Leading and Managing in Nursing exam 1
An RN colleague, who is a long-standing and collaborative member of your team, is performing a complex and novel dressing for the first time for the patient to whom she has been assigned. Which of the following would be the most appropriate communication with her?
"Here is what you need for the dressing, and I will show you what needs to be done."
In delegating to a UNP in a home health setting, which of the following represents the most appropriate delegation communication?
"Mrs. S. needs help to get into and out of her bathtub. Her bath will need to be completed by 10:00. When you are helping her to dry, please check between her toes and toenails, and phone me by 10:30 if you notice nail discoloration or redness."
An example of a care activity that would likely not be delegated by an RN to a UNP is (select all that apply):
1.Teaching self-catheterization to a patient with paraplegia who has limited English. 2.Basic care for a patient with a head injury who is rapidly deteriorating. 3.Assessment of patients being admitted through the Emergency Department.
ANS: A The primary nursing model assumes that the primary nurse is accountable for patient care, even while off duty. The primary nurse is responsible for establishing the patient plan of care and therefore for altering it with the input of an associate. The associate is responsible for implementation of the established care plan when the primary nurse is off duty.
A conflict develops between an associate nurse and a primary nurse over the assessment of a patient with pulmonary edema. Based on her assessment of the patient, the associate nurse insists that it is her role to change the care plan because she is the one who has made the assessment. As the nurse manager, you clarify that: a. It is the role of the primary nurse to make alterations based on assessment data and input. b. The associate nurse is accountable and responsible while the primary nurse is off duty and therefore is able to alter the care plan. c. Neither the primary nor the associate should make changes without first consulting you as the manager. d. It really does not matter who alters the nursing care plan as it depends on situation and time to do so.
ANS: C Significant overlap can be seen between primary nursing and total patient care in terms of breadth of assessment and knowledge required to provide holistic care. A primary difference is that nurses in the total care model assume accountability while on shift, whereas primary nurses assume responsibility from time of admission to discharge and 24 hours a day.
A nurse manager questions the true difference between primary nursing and total patient care. After careful consideration of both models, the nurse manager concludes that primary nursing differs significantly from total patient care in: a. Breadth of nursing knowledge and expertise required. b. Intention to provide holistic nursing. c. Degree of task orientation. d. Levels and types of assessment.
ANS: C Functional team nursing involves licensed and unlicensed personnel who perform specific tasks for a large number of patients. A disadvantage of functional team nursing is the fragmentation of care. The physical and technical aspects of care may be met, but the psychological and spiritual needs may be overlooked. Patients become confused with so many different care providers per shift. These different staff members may be so busy with their assigned tasks that they may not have time to communicate with each other about the patient's progress.
A patient complains to you that she has no idea who "her nurse" is on any given day. "I ask one nurse for my pills and she says, 'That's not my job.' I ask the pill nurse about my lab tests and she says that I should ask another nurse." The nursing care delivery model most likely employed in this situation is: a. Differentiated practice. b. Team nursing. c. Functional nursing. d. Case management.
ANS: D An advantage of functional nursing is that both unskilled assistive personnel and skilled staff are involved in performance of specific tasks, and the repeated performance of tasks enables staff to become very efficient in specific functions. Disadvantages of the model include difficulty in being able to assess the patient's nonphysical needs effectively and the potential for ineffective communication because of the focus on specific tasks.
A patient complains to you that she has no idea who "her nurse" is on any given day. "I ask one nurse for my pills and she says, 'That's not my job.' I ask the pill nurse about my lab tests and she says that I should ask another nurse." This nursing care delivery model employed in this situation might be particularly effective in: a. Promoting communication among diverse team members. b. Facilitating multiple perspectives on the total care of a patient. c. Avoiding patient-provider conflict. d. Developing competence and confidence in unskilled workers.
ANS: A Because of the breadth of nursing knowledge required, baccalaureate education is preferred for primary nurses.
A patient is admitted to a medical unit with pulmonary edema. His primary nurse admits him and then provides a written plan of care. What type of educational preparation best fits the role of primary nurse? a. Baccalaureate b. Associate c. Diploma d. LPN/LVN
Which of the following indicates safe delegation?
