Chapter 11: The Healthcare Delivery System Prep U's

A nurse says, "We have so many drills and safety checks for everything. It is almost like we are preoccupied with the possibility of failure." How should the charge nurse respond to this statement?

"Highly reliable organizations think about the possibility of failure and what to do to avoid it." Explanation: Characteristics of high reliability organizations include preoccupation with failure, reluctance to simplify, sensitivity to operations, deference to expertise, and commitment to resilience.

At the last hospital unit meeting, the policy for the insertion of Foley catheters was revised based on current evidence. The new nurse on the unit just learned "the old way" and is frustrated to now have to learn a new methodology. Several other nurses comment that the change is "all about money." The charge nurse must educate the staff about the importance of this new policy. Which explanation by the charge nurse is most appropriate?

"Incorporating evidenced-based practice into our care routines links our interventions to valued outcomes, thereby increasing quality care. When we provide quality care, we can decrease cost." Explanation: Evidenced-based practice improves client outcomes, thereby increasing the quality of care; quality care leads to decreased cost. Cost is a driver in quality health care delivery. Evidenced-based practice is not just a trend in care; it is an expectation in health care delivery. Clients are consumers of care, but they often do not understand evidenced-based care or the cost associated with care. Today's greater focus on quality makes it less likely that clients will suffer unnecessary or harmful treatment, reduces waste, and increases safety.

Which statement regarding health care reform trends is most accurate?

"Systems are in place to pay for performance and penalize hospitals for excessive readmissions." Explanation: Health care trends already include paying for performance (HEDIS, HCAHPS) and penalizing hospitals for excess readmissions. In the United States, private insurers dominate over public, unlike in most countries. The United States is first in health care spending worldwide, and it is estimated that 20% of the gross domestic product will be spent on medical services by 2021.

It is recommended that a client go to a convalescent center upon discharge following a minor stroke. The client says, "I don't want to go anywhere, I want to go home." Which information should the nurse offer?

"You will only stay until you are well enough to go home." Explanation: Those entering convalescent centers remain only until they have recovered. The nurse should explain this even though the client does have the right to refuse. There is no indication that the client will not be able to care for oneself again. There is a difference between a convalescent center and a nursing home.

Which client would a nurse correctly refer to Medicare services?

A 66-year-old client with diabetes Explanation: Medicare is a federal health care plan for individuals over the age of 65. An individual with a disability might be referred to Medicare, but other federal organizations must be involved for this to occur. A low-income family with infants needing immunizations would be referred to Medicaid. The client with cancer in this question is not noted to be over age 65.

The nurse is caring for several clients with chronic conditions that need to be evaluated for long-term care. After evaluating each client, the nurse determines which client is most appropriate to receive long-term care?

A client who suffered a stroke who has mobility issues and problems completing activities of daily living (ADLs). Explanation: Long-term care facilities provide health care and help with daily living for people of any age who are physically or mentally unable to care for themselves independently. This care may extend for periods ranging from days to years. A client who suffered a stroke who has mobility issues and problems completing ADLs is an appropriate client to receive long-term care services. A client requiring medication monitoring needs primary health care, not long-term care. The client with a back injury and physical therapy needs treatment and outpatient therapy, not long-term care. The client diagnosed with pneumonia requiring mechanical ventilation requires acute care, not long-term care.

A nurse demonstrates understanding of Healthy People 2030 by supporting which statement?

A client's health is affected by social, economic, and political factors. Explanation: People believe "quality of life" to be synonymous with a healthy community. There is growing recognition that to achieve the goals of Healthy People 2030 a model inclusive of multiple health determinants is needed. Clinical care has typically focused on diagnosing and treating symptoms. Understanding health in relation to personal behaviors, social factors, and other determinants provides a holistic context and not a quick resolution of needs. As an example, it is important to know whether an individual has access to a grocery store with fresh fruits and vegetables to comprehend that client's nutritional needs. To affect social, economic, political, and educational health determinants, health initiatives are more effective if they are based in the community and incorporate community collaboration. While physical therapy can be helpful for a client in the home, it does not have a basis for the community emphasis in Health People 2030.

