improve: Health care quality, having effective hospital staff and
patients relationship, patient satisfaction and also to limit complaints on medical errors
and nursing care.

4) The passage says about

a) Importance of patient care

b) Risks in patient care
c) Methods to reduce clinical risks

ERRORS IN ICU CARE

It is determined that most of potential errors have low discovery number showing that
the ICU nurses are familiar with potential errors of cares and will discover their causes
immediately. It is noteworthy, nursing failure and neglect is not the only causes of ICU
potential errors, there are many factors caused errors such as patients’ sensitivity,
patient with complex conditions and underlying disease, lack or malfunction of
equipment, negligence and malpractice of physicians and other personnel, lack of
proper training to the nurses, fatigue due to sensitivity and high volume of workload in
ICU. Team members also proposed some actions to control and eliminate each of
detected clinical errors.

5) Why the possible errors are less common now?

a) ICU nurses find the errors and solutions immediately

b) ICU nurses are able to find the causes of potential errors
c) Find other factors which leads to potential errors.

CODE OF ETHICS

As a main general conceptual background of the National code, the patients are not
considered as only people who receive the nursing care, and others including the
patients’ family and healthy people in the society are considered in the plans and
services. Another essence of the Code is that the individual dignity should be respected,
regardless of who is receiving the care, or from which nationality, ethnicity, religion,
culture, socio-economic class, gender, etc the patient/client is. Meanwhile, under the
provisions of the National Code, nurses must recognize and respect cultural sensitivity in
everyday practice, even in this era of globalization.

6) How individual dignity should be respected in code of ethics?

a) Nurses must recognize and respect cultural sensitivity in everyday practice

b) Patient and family requires appropriate nursing care as per code of ethics
c) Care in regardless of ethnicity, religion, culture, socioeconomic class, gender and
nationality.
 PART C

CRITICAL ROLE OF NURSE IN ANTIMICROBIAL STEWARDSHIP

Paragraph 1

The emergence and worldwide spread of antimicrobial resistance presents a global

health crisis that both the US Centers for Disease Control and Prevention (CDC) and the
World Health Organization (WHO) have labeled a grave threat to human health . The
“perfect storm” of widespread antibiotic use, pharmaceutical industry retreat from new
antibiotic development, and spread of antibiotic resistant organisms, combined with
rapid, accessible international travel has captured the attention of healthcare
professionals, national governments, the media, and the public at large. The main
immediately available strategy to address this problem is the utilization of currently
available antibiotics and resources in the most judicious manner to achieve the best
clinical results, while limiting the development and propagation of multi-drug resistant
microorganisms.

Paragraph 2

Antimicrobial stewardship is such a programmatic approach to the thoughtful use of

antibiotics. It is hoped that education of all healthcare providers, as well as the general
public, about the rationale for antimicrobial stewardship will lead to a restraint in the
use of antibiotics that was felt to be unnecessary in an earlier time when antibiotics
were regarded as abundant and effective “miracle drugs.” Although conceptual
guidelines for the ideal use of antibiotics were published in 1988, and warnings
regarding resistance to antibiotics were promulgated as far back as 1939 and 1945,
formal antimicrobial stewardship programs (ASPs) have developed only in the last 15
years . The major currently recognized stakeholders in ASPs include pharmacy,
infectious diseases, infection prevention, and microbiology professionals, with
administrative (including financial and regulatory) support. The sector currently absent
from the formal organizational chart is nursing.

