CNL Practice Questions*

172. All of the following are part of the data necessary for a CNL to fully understand and assess his or her clinical unit except: A. The organization's budget B. The target population and age distribution C. The percentage of full-time equivalents (FTEs) D. The rate of nosocomial infections and fall risks

Answer A—Rationale: A comprehensive assessment of the clinical unit is a foundation for the work of the CNL but does not include the financial statement of the organization. The financial statement or budget has to do with the macrosystem and not the microsystem.

49. The new hospital CNO works hard to cultivate a shared vision of leaders and followers motivating each other toward their highest potential. This is an example of which type of leadership? A. Transformational leadership B. Transactional leadership C. Situational leadership D. Hierarchical leadership

Answer A—Rationale: A transformational leader believes that leaders and followers motivate each other toward the end goal of developing followers into leaders. This is accomplished by leading and motivating by example.

161. Your hospital has just completed a study comparing outcomes in rehospitalization rates for CHF patients who received predischarge teaching from an advanced practice registered nurse (APRN) with those who received predischarge teaching from an RN. In the analysis of data, what resulting p- value would indicate that the intervention had a significant result? A. <.05 B. <.8 C. <.10 D. <.22

Answer A—Rationale: A value less than 0.05 is a significant statistical finding in research.

114. A nurse on the CNL's unit asks about accessing patient education materials via the electronic health record (EHR), as well as the availability of education on Cambodia. As the CNL guides the nurse in locating these materials, she or he recognizes this as an effective use of: A. Health care informatics B. Research utilization C. Clinical knowledge D. Evidence-based research

Answer A—Rationale: Accessing appropriate education in patients' native language is culturally competent; however, the ability to locate and provide these materials is effective use of health care informatics.

30. Amy, a nurse on your unit, is interested in implementing a project to improve health literacy and diabetes using follow-up phone calls. She asks the CNL for help in initiating the project. What would be her first step? A. Identify the clinical problem B. Implement follow-up phone calls C. Determine outcomes of the project D. Review literature for evidence

Answer A—Rationale: According to the EBP process, identifying the clinical problem is the first step.

93. An RCA is best used: A. In response to a critical or sentinel event B. Prior to a process implementation or change C. As part of a random audit process D. In response to malfunctioning tools or equipment

Answer A—Rationale: An RCA is meant to respond to a critical event or critical "near-miss" event to understand how it occurred and is intended as a retrospective tool.

108. You are in the process of initiating a mobility team and protocol on your unit. What members of the', 'interdisciplinary team should be considered? A. Nursing staff, physical therapist, nurse manager, occupational therapist, CNL, clinical nurse specialist, and physician B. Physical therapist, physician, nursing assistants, manager, and CNL C. Medical social worker, physician, nursing staff, physical therapy staff, and CNL D. Physical therapist, occupational therapist, nursing staff, and the discharge coordinator

Answer A—Rationale: An interdisciplinary team must include all key stakeholders so that patients can have the best outcomes.

98. A staff member asks you, the CNL, what is the best way to explain health policy? What statement best explains health policy? A. Health policy generally denotes guidelines that affect the health of the individual, families, or communities through production, provision, and financing health or health care services. B. Health policy analyzes system and outcomes datasets to anticipate individual client risk and improve quality care. C. Health policy evaluates the environmental health care outcomes. D. Health policy means to consult with other health professionals to design, coordinate, and evaluate client care outcomes.

Answer A—Rationale: Answers B-D are all related to QI, risk reduction, and patient safety rather than health policy.

54. Marci, a surgical nurse, is reviewing the operating room schedule and sees a coworker, Angie, is having surgery that day. Marci then calls the supervisor and manager to let them know Angie is having surgery. Marci then tells the CNL she is going to visit Angie in the postanesthesia care unit (PACU). What should the CNL do? A. Explain to Marci that this is a violation of the Health Information Portability and Accountability Act (HIPAA) and we must protect Angie's right to privacy and confidentiality B. Invite other nurses to visit Angie and bring her flowers C. Nothing; since this is a coworker, this is not considered a violation of HIPAA D. Arrange for Angie to have "VIP" treatment

Answer A—Rationale: As a CNL, you should be a guardian of information and educator to the nurses on the unit regarding HIPAA.

99. A nurse prepares to administer a patient's morning dose of metformin. After scanning the patient and the medication, a clinical alert appears on the computer screen warning of a possible interaction between the metformin and the CT contrast dye the patient received the day before. Based on this warning, the nurse chooses to hold the metformin and alert the pharmacy that this medication should be scheduled as held for 72 hours after receiving the contrast. This is an example of a: A. Clinical decision support system B. Health information technology C. Clinical alert warning system D. Decision tree

Answer A—Rationale: Automated warnings within the EHR are an example of a clinical decision support system. The EHR itself is health information technology. While this was a clinical alert it also', 'aided in guiding the nurse to action.

6. A 50-year-old woman with a history of stage 3 chronic obstructive pulmonary disease (COPD) presents to the emergency department (ED) with increased shortness of breath. Based on your lab results, what is the acid-base disorder? Labs as follows: pH 7.25 PaCO2 50 mmHg HCO3 22 mEq/L PO2 75 SpO2 88% Na + 136 BUN 18 A. Uncompensated respiratory acidosis B. Metabolic acidosis C. Respiratory acidosis D. Uncompensated respiratory acidosis

Answer A—Rationale: Based on the clinical scenario, the pH is decreased (less than 7.35); therefore, the patient has acidosis. The PaCO2 is elevated (more than 45 mmHg), which is also consistent with the pH.', 'The HCO3 is within normal limits, which suggests the kidneys are not compensating. COPD is commonly associated with respiratory acidosis.

87. Staff nurses have a clinical question regarding the effectiveness of two different surgical skin preps stocked on your unit. Both benzalkonium chloride and CHG are available, and the nurses are uncertain of the differences—particularly in terms of reducing surgical site infections. As the CNL, what is the next step to take? A. Review research on the effectiveness of each product in reducing surgical site infections and disseminate the evidence to staff B. Organize a study of patients on your unit, trialing the different surgical prep and tracking patient outcomes C. Determine the most cost-effective surgical skin prep for the patient D. Research what products are being used on other units and other hospitals within your area

Answer A—Rationale: CNLs should act to review evidence to answer clinical questions. Organizing a study to evaluate the greater trends of one skin prep versus another may be a lengthy process when evidence is already available.

145. You are a CNL working in a very busy 980-bed tertiary hospital. The hospital only has one MRI machine. This often causes delays in patient care. You write a proposal for the administrative team to advocate for more MRI scanners. If the proposal is approved, the money will come out of which budget? A. Capital budget B. Cash flow budget C. Operating budget D. Revenue

Answer A—Rationale: Capital budget involves large dollar amounts and long-term investments like equipment.

136. Which statement best describes the CNL acting as a client advocate for a domestic violence victim hospitalized in her microsystem? A. Consult domestic violence health care professional (DVHP) and ensure the patient has an alias name B. Ensure all the staff members are aware that she is a domestic violence victim C. Consult the master of social work (MSW) and call the patient's partner to ensure that he or she will not come to the hospital D. Consult the psychiatric physician and inform the primary care nurse

Answer A—Rationale: Consulting DVHP and ensuring the patient has an alias name is the best approach in providing patient advocacy. The CNL is advocating for patient safety.

183. When assessing a patient for a diagnosis of pneumonia, it is more difficult to make a proper diagnosis in the absence of the following symptom: A. Cough B. Cyanosis C. Tachycardia D. Bradycardia

Answer A—Rationale: Cough is one of the paramount symptoms used to help diagnose pneumonia.

144. You are a CNL on a medical-telemetry unit and orienting a new graduate nurse. Critical thinking is best demonstrated by which of the following? A. Calling the rapid response nurse when a patient's oxygen saturation drops to 79% on 2L of oxygen B. Drawing scheduled hemoglobin and hematocrit C. Delegating tasks to the nursing assistant D. Creating a script to welcome patients to the medical-telemetry unit

Answer A—Rationale: Critical thinking underlies independent and interdependent decision making. Critical thinking includes questioning, analysis, synthesis, interpretation, interference, inductive and deductive reasoning, intuition, application, and creativity.

74. You, the CNL, have noted that many staff nurses on your unit do not use available nurse aide (NA) staff to perform routine capillary blood glucose (CBG) checks, even though they are allowed to at your hospital. When you investigate, you discover that most nurses were unaware the NAs could perform', 'CBG checks. You, as the CNL, share information on the tasks NAs are able to perform during the next unit staff meeting in order to: A. Ensure each member of the care team has a clear understanding of his or her role B. Make sure staff nurses delegate as much work as possible C. Make sure staff are using skills and training often enough D. Ensure the NAs have enough to do

Answer A—Rationale: Ensuring mutual understanding of roles among care team members is a key component of the coordination piece of lateral integration.

55. What type of chart is used in QI and uses step-by-step symbols to plan projects and describe a process? A. Flowchart/process mapping B. Pareto chart C. Control chart D. Run chart

Answer A—Rationale: Flowchart/process mapping is a graphic illustration of the steps in a process.', '

126. The CNL recognizes the importance of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores in driving hospital reimbursement. These scores measure: A. Core measures and patient experience B. Core measures, patient experience, and clinical outcomes C. Core measures, patient experience, clinical outcomes, and readmission rates D. Patient experience, clinical outcomes, and readmission rates

Answer A—Rationale: HCAHPS measure core measures and the patient experience, but do not assess actual clinical outcomes, patient mortality, or readmission rates.

95. As you review a patient's medical record, you notice that the patient has an order for a chest x-ray. While reviewing the chart, you realize that the patient just completed a chest x-ray several hours ago while in the emergency department (ED). CNLs understand that diagnostic tests are very expensive so you call the doctor and find that the x-ray was duplicated by mistake. Unfortunately, by the time you find this mistake you see the radiology assistant exiting the patient's room. Once the error is found, you should: A. Perform a root cause analysis (RCA) to see why this test was duplicated B. Notify the patient's insurance company of the additional charges C. Notify the nurse manager of this error D. Review the order entry

Answer A—Rationale: Identifying processes that yield errors and negative outcomes for patients is a critical duty of the CNL. This is done through RCA. It is the job of the CNL to identify and help reduce cost to the patient.

132. Use of electronic health records (EHRs) can aid the CNL to conduct quality improvement (QI) efforts in which of the following ways? A. Allow rapid access to informatics data, provide a way of ongoing monitoring, organize data into meaningful groups, and aid in the dedication of errors B. Allow rapid access to informatics data, ensure all staff follow protocols and policies, add second checks to medication administration, and aid in the detection of errors C. Provide a way of ongoing monitoring, add second checks to medication administration, organize data into meaningful groups, and aid in detection of errors D. Provide a way of ongoing monitoring, ensure all staff follow protocols and policies, add second checks to medication administration, organize data into meaningful groups, and aid in', 'the detection of errors

Answer A—Rationale: Many EHR products can achieve each of these functions; however, not all are a part of QI efforts. Also, an EHR cannot ensure people act within established policies and procedures. Additionally, while an EHR can provide additional safeguards to medication administration and may improve safety, it does not help the CNL conduct QI efforts.

176. By leading which unit initiative can the CNL directly affect the financial health of the entire institution? A. Reducing readmissions B. Recruitment of new nursing staff C. Improving documentation compliance D. Encouraging staff to report safety events and near-misses

Answer A—Rationale: Medicare reimbursement rates include a penalty to those health care institutions with 30-day readmission rates that are higher than national benchmarks. Thus, the CNL may greatly affect finances by reducing readmissions.

135. A staff nurse is thinking about becoming a CNL. The unit CNL discusses with the staff nurse about the CNL's role and the importance of evidence-based practice (EBP). After further discussions, the staff nurse questions the CNL about what barriers she may face when implementing EBP. Which of the following do not describe barriers that have been recognized with initiating EBP? A. EBP is readily available for staff and low patient loads B. Lack of knowledge regarding EBP strategies and misperceptions about EBP C. Lack of time and resources to search for and appraise evidence D. Peer pressure to continue with practices that are steeped in tradition and inadequate content

Answer A—Rationale: Nurses, physicians, and other health professionals cite a number of barriers to EBP including: lack of knowledge regarding EBP strategies, misperceptions or negative views about research and evidence-based care, lack of belief EBP will result in more positive outcomes than traditional care, voluminous amounts of information in professional journals, lack of time and resources to search for and appraise evidence, overwhelming patient loads, organizational constraints, demands from patients for a certain type of treatment, peer pressure to continue with practices that are steeped in tradition, and adequate content and behavioral skills regarding EBP in educational programs.', '

107. Ongoing risk reduction and patient safety efforts are an important component of: A. Quality improvement (QI) B. Knowledge management C. Change theory D. Complexity theory

Answer A—Rationale: Ongoing risk reduction and patient safety monitoring are components of QI.

101. Tara, a CNL on a pediatric medical-surgical unit, conducted a 5P assessment and discovered that the discharge process was fragmented and parents were not satisfied with the process. Tara created a team to develop a change in order to improve the process. What model can Tara use to rapidly implement this change and test it to determine effectiveness? A. Plan-Do-Study-Act (PDSA) B. Strengths, weaknesses, opportunities, and threats (SWOT) analysis C. Fishbone diagram D. Gap analysis

Answer A—Rationale: PDSA is a model used to conduct rapid cyclical review of a process change to encourage continuous and ongoing efforts to improve.

158. You are the CNL on a medical unit and recognize a frequently readmitted patient with uncontrolled diabetes. You view this patient in terms of Prochaska and DiClemente's Stages of Change model and recognize that: A. Patients may spiral in and out of stages forward and backward. B. Timelines for patients may vary to progress through the stages; however, they always progress forward. C. The stages have been well studied and the timeline and progression are the same for all patients. D. Prochaska and DiClemente's Stages of Change model does not apply to this patient.

Answer A—Rationale: Prochaska and DiClemente's Stages of Change model states that each patient may experience each phase at different speeds, and may move forward or backward repeatedly through the stages.