A clinic-based nurse in a sparsely populated remote area far from a regional hospital is working with other local health care team members on a plan to improve client health and outcomes. The team has decided that which health care delivery system would best meet the population's needs?

A health clinic run by an advanced practice registered nurse (APRN) Explanation: The APRN-run health clinic would best meet the needs of clients who live both far from each other and from regional facilities. A PPO is an insurance/provider model that does not address the question's intent. Similarly, a multi-specialty group would likely be unsustainable in a remote, sparsely populated area. A medical neighborhood is similar to a health maintenance organization model.

The nurse is providing care to several clients. For which client should the nurse include secondary care in the nursing plan of care?

A middle-aged client who presents with new-onset angina Explanation: A middle-aged client who presents with new-onset angina requires a referral to a cardiologist and probably additional testing. Secondary care occurs when the primary caregivers refer clients for consultation and additional testing, such as with the referral of a client to a cardiac catheterization laboratory. The remainder of the clients require only primary care.

A nurse working for a home health agency is scheduled to evaluate a client with worsening heart failure to determine whether the client is a candidate for the new "Hospital at Home" program. Which statement accurately reflects an outcome for this program?

A nurse working for a home health agency is scheduled to evaluate a client with worsening heart failure to determine whether the client is a candidate for the new "Hospital at Home" program. Which statement accurately reflects an outcome for this program?

Which is an emerging trend in health care delivery?

Active involvement of consumers Explanation: Trends in health care delivery include the active involvement of consumers, continuing nursing shortage, increased complexity of client care, and a technology explosion. Other trends include changing demographics, increasing diversity, globalization of economy and society, increasing costs of health care, and the effects of health policy and regulation.

Which government policy addresses penalizing hospitals for readmissions of clients with certain diagnoses within 30 days after discharge?

Affordable Care Act Explanation: As part of the Affordable Care Act, hospitals may accrue penalties for readmissions of clients with certain diagnoses within 30 days of discharge. To improve client outcomes and avoid penalties, care transitions are being implemented to improve the continuity of services from hospital to home and to reduce readmissions. A collaborative discharge plan that includes the client's primary care services as well as any home care is essential for transitional care to be successful. The Americans with Disabilities Act (ADA) became law in 1990. The ADA is a civil rights law that prohibits discrimination against individuals with disabilities in all areas of public life, including jobs, schools, transportation, and all public and private places that are open to the general public. American Nurses Association (ANA) bylaws are rules established by the ANA to govern members of the ANA. The National Commission for Minorities is an organization based in the country of India.

Which scenario is using a prospective payment plan to reimburse for services?

An older adult client is admitted to the hospital and treated for pneumonia. The hospital is reimbursed based on a predetermined fixed price. Explanation: A prospective payment system uses financial incentives to decrease total healthcare charges by reimbursing hospitals on a fixed rate basis. Reimbursement is based on the diagnostic-related group (DRG). Therefore, the scenario in which the hospital is reimbursed is an example of a prospective payment plan. The other scenarios demonstrate other types of payment plans.

During a hospice visit, the client's spouse suddenly begins to cry and says, "I am so tired. I just can't do this anymore. I am not getting to sleep and I just eat sandwiches when I can." What is the nurse's best intervention?

Arrange for short-term inpatient care for the client. Explanation: This spouse is exhausted and needs respite care. The hospice nurse can arrange for short-term inpatient care for the client so that the spouse can rest. The other options will not be effective for exhaustion.

The nurse is providing care to several clients on a medical-surgical unit. For which client's plan of care should the nurse include information regarding extended care?

An older adult client who fell at home and required a hip replacement Explanation: Extended care meets the health needs of clients who no longer require acute hospital care but require rehabilitation and skilled nursing care, such as an older adult following a hip replacement surgery, who may need additional assistance with mobility and more time for physical therapy before being ready to be discharged home. The other clients do not require, or would not benefit from, extended care.

Unlicensed assistive personnel (UAP) include which workers?