A unit manager agrees to release a staff from her unit to Unit B. The staff member she agrees to release is experienced on Unit B and is agreeable to the change. The unit manager's unit is fully staffed and patients are stable.
The nurse on the 7-7 shift is assigning a component of care to an unlicensed nursing personnel employee. The night nurse should remain:
Accountable.
County Hospital has position descriptions for all staff, including RN Team Leaders. Sarah, a team leader on the rehab unit, assesses the needs of the patients in her area, assesses the skills and backgrounds of each of the individuals on her team, and then assigns and delegates the appropriate care provider to each patient and task. Sarah's activity in the example described is termed:
Active delegation.
Sally is an experienced nurse on the unit and is very experienced with ICP monitoring. She is assigned David, a patient who has been admitted with a severe head injury. In communicating with Sally, you would:
Advise her that you are available if she needs you.
You ask Evelyn, a new UNP, to check what is left in Mrs. N.'s inhaler when Evelyn makes visits to Mrs. N. and also to check whether Mrs. N. is receiving any positive effect from the medication. Evelyn reports for 3 weeks that Mrs. N. is using the inhaler and that there is enough medication left in the device. The day of her last visit to Mrs. N., Mrs. N. is admitted to the hospital in severe respiratory distress. When she is admitted, she tells the physician that she has not been using the inhaler for 4 weeks. Before assigning Evelyn to Mrs. N.'s care, the most appropriate action of the care coordinator would have been to:
Ask Evelyn if she has worked with inhalers before and to describe what she knows about them.
The nurse manager is setting up the room assignments for the unit. She has one critical patient on the unit, who is going to require more care than the others. Before delegating a task, a nurse manager should:
Assess the amount of guidance and support needed in a particular situation.
The day shift nurse asks an LPN/LVN to complete a component of care for a client. The day shift nurse is engaging in what function?
Assigning
County Hospital has position descriptions for all staff, including RN Team Leaders. Sarah, a team leader on the rehab unit, assesses the needs of the patients in her area, assesses the skills and backgrounds of each of the individuals on her team, and then assigns and delegates the appropriate care provider to each patient and task. Sarah provides Colleen, her RN colleague with details regarding the patients to whom Colleen has been assigned on the day shift. This is an example of:
Assignment.
Ali, an RN on your unit, is consistently late to work and makes remarks such as "Do you really want me to do that?" when patients and care are assigned to her. You have spoken with her frequently about her:
Attitude.
You ask Evelyn, a new UNP, to check what is left in Mrs. N.'s inhaler when Evelyn makes visits to Mrs. N. and also to check whether Mrs. N. is receiving any positive effect from the medication. Evelyn reports for 3 weeks that Mrs. N. is using the inhaler and that there is enough medication left in the device. The day of her last visit to Mrs. N., Mrs. N. is admitted to the hospital in severe respiratory distress. When she is admitted, she tells the physician that she has not been using the inhaler for 4 weeks. Determination of Evelyn's educational preparation and certification is related to the concept of:
Authority.
ANS: A Case managed care is not revenue generating but rather revenue protecting in that better coordination of care enables efficient achievement of patient outcomes, can result in shorter length of stay, and can prevent readmission.
Case managed care may enhance profit in a for-profit health organization by: a. Minimizing costs in high resource consumption areas. b. Combining licensed and non-licensed care providers in delivering patient care. c. Increasing reimbursement from third-party payers. d. Reducing the amount of technology used to support clinical decision making.
ANS: D Differentiated nursing practice models are models of clinical nursing practice that are defined or differentiated by level of education, expected clinical skills or competencies, job descriptions, pay scales, and participation in decision making.
Complex care of acutely ill patients is required on a surgical unit, which utilizes differentiated nursing practice as its model of care delivery. The concept of differentiated nursing practice is based on: d. Education and expertise.
The night nurse understands that certain factors need to be considered before delegating tasks to others. These factors include the:
Complexity of the task and the potential for harm.