Paragraph 3

Repeatedly, in guidelines for the development of ASPs, broad-based, multidisciplinary

involvement is highlighted as an essential feature to achieve the goals of antimicrobial
stewardship. Brief mention of including staff nurses is made in these recommendations,
but is limited to at most 3 or 4 sentences. In 2 articles from the United Kingdom and
from Australia and in the Institute for Health Improvement/Centers for Disease Control
and Prevention (IHI/CDC) Antibiotic Stewardship Driver Diagram and Change Package,
comment is made about nursing functions. However, in the latter, the itemized
secondary drivers are not explicitly assigned or attributed to nurses, and in the 2
infection control journal articles, the interventions are described as “should be
implemented” or “could impact” antimicrobial stewardship efforts. We assert that staff
nurses are already participating in these activities, albeit not in an acknowledged or
integrated fashion. Because of this exclusion, they cannot contribute most effectively to
the diverse goals of ASPs. The unintentional mischaracterization of the participation of
nurses in ASPs as only potential rather than actual has the additional unintended
consequence of divorcing nursing from those very activities that nurses need to
understand as critical attributes of antimicrobial stewardship.

Paragraph 4

The dichotomy between the omission of nurses from formal ASP guidelines and the
reality of daily nursing practice becomes obvious if one examines a stepwise progression
through a typical inpatient hospital admission. On arrival at the hospital emergency
department, a patient is triaged and placed on appropriate precautions. This triage
function is actually made by the emergency department triage nurse or by the admitting
staff nurse. That decision may be reviewed or modified later by an infection
preventionist, sometimes guided by microbiology results, but the immediate
determination regarding necessary isolation is an established staff nursing judgment.

Paragraph 5

Next, medication allergy history is assessed, either by the triage or admitting nurse. A
label of penicillin “allergy” has been documented to be associated with increased
antibiotic costs, increased selection of antibiotic resistant microbes, and increased
length of stay and hospital costs . These subsequent consequences are traditionally
linked to pharmacy, microbiology, case management, and fiscally to administration, but
the identification and documentation of a medication allergy history is a well-accepted
staff nurse responsibility. Nurses therefore need to be taught the difference between a
true allergy and the adverse events that would not preclude the use of certain classes of
antibiotics. As many electronic medical record systems preserve the past history of a
patient's medication usage, the nurse's review of past safe (or not) receipt of cross-
related antibiotics (eg, cephalosporins in a patient with a history of alleged penicillin
allergy) could become a useful component of “medication allergy reconciliation.”
 Paragraph 6

Timely antibiotic ordering and administration, regarded as a Joint Commission National

Quality Core Measure and identified as Centers for Medicare and Medicaid Services
(CMS) performance measure, is typically viewed purely as a physician prescribing event.
But it is the staff nurse who receives the order for antibiotics, submits the order to the
pharmacy, administers the medication, records its dose and timing, and monitors the
effects of treatment and adverse events. Likewise, collection and submission of
specimens for culture are almost universally performed by nurses. This underscores the
need for nurses to be educated about how to obtain appropriate specimens for culture
and then to send such specimens by protocol in suitable clinical settings without
awaiting a physician order.

7) What does the paragraph 1 says about?

a) Future actions needed to solve a serious problem
b) Highlight an instantly obtainable solution for a serious threat
c) Immediate actions needed to address the antimicrobial assistance
d) Explains the seriousness of antimicrobial resistance

8) What does the phrase “miracle days “indicates?

a) Drugs which elicit a dramatic response in a patient’s condition

b) Plentiful and effective drugs which are newly discovered
c) Antibiotics which produce wonderful effect on patients
d) Abundantly available effective drugs

9) In paragraph 2, when commenting on the popularity of ASPs, these were actually

making know in

a) 1988
b) 1939 and 1945
c) 1945
d) Last 15 years

10) According to paragraph 3, what is the limitation of recommendation which states

regarding inclusion of staff nurses?
a) Limited to fewer than 3 or 4 sentences
b) Guideline was just about 3 sentences
c) Restricted to maximum 3 or one sentence more than that
d) Extended to at most 3 or 4 sentences

11) Why microbiology results are using triaging the patient?

a) Triage function may be based on microbiology results.
b) Sometimes triaged patients are reviewed on the basis of these results.
c) For necessary isolation purpose
d) To modify the triage decision which made by the nurses.