Certified nursing assistants, orderlies, attendants, and technicians Explanation: Certified nursing assistants, orderlies, attendants, and technicians are considered UAP. Volunteers, admission clerks, and housekeepers, although invaluable to hospital function, are not UAP.

Based on the Patient Protection and Affordable Care Act (ACA), nurses are to assume an important new role in health care. Which is an example of this new role?

Collaborating with all agencies to provide for the client's home health needs Explanation: As the various components of the ACA are phased in, nurses have begun to play an influential role in the implementation of new health policy. The newest opportunity is collaborating with all agencies to provide for the client's home health needs. Nurses have already been involved in screening individuals for type 2 diabetes mellitus and providing postoperative teaching for ostomy care. Nurses recheck paperwork for consent prior to surgery, but this is not just limited to nurses. Other health care providers also review consent prior to surgery.

Which is the main focus of care for a school nurse?

Community care Explanation: A nurse employed as a school nurse is considered to be working in community-based care. School nurses provide many different services, including maintaining immunization records, providing emergency care for physical and mental disorders, administering prescribed medications, conducting routine health screenings (e.g., vision, hearing, scoliosis), and providing health information and education. Ambulatory care centers and clinics deliver outpatient, walk-in medical care and may be located in hospitals or may be freestanding services provided by a group of health care providers who work together. Inpatient facilities are those in which clients may be admitted and stay overnight for an indeterminate time, such as a hospital. Rehabilitation centers specialize in services for clients requiring physical or emotional rehabilitation and for treatment of chemical dependency. The goal is to return clients to optimal health and to the community as independent members of society.

Nurses in various health care settings provide services to prevent the fragmentation of care that is occurring as a health care trend in today's society. What role of the nurse is most important in preventing this effect?

Coordinator of care Explanation: The most important role of the nurse in preventing fragmentation of care would be coordinator of care. Care coordination is the deliberate organization of client care activities between two or more participants (including the client) involved in a client's care to facilitate the appropriate delivery of health care services. The roles of care provider, counselor, and educator are all important roles, but the priority role is as the coordinator of care.

What are chief tasks of the home health care nurse? Select all that apply.

Developing a nursing care plan Providing client education and counseling Providing continuity of care Administering medications Explanation: The chief tasks of the home health care nurse are developing a nursing care plan, providing client education and counseling, providing continuity of care, and administering medications. The home health care nurse is not tasked with collecting payment for nursing care. The home health care nurse is not tasked with providing for a dignified death at home. This is the role of the hospice nurse.

When conducting an education program for a group preparing for retirement, the nurse would include information about applying for Social Security benefits and Medicare insurance. The nurse would include in the education that Medicare is a federally funded insurance program which bases the fee for payment on what?

Explanation: The nurse must understand that Medicare is a federal insurance program for older adults. It is based on a prospective payment plan that pays a predetermined fixed amount for in-hospital costs. Medicare does not pay physician groups and is not for indigent older adults. Retrospective payment plans pay for services after they have been received.

A nurse is caring for a client with end-stage liver failure. Which healthcare agency should the nurse recommend for continuity of care?

Extended care Explanation: Extended care services meet the needs of clients who no longer require acute hospital care, including rehabilitation, skilled nursing care in a person's home or nursing home, and hospice for dying clients. HMOs are corporations that provide health care for members in exchange for preset, fixed, or yearly fees. PPOs are agents for health insurance companies that control healthcare costs on the basis of competition. A client with end-stage liver failure would not require emergency care.

The Patient Protection and Affordable Care Act (ACA) was passed in 2010 and aims to provide affordable health care to everyone. Which are goals of the ACA? Select all that apply.

Health care affordability Ability to compare insurance options Accessibility to insurance services Decreased number of uninsured Explanation: The ACA seeks to make health care more affordable, create competitive insurance plans and allow comparison of insurance options, provide greater accountability, end discrimination, ensure accessibility to health insurance, decrease the number of uninsured, and make the budget and economy more stable (White House, 2014). The ACA does not support high-quality insurance and allows the insurance companies to regulate themselves as they compete for uninsured clients in the various states.