ANS: A The case method may involve total patient care provided by a registered nurse, which, in today's costly healthcare economy, is very expensive. In times of nursing shortages, there may not be enough resources or nurses to use this model.
During times of nursing shortages and increased nursing costs in health care, which of the following nursing care delivery models might come under greatest scrutiny? a. Case method b. Team nursing c. Functional nursing d. Nurse case management
You ask Evelyn to check what is left in Mrs. N.'s inhaler when makes visits also to check if she is receiving positive effects from medication. for 3 weeks that Mrs. N. is using the inhaler and that there is enough medication left. day of her last visit to Mrs. N. is admitted to hospital in severe respiratory distress. When admitted, reports not been using inhaler for 4 weeks.
Failure to follow through.
ANS: A Although repetition of tasks increases confidence and competence, it can also lead to boredom. Rotation of tasks can assist specifically in this model to reduce the boredom that is a potential disadvantage of this model.
For a nurse manager in the functional nursing model, an approach that will assist in maintaining staff satisfaction in this specific model is: a. Rotation of task assignments. b. Frequent opportunities for in-service education. c. Orientation to job responsibilities and performance expectations. d. Team social events in off hours.
ANS: C The partnership care delivery model is a variation of primary nursing in which an RN works with a consistent assistant, who performs basic nursing functions consistent with state delegation rules.
In a small rural nursing home, a director of nursing decides, because of a shortage of nurses, to implement a partnership model to help with basic tasks that comply with state rules regarding delegation. What type of design constitutes a partnership care delivery model? a. RN and LPN/LVN b. RN and RN c. RN and medication assistants d. RN and certified nurses' aides
ANS: D In a functional nursing model, where other team members are focused on performing specific tasks, the nurse manager assumes primary responsibility for patient outcomes.
In an acute care unit, the nurse manager utilizes the functional nursing method as the care delivery model. The nurse manager's main responsibility is the needs of the: a. Department. b. Unit. c. Staff. d. Patient.
ANS: A Team nursing delivers care to a small group of patients, using a mix of licensed and unlicensed personnel. Team nursing uses the strengths of each caregiver.
In comparing team and functional models of care, a nurse manager favors the team model. In particular, she finds that the team model: a. Can be effective in recognizing individual strengths and backgrounds of staff. b. Promotes autonomy and independence for the RN. c. Avoids conflict because of role clarity. d. Is efficient in delivering care to a large group of patients, utilizing a staffing mix.
ANS: C Magnet™ hospitals exemplify hospitals whose focus processes attract and retain nurses who value and promote quality care and excellence in nursing environments.
In considering whether or not to accept a job offer as a nurse manager at a Magnet™ hospital, you look at an environment that you might encounter as a head nurse at the hospital. You determine that you could expect to: a. Find it difficult to recruit new staff. b. See rapid turnover of staff on your unit. c. Find nurses who exemplify interest in quality care. d. Find limited interest in excellence in the nursing environment.
ANS: B Nurses who have less than 2 or 3 years' experience in primary nursing and/or less than 2 or 3 years of nursing experience will likely require more assistance than other nurses, which will put a greater demand on the unit during a time of transition.
In hiring nurses during the transition from team nursing to a primary nursing model, Benner's work would suggest that you give priority to nurses who are at least at which level of competency? a. Advanced beginner b. Competent c. Proficient d. Novice
ANS: B The nurse manager who is considering movement to primary nursing needs to consider how the role of the manager changes, as well as the roles of the staff. The role of decision making at the patient care level is relinquished to the primary nurse, and the role of manager becomes that of facilitator, coach, mentor, role model, and clinical resource.
In transitioning to a primary nursing model, it is important for a nurse manager who enjoys a high level of control over patient care to understand that his or her decision making at the patient care level: a. Is increased. b. Is decreased. c. Is relinquished. d. Remains the same.
The unit manager is working in a large metropolitan facility and is told that two UNPs are to be assigned to work with her. Delegation begins with:
Matching tasks with qualified persons.