123. You are the unit-based council chair for shared governance of a high-acuity progressive care unit. You notice that the staff is not aware of new evidence in caring for this patient population. You discuss this with the management team and the CNL to determine what can be done to increase the staff awareness and knowledge of EBP. What strategy can best be used to increase evidence into practice? A. Start a journal club with help from CNL B. Learn how to determine if an article is peer-reviewed C. Encourage nurses to conduct research D. Discuss the importance of EBP in staff meeting

Answer A—Rationale: Strategies to increase evidence into practice include ensure policies/procedures are based upon the latest literature, journal club, nursing grand rounds, update staff on latest evidence in short gatherings, link quality indicators in EBP, and mentor staff to complete EBP activities for school and clinical ladder.

112. As a CNL on your unit, you are rounding on your microsystem. Jen, a 70-year-old patient with stage IV cancer, chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and chronic kidney disease, is currently on an Ativan drip and morphine drip. She has a do-not-resuscitate (DNR) order and is a hospice patient. You notice she has multiple grieving family members in her room. You speak with the family and collaborate with the palliative care unit (PCU) CNL and charge nurse and decide to move the patient to a bigger room in the PCU. What CNL role was demonstrated in this scenario? A. Advocate B. Outcomes manager C. Team manager D. Risk analyst

Answer A—Rationale: The CNL acted as a client advocate to ensure the best situation for the patient and family by coordination of care through the use of resources and services.

97. Heather, a nurse for 7 years, recently attained her MSN-CNL. She is very passionate about being involved in her local community. She volunteers frequently at a community center for underprivileged children. During her time there, she noticed that obesity is a concern with this population. What step best describes Heather's advocating for this local community center? A. Heather collaborates with the community center leaders to get donations from local health food corporations to ensure a healthy meal is provided for the children. B. Heather collaborates with another CNL and plans to do a literature review on obesity. C. Heather discusses her concern of obesity with the community center leaders. D. Heather calls other community centers for underprivileged children to inquire about obesity in their population.

Answer A—Rationale: The CNL advocates by building partnerships with community organizations to identify and address health disparities.

50. The CNL's role is to lead frontline staff in line with the organization's core competencies. Which of the following best describes how a CNL can promote a high-performing clinical microsystem? A. Support an atmosphere for learning and redesign supported by continuous monitoring of care, use of benchmarking, and frequent tests of change B. Promote a microsystem that is in silo from the community and does not cross professional boundaries C. Encourage staff to provide opinions and feedback, though the manager will make the final decision D. Promote engagement by sharing positive outcomes with the staff and having celebrations, but keep negative outcomes confidential in order to keep the staff from feeling defeated

Answer A—Rationale: The CNL can promote high quality in high-performing clinical microsystems by providing a supportive atmosphere for continuous process improvement.

64. Lisa is a CNL who works with high-risk obstetric patients both inpatient at the hospital and outpatient in the local health clinic. Lisa follows each patient throughout his or her episodes of care, ensuring the patient receives streamlined, comprehensive care. Which critical component of lateral integration best describes what Lisa is demonstrating? A. Coordination B. Communication C. Collaboration D. Evaluation

Answer A—Rationale: The CNL coordinates care by managing the care of clients across settings and episodes of care. Coordination is not to be confused with collaboration. Collaboration is defined as an interdisciplinary process of problem solving that involves shared responsibility for decision making and execution of plans of care.

109. As a CNL on a very busy medical-telemetry unit, you have noticed that nurses are not utilizing incentive spirometry for patients with acute or chronic lung conditions. To ensure that patients are given the best care, you ask the electronic order entry representative to allow incentive spirometry to be entered as a nursing task. This will be used as a reminder for the nursing staff to perform this task. What action of the CNL is this? A. Demonstrates use of health care technologies to maximize health care outcomes B. Understands your microsystem and uses available resources C. Unfreezes D. Identifies unwanted variation, rework, and waste

Answer A—Rationale: The CNL is on the frontline at the point of care delivery, making recommendations to management and other providers about disease management and use of standardized protocols, ensuring that all charges incurred are assessed and tracked to the appropriate cost center. The CNL should be involved in health care technologies and informatics.

147. Ranesha, a nurse on the unit, has just finished receiving bedside report on a patient, Mr. Smith, admitted with pneumonia. She told the patient his goal was to ambulate in the hallway three times that', 'day. The CNL, Valerie, walked in the room while Ranesha discussed his goal. Valerie recognized that the goal will not work because Mr. Smith was not involved in deciding on the goal. In what way can Valerie act as a client advocate? A. Involve the patient in setting the goal with Ranesha, to discuss the reason for setting goals, barriers, and concerns, and determine the best time for Mr. Smith to ambulate in the hallway B. Do not discuss setting the goal and involving Mr. Smith as the nurse has already told the patient the plan for the day C. Tell Ranesha that Mr. Smith should be in the driver's seat of his own care D. Involve the patient by asking him what he wants to do for the day and if he replies "Nothing" then let him rest

Answer A—Rationale: The CNL keeps the patient informed and ensures he understands the reason for setting goals and involves him in making health care decisions.

51. The CNL completes a 5P assessment of the microsystem and discovers that the geriatric population has increased. Forty-three percent of the patients within the microsystem are older than 65 years. Recognizing this change, the CNL determines which of the following is an appropriate action? A. Coordinate monthly lunch-and-learn opportunities for the staff to discuss topics related to nutrition, cognitive impairment, and mobility B. Discuss the change with the nurse manager and order more bed alarms for the microsystem C. Volunteer to take blood pressures and check hemoglobin A1cs at the local adult day-care center D. Conduct a randomized control study on visual impairment in diabetic patients older than 70 years

Answer A—Rationale: The CNL recognizes it is important for the staff to be well prepared to care for the patient population. Malnutrition, cognitive impairment, and immobility are common geriatric problems. Educational opportunities will help inform the staff, allowing them to provide evidence-based care.', '

138. Nicole, a nurse of 5 years, comes to you with an idea for a medication administration safety zone. How can you best support Nicole with this project? A. Guide Nicole through a literature search to determine if evidence exists to support such a change B. Help Nicole design the medication administration safety zone C. Set up a meeting with the manager and Nicole to discuss the project D. Encourage Nicole to implement the project

Answer A—Rationale: The CNL serves as a horizontal leader by assisting nursing staff in using EBP principles to design care for individuals. The CNL helps Nicole to search for the best evidence by conducting a literature review.

81. How can the CNL help determine the meaningful use of the EHR within his or her microsystem? A. Identify data that should be collected and managed, and note how that data should be shared for improving client outcomes B. Coordinate with physicians to identify which clinical information would be meaningful for the patients under their care C. Discuss with unit leaders and stakeholders what data could provide meaningful use of the EHR within the unit D. Review the available client data currently in the EHR and assess for meaningfulness in improving patient outcomes

Answer A—Rationale: The CNL should be able to identify meaningful data, as well as its collection and management, and use that data to improve clinical outcomes on the unit.

76. During your daily rounds, you are performing an advance assessment on a patient in your cohort. The patient was admitted for sepsis and appears very weak, and has a very poor appetite. The patient tells you that he has not been out of the bed for 3 days. What needs to happen to provide the best care for this patient? A. Enter an order for physical and occupational therapist, and ask the nursing staff to perform the Egress test to assess the patient's mobility level B. Tell the patient to get out of bed and sit up in the chair three times a day C. Place the bed in a bed-to-chair position D. Order an incentive spirometer for the patient

Answer A—Rationale: The CNL understands the role of the interdisciplinary team members including PT and OT. Bedside nurses and CNLs are at the frontline caring for patients, assessing interventions, and listening to patient concerns, and are the best advocates for patients receiving care from other team members.

61. A nurse is trying to determine the difference between evidence-based practice (EBP) and research. She approaches her unit CNL to assist her in her dilemma. What statement best describes the appropriate response by the CNL? A. EBP involves critiquing and synthesizing evidence, while research involves designing a study because there is a gap in knowledge. B. EBP needs institutional review board (IRB) approval, while research does not. C. EBP involves collecting and analyzing data, while research includes critiquing and synthesizing evidence. D. In EBP, the first step is identifying a clinical problem, while in research identifying a clinical problem is the last step.

Answer A—Rationale: The EBP process involves these steps: identify clinical problem, review literature/search for evidence, critique evidence, synthesize evidence and patient view, implement evidence-based change, evaluate outcomes, and present or publish findings. Both EBP and research can require IRB approval. The research process is done for a gap in knowledge: identify the clinical problem, review literature/search for evidence, design a study, write a research proposal, collect and analyze data, and present or publish the findings.

65. From which database would the CNL collect the most useful nursing-sensitive indicator metrics? A. National Database of Nursing Quality Indicators® (NDNQI) B. Hospital Compare C. The Joint Commission (TJC) D. Nursing Quality Forum (NQF)

Answer A—Rationale: The NDNQI evaluates unit and hospital-specific nursing-sensitive data. NDNQI also provides benchmarks that can be used for comparison.

137. Recently, your unit replaced all of its current beds with air beds, designed to help prevent skin breakdown in your patients. Using informatics, what is the best way to evaluate the effectiveness of this intervention? A. Review the electronic health record (EHR) for new pressure ulcer incidence since the new beds were utilized B. Complete a pressure ulcer prevalence study on all currently admitted patients C. Gather data on all patient Braden scale scores since implementation D. Review all nurse skin integrity assessments since implementation

Answer A—Rationale: The best way to evaluate the effectiveness of the implementation of air beds is to review the incidence of new pressure ulcers. A prevalence study only assesses pressure ulcers at the current time. The Braden scale does not necessarily indicate effectiveness of preventing skin breakdown. Reviewing all assessments is unneeded, as the data regarding pressure ulcers is the only meaningful data.

44. While rounding on your cohort of patients, you are informed by one of your patients that she does not have health care insurance. As a CNL, you know that interdisciplinary communication is very important. What member of the team is most effective in helping with this matter?' A. The care management team: medical social worker, clinical case manager (CCM), and medical team B. Pastoral care C. The business office of the hospital D. Nursing staff

Answer A—Rationale: The case management team works closely with the medical team to ensure that patients have the means to pay for their medication.

140. What best describes an elevator speech about the CNL's role? A. Succinctly define, advocate, and explain the CNL's role B. Briefly educate peers on current issues in the nursing profession C. Provide a summary presentation on specific measured outcomes of the CNL D. Convince peers and stakeholders to create buy-in for the CNL

Answer A—Rationale: The elevator speech should define, advocate, and explain the CNL role. A summary of the specific outcomes does not address the role itself. While the elevator speech may work to create buy-in, it should do so by defining and explaining the role.

168. Judy completed an evidence-based practice (EBP) study that resulted in a 25% reduction in noise on the unit and increased patient satisfaction to 100% for patients always saying it is quiet at night. Utilizing the EBP process, what would Judy's next step be? A. Apply for a poster presentation for a national conference B. Compare results to a similar unit in her hospital C. Identify stakeholders within her organization D. Conduct a literature search and assess validity

Answer A—Rationale: The final step of the EBP process is to disseminate findings via presentations or publications.

17. Jane, a CNL, successfully implemented an evidence-based practice (EBP) project utilizing music therapy to help with pain control in sickle cell patients on a medical-surgical unit. Jane was asked by the chief nursing officer (CNO) to implement the project within the medical division. What system will Jane be working in? A. Mesosystem B. Macrosystem C. Microsystem D. Unit system

Answer A—Rationale: The mesosystem encompasses multiple microsystems, such as a medical division within a hospital.

150. During morning report, you observe a new staff member you have been mentoring struggling to identify which of her patients she will assess first. As the CNL, you identify the priority patient as: A. The 72-year-old patient with a chest tube to wall suction and unstable vital signs B. The 19-year-old patient with family demanding to speak with you regarding discharge plans C. The 57-year-old postoperative patient with patient-controlled analgesia (PCA) pump D. The 92-year-old patient who is a high-fall risk

Answer A—Rationale: The priority assessment is the patient with a chest tube to ensure both patency of the tube and adequate airway.', '

18. Judy has a family history of type 2 diabetes. After education, Judy knows she can help to prevent diabetes by maintaining a healthy weight, healthy eating habits, and daily physical activity. Judy is exhibiting what type of prevention strategies? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Quaternary prevention

Answer A—Rationale: The purpose of primary prevention is to prevent the onset of chronic illness, focusing on healthy lifestyle habits and behaviors.

10. When assessing a new microsystem, the CNL will often use a tool known as the "5 Ps." As a CNL, you recognize the "5 Ps" to include are: A. Purpose, patients, process, patterns, professionals B. Patients, providers, policies, patterns, prevention C. Purpose, patients, providers, patterns, prevention D. Patients, process, professionals, policies, patterns', '

Answer A—Rationale: These answers make up the 5 Ps; the others are components of other aspects of the CNL's functions or tools.

159. Consideration of your unit's nurse workflow, specific challenges and needs of clients on your unit,', 'staff experiences, and staff ratios are examples of which of the following important CNL function components? A. Ongoing evaluation B. Collaboration C. Advanced clinical assessment D. Knowledge management

Answer A—Rationale: These are examples of a CNL continuing to assess and reassess important aspects of the care delivery system and used processes. including the monitoring not only of patient outcomes but experiences at each step of the care process, which embodies the ongoing evaluation aspect of the CNL as a lateral integrator.

149. A patient who has been diagnosed with colon cancer remarks that since his diagnosis, many people he knows have mentioned someone they know who has colon cancer. Most of these people live nearby. The patient asks you if colon cancer rates in the area have been increasing recently. The patient is asking about what type of measure? A. Incidence B. Prevalence C. Mortality D. Correlation

Answer A—Rationale: This would measure the number of new cases of colon cancer in the area during a specific period.

41. Which stage of Lewin's change theory involves explaining that the current situation must change? A. Unfreezing B. Adoption C. Evaluation D. Change

Answer A—Rationale: Unfreezing is a process that involves finding a method of making it possible for people to let go of an old pattern that was counterproductive in some way.

193. Vaccinations are considered what level of prevention? A. Primary B. Secondary C. Tertiary D. None of these

Answer A—Rationale: Vaccinations are preventative and therefore considered a primary level of prevention.