A hospitalized client with advanced metastatic lung cancer states, "I want to go home. I don't have much time left. I want to be with my family." Which type of care referral by the nurse is most appropriate?

Hospice Explanation: Hospice is a program of palliative and supportive care services providing physical, psychological, social, and spiritual care for dying people, their families, and other loved ones, often provided in the client's own home. Because the client is near the end of life, hospice care would be the most appropriate referral. Respite care is a type of care provided for caregivers of homebound ill, disabled, or older adults, to give them some time away from the responsibilities of day-to-day care. This type of care would not be appropriate for this client because the client has been hospitalized and wants to be with family. Extended-care services provide medical and nonmedical care for people with chronic illnesses or disabilities. Extended care occurs outside the home, however, which is not what the client desires. Palliative care evolved from the hospice experience but also exists outside of hospice programs. It is not restricted to the end of life and can be used from the point of initial diagnosis. Palliative care, which may be given in conjunction with medical treatment and in all types of health care settings, is patient- and family-centered care that optimizes the quality of life by anticipating, preventing, and treating suffering. Palliative care alone is not as appropriate as hospice care in this case, given that the client is near the end of life.

Which type of facility employs the greatest number of nurses?

Hospitals Explanation: Although the trend is changing, hospitals still employ more nurses than any other type of facility. The percentage of registered nurses (RNs) working in hospitals is declining, but about 61% of RNs are still employed in hospitals (Bureau of Labor Statistics, U.S. Department of Labor, 2017).

Which is the acute care setting for people who are too ill to care for themselves at home, are severely injured, or require surgery?

Hospitals Explanation: Hospitals are the most appropriate acute care setting for people who are too ill to care for themselves at home, are severely injured, require surgery or complicated treatments, or are having babies. An ambulatory care center, which may be referred to as an outpatient care center, is a medical care facility that provides outpatient services. These include diagnosis, treatment, consultation, and intervention services. Day care centers have a variety of purposes: some care for healthy infants and children whose parents work; some care for children with minor illnesses; some provide a place for older adults to socialize and to receive care while family members work; some provide health-related services and care to people who do not need to be in a health care institution but cannot be at home alone. Primary care is the day-to-day health care given by a health care provider and can be provided in an outpatient facility.

What methods are used to ensure that clients have continuity of care and cost-effective care during movement throughout the health care system? Select all that apply.

Managed care Case management Primary health care Explanation: Methods to ensure continuity of care and cost-effective care would include managed care, case management, and primary health care. Rural health centers are often located in geographically remote areas that have few health care providers. The primary focus of rural health centers is providing primary care. Parish nursing is an expanding area of specialty nursing practice that emphasizes holistic health care, health promotion, and disease-prevention activities. The focus of parish nursing is not continuity of care or cost-effective care. Primary care center services include the diagnosis and treatment of minor illnesses; performing minor surgical procedures; and providing obstetric care, well-child care, counseling, and referrals. The primary care center's main focus is not continuity of care or cost-effective care.

A nurse has very strong client education skills. In which health care setting would the nurse make best use of these skills?

Primary care center Explanation: Primary health care provides care for common health problems and provides preventative measures. Client education is a common part of the nurse's activities in this setting. While teaching does (and should) occur in the other environments, the nurse does not have the opportunity to see the client repeatedly to teach and reinforce teaching.

What nursing function would be most commonly found in an ambulatory care facility?

Providing direct client care Explanation: Ambulatory care centers and clinics (agencies that deliver outpatient medical care) may be located in hospitals, may be a freestanding service provided by a group of health care providers who work together, or may be managed by an advanced practice registered nurse. Although a nurse may serve as an administrator or manager in such a facility, the nursing function most commonly found in this setting is providing direct client care. Educating individuals or groups would be a nursing function more commonly found in a primary care facility. Assessing the home environment would be a nursing function more commonly found in home health care.

Which statement regarding pay for performance is most accurate?