12) When assessing medication allergy, why is it important to label penicillin

hypersensitivity?
a) It is documented in relation to various factors
b) Mainly it is associated with antibiotic costs
c) To reduce the total expenses of a hospital stay
d) It is related to pharmacy, microbiology, case management and administration

13) In paragraph 5, what does the word “reconciliation “means?

a) Restoration of patient’s medication allergic history
b) Harmonization of patient’s medication allergy
c) Consistent history of medication allergy
d) Review of past allergic history

14) In the final paragraph what the writer says about the need for nurses education?
a) It is important to follow the protocol in clinical setting
b) Need to educate regarding proper specimen collection and following procedures to
send specimen for culture
c) Education needed for collection and submission of culture, these are almost
universally performed
 ADHERENCE AND HEALTH CARE COSTS

Paragraph 1

Medication non-adherence is an important public health consideration, affecting health

outcomes and overall health care costs. This review considers the most recent
developments in adherence research with a focus on the impact of medication
adherence on health care costs in the US health system. We describe the magnitude of
the non-adherence problem and related costs, with an extensive discussion of the
mechanisms underlying the impact of non-adherence on costs. Specifically, we
summarize the impact of non-adherence on health care costs in several chronic
diseases, such as diabetes and asthma. A brief analysis of existing research study
designs, along with suggestions for future research focus, is provided. Finally, given the
ongoing changes in the US health care system, we also address some of the most
relevant and current trends in health care, including pharmacist-led medication therapy
management and electronic (e)-prescribing.

Paragraph 2

Patients are considered adherent to medications when they take prescribed agents at
doses and times recommended by a health care provider and agreed to buy the patient.
As the health care community adopts the concepts of patient centeredness and
activation, it is moving away from the term “compliance”, which implies patient
passivity in following the prescriber’s recommendations. Medication persistence is the
length of time from initiation to discontinuation of therapy.

Paragraph 3

Adherence may be measured indirectly or directly as shown in . Two indirect adherence

metrics used in research and administrative work are the medication possession ratio
(MPR) and the proportion of days covered (PDC). MPR is calculated as the total number
of days supplied, divided by the number of days between the first and last refills; while
PDC is calculated as the total number of days supplied during an interval, divided by the
total number of days during that interval. An MPR of 80% is often used as the cut off
between adherence and nonadherence based on its ability to predict hospitalizations
across selected high prevalence chronic diseases. These measures rely on pharmacy
claims data, which does not account for the use of free drug samples, can miss coverage
through a different insurance plans, and is insensitive to therapy changes. Insurance
claims data also do not assess whether patients time doses, or use delivery devices,
correctly. These protocols are important in conditions like COPD and asthma, where the
way a patient uses inhaled therapy can also affect outcomes significantly.

Paragraph 4

In clinical settings, adherence may be indirectly assessed using patient recall. Because
patients may significantly overestimate adherence during self-reports, patient recall is
more effectively interpreted when combined with a validated questionnaire to assess
adherence barriers. Other methods such as pill counting and reviewing pill bottles
against medication lists may provide important clinician insights and an opportunity for
patient education. Bidirectional electronic (e)-prescribing interfaces which provide
clinicians data on medication refill intervals at the time of care, are available in settings
with electronic medical records. Electronic and mechanical dose counters provide
estimates of adherence that can be reviewed during clinician visits; these may also
improve adherence by providing patient reminders. Finally, clinicians may assume
patients are adherent with medications when therapeutic goals are achieved. Like
claims data, clinical setting measures lack the ability to verify doses are taken but
require less time and expense to implement, compared to directly measured
adherence.Direct methods, including observed therapy, and blood or urine drug and
metabolite concentrations are most commonly used in research when therapy involves
high risk medications, or when public health needs merit the additional costs,
invasiveness, and resources required to implement them.
Paragraph 5

Optimizing expenditures and outcomes

In 2010 spending for prescription drugs in the US was US$259 billion. Considering the
prevalent rates of nonadherence, drug-related expenses could increase substantially if
adherence improved. Medication nonadherence is widespread and varied by disease,
patient characteristics, and insurance coverage, with nonadherence rates ranging from
25% to 50%. In the US, nearly half of all adults have at least one chronic disease28 and
the percentage of Americans taking at least one prescription drug increased from 38% in
the period 1988–1994 to 49% in the period 2007–2010; during the same time the
number of adults taking three or more prescription drugs doubled. Prescription
medication use will increase as the population ages. Based on these statistics, increasing
adherence from current levels could increase medication expenses by billions of dollars.