You are working in a home health service and have 3 UNPs assigned to your team. You have worked with two; the third is new. The two experienced UNPs have patients with complex illnesses. The third has been assigned to patients with less complex illnesses.
Meet the new staff member at the first patient care site and call the others with questions to determine whether anything is unusual.
Which of the following exemplifies accountability? Karen, the nurse manager on 5E:
Outlines her rationale for reduction of RN coverage on nights to the Nursing Practice Committee after serious patient injury.
Functions such as "delegates tasks to assistive personnel" that are outlined in a position description for an RN Team Leader would be considered:
Passive delegation.
With delegation, responsibility and accountability remain with the:
Professional who delegates.
You are a member of a team assigned to care for 15 general medical/surgical clients. You have all worked well together in the past in this same type of care. If you are assigned to coordinate this team's work, your best strategy, based on the Hersey and Blanchard model, would be to:
Provide minimal direction and let them come to you with questions.
Leslie, a UNP, transfers a patient while using improper technique. The patient is injured, and as a result, a suit is launched in which both Sarah (the delegator) and Leslie (the delegatee) are named. Sarah is named in the suit because she:
Retains accountability for the outcomes of care for the patient.
A key advantage that a nurse manager has in terms of delegating is that:
Team skills can be used more effectively.
ANS: C This model is especially useful in the care of complex patients who need active symptom management provided by an RN, such as the care of the patient in a hospice setting or an intensive care unit. This method would be justifiable delivery in the pediatric intensive care unit, where the status of patients can change rapidly and where complex functions of care involve both patients and families.
The case method of care delivery could be best justified in which of the following scenarios? a. Stable patient population with long-term care and family needs b. Acute care surgical unit with predictable postsurgical outcomes and many technical procedures c. Pediatric intensive care unit that heavily involves families as well as patients d. Home healthcare environment with patients at varying levels of acuity
During staff development programs, staff nurses verbalize their frustration about their workloads and having to delegate so many tasks to others. One of the main reasons that delegation has emerged as an issue is because of:
The complexity of client care.
During a fire drill, the nurse manager becomes very assertive and directive in her communications with staff. This type of situational leadership depends on:
The development level of the followers and the type of behavior of the leader.
ANS: D The goals and outcomes established in a critical pathway are designed to support the aims of case management, which are shortened hospital stays and prevention of hospital readmissions.
The nurse case manager is working with a client admitted for end-stage renal disease. The case manager's major goal during this hospitalization is to: a. Implement the care pathway on admission. b. Provide direct nursing care throughout the hospitalization. c. Supervise the nursing staff members who implement the care map. d. Prevent additional hospitalizations resulting from complications of the client's disease.
ANS: B Team nursing, functional nursing, and case management are all considered efficient, cost-effective methods of care delivery because they enable utilization of various types of healthcare providers (rather than baccalaureate nurses in direct care, which is the primary nursing method). Case management is considered particularly cost-effective in patient care settings because it maintains quality care while streamlining costs for high-risk, high-volume, high-cost patient populations and seeks the active involvement of the patient, the family, and diverse healthcare professionals.
The nurse manager at a cardiac rehabilitation unit was asked to select a care delivery model. Which of the following methods would be the most cost-effective? a. Functional method b. Case management method c. Primary care method d. Team method
ANS: A Because the basic education of baccalaureate-prepared RNs emphasizes critical-thinking, clinical reasoning, and leadership concepts, they are likely candidates for such roles. Benner (2001), however, identified five stages of clinical competence for nurses: novice, advanced beginner, competent, proficient, and expert. She suggests that competence is typified by a nurse who has been on the job in the same or similar situation 2 to 3 years. Nurses who are at the novice or advanced beginner stage would be less likely than their more experienced counterparts to implement any type of delivery model effectively and thus, this assignment overlooks the nurse's level of clinical expertise and leadership experience.
The relief charge nurse has assigned a newly licensed baccalaureate-prepared nurse to be one of the team leaders for the 3-11 shift. In making this decision, the charge nurse has overlooked this nurse's: a. Clinical expertise.