86. A nurse on your unit expresses concern about her patient. The patient is an 88-year-old male on the unit due to a chronic obstructive pulmonary disease (COPD) exacerbation. He has become deconditioned and therapy is involved. The patient is due to be discharged, but still appears very weak and unsteady. During his stay he was newly diagnosed with insulin-dependent diabetes, and although he has been educated on insulin administration, the nurse is uncertain he can properly administer the medication at home. As the CNL, how do you proceed? A. Organize an interdisciplinary team meeting to discuss the multiple concerns over patient treatment and condition, as well as greater discharge needs B. Place an ethics consult C. Encourage the nurse to call the MD and relay her concerns D. Provide tools to the nurse that can help improve the patient's functioning regarding the insulin, and advocate for the use of oxygen at home

Answer A—Rationale: When multiple health care team members are involved in a patient's care and coordination of their health care needs, the interdisciplinary team meeting can best coordinate needs.

80. As a CNL, it is important to remain aware of current changes to national health care policies, namely from ongoing focuses from the Centers for Medicare & Medicaid Services (CMS) and law prescribed by the Affordable Care Act (ACA), both of which have set reduced reimbursement for which of the following issues? A. Elevated readmission rates B. Medication errors C. Falls D. Nurses practicing below their scope

Answer A—Rationale: While each item is an important focus for the CNL, and B and C can result in nonreimbursed costs, the ACA via the CMS has set reducing hospital readmission rates as a key priority, and decreases reimbursements for hospitals with frequent readmissions.

31. Mrs. Jones, a patient with multiple comorbidities, has been hospitalized for over 3 months due to her recent stroke. During this period, she has not progressed and has had a tracheostomy and percutaneous endoscopic gastronomy (PEG) tube placed. Two of the daughters refused to make the patient a do not resuscitate (DNR), while the son and husband want the patient to be a DNR. As a CNL, you are conflicted and want the best outcome for the patient. What is the best step for you to take? A. Find out if the patient has an advance directive or wants to be a DNR B. Prevent the patient from being a DNR C. Call the physician to make the decision D. Make the patient a DNR according to the husband's wishes

Answer A—Rationale: You, as the CNL, are acting as a client advocate. You are taking the next step to ensure appropriate care is provided for the patient. You assume accountability for the delivery of high- quality care, including the evaluation of care outcomes and provision of leadership in improving care.

196. D.M. is 80 years old and admitted for a hip fracture, caused by a fall from standing. As a CNL, you would know a fracture obtained this way is typically found from what? A. Osteomyelitis B. Osteoporosis C. Anemia D. Rheumatoid arthritis

Answer B—Rationale: A fracture of the hip from a fall that occurs from standing is indicative of osteoporosis. It is imperative for CNLs to identify such patterns to help the patient get a holistic plan of care.

40. The group known as "Maternal Child Health" has many subunits such as pediatrics, well baby nursery, NICU, and maternity. This collection of units belongs to which system? A. Microsystem B. Mesosystem C. Macrosystem D. Megasystem

Answer B—Rationale: A mesosystem is a collection of other microsystems that facilitate processes.

110. You are precepting a CNL student. She discusses her capstone project with you. She needs help determining the design of her study. She states that she will be working with diabetes patients on a medical unit. She intends to collect basic data and do a pre- and postintervention questionnaire based on the diabetes survival skills. She wants to compare the pre- and postdata to determine if her educational intervention was effective. She will not use randomization. What option best describes her study design? A. Well-designed randomized controlled trial (RCT) B. Quasi-experimental C. Meta-analysis D. Quality study

Answer B—Rationale: A quasi-experiment is not a true experiment. A quasi-experiment does not have randomly assigned groups, but would include pre- and postmeasures.

167. What are ways in which the CNL can present his or her effectiveness and outcomes? A. Peer-reviewed journal, conference or seminar, and TV B. Peer-reviewed journal, conference or seminar, and Internet C. Peer-reviewed journal and TV D. TV and Internet

Answer B—Rationale: All are valid ways in which the CNL can disseminate his or her effectiveness and outcomes (journal articles, conference, and Internet).

70. A 28-year-old patient with asthma is requesting the pneumococcal vaccine. Which of the following conditions are appropriate for receiving the pneumococcal vaccine? A. Congestive heart failure (CHF), HIV, diabetes, pregnancy B. CHF, HIV, diabetes, sickle cell disease C. Diabetes, chemotherapy, sickle cell disease, pregnancy D. Pregnancy, CHF, diabetes, chemotherapy

Answer B—Rationale: All of these medical conditions require a patient to receive the pneumococcal vaccination.

11. Mr. Johnson is an 80-year-old patient who lives alone. He had fallen and was found by his neighbors. Mr. Johnson has a history of multiple falls, congestive heart failure (CHF), myocardial infarction (MI), diabetes mellitus (DM), and asthma. Mr. Johnson is admitted to the hospital with a hip fracture. Using an interdisciplinary approach, who should the CNL include in the plan of care initially? A. Clinical care manager, medical social worker, clinical nutritionist, CNL, and physician B. Clinical care manager, medical social worker, clinical nutritionist, physical therapist, registered nurse, CNL, and physician C. Speech therapist, clinical care manager, medical social worker, CNL, registered nurse, and nursing supervisor D. Clinical care manager, medical social worker, CNL, registered nurse, and nurse manager

Answer B—Rationale: An interdisciplinary team is composed of many disciplines who work together toward a patient's and family's common goals, such as safe discharge coordination. Learning to advocate for clients occurs by communicating effectively with other interdisciplinary team members, including nurses in other settings. The opportunity to learn and work in an interdisciplinary team will provide the best opportunity to give patients the best outcome.

48. You are a CNL on a surgical unit. Your manager has asked you to review and update the current patient skin prep procedure as needed. After reviewing the evidence, you determine the current surgical skin prep does not match current evidence suggesting a need for chlorhexidine gluconate (CHG) wipes. At your next meeting with your manager, how do you best advocate for change? A. Provide a list of resources for the new CHG skin prep, costs, and available vendors B. Interpret the evidence of effectiveness of the CHG wipes prep and the related patient', 'outcomes for patients receiving this skin prep; present the findings and suggest how this could be best used to change practice on the unit C. Present feedback from the nursing staff on the current practices on the unit D. Alert the manager that there is a discrepancy between the current practice and evidence, and await further instructions before proceeding

Answer B—Rationale: As the CNL, you should assess evidence, interpret research for policy makers or stakeholders, and offer suggestions for improvement to practice. Providing a list of resources to the manager does not create buy-in for the change. Feedback from nurses does not address evidence. CNLs should always provide suggestions for practice improvement.

104. How can a CNL help to identify the general discharge needs of patients on his or her unit? A. Coordinate outpatient care and follow-up appointments B. Assess protective and predictive factors of patient health C. Discuss with each team's doctors the anticipated discharge needs of their patients D. Approach staff nurses about their patients' discharge needs

Answer B—Rationale: Assessing protective and predictive factors of patient health is the best way a CNL can identify potential needs or issues with patient discharges.

45. Who can function as an important ally to the CNL in engaging frontline staff in a major initiative? A. Content expert B. Unit champion C. Initiative sponsor D. Senior leadership

Answer B—Rationale: B is the best answer because as a CNL implementing a major initiative, you want individuals who will help advocate and support your initiative. A champion is someone who fights or speaks publicly in support of a person, belief, cause, or initiative.

105. Lisa, a CNL, is educating the staff on the effects of long-term bed rest. A majority of these patients have been on bed rest with a shortened cervix since 25 weeks gestation. Which of the following statements is true? A. Bed rest is psychologically healthy. B. Music therapy can ease the psychological effects of bed rest. C. Bed rest prevents deep vein thrombosis (DVT). D. Bed rest has been proven to prevent preterm labor.

Answer B—Rationale: Bed rest can be detrimental to a mother's psychological well-being, because there is separation between the patient and her family. The patient can also experience financial burdens, which put a strain on the family. Currently, there is no evidence that bed rest prevents preterm labor.

175. Sustaining process improvement requires the use of appropriate learning principles and strategies. The CNL function that best utilizes this competency is: A. Advocate B. Educator C. Clinician D. Information manager

Answer B—Rationale: CNL competencies are described in the AACN white paper. Nursing education', 'involves using appropriate learning principles and strategies.

12. As the CNL on a cardiac telemetry unit, you are performing a root cause analysis (RCA) due to the high volume of catheter-associated urinary tract infections (CAUTIs) over the last 6 months. Realizing that the Centers for Medicare & Medicaid are on a pay-for-performance basis, you develop a CAUTI task force in an effort to reduce costs. This is an example of which of the following? A. Implementing cost reduction and savings B. Anticipating risk and designing plans of care to improve outcomes C. Evaluating the effect of the health care financing on care access and patient outcomes D. Applying basic business and economic principles to the microsystem

Answer B—Rationale: CNLs must have the ability to critically evaluate and anticipate risks to client safety; this is a critical component role.

36. You are a CNL on a busy surgical unit. Recently, several nurses have reported confusion regarding their patients' discharge process. The nurses stated that they were often unaware of all communications between the surgeon, discharge planners, social workers, and pharmacists. As a result, the nurses were often unaware of their patient discharge plans, status, and needs. As a CNL, how can you best improve this process? A. Educate nurses on how to access progress notes from other providers within the current electronic health record (EHR) B. Discuss with each health care team member the clinical issue regarding the discharge process and suggest the creation of a daily interdisciplinary team meeting C. Communicate to the surgeons the nurses' concerns, and advocate for the nurses' needs for communication in their role D. Assume responsibility for the coordination of all discharge needs for patients on the unit', '

Answer B—Rationale: CNLs should advocate for the role of the professional nurse as an equal part of the interdisciplinary team. Education for nurses on accessing progress notes does not address the issue of nurses not being communicated with as part of the team. Communication to surgeons may improve communication to the nurse, but does not necessarily improve communication between each provider equally. The CNL should not assume all of the responsibility of patient discharge planning.

2. What organizational theory is used with rapid, unpredictable, and constant change? A. Systems theory B. Chaos theory C. Change theory D. Traditional theory

Answer B—Rationale: Chaos theory is used to understand rapidly changing, unpredictable health care environments.

119. Lateral integration is one of the main functions of the CNL, incorporating multiple disciplines into the care of clients and populations. Which of the following ongoing components constitute lateral integration? A. Advocacy, assessment, clinical knowledge, evaluation B. Collaboration, communication, coordination, evaluation C. Altruism, benchmarking, cost reduction, evaluation D. Advocacy, collaboration, coordination

Answer B—Rationale: Communication, collaboration, coordination, and evaluation—while all the components listed make up important aspects of different CNL roles, only these four address lateral integration.

191. You have done some research and found a new fall prevention tool that you would like to trial on your unit. The tool was recently developed and tested at a large city hospital with a population of open heart patients. You are not sure that this tool can be effectively implemented in your small community hospital. You are questioning the tool's: A. Relative risk B. External validity C. Transportability D. Causal association

Answer B—Rationale: External validity is the degree to which the results of the original study are applicable to a population other than the one initially targeted.

24. A group composed of unit-based council members was put on a task force to improve the discharge planning process because patients felt unprepared and rushed at discharge. A decision was made to create a discharge planning nurse position to educate patients the night before the discharge. Even though the new nurses did not like this solution, they deferred to the senior nurses of this group who were adamant about implementing this position. Which barrier to effective teamwork does this exemplify? A. Physical threats B. Groupthink C. Team dysfunction D. Authority gradient

Answer B—Rationale: Groupthink is a phenomenon that occurs when group members try to minimize conflict and reach consensus too early without fully vetting all ideas and consequences.

156. The CNL provides integration of care by working with multiple interdependent and independent disciplines, breaking down barriers, and proactively managing care across the continuum. This describes a(n): A. Vertical leader B. Lateral integrator C. Outcomes manager D. Systems analyst

Answer B—Rationale: Lateral integration of care involves the delivering and coordination of care using a multidisciplinary approach. The CNL can oversee care provided by the health care team, identify barriers, and work with the team to proactively manage potential problems.

111. B.F. is a 52-year-old female recently placed with the palliative care team. The CNL makes sure that B.F. is transferred to another unit with a specific palliative care section. How is this a demonstration of advocacy? A. Physicians understand when to transfer patients. B. It ensures that the system meets the needs of the population. C. It advocates for the professional nurse. D. It applies ethics toward patient care.

Answer B—Rationale: Make sure the patient is placed where the most optimal outcomes and palliative', 'care can be delivered.

151. You are the CNL in an outpatient pediatric clinic. The most common diagnosis for your patient population is asthma, and your patients are frequently seen at local emergency departments (EDs) for asthma exacerbations. Which action most directly optimizes the level of function in daily life for these patients? A. Provide or reinforce previous education to patients and families on asthma and inhaler use B. Review discharge orders and ensure that all clients are prescribed a long- and short- acting inhaler C. Provide an in-service at local schools to educate teachers on managing asthma exacerbations in children D. Advocate for the development of a nurse phone triage to answer urgent patient and family asthma concerns

Answer B—Rationale: Many of these interventions can help promote knowledge on what to do in the event of an asthma exacerbation; however, ensuring that each patient has the proper inhalers best optimizes the daily level of function.

37. How can the CNL best provide and educate staff on giving culturally competent care within the unit? A. Educate staff on assessment questions/phrases in the most common secondary language present in the community or seen within the hospital B. Educate staff on varying cultural perceptions and beliefs surrounding the concept of health C. Provide an in-service on accessing patient education and handouts in another language D. Ensure that nurses are assigned to the most culturally appropriate patients currently on the unit

Answer B—Rationale: Nurses should never attempt to use a family member or their own limited ability for conversation in another language; a certified medical interpreter should be used. An in-service on accessing education in multiple languages would likely be very useful to staff, but is not as good an intervention as education on cultural differences. Staffing and patient assignment should not be based on only cultural associations; individual preferences may also need to be considered.

146. As a CNL, you are asked to speak to a local church group, mostly elderly, regarding the importance of annual influenza shots and pneumonia vaccines. You want to be well prepared for the talk as you know the leaders have several questions about the relationship in developing pneumonia and vaccination. You decide to develop a PICOT question and initiate a literature review. Which of the following statements best exemplifies the PICOT method? A. For patients 65 years and older, the use of an influenza/pneumonia (PNA) vaccine vaccine will reduce the risk of developing pneumonia. B. For patients 65 years and older, the use of an influenza/PNA vaccine will reduce the risk of developing pneumonia when compared to patients not receiving vaccination within a year. C. For patients 65 years and older, the use of an influenza/PNA vaccine will reduce the pneumonia. D. For patients in a church, the use of an influenza/PNA vaccine will reduce the risk of developing pneumonia in a year

Answer B—Rationale: PICOT is a process in which clinical questions are phrased to reveal the most relevant information (P = patient population; I = intervention, C = comparison; O = outcome).