Quality of care is measured and used to evaluate hospitals and other providers and to award reimbursement. Explanation: In pay for performance, quality of care is measured and used to evaluate hospitals and other providers and to award reimbursement. Financial incentives are offered to health care providers for achieving certain clinical measures established by the payer, not client objectives. These clinical measures include not only delivery efficiencies, improved quality, and patient safety, but also submission of data to the payer. Pay for performance is not limited to any particular hospital size.

Who provides care in the primary nursing model?

Registered nurses Explanation: In the primary nursing model, one registered nurse (RN), frequently with the assistance of a licensed practical or vocational nurse or nursing assistant, is responsible for providing (either directly or by delegating to others) all care for a group of clients throughout their stay in a hospital unit or department. Nursing students, who are not yet licensed, cannot independently provide care to clients. Nursing assistants assist RNs in providing care to clients, but the RN is responsible for the client's care. An RN need not have a Master's degree to provide care in the primary nursing model.

A nurse recommends palliative care for a client who is being discharged following a diagnosis of cancer. What is the chief focus of this type of care?

Relief from physical, mental, and spiritual distress Explanation: The chief focus of palliative care is relief or management from physical, mental, and spiritual distress. The goal of palliative care is to prevent and relieve suffering by early assessment and treatment of pain and other physical problems (such as difficulty breathing, nausea, fatigue, and problems with sleeping). Like hospice care, palliative care is provided by an interdisciplinary team. Physical rehabilitation and occupational therapy would be the goal of home care, moving the client from the functional level at discharge from the hospital to a higher level of functioning, closer to the level prior to the hospitalization. Provision of a dignified death experience would be the goal of hospice.

The nurse is providing care for a client who has a tracheostomy and whose pulse oximeter has recently alarmed, showing the client's oxygen saturation to be 77%. The nurse has repositioned the client and applied supplementary oxygen, interventions that have raised the client's oxygen levels to 80% and have somewhat decreased his work of breathing. The client is not in immediate distress, and his level of consciousness remains high. The nurse should page which practitioner?

Respiratory therapist Explanation: A respiratory therapist is an expert in lung function and oxygenation whose expertise is needed in the care of this client. Because the client is not experiencing severe distress or respiratory arrest, the nurse is justified in foregoing contact with the physician in the short term. A physical therapist or occupational therapist is not likely able to provide needed interventions at this time.

During a home care visit to a home-bound older client, the client's spouse, who is the caregiver, verbalizes anger, fatigue, and sleeplessness. Which recommendations by the nurse would be most effective in relieving caregiver role strain?

Respite care Explanation: Hospice, voluntary services, and palliative care would all be helpful to the client and spouse, but only respite care directly provides the spouse with a break from caregiving duties.

A nurse is providing care to a client recently admitted to the health care facility for treatment of an infection. The client experienced a traumatic brain injury several months ago that resulted in paralysis of both lower extremities and difficulty swallowing and speaking. The client's spouse is the primary caregiver. The client's spouse says to the nurse, "It's been really tough this last month caring for my spouse. Even though I have an aide who comes in to help for a couple of hours a week, I'm just spent, physically and emotionally." A referral for which service would be appropriate?

Respite care Explanation: Respite care is a type of care provided for caregivers of homebound ill, disabled, or older clients. The main purpose is to give the primary caregiver some time away from the responsibilities of day-to-day care. Although parish nursing and palliative care may be helpful in providing the spouse with support, it would not necessarily provide the respite needed. Parish nursing emphasizes holistic health care, health promotion, and disease-prevention activities and combines professional nursing practice with health ministry, emphasizing health and healing within a faith community. Palliative care evolved from the hospice experience but also exists outside of hospice programs. It is not restricted to the end of life and can be used from the point of initial diagnosis. Palliative care, which may be given in conjunction with medical treatment and in all types of health care settings, is client- and family-centered. Hospice care is typically provided to clients with less than 6 months to live. There is no indication that the client is at this stage.

A client is admitted to the facility after fracturing a hip. The client has undergone surgery to repair the fracture and is receiving services to promote healing of the surgical site and regain mobility. Which discussion should the nurse have with a member of the interdisciplinary team member to promote the goal of regaining mobility?