Which of the following would be most in line with Hersey and Blanchard's concepts?
The team of caregivers on day shift are familiar with their roles and with the patients. The nurse manager decides to work on the unit budget in her office.
ANS: C A particular challenge in team nursing is that staff mixes and staff may change daily because of individual schedules and shortages.
To effectively delegate in a team nursing environment, the RN team leader must be familiar with the legal and organizational roles of each group of personnel and must: a. Be able to effectively communicate with patients. b. Build relationships with physicians. c. Be able to adapt to daily changes in staffing. d. Adapt in communicating information to her supervisor.
20. In a job interview for a staff position, which of the following indicates your knowledge of patient safety?
c. "Is there a strategy in place to reduce the number of overtime hours on the unit?" ANS: C Overtime, whether voluntary or mandatory, to fill staff vacancies is seen as a risk to both patients and nurses because it is more likely to lead to compromised decision making and technical skills because of fatigue.
ANS: D Although some studies suggest there is little difference between functional nursing and primary nursing, primary nursing tends to be more satisfying for RNs, who enjoy a high level of accountability and autonomy in decision making. Patient satisfaction is also high, as patients form close therapeutic relationships with the nurse because of the continuity of the relationship. Functional nursing is criticized for low patient satisfaction and potential staff dissatisfaction related to boredom and an autocratic approach to management.
When comparing functional nursing and primary nursing, a nurse manager, after evaluating particular models of nursing care for potential adoption, determines that patient and nurse satisfaction in primary nursing are: a. Similar to those in functional nursing. b. Not of significance in either model. c. Low by comparison with functional nursing. d. High when compared with functional nursing.
ANS: D Case managers can come from a variety of disciplines but should have advanced preparation with the particular at-risk population being served, be comfortable in an advocate role, and be outcome and patient focused.
When hiring a case manager for a rehabilitation setting, you would most likely consider a: a. Registered nurse with a master's degree. b. Physiotherapist with a background in stroke rehabilitation. c. Social worker with a background in counseling. d. Health professional with advanced background who is client and outcome focused.
ANS: B The functional model of nursing is a method of providing patient care by which each licensed and unlicensed staff member performs specific tasks for a large group of patients.
When interviewing an applicant for a position, the nurse manager describes the unit's care delivery system as one in which each nursing assistant is cross-trained to perform specific tasks, and the RNs do all treatment, medication administration, and discharge teaching. The nurse applicant knows this nursing care delivery strategy to be: b. Functional nursing.
ANS: B This particular model includes a focus on patient care that includes multidisciplinary teams and assistants at the bedside. Services, including laboratories and pharmacies, are decentralized to bring them closer to where care is delivered.
You are considering putting forward a proposal to move the model of care from team nursing to a primary nursing hybrid: patient-focused care model. In considering this proposal, you recognize that significant costs specific to operationalizing this model are related to: a. Implementation of an all-RN staff complement. b. Significant changes in the physical structure of units. c. Orientation of staff to new roles and responsibilities. d. Testing and piloting technology at the bedside.
ANS: C A critical pathway outlines outcomes, clinical standards, and interventions for a patient in each phase of treatment. The goal of critical pathways is effective coordination of care across various staff and levels of care.
You are the nurse manager of a nursing service organization that provides around-the-clock care to clients in their homes. To achieve maximum reimbursement for a client who is recovering from a hip replacement, the nursing staff most likely will follow the nursing care guidelines presented in the: a. Nursing care plan. b. Physician's orders. c.
ANS: A, B, E Transforming care at the bedside (TCAB) relies on active involvement of staff in the generation of innovative ideas to improve patient care. Staff are actively engaged in selecting innovation, planning, and evaluation of the innovations. Critical to practice changes, rapid cycle change is a process that encourages testing creative change on a small scale while determining potential impact.
Your organization has made a decision to implement TCAB in your hospital. As a manager, what strategies would you use to implement TCAB? (Select all that apply.) a. Encourage recognition among staff of their knowledge of the patient-care environment. b. With staff, select small changes for consideration. c. Select only projects that have widespread impact. d. Secure external advisors to evaluate innovation. e. Present ideas based on best practices and ask staff for advice on implementation.