85. Isabella is a 62-year-old female who enters the community health clinic where you are employed as a CNL. The front desk staff approaches you and states that Isabella has refused to complete the standard health questionnaire form and health information release form. Isabella states that she forgot her glasses and that she will just take the form home to complete. Which of the following would be the most appropriate response by you as the CNL? A. Tell the front desk staff to send the forms home with Isabella and provide her with a prepaid envelope to send the forms back to the office B. Inform Isabella that many people have difficulty understanding these forms, and ask if she would like you or someone to help her complete the forms C. Explain the importance of completing the forms to Isabella and ensure she completes the forms prior to entering the examination room D. Provide Isabella with a magnifying glass to allow her to read the forms more easily

Answer B—Rationale: Patients will frequently hide issues with health literacy due to feelings of embarrassment and shame. Health care providers may pick up on behavioral clues such as patients that provide incomplete forms, make excuses such as they forgot their glasses, or state they will complete the paperwork at home.

113. With health care reform, the CNL recognizes that evidence-based practice (EBP) is imperative. The CNL decided that her staff should be knowledgeable about health care reform. She collaborated with the educator and administration team to educate the staff about health care reform and pay for performance. What statement best reflects the definition of pay for performance? A. It is a voluntary program that encourages hospitals nationally to report quality measures for heart attacks, heart failure, and pneumonia.', ' B. It is a national program in which physicians and hospitals receive more money if their quality measures exceed certain benchmarks or if the measures improve year to year. C. It is a process that involves the surveillance of and intervention in clinical activities of physicians for the purpose of controlling costs. D. It is a Medicare program that began the physician quality reporting initiative.

Answer B—Rationale: Pay for performance gained widespread acceptance in health care; it goes one step above pay for reporting, as it requires physicians or hospitals to report quality measures, in which they receive more money if their quality measures exceed certain benchmarks or if the measures improve year to year.

181. You are listening to report with a novice nurse. As part of mentoring new staff and supporting clinical decision making, you ask the new nurse which patient she should assess first. Which patient is the most important for this nurse to assess first? A. A 46-year-old receiving IV antibiotic therapy on day 3 B. A 60-year-old 15 minutes s/p liver biopsy C. A 56-year-old with pneumonia on day 2 D. A 72-year-old hip replacement impatiently waiting for discharge

Answer B—Rationale: Post-op liver biopsy patients have an increased risk of bleeding and need close monitoring after the procedure. The question does not indicate how recently the biopsy was done; therefore, this is the best choice based on the information provided.

162. A professor is discussing the difference between quantitative and qualitative research. As a CNL student, you are aware that quantitative research is related to numeric data with statistical analysis, while qualitative research focuses on non-numeric forms of research. Which of the following is an example of a quantitative study? A. Personal interviews B. Randomized controlled trial (RCT) C. Ethnography D. Phenomenology

Answer B—Rationale: RCT is a quantitative research process that is a true experiment; it is the strongest design to support cause-and-effect relationships, in which subjects are randomly selected.

130. What level of prevention are you providing by performing screenings? A. Primary B. Secondary C. Tertiary D. Quaternary

Answer B—Rationale: Secondary prevention involves activities that help increase early identification of disease.

78. A certified nursing assistant (CNA) approaches the unit CNL to discuss her frustrations in attaining appropriate equipment for patient care. The CNA explains that the clean utility room is too far and that staff constantly have to make frequent trips. The CNA wants to know what steps to take to make a change. As a CNL, what statement best describes the appropriate response? A. "We will just have to adjust to what we have right now." B. "Well, you have identified a problem, the next step is to review any literature that can help resolve our issue." C. "I suggest that you and the staff take the appropriate equipment to your rooms." D. "Well, let us implement the process that another unit is using."

Answer B—Rationale: The CNA already identified a problem, the first step of EBP. The second step of the EBP process is to review the literature.

59. A Vietnamese patient is admitted with pneumonia on a medical-surgical unit. The patient appears very nervous when the medical staff enters the room. As a CNL, what is the best course of action to take in this situation? A. Try to talk to the patient calmly and ease his fears B. Call language services and request a Vietnamese interpreter C. Ask your housekeeper who is from Vietnam to come in and interpret for the medical staff D. Keep all interactions with the patient as brief as possible

Answer B—Rationale: The CNL bridges cultural and linguistic barriers by being an advocate for the', 'patient and his or her family. An interpreter should be present anytime there is a language barrier.

127. During a unit-based council meeting, the chair states that the unit has had 10 falls this year related to bathroom needs. Frank, a staff nurse, states he conducted observations and determined these falls are likely related to a lack of purposeful hourly rounding. Judy, a nursing assistant, states she has heard everyone is doing hourly rounding but it does not help because patients still get out of bed. Which of the following is the most appropriate response by the CNL? A. Encourage the staff to stop hourly rounding B. Educate the staff on the importance of utilizing evidence-based practice (EBP) like hourly rounding to prevent falls and show the evidence C. Instruct the staff to utilize new chair alarms for all patients as these have been proven to reduce falls D. Ask the team to search the literature for evidence related to fall prevention

Answer B—Rationale: The CNL coaches and leads teams to sustain a culture of safety by utilizing EBPs.

124. Jennifer, a CNL student, is shadowing a CNL on a busy medical-telemetry unit. The CNL encourages Jennifer to follow up on a 24-year-old patient admitted with diabetic ketoacidosis (DKA) for the fourth time in a 2-month period. Which statement best describes the CNL student acting as a client advocate for this patient? A. Round on the patient and consult a diabetes educator B. Round on the patient and discuss reasons for frequent readmissions, discuss concerns with the primary nurse, order a HgA1c, and consult a diabetes educator and social worker C. Round on the patient, and tell the primary nurse to educate the patient on diabetes D. Discuss with the primary care nurse that the patient has been again readmitted and the patient', 'needs more education on diabetes and preventing readmissions

Answer B—Rationale: The CNL demonstrates advocacy for the patient by involving the patient and discussing possible reasons for readmission and taking an interdisciplinary approach to address patient concern.

29. Which of the following is the best description of health care economics? A. Understanding run charts B. Competence demonstrated by knowledge and ability to articulate federal, state, and private payer system regulations and issues, as well as the impact on organizations C. Identifying the number of patient falls per patient day D. The number of staff assigned to work on a given shift on a given day

Answer B—Rationale: The CNL has a very powerful role to fill when it comes to economics and health care finance. The CNL must understand finance to make the most appropriate decisions in regard to services provided, by whom, and for the length of time.

63. The CNL completed an assessment of the community and identified a need for a public health program. Which of the following would have the potential for the greatest impact on the community? A. Implement a small pilot program at the local hospital B. Write a proposal to make the change and send it to the legislators to build their support for the change C. Research and analyze public health programs in other communities D. Write an article for the local paper discussing the need for the program

Answer B—Rationale: The CNL is responsible for influencing regulatory, legislative, and public policy to promote and preserve healthy communities. The CNL is advocating for a healthy community by writing to legislators.

148. The CNL knows in order to serve as a lateral integrator she or he must conduct ongoing evaluation of care delivery systems and processes. Which of the following is the best example of how the CNL demonstrates evaluation? A. Ensures each member of the team clearly understands each member's role B. Conducts an ongoing analysis of risk to promote patient safety C. Synthesizes gathered information to find common goals and shares this with the team D. Fosters open rapport across professional boundaries

Answer B—Rationale: The CNL monitors not only the final outcomes of care, but also the implementation and ongoing progression of care. By analyzing and evaluating risk, adjustments can be made to improve the overall outcomes while promoting patient safety.

47. Which of the following is the best example of a CNL protecting patient autonomy? A. The CNL ensures the patient understands how to use an incentive spirometer. B. The CNL ensures the patient has all information and understands the procedure for esophagogastroduodenoscopy (EGD)/colonoscopy scheduled for the morning. C. The CNL discusses the plan of care for treatment of pneumonia with the daughter and the doctor. D. The CNL closes the door to protect the patient's privacy when discussing her diagnosis.

Answer B—Rationale: The CNL protects patients' autonomy by keeping them well informed and ensuring they understand their decision about their plan of care.

4. Your hospital is currently trialing the integration of the clinical nurse leader (CNL) role. At the', 'end of the trial implementation period how can you, as the CNL, best illustrate the effectiveness of your role during this trial? A. Refer to increased patient satisfaction scores over the course of the trial B. Present data that demonstrates the effect of the CNL and outcomes achieved over the course of the trial C. Present a list of projects and tasks completed over the course of the trial D. Refer to your performance review over the course of the trial

Answer B—Rationale: The CNL should present the effect and outcomes to illustrate the importance of the integration of his or her role. Increased patient satisfaction is not necessarily directly related to the CNL. Presentation of projects and tasks completed does not address measurable outcomes. Performance review of the individual does not indicate outcomes were affected.

188. Which of the following is not part of the PDSA change model? A. Plan B. Assess C. Do D. Study

Answer B—Rationale: The PDSA change model consists of plan, do, study, and act.

139. The CNL works in a medical intensive care unit (MICU) at a level one trauma center. The CNL conducts a comprehensive assessment of the microsystem. All of the following are vital aspects that the CNL would need to identify within the microsystem except: A. The rate of ventilator-associated pneumonia B. The organization's operating budget C. The top three diagnoses D. The average age of patients

Answer B—Rationale: The assessment of the microsystem focuses on the small, frontline unit, which does not include the organization's operating budget. The rate of nosocomial infections, top diagnoses,', 'and age of patients within the microsystem are vital information for the CNL.

39. A 6-year-old boy is in critical condition following a car accident. The patient has head trauma and internal bleeding. The patient's parents have stated multiple times that they are Jehovah's Witnesses and do not want their son to receive blood. The CNL knows that the blood transfusion is needed immediately and could save the boy's life. Which of the following statements is the best thing for the CNL to do? A. Listen to the parents, as U.S. minors have no legal rights and remain under parental jurisdiction B. Obtain a court order in the best interest of the child to receive blood, based on the avoidance of physical harm C. Based on religious beliefs, do not give blood D. Follow the physician's decision to give blood since the physician's decision overrides the parental decision', '

Answer B—Rationale: The child's interests as well as the state policies outweigh the parental rights to refuse medical treatment for a minor. A court order is needed to enforce this.

28. While assisting Dr. Smith with a central line insertion you notice she did not properly execute sterile technique. What is the most appropriate way to provide feedback? A. Stop Dr. Smith while she is talking to the patient and provide feedback B. Ask Dr. Smith to stop the procedure so you can get her another central line insertion kit C. Refer Dr. Smith to the policy and procedure manual and ask that she read the section on using aseptic technique D. Debate with Dr. Smith at the bedside and tell her errors like this are the reason patients acquire hospital-acquired conditions

Answer B—Rationale: The most important action is to protect the patient by providing another sterile central line insertion kit.

157. A nurse on your unit has a question about required documentation for a patient with a nasogastric (NG) tube to wall suction. You guide her to what resource? A. The unit charge nurse B. Hospital policy/procedure manual C. The States Board of Nursing Scope of Practice D. The Joint Commission website

Answer B—Rationale: The most reliable resource is the hospital policy and procedure manual. While the charge nurse may be a source of knowledge, it is not the best or official source.

178. You are helping the nurse to care for a patient with congestive heart failure (CHF). He has just completed a transfusion of 2 units of packed red blood cells (PRBCs). Upon your entering the room, the patient complains of shortness of breath. His O2 saturations are 85% on 2 L and he is breathing 28 respirations a minute. What drug do you anticipate administering? A. Nitroglycerin SL B. Lasix IV C. Albuterol HHN D. Prednisone PO

Answer B—Rationale: The patient is most likely in pulmonary edema. Lasix is a loop diuretic.

75. Failure mode-effect analysis is best used as follows: A. In response to a critical or sentinel event B. Prior to a process implementation or change C. As part of a random audit process D. In response to malfunctioning tools or equipment

Answer B—Rationale: The purpose of a failure mode-effect analysis is to anticipate potential problems; by virtue, this is best conducted prior to a process implementation.

43. A healthy work environment is an important factor in supporting ongoing quality and safety. As the CNL, you recognize that the hallmarks of a healthy work environment include all of the following except: A. Skilled communication B. Upward mobility C. Effective decision making D. Appropriate staffing

Answer B—Rationale: Upward mobility is not a hallmark of a healthy work environment or area of focus for the CNL.

179. An 88-year-old woman suffers a stroke in the nursing home. She develops pneumonia and is transferred to the hospital. She continues to decline, is having trouble breathing, and becomes unconscious with little hope of recovery or quality of life. She has no family and no health care proxy, living will, or directions about whether she wants to be intubated or not. The physician wants to intubate the patient. The staff nurse strongly believes the patient would not want to be intubated, as the nurse had cared for the lady before she became unconscious. What is the best thing for the CNL to do first? A. Take a vote among the staff nurses B. Call for an ethics consultation C. Ask the social worker to make a recommendation or decision D. Do a literature review on quality of life of elderly patients with pneumonia

Answer B—Rationale: When a patient has not declared his or her wishes and there is no family or', 'documentation and there is a dispute, then there is an ethical issue and the best choice is to ask for an ethics consultation.

142. During a client's admission medication reconciliation, the admitting nurse comes to you for assistance. On review of the client's case, you discover the client has several separate opioid prescriptions from multiple different providers. When you discuss the issue with the patient, the patient tells you he or she thought each prescriber had been consulting with the others. Which function of the CNL best addresses this issue? A. Client advocacy B. Lateral integration C. Injury prevention D. Advanced clinical assessment

Answer B—Rationale: While aspects of each of these functions could be used to address parts of this issue, only lateral integration addresses coordinating multiple players across multiple disciplines, collaboratively, toward the common goal of proper, safe management of pain for this complex patient through improved communication among these stakeholders and with the client, as well as collaboration for proper ongoing monitoring and evaluation of the client.