Paragraph 6

Strategies to enhance adherence should consider the impact on overall health care
costs, weighing increased drug expenditures against savings from improved outcomes.
The majority of the costs attributed to medication nonadherence result from avoidable
hospitalization. Additional direct costs are incurred by progression of controllable
disease with: increased service utilization at physician offices, emergency rooms, and
urgent care and treatment facilities such as nursing homes, hospice, or dialysis centers;
avoidable pharmacy costs related to therapy intensification as co morbid conditions
develop; and diagnostic testing that could be avoided by controlling the primary illness.

Paragraph 7

Because the adverse consequences of most chronic illnesses may not present for years,
it is argued that additional expenditure to increase medication adherence might not be
economically attractive to payers. Even in illnesses where total health care costs are
lower in adherent patients, savings might reflect the impact of patient characteristics,
other than adherence, that make them healthier overall than non-adherers. If this were
true, investing resources in activating “unhealthy non-adherers” might not be cost
effective. However, as discussed in our review, there is substantial evidence that the
long term costs of poor outcomes exceed costs of medications in much chronic illnesses.
In contrast, increasing adherence in mild illness may not save costs. If the cost of the
medication is relatively high, while the baseline rate of hospitalizations and emergency
department visits is low (eg, mild asthma or early human immunodeficiency infection),
total health care costs may increase with better adherence. In cases like these, using
low-cost generic medications and targeting higher severity patients may shift the
balance towards cost savings.

Paragraph 8

Increasing adherence in patients with higher acuity may be a better investment,

especially when rates of hospitalization are high. An estimated 10% of hospitalizations in
older adults may be caused by medication non-adherence. To prevent admissions and
readmissions, payers and hospitals have implemented programs to improve medication
adherence after discharge.
15) Which of the following statements best matches the information in the first
paragraph?
a) A study which relates healthcare cost and non-adherence.
b) Medication adherence health outcomes and health care cost
c) Emphasize on the need for future research studies.
d) Describing the current trends and related cost.

16) Why do the health care committee moving away from the term compliance?
a) They focus more on the concepts patient activation.
b) There is more appropriate word to describe patient centered care.
c) It indicated patient’s inactivity in obeying prescriber’s recommendations.
d) They espouse the patient centeredness and activation concepts.

17) According to paragraph 3, pharmacy claims data is not responsible

for
a) Therapy changes and insurance plans.
b) Utilization of free drug samples.
c) Cut off between adherence and non-adherence.
d) MPR’s ability to predict hospitalizations among selected high prevalence chronic
disease.

18) What is the advantage of indirect assessment of adherence compared to direct

methods?
a) Patient recall is more effectively interpreted
b) Less laborious and cost effective to execute.
c) Replenish intervals at the time of care.
d) Direct method requires additional costs and resources to implement.

19) The main idea presented in paragraph 5 is

a) Increasing rates of non-adherence and expenses.
b) Research on medication adherence and increased number of prescribed medications.
c) Enhancement in adherence could significantly increase the medication expenses.
d) Medication expenses could improve the drug adherence.

20) Attribution of costs to the drug non-adherence is due to _

a) Additional direct costs.
b) Progression of controllable disease.
c) Unnecessary hospitalization.
d) Avoidable hospital admissions.

21) What is the relation between medication cost and rate of hospitalization?
a) Total health care cost will increase.
b) Cost of medication exceeds proportion of hospitalization.
c) These are inversely proportional to each other.
d) Rate of hospitalization and emergency department visit is low.

22) The word “acuity” in paragraph 8 indicates -

a) Keenness
b) Knowledge
c) Clarity
d) Attitude