21. To reduce reliance on overtime hours, an organization develops a strategy for floating nurses during staff shortages. To maximize patient safety and reduce costs, the healthcare organization:
a. Develops a centralized pool of float nurses. ANS: A A centralized pool usually includes experienced nurses who maintain a broad range of competencies. Other approaches are less satisfying for nurses, are less efficient, and may be less safe.
MULTIPLE RESPONSE 1. In reviewing the job description of a nurse manager, the staff becomes aware that a nurse manager's role is complex. Which of the following duties are required of a nurse manager? (Select all that apply.)
a. Ensure unit productivity reports. d. Prepare a unit budget that reflects unit staffing needs. e. Monitor nurse-sensitive indicators such as falls and incidence of infections. ANS: A, D, E A nurse manager manages financial resources by developing business and staffing plans.
10. A busy neurologic ICU and step-down unit most likely would use which patient classification system?
a. Factor evaluation ANS: A A factor evaluation system is considered more objective than a prototype evaluation system. It gives each task, thought process, and patient care activity a time or rating. Some patient types with a single healthcare focus, such as maternal deliveries or outpatient surgical patients, would be appropriately classified with a prototype system. Patients with more complex care needs and a less predictable disease course, such as those with pneumonia or stroke, are more appropriately evaluated with a factor system.
In accordance with changes by the Joint Commission (TJC), Johns hopkins Hospital amends its safety practices and policies to emphasize: a. Safety goals specific to Johns hopkins.
a. Safety goals specific to Johns Hopkins. When the TJC, a not-for-profit organization that accredits healthcare organizations, changed its focus from processes to outcomes, it emphasized patient safety and issues setting-specific annual patient safety goals.
18. As the unit manager, you post the staffing plan and compliance reports. This initiative is aimed at:
a. Maintaining unit morale. ANS: A Hospitals are responsible for monitoring the extent to which actual staffing matches the staffing plans, making revisions as necessary. The Joint Commission accreditation reviews staffing plans against any obvious staffing deficiencies and patient care concerns. Posting of the staffing plan is required in some states so that staff may view it. Adequate staffing, as demonstrated through a staffing plan, and compliance reports contribute to staff morale.
6. A nurse manager must also consider a number of internal variables that will affect staffing patterns. An internal variable to be considered is:
a. Organizational staffing policies. ANS: A State licensing standards outline what a nurse can do. Internal policies determine what a nurse may do in a particular setting as well as the amount of flexibility that is allowed to manage times of high and low volumes, as well as changes in acuity. Organizational policies can put the nurse manager in a situation where patient safety cannot be maintained or financial obligations met.
9. The difference between staffing and scheduling is that staffing:
a. Puts the right person in the right position. ANS: A Nursing staffing involves planning for hiring and deploying qualified human resources to meet the needs of a group of patients. Scheduling, on the other hand, is a function of implementing the staffing plan by assigning unit personnel to work specific hours and days of the week.
19. To maintain patient safety, studies suggest that scheduling should avoid:
a. Rotating shifts. ANS: A Rotating shifts and overtime past 12 hours (mandatory or not) are being shown to increase nurse error and jeopardize patient safety.
Which of the following would managers and staff review annually in order to ensure compliance with the Joint Commission (TJC) to improve patient safety? a. Appropriateness of charting terms and abbreviations
a. Appropriateness of charting terms and abbreviations The Joint Commission issues setting-specific patient goals annually, as well as a list of "do-not-use" terms, abbreviations, and symbols and sentinel events.