200. You want to do some research for a potential policy change. All of the following are excellent resources, except: A. Centers for Disease Control B. Wikipedia C. American Diabetes Association D. Institute for Healthcare Improvement

Answer B—Rationale: Wikipedia is NOT a valid or credible site—anyone can post to this site. Case Study

195. While being admitted to the unit after a car accident, the patient informs you that she has been off her psychiatric medications Seroquel and Celexa due to the cost and no longer has a doctor. As an advocate, you would talk with the physician in hopes of obtaining what two consults? A. Medicine and clinical case manager (CCM) B. Psychiatry and social worker C. CCM and social worker D. Medicine and psychiatry

Answer B—Rationale: Without a physician to monitor the results of the patient withdrawing herself from these two medicines, the result could be detrimental. This consult can also help get the patient back with a psychiatrist upon discharge. The social worker would assist with any social issues upon discharge, such as affording medications.

199. A new health policy is being voted on in Congress. Your professional organization supports this policy and is recruiting nurses to go to Washington, DC, to help promote their view and to have a bigger voice. You do not support this policy. Your manager wants you to go as a leader and represent your unit. What should you do? A. You should go, as you need to stick together with your professional organization and yield to your manager. B. You should learn more about the policy and why your organization supports it. C. You should politely decline, as you do not agree with the policy. D. You should go, but rally against the policy since you do not agree with it. This is America and you are exercising your freedom of speech.

Answer B—Rationale: You should know how your professional organization stands—we need to support each other and have one voice as nurses.

116. The CNL works in a small primary care practice and has identified that several patients have missed appointments. After investigating why the patients were not going to appointments, the CNL determines that the patients made the appointments so far in advance that they forgot them. The CNL discusses these findings with the team and they decide to implement a program with reminder calls 2 days prior to the appointment. The CNL wants to be sure to identify aspects that may positively or negatively affect the project, so the CNL suggests the team utilize which of the following? A. 5P (persons, patients, professionals, processes, patterns) assessment B. Plan-Do-Study-Act (PDSA) cycle C. Strengths, weaknesses, opportunities, and threats (SWOT) analysis D. 5S methodology

Answer C—Rationale: A SWOT analysis is a vital assessment for successful planning and implementation of a change. A SWOT analysis is used to determine strengths, weaknesses, opportunities, and threats that may affect the project.

60. Which of the following is not an example of health care finance and economics? A. Developing and leveraging human, environmental, and material resources B. Understanding the fiscal context in which practice occurs C. Leading a gap analysis to create a cohesive health care team D. Applying basic business and economic principles and practices

Answer C—Rationale: A gap analysis is a method of assessing the differences in performance between a business information system or application to determine whether the system requirements are being met and, if not, the step needed to do so. It is not an example of health care finance and economics.

88. A patient presents with severe pain in the upper right abdomen after eating a fatty meal. These symptoms lead you to suspect cholecystitis. Which assessment finding is most likely to be associated with this condition? A. Positive Homans sign B. Positive Psoas sign C. Murphy's sign D. Aaron's sign

Answer C—Rationale: A positive Murphy's sign is identified when the patient inhales and feels pain due to the inflamed gallbladder pushing into the palpating hand.

143. As a CNL, you recognize a sentinel event as which of the following? A. Any unintended event that results in ANY harm, physical or psychological, to a patient B. Any unintended event that has the POTENTIAL to result in ANY harm, physical or psychological, to a patient C. Any unintended event that results in SIGNIFICANT harm, physical or psychological, to a patient' D. Any unintended event that has the POTENTIAL to result in SIGNIFICANT harm, physical or psychological, to a patient

Answer C—Rationale: A sentinel event only occurs if the event reaches and significantly harms a patient.

122. As the CNL, you assess the needs of your unit on an ongoing basis. You notice while rounding on the nursing staff that nurses are complaining about the demands of patient care. The nurses state that the patients are requiring more help than usual. This prompts you to look at the level of intensity of care required by patients. Level of intensity of care required by patients is referred to by, which of the following? A. Volume B. Case mix C. Acuity D. Staffing mix

Answer C—Rationale: Acuity is the level of intensity of care required by patients.

69. You recognize that a large proportion of your surgical patients have cultural or religious concerns about the use of blood transfusions, although the need for such transfusions are common with many of your surgeries. As the CNL at a surgical center, how can you best ensure health promotion of this population while providing culturally competent care? A. Develop education on the importance of blood transfusions when medically necessary, and the benefits postoperatively B. Provide resources like the other clinics in the area that may be able to perform the surgery with lowered risks of estimated blood loss C. Evaluate evidence on alternatives to blood transfusions, such as autologous blood transfusions and alternative blood products, and present this information at an interdisciplinary team meeting D. Educate staff on respecting client wishes and do not attempt to pressure patients into receiving transfusions

Answer C—Rationale: Although still debated, many communities believe that autologous blood transfusions are acceptable and the blood is still from "self." Education on transfusions and benefits may be useful but does not truly address the patients' concerns. Providing resources on where else to seek care is not appropriate.

20. You are the CNL on a surgical unit. You have noticed that readmission rates for your orthopedic patients have increased steadily over the last several months. Upon investigation, you find that patients are reporting that they do not believe they are receiving adequate education on postoperative wound management. As the CNL, you recognize that one way you can act to promote the health of your patients is: A. Provide direct, culturally appropriate education to all patients on your unit B. Arrange post-op visits at the outpatient surgical clinic for all patients upon discharge C. Educate the nursing staff regarding how they can evaluate patient health literacy, provide education at an appropriate level for each patient, and evaluate patient understanding of education provided D. Discuss with pre-op staff beginning patient education much earlier in this hospital process

Answer C—Rationale: Although the CNL may do direct patient teaching, it may not be possible to coordinate the discharge education for all patients on the unit; this would depend upon the patient's nurse. Post-op visits are important follow-ups for patients, but do not need to be scheduled by the CNL. Valuable teaching may occur preoperatively; however, demonstration of wound care and dressings cannot occur until after the surgery. CNLs should educate nurses on how to best provide education to their patients, and ensure that nurses understand how to evaluate health literacy.

57. In recent months, there has been a marked increase in the number of intravenous (IV) infections and infiltrations on your unit. Some of these IVs were started on your unit while others were started on other units or in the emergency unit before being transferred to your unit. The nurse manager has asked you to investigate this issue. As the CNL, your best intervention would be to: A. Call other units to make sure policies and procedures are being followed B. Wait to see if the infection occurrences are a coincidence C. Form a group to investigate this issue including staff nurses from your unit, representatives from IV therapy, and infection prevention services D. Retrain all staff nurses on your unit in correct IV care procedures

Answer C—Rationale: Because this issue involves shared responsibility and is a serious concern, it should also be addressed with collaboration, shared investigation, and decision making that occurs in a robust, focused workgroup.

189. In order to generate ideas aimed at designing an implementation plan, a team reviews the topic and members verbalize solution ideas in a random fashion. This is an example of which of the following strategies? A. Multivoting B. Process mapping C. Brainstorming D. Nominal group technique

Answer C—Rationale: Brainstorming is creative, interactive, and unstructured, as team members suggest possible ideas in a free-flow format without regard to the details of the suggested solutions.

46. Which of the following best utilizes the PICOT method of developing a clinical question? A. Will a preoperative class for coronary artery bypass graft (CABG) surgery patients decrease anxiety? B. What is the effect of early mobility in patients 65 years and older on length of stay? C. Will the implementation of quiet time and employee education of harmful effects of noise reduce peak levels and improve patient satisfaction of patients on a medical-telemetry unit over a 1-month period? D. Will the use of secret shoppers increase compliance with hand washing and PPE in a large hospital in the Southeast?

Answer C—Rationale: C is the best choice as it addresses the population, intervention, outcome, and time period.

118. Part of your hospital's pre-op admission process is to collect a urinalysis (UA), hemoglobin A1c (HgA1c), comprehensive metabolic panel (CMP), and complete blood count (CBC). You review the HgA1c results of these patients. As the CNL, how can you best work with your health care team to ensure health promotion of clients with elevated HgA1c results? A. Inform patients of elevated HgA1c results, as well as implications of those results B. Provide diabetes education to patients with elevated HgA1c results postoperatively C. Place a consult for the diabetes educator to meet and evaluate patients with an elevated HgA1c during this admission D. Inform the surgeons of these elevated HgA1c results and ask them to consider what the next step should be

Answer C—Rationale: CNLs should work to incorporate other members of the interdisciplinary team in the patient's care when needed and appropriate.

42. A client with complex behavior concerns is getting ready to be discharged to a skilled nursing facility. However, the client has expressed that he wishes to stay in the hospital and not be discharged. As the CNL, your best action would be to: A. Inform the patient and his or her family that they must go and remaining on the unit is not an option B. Advocate letting the client stay on the unit one extra day, then discharge tomorrow C. Identify the client's concerns and collaborate with the care team to see they are addressed D. Ask the family to help encourage the client to discharge to the skilled nursing facility

Answer C—Rationale: Clients can often experience apprehension when changing care settings. Identifying specific concerns and working rapidly to ensure they are addressed in collaboration with other members of the care team can greatly reduce a client's hesitation. Additionally, such collaboration ensures other members of the care team are aware of the clients' concerns, possibly providing additional information and insight regarding the clients and their care needs.

21. A mother presents to the emergency department (ED) with her 8-month-old son, who has the following symptoms: coughing, recurring respiratory infections, fatty stools, and failure to thrive. Upon examination, the infant's vitals are as follows: Temp 99.4°F, pulse 150, respirations 65, blood pressure 88/50 mmHg. A CNL in the ED receives a phone call from the laboratory stating that Staphylococcus aureus was found colonized in the patient's airway. As a CNL in the ED, you know that the preceding symptoms and laboratory results are consistent with which of the following diseases? A. Asthma' B. Lobar pneumonia C. Cystic fibrosis D. Croup

Answer C—Rationale: Cough, recurring respiratory infections, fatty stool, and failure to thrive are all symptoms of cystic fibrosis. Many children with cystic fibrosis have colonizing Staphylococcus aureus in their airways.

102. A Native American patient is admitted with sepsis from a urinary tract infection. The patient is very weak and unable to ambulate much further than her room. The patient tells the CNL that she is very discouraged and feels that she is not able to get better because she is unable to touch "mother earth" with her feet. The CNL gathers some dirt, grass, and flowers from outside the hospital and places it in a bucket. The CNL brings the bucket in the patient's room and helps her to stand on the dirt. Which of the following best describes what the CNL is demonstrating? A. Cultural knowledge B. Cultural awareness C. Cultural skills D. Cultural management

Answer C—Rationale: Cultural skills are described as the ability to identify, assess, and incorporate the values, beliefs, and cultural customs of an individual.

58. As the CNL when engaging in a QI effort, you recognize the first of the common steps of the QI process to be: A. Review literature B. Analyze the root cause C. Establish a clear purpose or aim D. Select metrics

Answer C—Rationale: Establishing a clear aim or purpose for a QI effort is foundational to all other pieces. While other steps may occur first and trigger a QI effort, such as a sentinel resulting in an RCA that then becomes part of a QI effort, when the actual QI portion starts it is important to provide a clear, explicit purpose to provide focus and mission to participating players.

125. As the CNL on a surgical unit, nurses have expressed to you their concern over conflicting orders regarding patient intravenous fluids (IVFs). Most patients have conflicting order sets for fluids and rates, as ordered by the surgeons and hospitalists. From a health care informatics perspective, what is the best action you can take as the CNL? A. Coordinate with the surgical and hospitalist groups to alert them of this clinical concern B. Instruct the nurses to discontinue the older orders per protocol to clean up the order set within the electronic health record (EHR) C. Work with the computer specialists to create a hard stop in the system requiring physicians to verify or modify IVF orders when new orders are placed D. Discuss with the pharmacy if there is a way to prevent more than one IV fluid order from being allowed in the EHR at a time

Answer C—Rationale: From the health care informatics perspective, creating a hard stop that requires doctors to evaluate the current orders would be most beneficial. There are times when multiple fluid orders may be clinically appropriate, and changes to the system to not allow more than one order under any circumstance would not be beneficial.

197. You are caring for Sara, a 76-year-old grandmother recovering from heart failure. You know that she is ready to go home because: A. Her ECG is normal, her pulse oximetry is normal, and she has a supportive family to help care for her at home. B. She tells you she is ready to go home. C. You observe her ambulating in the hallway, free from dyspnea.', ' D. She says she is free from dyspnea and fatigue, she has a follow-up appointment set up for the following Monday morning, and her daughter said she can drive her to the appointment.

Answer C—Rationale: HF symptoms are often not well evaluated, as clients remain relatively inactive while in the hospital. Activities such as walking in the hall provide an opportunity for objective evaluation of dyspnea, fatigue, and gait issues.

83. The CNL works with the interdisciplinary team and encourages all members to voice their opinion and provide feedback. What type of leadership is the CNL demonstrating? A. Vertical leadership B. Diagonal leadership C. Horizontal leadership D. Systems leadership

Answer C—Rationale: Horizontal leadership focuses more on collaboration and equality within the group. Vertical leadership is a top-down style of leadership with one team leader driving down change.

32. Team coordination skills can help avoid all of the following except: A. Undefined team member roles B. Poor membership involvement C. Member conflict D. Confusion regarding next steps

Answer C—Rationale: In most working groups, conflict arises at some point. In addition to sound team coordination skills, the CNL must also possess effective conflict management skills.

171. You are a CNL selected to lead a team focused on implementing a multidisciplinary clinical pathway for acute ischemic stroke and transient ischemic attack. The risk assessment tool that you have adopted identifies all of the following as independent stroke risk factors except: A. Age B. Systolic blood pressure', ' C. Liver dysfunction D. Current smoking E. Diabetes mellitus (DM)

Answer C—Rationale: Independent stroke predictors include age, systolic blood pressure, hypertension, DM, current smoking, established cardiovascular disease (any one of MI, angina or coronary insufficiency, CHF, or intermittent claudication), atrial fibrillation, and left ventricular hypertrophy on electrocardiogram (ECG).

186. To demonstrate active listening, the CNL would exhibit which behavior? A. Avoid making any facial expressions B. Preserve at least 3 ft between the parties C. Lean slightly forward D. Fold hands in the lap

Answer C—Rationale: Leaning slightly forward indicates desire to concentrate on the interaction at hand and relays openness and attention to the talker.