Speak with the physical therapist about exercises to strengthen muscles. Explanation: The nurse should discuss the goal of regaining mobility with a physical therapist. A physical therapist assists with restoring mobility, strengthens muscle groups, and teaches ambulation with new devices. Respiratory therapists are trained in techniques that improve pulmonary function and oxygenation. Occupational therapists evaluate functional level and teach activities to promote self-care in activities of daily living. Speech therapists deal with swallowing difficulties and help clients speak more clearly.

The nurse is a member of the multidisciplinary team in a large primary healthcare setting. The nurse understands that which healthcare team member is responsible for a client's swallow evaluation following a cerebral vascular accident?

Speech pathologist/therapist Explanation: It is within the speech pathologist's/therapist's scope of practice to conduct a swallow evaluation for a client but outside the scope of the occupational therapist, the physical therapist, and the physician assistant.

A nurse is a member of an interdisciplinary team providing home health care to a client who was discharged home after experiencing a stroke. The client has been receiving services to assist with swallowing. The nurse would collaborate with which member of the team to discuss the client's progress?

Speech therapist Explanation: A speech therapist diagnoses and treats swallowing problems in clients who have had a head injury or a stroke. A physical therapist seeks to restore function or to prevent further disability in a client after an injury or illness. Occupational therapists evaluate the client's functional level and teach activities to promote self-care in activities of daily living. Social workers assist clients and families in dealing with the social, emotional, and environmental factors that affect their well-being.

Which statement is true when comparing home care with acute care?

The nurse is the guest in the client's home. Explanation: An essential difference in home care versus acute care is that the home care nurse is a "guest" in the client's home. In the home, clients and families retain the power and control that they give to providers in other settings. Nurses in the home usually work as members of a therapeutic team that includes the client and other members of the health care team working collaboratively. The client does not direct the education of the caregivers.

Which are helpful tips for a nurse who has been active in health care policy and reform give to a nurse who is interested in becoming active in this area? Select all that apply.

Stay up to date regarding new pending legislature that will determine nursing practice. Join and participate in nursing associations. Advocate for the rights of all people in health care. Explanation: Some of the things that the nurse can do to be involved in health care policy and legislature are to stay informed about current issues and pending legislation, write or e-mail members of Congress to support legislation to improve nursing and client care, belong to and participate in nursing organizations, document the outcomes of nursing care and develop a database to influence health care costs and quality of care, participate in efforts to design and implement innovative health care delivery models, be a leader in local, state, and national nursing and consumer groups, and advocate for the rights of all people for equal, affordable, accessible, and knowledgeable health care. Although working overtime whenever asked and reporting workers who may be impaired may be good things for the nurse to do, they do not relate to health care policy and reform.

A client diagnosed with lung cancer has been given a prognosis of 3 to 4 months of life. The nurse discusses hospice care with the client and family. Which aspect of the client's health status indicates that hospice care is appropriate?

The client has a life expectancy of less than 6 months Explanation: The client with a life expectancy of 3 to 4 months is a candidate for hospice care. Hospice care provides support and services to dying clients (with a life expectancy of less than 6 months) and their families. The client with metastatic cancer may be a candidate, but only after further treatment is determined to be futile as not all metastatic cancers are terminal. Hospice can be implemented with or without a support system. Hospice is not considered alternative medicine but is a philosophy of providing comfort care and death with dignity.

In the 1980s, the nursing care delivery model shifted from a team nursing model to a:

primary nursing model. Explanation: In the 1980s, the nursing care delivery model shifted from a team nursing model, in which a team of nurses collaboratively provide care to a given client during a stay, to a primary nursing model, in which one registered nurse (RN) is responsible for providing all care needed by a given client during the client's stay (either directly or by delegating to others). The managed care model is an approach to health care delivery that seeks to contain the costs of health care while providing quality care. Modular nursing is similar to team nursing except that the clients assigned to a given team of nurses are grouped according to geographical location on the unit. A clinical specialist is a nurse who has additional training in a medical specialty, such as cardiology.