91. A CNL using Rogers's diffusion of innovation theory realizes while implementing a new health information management (HIM) system that when dealing with a member of the health care team she should: A. Spend a majority of time educating the laggards to become supporters of change B. Spend a majority of time on innovators because they will need a lot of convincing to make a change C. Spend a majority of time with early and late majority adopters because when they support the change it will be successful D. Spend very little time with the early majority adopters because they are not adaptable to change

Answer C—Rationale: Looking at Rogers's diffusion of innovation theory's bell curve, 2.5% of people are innovators. Following them are the early adopters (13.5%) and then the early majority (34%), consumers who make their moves through the market more carefully, but tend to adopt a new product more quickly than most. At the hump of the bell curve are the late majority (34%), consumers who adopt a new product only after the majority has weighed in on its value. Finally, sloping downward are laggards (16%), the critics, curmudgeons, and haters who do their best to resist adoption but will eventually do so.

141. As the CNL on a medical floor, you recognize the importance of annual flu vaccinations, especially considering your geriatric population. How can you promote vaccination rates within your population? A. Organize a flu clinic for staff and visitors B. Ask a physician to order flu shots for all admitted patients, and organize a flu clinic for staff and visitors C. Within the hospital, develop a nurse-driven protocol that allows nurses to place an order for flu shots for your population D. Ask the physician to order flu shots for all admitted hospital patients

Answer C—Rationale: Nurse-driven protocols are an excellent way to ensure that the population receives vaccinations. Flu shots may not be appropriate for all hospitalized patients, based on personal beliefs or current treatment, and should not be mass ordered.

67. A 55-year-old male is readmitted to the hospital with hypertension four times within the past 8 months due to medication noncompliance. The patient has been given a blood pressure machine, set up with a primary care provider, and arranged telehealth services in previous admissions. During your discussion with the patient, he states that he is taking his medication as his doctor prescribed. The patient brought his medications into the hospital, so you ask him to hand you his blood pressure', 'medication bottle. The patient hands you the bottle labeled Neurontin. Which of the following would be the next best step for you to take as the CNL? A. Obtain records from the patient's primary care provider B. Coordinate a family meeting with the patient and the care team C. Have the patient hand you the rest of the bottles, tell you what each medication is, and describe how and when he takes that medication D. Consult with a pharmacist to determine the best medication options for the patient

Answer C—Rationale: Oftentimes, patients develop coping skills to help with limited literacy, leading health care providers to misjudge their ability to comprehend patient teaching. By having the patient explain how and when he takes medications, the CNL can assess the patient's ability to understand his regimen. The patient may have difficulty reading and may need an alternative method for understanding his regimen such as color coding bottles rather than reading labels.

177. Before beginning data collection, what is the primary key factor to determine? A. Personnel to collect data B. A secure database for holding data C. Operational definitions of data D. A user-friendly collection method

Answer C—Rationale: Operational definitions clearly define what is to be collected and helps avoid confusion for those collecting the data; this should be the first step. Clear operational definitions also help those who are interpreting the data. Failure to determine operational definitions may result in data that are inaccurate.

23. A CNL in the emergency department (ED) is auditing stroke patients' charts and the administration of tissue plasminogen activator (tPA) and notices that only 83% of patients who are eligible to receive tPA are receiving it. The CNL knows that the 83% administration rate is below the national benchmark. The CNL identifies that there is a time lag in MRI. The CNL creates a stroke team to develop a guideline implementation action plan to improve the process of timing of the MRI. What is the best tool utilized by the CNL in implementing change? A. Research study B. Meta-analysis C. Plan-Do-Study-Act (PDSA) D. Standardize-Do-Study-Act

Answer C—Rationale: PDSA is a model for quickly and easily testing ideas that could lead to improvement, based on existing ideas, research, feedback, theory, reviews, audits, or evidence of what has worked elsewhere.

35. Maureen is a 45-year-old female who is undergoing chemotherapy for ovarian cancer. Maureen complains of increased nausea, vomiting, and abdominal pain uncontrolled by medications prescribed by her oncologist. Maureen expresses that she wants to continue chemotherapy, but she is unable to eat and maintain her weight due to her symptoms. She describes the pain as unbearable and at times she is unable to get out of bed. What would be the best step for the CNL to take next? A. Discuss code status and health care power of attorney with Maureen B. Contact hospice care to arrange a meeting with Maureen C. Call the physician and suggest a palliative care consult D. Suggest alternative methods for pain relief such as meditation, healing touch, and aromatherapy

Answer C—Rationale: Palliative care focuses on improving the quality of life for individuals by concentrating on pain and symptom management, communication, and coordinated care. Palliative care would help Maureen control symptoms of nausea, vomiting, and pain while she continues treatment.

170. Patient satisfaction scores in the ED have shown a downward trend over the past three quarters. As a CNL in the emergency department (ED), your focus is to: A. Create a script for the triage nurse in welcoming the patient B. Assign a volunteer to welcome patients to the hospital C. Compare desired outcomes with national and state standards D. Write a letter of apology to each dissatisfied patient

Answer C—Rationale: Patient satisfaction is an important client care outcome. And client care outcomes are a measure of quality practice. CNLs must know how to compare desired outcomes that will improve safety, effectiveness, timeliness, efficiency, quality, and the degree to which they are client centered.

192. A nurse approaches you and expresses her knowledge deficit regarding the difference between signs and symptoms of left- and right-sided heart failure. You explain the physiology between the two types of heart failure and identify which of the following has a primary symptom of right-sided heart failure? A. Shortness of breath on exertion B. Heart murmur and distended veins C. Peripheral edema D. Cool extremities and weak peripheral pulses

Answer C—Rationale: Right-sided heart failure leads to congestion of systemic capillaries. This generates excess fluid accumulation in the body and usually affects the dependent parts of the body first.', '

94. You are doing a daily assessment of your patient who has transferred from the medical intensive care unit (MICU). The patient has a history of congestive heart failure (CHF), myocardial infarction, atrial fibrillation, and diabetes. During your review of the medication administration record, you notice that the warfarin has not been ordered on admission. What is your next step as the CNL? A. Call the pharmacist and ask for the medication to be put on the medication administration record B. Find out what dosage of the medication the patient was taking and order it C. Notify the primary nurse and suggest that she call the physician and notify him of the near miss D. Call your nurse manager and notify him or her of this medication error

Answer C—Rationale: The CNL assesses patients' needs, is a risk anticipator, and communicates effectively with team members to prevent patients from having an adverse event.

16. The unit implemented bedside reporting 6 months ago, but the change has not been sustained. As a CNL, you begin to participate in bedside reporting and provide constructive, immediate feedback to the nurses for improvement. What best describes this situation? A. Mentoring B. Transformational leadership C. Coaching D. Precepting

Answer C—Rationale: The CNL coaches by evaluating team members and providing constructive feedback. Mentoring is a long-term relationship between two individuals focused on clinical advancement.

62. Maria, a 55-year-old Spanish-speaking patient, is scheduled for a paracentesis. You, the CNL, rounded on her with an interpreter in the morning and explained to her the procedure is scheduled for today at noon. After you mentioned this, Maria stated that she was not aware of this procedure. You noted that a consent was signed by the physician in her chart. What is the next step as a CNL? A. Keep the consent. Utilize the teach-back method to ensure Maria understands the risk and benefits of the procedure. B. Discard the previous consent. Explain to Maria that she needs this procedure and it is the best decision for her. Obtain a new consent. C. Inform the physician and ensure he explains the procedure to Maria with an interpreter present and obtains a new consent. D. Keep the consent. Leave a note for the physician and explain that the patient was unaware of the procedure.

Answer C—Rationale: The CNL protects patients' autonomy by keeping them well informed and ensuring they understand their decision about their plan of care. The CNL addresses the language barrier, ensuring an interpreter is present to assist in understanding, and a new consent is signed.

115. Which of the following best demonstrates how the CNL exhibits collaboration? A. Sets and shares clear goals for teams B. Keeps all team members informed by e-mailing updated minutes C. Includes all contributors to the health care delivery process in the team, including patients/family, and seeks consultation from all members when making decisions D. Monitors and evaluates the use of technology and information systems

Answer C—Rationale: The CNL seeks collaboration and consultation with all contributors to the health care delivery process, including the patient and family.

103. A nurse comes to you with a concern about a telephone order she received from a doctor. The doctor asked her to review a physician order for life-sustaining treatment (POLST) form with a client, then sign and place it in his chart. The nurse is uncertain if this is in her scope of practice. You advise the nurse to: A. Complete the form as ordered by the MD B. Review the hospital's policy and procedure manual, and handle per policy C. Review the State Board of Nursing Scope of Practice and handle according to your', 'scope of practice D. All of the above

Answer C—Rationale: The CNL should identify the State Board of Nursing as the correct source of any scope of practice questions, and advise the nurse that it is not within her scope.

77. As you are planning a discharge for a patient in your cohort, the patient tells you that, even though she has insurance, there is a financial strain on her to pay for her medication. The patient has a history of HIV/AIDS and is currently on three antiviral medications. The patient was admitted with pneumonia on this admission and the doctor has prescribed Zyvox in addition to her other medication regimen. You investigate the cost of this medication and find out the medication will cost the patient $100 after insurance. Which of the following is the most appropriate and first action for you as the CNL? A. Tell the patient that she should take this prescribed medication so she can get better B. Encourage the patient to take the medication because the doctor knows best C. Call the doctor and ask him if there is a more cost-efficient medication to treat the patient's pneumonia D. Consult with the medical social worker to find coupons for this medication

Answer C—Rationale: The CNL uses her knowledge and collaboration skills to reduce cost of care delivery and increase compliance.', '

117. As the CNL is integrated into practice, what best defines his or her level of practice?', ' A. Unit system B. Mesosystem C. Microsystem D. Macrosystem

Answer C—Rationale: The CNL works on the microsystem level.

96. You, as the CNL, plan to implement the use of bed alarms and hi-low beds to prevent falls on your unit. You are completing a literature review. While doing so, you are trying to determine the strength of the articles you have obtained. What process should you use to determine the most credible evidence?', ' A. Plan-Do-Study-Act (PDSA) B. Evidence-based practice C. Melynk and Fineout-Overholt hierarchy (Level 1-7) D. Research utilization

Answer C—Rationale: The Melynk and Fineout-Overholt hierarchy includes seven levels based on the design (Level 1: systematic review or meta-analysis of randomized controlled trials [RCTs] and evidence-based clinical practice guidelines to Level 7: expert opinion and/or expert committee reports).

22. An elderly Chinese woman has just been diagnosed with terminal cancer. While discussing end-of-life care decisions with the family, patient, and CNL, the CNL notices there are conflicting viewpoints between the family and patient regarding advance directives. Which of these is the best answer regarding advance directives? A. In the Chinese culture, the family makes the decisions regarding end-of-life care in order not to burden the patient. B. It is best not to fully inform the patient of his or her condition so that he or she will remain positive. C. The patient has the right to enact his or her own advance directive to guide his or her medical treatments according to the Patient Self-Determination Act. D. The interdisciplinary team has the most information on palliative care to make the best decision.

Answer C—Rationale: The Patient Self-Determination Act explains the patient's right to accept or the right to refuse medical or surgical treatment. The patient is also entitled to receive information about the right to create his or her own advance directive.

1. A new graduate nurse, Jenny, approaches you and states she needs help removing a peripherally inserted central catheter (PICC). Which of the following is the best response when acting as a horizontal leader? A. Remove the PICC yourself B. Tell Jenny to find the policy and then remove the PICC C. Help Jenny find the policy and review it with her. Coach Jenny while she removes the PICC and provide feedback D. Help Jenny find the policy and refer her to a nurse with 12 years of experience for assistance

Answer C—Rationale: The clinical nurse leader (CNL) acts as a horizontal leader by helping the new graduate nurse to learn through sharing knowledge and coaching, rather than doing the task for the nurse.

56. On the rehabilitation unit, the CNL notes that the stroke and amputee patients that require maximum assistance are being assigned to the float nurses. It is noted that many of these patients have had falls while being assigned to the float nurses. This is a patient and family dissatisfier. What type of delegation practice is in question? A. The right circumstance B. The right supervision C. The right person D. The right task

Answer C—Rationale: The licensed nurse delegating the task must ensure that the delegatee possesses and has demonstrated the knowledge base and appropriate skills and resources to perform the task and provide adequate supervision and evaluation to ensure the patient's safety and appropriate outcome.

34. A CNL works in an inpatient unit that provides health care to medical-surgical patients. This best describes which of the following? A. Macrosystem B. Mesosystem C. Microsystem D. Megasystem

Answer C—Rationale: The microsystem is used to describe the small, functional, frontline unit that provides the most health care to the most people.

82. Regarding information technology, how can the CNL improve the identification of meaningful data? A. Clarify with nurses what vendor-related terms may be used in their documentation B. Develop a tool to identify relevant nursing clinical data and its location within the electronic health record (EHR) C. Advocate for standardized nursing terminology within the EHR D. Coordinate with the informatics the best way to document care for efficient data retrieval

Answer C—Rationale: The most important way the CNL can improve the identification of meaningful data is through the standardization of nursing technology within the EHR, away from the use of any vendor-related terms.

164. A staff nurse is curious about whether emptying the nasogastric (NG) suction canister is a task that can be delegated to a CNA. You, the CNL, guide her to what resource? A. The unit charge nurse B. Hospital policy/procedure manual C. The State Board of Nursing Scope of Practice D. The Joint Commission website

Answer C—Rationale: The most reliable source for what tasks may be delegated is the individual state's scope of practice.

120. A client on your unit receives 10 times the ordered dose of an opioid, resulting in serious complications from which the patient fully recovered. In response to this occurrence, you as the CNL: A. Reprimand the nurse who administered the medication in error to ensure it does not happen again B. Conduct a failure mode-effect analysis C. Conduct a root cause analysis (RCA) D. Apologize to the client and family

Answer C—Rationale: The priority is to conduct an RCA, which would include investigating what occurred with the nurse who administered the opioid and identify any issues in personal or unit process that may have affected the error, to prevent not only the individual nurse from making the same mistake again, but the whole unit from making a similar mistake. Errors should be met with investigation, not with punishment. If there is a performance issue, then it should be addressed by management.

19. You are a CNL on a surgical unit. Your unit has just hired several new graduate nurses. As the CNL, what is your role in relationship to these new team members? A. Provider of all clinical education B. Evaluator for performance reviews C. Coach and mentor D. Individual with a hands-off approach to allow new nurses to develop skills independently

Answer C—Rationale: The role of the CNL is to mentor and support all nurses on the unit, especially new nurses. Although the CNL may act as an educator, he or she does not guide the education and training of nurses on the unit. The CNL is not a member of management and does not complete employee performance reviews. While the CNL may take a hands-off approach, he or she should still offer support and mentorship to his or her peers.

152. As the CNL, you recognize that leveraging technology and information systems is an important part of acting toward high quality, patient-centered, lateral integration. Which of the following are examples of using technology and information systems to benefit patient care? A. Use of bed alarms and use of call lights B. TV in patient rooms with many channels, use of call lights, guest Wi-Fi Internet access, and e-readers available with e-books for patients C. Use of bed alarms, use of call lights, remote telemetry, and barcoded supplies, and medications D. TV in patient rooms with many channels, guest Wi-Fi Internet access, and e-readers available with e-books for patients

Answer C—Rationale: This answer addresses technology used in patient care while the others address technology used in patient experience and satisfaction.

155. A staff nurse is performing a literature review on the best tool for determining health literacy for diabetic patients. When analyzing and appraising the literature, what methods can the nurse use to determine if the study is flawed? A. Are the results of the literature reliable and critical? B. Are the results of the literature effective and modifiable? C. Are the results of the literature valid and reliable? D. Are the results of the literature valid and modifiable?

Answer C—Rationale: Three questions to consider when appraising any study: Are the results for the study valid? Are the results reliable? Will the results be applicable to study?

174. You are using failure mode effect and analysis (FMEA) to anticipate the risk of medication errors in the ICU related to invasive lines. You begin your FMEA analysis with: A. The effects of each failure B. The potential cause of each failure C. Process mapping D. Specific defects and delays in the medication administration process

Answer C—Rationale: Utilizing tools for process improvement can provide new insights into routine practices.

153. Which of the following is not a part of the National Patient Safety Guidelines (NPSG)? A. Improve the accuracy of patient identification B. Reduce the risk of health care-associated infections C. Improve patient satisfaction D. Prevent health care-associated pressure ulcers

Answer C—Rationale: While a part of the NPSGs, improving patient satisfaction it is not, by itself, an NPSG.

106. Recently, several major practice changes have been implemented hospital-wide at your facility. While all of these changes are evidence based, some of the practice changes have been received by the staff on your unit with strong resistance and poor compliance. As the CNL, you recognize that the best way to approach this issue is to: A. Have the unit manager write-up noncompliant staff B. Advocate to have the policies altered or revoked C. Form a task force of involved parties to identify barriers to compliance D. Re-educate staff on the policies and their importance

Answer C—Rationale: While any of these interventions may be appropriate, when addressing any issue, especially issues with strong opinions and various stakeholders, it is critical that the CNL solicit input from all invested players.

9. Your pediatric oncology unit is considering the implementation of a social/activity program for child clients that would provide volunteer social interactions and age-appropriate activities to admitted clients. As the CNL for this unit, you recognize this intervention as a way to: A. Be helpful to the floor staff by distracting clients B. Be a wasteful expenditure C. Meet the psychosocial needs of clients D. Prevent poor client experience ratings on discharge surveys

Answer C—Rationale: While social interaction and activities may provide distraction to clients and prevent poor client experiences, such a program would most importantly meet the holistic needs of young clients that may otherwise be neglected during a lengthy hospital stay. They also act to integrate such services with the medical care being delivered, meeting the CNL's call to develop and integrate services across settings in a holistic manner.

33. The CNL of the heart failure unit encourages the staff to earn advanced degrees, obtain certifications, and present and publish EBP projects. The CNL exhibits which type of leadership style? A. Relational leadership B. Transactional leadership C. Situational leadership D. Transformational leadership

Answer D—Rationale: A transformational leader motivates others to higher performance.

131. As a CNL on a high-risk oncology unit, you recognize the need for regular access to chaplaincy services among your client population. You work with your unit and chaplaincy department to bring these services to your unit regularly. This is primarily an example of: A. Advocacy B. CNL role integration C. Leadership D. Lateral integration

Answer D—Rationale: Accessing resources across disciplines to meet the needs of a client population in a patient-centered manner addresses specifically lateral integration.

84. The diabetes liaison on an adult medical-surgical unit informed the team that the unit was only 45% compliant with checking blood sugars within 15 minutes after a hypoglycemic event. The team decided to implement a process change to ensure the blood sugar recheck is completed within 15 minutes. The change was implemented and there was an increase to 85% compliance of hypoglycemic rechecks. What is the next step for the team in the PDSA cycle? A. Plan B. Do C. Study D. Act

Answer D—Rationale: After analysis of the results of the trial (also known as study), the team will then act by devising the next steps based on the analysis.

25. You are a CNL on a pediatric unit. You are doing chart audits on attending physicians' daily charting and assessment notes and notice that a small number of attending physicians are not seeing patients daily. They are putting in discharge orders days prior to discharge. As a CNL, you know the hospital has a policy that attending physicians must see their patients every 24 hours. The CNL waits to see what happens during the next scheduled chart audits. What conflict resolution is demonstrated? A. Compromise B. Accommodate C. Compete D. Avoidance

Answer D—Rationale: Avoidance is characterized by behaviors that either ignore or refuse to engage in the conflict.

173. A patient asks the CNL about the regulations on abortion in North Carolina. What should the CNL do? A. Tell the patient he or she cannot answer that because it is an ethical situation B. Let the doctor know the patient is asking about abortion C. Inform the patient care nurse D. Look up the regulations in North Carolina and share them with the patient

Answer D—Rationale: Being able to look up policies and regulations is an important role of the CNL, along with educating patients. Giving the policy does not cross any ethical barriers; it is only providing facts.

5. You are a CNL on an oncology unit. Recently, there has been an increase in the number of catheter- associated urinary tract infections (CAUTIs) on your unit. After shadowing nurses and aides you observed a variety of practices, techniques, and expectations surrounding daily catheter care. Your hospital does not have a current policy or procedure regarding catheter care. As the CNL, what should you do next? A. Review current evidence for catheter care practice and disseminate evidence to the staff B. Form an interdisciplinary team meeting to evaluate current hospital catheter care policies C. Create a rubric for educating patients and staff on catheter care D. Discuss with the unit manager the clinical issue and create a set of evidence-based unit expectations and practices for the oncology unit. Evaluate the need to address this issue with a hospital-wide policy or procedure

Answer D—Rationale: CNLs should gather and disseminate evidence to solve clinical problems; however, that should not be the initial step. Further review of hospital practices and policies may come after this issue is addressed. Creation of a rubric for educating patients and staff on catheter care may come after reviewing evidence. The CNL should act to solve the clinical issue in the short term, and evaluate the need for a larger policy to address gaps in practice hospital-wide.

198. You are working with your team to modify the unit's budget. You know that the best way to create a budget is: A. Looking at the previous budget's variance B. Requesting a large capital budget C. Being in line with your budget goal D. Utilizing a case mix

Answer D—Rationale: Case mix is the best way to create a budget. It looks at human and material costs and environmental resources.

14. A CNL rounds with Dr. Camper on a Spanish-speaking patient. The CNL asks the physician to call an interpreter, but the MD states that it is not necessary because the patient's daughter speaks English. However, the CNL insists and ensures an interpreter is present. What CNL role was fulfilled? A. Educator 'B. Team manager C. Clinician D. Client advocate

Answer D—Rationale: Client advocacy is a hallmark of the CNL's role. As a client advocate, the CNL assumes accountability for the delivery of high-quality care, including the evaluation of care outcomes and provision of leadership in improving care. Historically, the nursing role has emphasized partnership with clients—whether individuals, families, groups, or communities—in order to foster and support active participation in determining health care decisions. In addition, the CNL advocates for improvement in the institution or health care system and the nursing profession.

121. In your cohort you work with all members of the team. You develop an effective plan of care across settings in collaboration with all disciplines, professions, and stakeholders, including patients. This', 'would be an example of what component of lateral integration? A. Communication B. Coordination C. Evaluation D. Collaboration

Answer D—Rationale: Collaboration is defined as the interdisciplinary process of problem solving that involves shared responsibility for decision making as well as the execution of specific plans of care while working toward a common goal. The CNL promotes collaboration and consultation with all contributors to the health care delivery process, including the patient and his or her family.

133. The patient confides in you and states that she does not take her medications as prescribed and does not go to her doctor's appointments due to lack of transportation. As the CNL, you discuss your findings with the CCM, and place a financial counseling consult. The CCM orders a home safety evaluation, and a medical-social worker provides bus passes and community resources. This is an example of what key element of the CNL role? A. Ongoing evaluation B. Communication C. Collaboration D. Coordination

Answer D—Rationale: Coordination requires intentional planning and direction. The CNL is responsible for coordinating the flow of communication, activities of the team members, and the services provided to the patients.

169. The nurse manager of a regional home health services company allows the employees to determine solutions for change, and always considers their opinions, suggestions, and concerns. What type of leadership style is the manager demonstrating? A. Autocratic B. Laissez-faire C. Consultative D. Democratic

Answer D—Rationale: Democratic leadership involves the whole group in the decision-making process.

13. You notice a trend of increased central line bloodstream infection (CLBSI) on your unit. You conduct a literature search and, after critiquing and synthesizing the available evidence, you find that central line bundles have been shown to decrease CLBSI. You want to implement this bundle on your unit, and plan to evaluate the effect of this change. Which of the following best describes this process? A. Plan-Do-Study-Act (PDSA) B. Research C. Process improvement D. Evidence-based practice (EBP)

Answer D—Rationale: EBP involves applying the best available research evidence, clinical expertise, and patient preferences to improve a clinical outcome.

8. A CNL in the neonatal intensive care unit (NICU) is collecting data on the hours worked weekly by the staff nurses. The CNL wants to see if there is a normal distribution of hours worked. What technique is the best to display the distribution of the data collected? A. Run chart B. Fishbone chart C. Failure modes and effects analysis (FMEA) chart D. Histogram chart

Answer D—Rationale: Histogram is a graphical representation, showing a visual impression of the distribution of data.

66. You are working with a team to reduce patient waiting time for transport to diagnostic imaging (DI). An effective goal would be to: A. Decrease waiting time during the evening shift B. Increase monthly patient satisfaction C. Improve communication between the emergency department (ED) and the DI departments D. Decrease the waiting time for DI by 5%

Answer D—Rationale: Improvement goals must be specific and measurable. The team must have clear, measurable results to indicate whether an implementation resulted in improvement.

128. In order to be successful while utilizing Kotter's change theory, you realize it is vital to spend time on the first step. Which of the following best represents the first step in Kotter's change theory?', ' A. Having celebrations for short-term wins B. Communicating the change vision C. Consolidating gains and producing more change D. Obtaining buy-in and creating a sense of urgency for change

Answer D—Rationale: Kotter's change theory emphasizes that adequate time be placed on the first step of change, which is establishing a sense of urgency in order to have adequate buy-in from stakeholders.

7. A CNL evaluates a 17-year-old patient who has been a victim of rape. The patient has visible bruising and a head laceration. After the CNL's assessment, law enforcement officials have contacted the CNL requesting information regarding the attack and the visible injuries seen during the visit. The CNL knows she must first: A. Take pictures and complete the rape kit B. Provide law enforcement with a record as requested C. Call the patient's parents first D. Explain to the patient in order to obtain consent for release of records

Answer D—Rationale: Legally, there must be consent from the patient to share information with law enforcement and to abide by Health Insurance Portability and Accountability Act (HIPAA) regulations.

194. Medicaid covers which population? A. Employed B. Underinsured C. Unemployed D. Poor and disabled

Answer D—Rationale: Medicaid is a publicly funded insurance provided to the poor and disabled in each state.

3. A 65-year-old African American male was admitted to your microsystem with hyperglycemia. The patient has a history of hypertension, gout, obesity, and smoking. The patient has a family history of diabetes and hypertension. Which statement by the patient demonstrates his understanding of modifiable risk factors for diabetes? A. "As I get older, my risk for diabetes increases." B. "I know that a family history of diabetes is a risk factor, so I will educate my children on diabetes prevention." C. "I will keep a record of all my blood sugars to take to my doctor's appointments." D. "I will attend a smoking cessation class, because I know smoking increases my risk for diabetes."

Answer D—Rationale: Modifiable risk factors are lifestyle factors that a person can alter in order to prevent disease. Smoking cessation class is an intervention for modifying the risk factor of smoking.

71. A new graduate nurse expresses concern about a frenotomy of the tongue-tied newborn to the CNL. The CNL decides to accompany the new nurse to the procedure room. Upon entering the procedure room, the new nurse notices that there is no consent signed and explains to the pediatrician consent must be signed before continuing. The pediatrician hollers at the nurse and refuses to have consent signed. How should the CNL respond? A. The CNL hollers back that this is against hospital policy. B. The CNL asks the parents to sign the consent without the physician speaking to the parents. C. The procedure continues without consent and the CNL assures the new nurse the consent will be obtained after the procedure. D. The CNL and new nurse professionally explain to the physician that they will not participate in the procedure until a consent is signed and they will contact hospital administration regarding this procedural violation.

Answer D—Rationale: Part of the CNL's duties is to discuss difficult situations in which the nurse must advocate for her patients. Consent must always be signed for a procedure with a physician present and a nurse as a witness.

182. A nurse on the unit comes to you and says that every shift he works day or night he finds at least one of his patients without an identification band in place. He is very concerned about patient safety and feels a harmful mistake could occur in the near future if the practice on the unit is not improved. As the CNL, how should you help this nurse? A. Perform daily audits on all the patients and report results to management B. Have the unit secretary make new identification bands for all the patients daily so the charge nurse can place new bands on the patients daily C. Research a new style of patient identification bands since the current product does not stay on the patient properly D. Provide support to the nurse on the unit who determines the problem and help him identify areas in the process to improve patient identification

Answer D—Rationale: Part of the CNL's role is to provide staff with education, support, and the tools needed to improve practice. This nurse is already concerned about improving a process. As a CNL, it is important to foster leadership and ownership instead of providing solutions to problems.

15. During the policy formulation phase, all of the following are correct except: A. Possible solutions are offered. B. Political circumstances are considered. C. A problem is identified. D. Policy decisions are adjusted to accommodate changing circumstances or needs.

Answer D—Rationale: Policy formulation is the development of effective and acceptable courses of action in order to address what has been placed on the policy agenda. This should include the following characteristics: (a) The problem is identified, (b) possible solutions are offered, (c) political circumstances are considered, and (d) policy makers, stakeholders, and legislative staff are involved.

72. A CNL on a medical unit is following up with patients on warfarin therapy postdischarge and concludes that patients are not receiving adequate education on medication administration. The CNL formulates an action plan and develops a team to improve warfarin discharge education. What competency was portrayed by the CNL? A. Lifelong learner B. Delegator C. Lateral integration D. Risk anticipator

Answer D—Rationale: Risk anticipation is the ability to critically evaluate and anticipate risks to client safety; this is a critical component to the CNL role.

187. To confirm a scope of practice question, the CNL should consult which administrative body guidelines? A. The Joint Commission B. Centers for Medicare & Medicaid Services C. Hospital Policy and Procedure Manual D. State Nursing Practice Act

Answer D—Rationale: Scope of practice is defined according to each individual state. The CNL must have a full understanding of licensure standards of practice according to role before delegation of tasks.

190. You have been charged with examining the heart failure 30-day readmission rate of your unit. In doing so, it is important for you to examine data from what other sources? A. National and state readmission rates B. National benchmarks C. Readmissions to other units in your hospital D. All of the above

Answer D—Rationale: The 30-day readmission rates are a key factor in CMS reimbursement rates to hospitals. A CNL should have a broad perspective of readmission rates across multiple settings. The CNL can then resource share with other areas to gain insight into best practices and pre-existing initiatives at the microsystem, hospital, state, and national levels.

53. A 16-year-old female with a history of smoking, tanning bed use, and sexual activity presents to the emergency department (ED) with a mole that is continuously bleeding and itchy. The patient is concerned that this might be a sexually transmitted disease (STD) because the mole is on her inner thigh. Upon examination, the mole is asymmetrical, 7 mm big, and has uneven borders. As a CNL, you know these characteristics represent which of the following? A. Genital herpes B. Human papillomavirus C. Basal cell carcinoma D. Malignant melanoma

Answer D—Rationale: The ABCDE's of malignant melanoma include asymmetrical; uneven borders; variety of colors; large diameter greater than 6 mm; and evolving.

163. Elizabeth, an 87-year-old female, is admitted to the orthopedic unit with a fractured hip. Elizabeth lives at home alone, but her retired son lives just 2 hours away and comes to visit her often. The physical therapist comes to you and states he is recommending that Elizabeth go to a rehabilitation center prior to returning home. When Elizabeth is told that she will require rehabilitation, she', 'becomes visibly upset and states she refuses to go to a facility. Utilizing an interdisciplinary approach, you ask the social worker, case manager, physician, and physical therapist to help create a plan for Elizabeth. Which of the following is the best plan for Elizabeth? A. Convince Elizabeth to go to a rehabilitation facility where she will receive 24-hour care and 3 hours of therapy a day B. Keep Elizabeth in the hospital until she has fully recovered, then discharge her home C. Discharge Elizabeth home and arrange for a physical therapist to come to her house once a week D. Contact Elizabeth's son, inform him of Elizabeth's refusal of the rehabilitation facility, and have him help develop an alternative to the original plan for her discharge

Answer D—Rationale: The CNL generally needs to involve multiple disciplines in the plan for discharge, but the CNL must also encourage the patient and family to participate. Elizabeth was not willing to go to a rehabilitation center, so the best option would be for her to go home with her son where she can be safe and monitored, while receiving home health services.

79. As Jeff, a new CNL, walks into his newly assigned intensive care unit (ICU), he notices that the charge nurse assigned him as a primary care nurse for a group of a patients, like she would do for a staff nurse. Jeff discusses the role of a CNL with the charge nurse. What statement best describes the appropriate approach by Jeff? A. Jeff asks the charge nurse if she understands the role of a CNL, and states he cannot be assigned a group of patients. B. Jeff asks the charge nurse if she understands the role of a CNL, then explains that the CNL does not provide direct care to patients. C. Jeff discusses that CNLs are not supposed to take patients and only coordinate care for difficult patients. D. Jeff explains that the CNL operates in a microsystem as an advanced generalist to communicate, coordinate, and collaborate care and does not serve as a primary care nurse.

Answer D—Rationale: The CNL operates in a microsystem as an advanced generalist who communicates, coordinates, and collaborates care with major stakeholders. The CNL is a leader in the nursing profession. The CNL in this scenario is protecting the CNL role by advocating for the appropriate use of a CNL.

52. Your hospital is changing to a new electronic health record (EHR) system. As a CNL, you recognize that while this change may ultimately improve workflow, during the transition there will likely be both technical issues and knowledge gaps. What are some ways you can improve the ease of transition? A. Assess the current transition timeline, including education and practice time for the staff B. Identify leaders on the unit who can commit to extra training on the EHR and staff support during the transition C. Create guidelines for the nurses to use as a quick reference for locating items in the EHR D. All of the above

Answer D—Rationale: The CNL should consider the timeline for any education or training implemented occurring on their unit. Advocating for nurses during this time allows them to focus on the change. Identification of leaders who can act as peer educators supports the staff. The CNL should create tools to help increase or support workflow.

68. Promotion of personal goals for professional development and continuing education is a hallmark of the CNL role. Ultimately, what is the importance of professional development? A. Maintaining professional practice competencies B. Fulfillment of the CNL as a lifelong learner C. Providing an example of professional nursing to peers D. All of the above

Answer D—Rationale: The development of goals and continuing education maintains the CNL's competencies, illustrates the CNL is a lifelong learner, and provides an example to their peers.

90. You, the CNL, are working in the ICU with a high volume of patients with prolonged Foley catheter use. What analysis tool is appropriate for the CNL to use in prevention of CAUTIs? A. Root cause analysis (RCA) B. Fishbone diagram C. St. Thomas risk assessment tool D. Failure mode-effect analysis

Answer D—Rationale: The failure mode-effect analysis tool is a proactive risk assessment of high-risk or high-vulnerability areas that identifies and improves steps in a process, with a focus on failure prevention, not detection.

100. The health care team determines that the discharge process is ineffective and must be changed. The team determines the stakeholders and utilizes a force field analysis to weigh the pros and cons of the change. This was then used to motivate other team members and encourage buy in. Utilizing Lewin's theory of change, what stage is the team in? A. Sustaining B. Moving C. Refreezing D. Unfreezing

Answer D—Rationale: The first step of Lewin's theory of change is the unfreezing stage. In order to battle the resistance of change, the leader must assess readiness for change and motivate others to see the reason for change.

129. The primary focus of the CNL is best defined as: A. Delivery of high quality, evidence-based, culturally competent care at the patient's bedside B. Educating and mentoring peers to improve clinical competence C. Providing patient care management and leadership of the interdisciplinary team meetings D. Evaluating and supporting evidence-based practice (EBP) decisions to ensure best possible outcomes

Answer D—Rationale: The focus of the CNL is on ensuring outcomes, and the CNL does so by evaluating and implementing evidence-based research.

134. The CNLs noticed that the supply room was cluttered and oftentimes supplies had expired. They created a team and conducted a 5S to organize the supply bins and reduce waste. Where will the CNLs see the cost savings with supplies reflected? A. Capital budget B. Cash flow budget C. Cost-effectiveness analysis D. Operating budget

Answer D—Rationale: The operating budget is the day-to-day operations of the unit, including revenue, volume, and expenses. Cost savings related to supplies would be in the operating budget.

38. A 40-year-old postpartum patient with chronic hypertension and gestational diabetes who is gravida 5 para 4 is transferred from labor and delivery to the postpartum unit with lactated Ringer's at 125 mL/hr. Upon assessment of the patient, the nurse notices the patient's fundus is three finger breaths above umbilicus and to the right of midline and her bladder is palpable. The nurse also notes moderate to heavy bleeding and a full bladder and notifies the CNL. As a CNL, the most important nursing intervention is to: A. Encourage the nurse to massage the fundus and heplock the patient B. Encourage the nurse to call the physician stat to order Methergine (methylergonovine maleate) C. Encourage the nurse to monitor the patient over the next hour because there are no risk factors for a postpartum hemorrhage D. Encourage the nurse to straight catherize the patient to decrease the likelihood of a postpartum hemorrhage

Answer D—Rationale: The patient is at risk for a hemorrhage due to being a multipara and having a full bladder. Methergine is contraindicated in patients with hypertension.

73. A small group has been formed on the medical-surgical unit to implement change. Team members also have struggles over decision making and clarity of purpose. What stage of the Tuckman and Jensen's model is represented by members communicating their feelings but still viewing themselves as individuals rather than part of the team? A. Performing B. Norming C. Forming D. Storming

Answer D—Rationale: The storming phase is where competition and conflict are at their highest.

154. During the 5P assessment, you find out that 64% of patients have Medicare, 18% have Medicaid, 16% have private insurance, and 2% have no insurance. You can conclude that the majority of your patients are what type of payer source? A. First-party payer B. Second-party payer C. Fourth-party payer D. Third-party payer

Answer D—Rationale: Third-party payers include government and private insurance entities.', '

166. Which method of payment accounts for only 5% of the U.S. population? A. Out-of-pocket payments B. Employment-based private insurance C. Government financing D. Individual private insurance', '

Answer D—Rationale: This information is available in health policy books.

89. The CNL has been requested to assist with end-of-life care decision making for an elderly homeless patient who has no family; he was deemed incompetent and is now unresponsive. The best decision- making guide that the CNL could use in this situation is: A. Plan-Do-Study-Act (PDSA) B. Autonomy model C. Orem's self-care theory D. MORAL model

Answer D—Rationale: This is a model that addresses ethical issues and guides an objective, orderly, and systematic decision.

185. A 65-year-old man with a history of chest palpitations was seen by his cardiologist for new onset palpitations. He was put on a beta-blocker and told to return for a follow-up in 1 week after taking a stress test. The beta-blocker's action includes: A. Increasing the consistency of the heart rate B. Decreasing the ability of the heart muscle to contract C. Decreasing the chance of dysrhythmia D. Increasing contractility and decreasing heart rate

Answer D—Rationale: This is the mechanism of action of all beta-blocker medications.

184. As the CNL on a medical unit, which of the following cost-effective interventions would you support to reduce the readmission rate on your unit? A. patients one extra day to ensure they are prepared for discharge home B. Arrange for all patients to have at least 1 week of visiting nursing postdischarge C. Review discharge instructions with the patient and one family member D. Begin discharge planning and teaching on the day of admission

Answer D—Rationale: Using every opportunity to communicate to and educate the patient and family on their care and planning for discharge will better prepare the patient and family for returning home in a cost-effective manner.

165. The CNL on the unit has an idea to generate a new EBP study. He has conducted a literature review and critical appraisal. The CNL has also developed a collaborative interprofessional team to be part of the planning process. He has established a date for the research design meeting. What pertinent information should be included in his outline of the study in preparation for this meeting? A. Form an interprofessional team B. Perform a review of literature C. Consult with another CNL D. Indicate the aim of the study and research question

Answer D—Rationale: When developing a study outline for a meeting, questions related to the study that should be answered include: Is this idea feasible and clinically important? What is the aim of the study, along with the research question or hypothesis to be tested? What are the potential sources of data? Are there valid and reliable instruments to measure the desired outcomes? What should be the inclusion and exclusion criteria for the potential study participants? What are the essential elements of the intervention, if applicable?

27. Quality improvement (QI) is a key function of the CNL. While QI efforts can yield many benefits in health care, as the CNL you recognize which of the following to be the most important potential effect of a nursing QI effort? A. Increased hospital cash flow/decreased expense B. Increased competitiveness with other facilities C. Reduction in lawsuits/liability D. Improvement of nursing quality indicators

Answer D—Rationale: While a QI effort may yield any of these potential answers, only the improvement of nursing quality indicators is patient centered.

180. As the CNL on a medical-surgical unit, you have noticed a trend over the past 3 months with patients having high blood glucose before lunch and dinner. What is the best way to address this problem? A. Investigate whether the blood glucose monitors on the unit are accurate B. Provide an educational in-service about diabetes to the staff C. Ensure all patients with diabetes receive a consultation with the nutritionist D. Determine what other changes in processes have occurred on the unit in the past 3 months that could influence this trend

Answer D—Rationale: While checking the accuracy of blood glucose meters, providing education to staff and patients is important. However, other processes on the unit that have changed need to be further evaluated to determine their influence on patient outcomes.

26. Attending physicians have noted that on your unit nurse communication by telephone has been scattered, disjointed, lengthy, and often contains erroneous information. As the CNL, good interdisciplinary communication is a priority. To best address this issue, the CNL would: A. Wait to see if the issue persists B. Encourage floor nurses to provide less information when calling physicians to limit the length and complexity of their calls C. Ask physicians to provide their feedback directly to individual nurses D. Refamiliarize staff nurses with the use of situation background assessment recommendation (SBAR), your hospital's communication standard

Answer D—Rationale: While professionals should provide direct feedback to each other in a meaningful, constructive manner and limiting communication to key information is an important aspect of clear communication, the use of a standardized tool, already a standard at this hospital, would most readily help to guide nurses to communicate in a clear, concise, efficient manner to ensure high-quality communication between care team members.

92. A client on your unit is going home to finish rehab following a bilateral total knee replacement. You, as the CNL, would be enacting the function of lateral integrator by which of the following? A. Delivering the bedside discharge education B. Helping the client arrange transportation home C. Making a checklist of the client's belongings to ensure nothing was left behind D. Ensuring follow-up appointments and services, including transportation, have been scheduled

Answer D—Rationale: While the CNL might be useful in any of these areas, ensuring proper scheduling of follow-up care with other providers is a function of coordination, a key component of the CNL's role as a lateral integrator.

160. Quality improvement (QI), as a function of the CNL role, is related to which core role competency of the CNL? A. Client advocacy B. Clinician C. Risk anticipator D. Team manager

Answer C—Rationale: QI is a direct function of risk anticipation.