Which of the following patients would be at greatest risk in a healthcare visit (select all that apply)? a. Clyde requires an anticoagulant. He tells the nurse about his medications. He does not include an herbal supplement. c. Sarah is a new parent who finds that nurses on the children's unit are very helpful. She is eager to accept all suggestions, including those that she does not yet understand. d. Claude is booked for bowel surgery. His doctor explains about the colostomy. Later, Claude tells his wife that he really doesn't know what the doctor meant by colostomy.
a. Clyde requires an anticoagulant. He tells the nurse about his medications. He does not include an herbal supplement. c. Sarah is a new parent who finds that nurses on the children's unit are very helpful. She is eager to accept all suggestions, including those that she does not yet understand. d. Claude is booked for bowel surgery. His doctor explains about the colostomy. Later, Claude tells his wife that he really doesn't know what the doctor meant by colostomy. Safer health care involves the patient as an active consumer who keeps and brings a list of all medications, including natural remedies, and questions if there are doubts, concerns, or lack of understanding.
The SBAR approach to patient safety encourages: a. Consistency in assessment and practices.
a. Consistency in assessment and practices. The use of SBAR (Situation, Background, Assessment, and Recommendation) checklists are designed to decrease omission of important information and practices.
You notice that Sally, a student on your unit, is giving information to an anxious young teen who seems very uncertain about preparation for an upper GI series. After Sally leaves the room, you ask her how she thought her conversation with the patient went and: a. Encourage her to ask the patient if he has questions or concerns about the procedure.
a. Encourage her to ask the patient if he has questions or concerns about the procedure. The Five Steps to Safer Health Care for Patients includes the step of asking questions if there are doubts or concerns. The nurse can encourage patients to take a larger role in care by taking these steps and by providing patients with coaching in the steps.
To achieve nurse-sensitive care standards developed by the NQF, you advocate for which of the following in your health facility? a. Evidence-based practice to reduce the prevalence of pressure sores
a. Evidence-based practice to reduce the prevalence of pressure sores The National Quality Forum (NQF) outlines nursing-centered intervention measures related to prevalence of pressure sores, ventilator-associated pneumonias, volunteer turnover, nursing care hours per day, and skill mix of staff.
As a manager in a new nursing home, where might you consult for guidance and evidence to support the development of safe patient practices? a. Hospitals
a. Hospitals Practices that were once mostly studied in hospital settings are now scrutinized for implementation in other settings, such as outpatient clinics, rural settings, and nursing homes.
During review of back injuries, it is determined that a large number of injuries are occurring in spite of mechanical lifts being used. Furthermore, it is determined that some lifts are outdated. In addressing this concern, the unit manager: a. Meets individually with nurses who are observed to be using the lifts incorrectly to review the correct procedure.
a. Meets individually with nurses who are observed to be using the lifts incorrectly to review the correct procedure. The IOM report (2004) points to the need to involve nurses in decisions that affect them and the provision of care.
If you are supporting the steps in the AHRQ document "Five Steps to Safer Health Care," you would ensure that: a. Patients are actively encouraged to make decisions related to care.
a. Patients are actively encouraged to make decisions related to care The Agency for Healthcare Research and Quality (AHRQ) outlines "Five Steps to Safer Health Care," which suggests that safe, patient-centered care is facilitated by assisting patients to become active partners in their own care.
Sarah is a second-year nursing student. The clinical instructor overhears Sarah telling a patient that she "always" checks patients' bracelets before giving medication and she is not sure how the nurses on the unit "get away with" not making more errors than they do. The clinical instructor pulls Sarah aside and explores with her how her communication might affect the patient and what it reflects about her beliefs related to the team. The actions of the clinical instructor reflect competencies outlined by: a. QSEN. quality and safety education for nurses
a. QSEN. The Quality and Safety Education for Nurses (QSEN) project provides resources related to competencies that prelicensure and graduate students need to develop to serve as safe practitioners. These competencies include leading and managing, teamwork and collaboration.
As a manager, the development of your decision-making skills related to safe patient care is facilitated by: a. Regular reflection on decisions.
a. Regular reflection on decisions. Reflection on how well decisions were enacted enables knowledge of the complexity of situations and ramifications of the decisions made. Reflection enables elimination of strategies and methods that are inappropriate in meeting needs and aids in narrowing choices of best actions to take.
7. A nurse manager uses many sources of data when planning the unit's workload for the year. Which of the following data must be considered in the planning?
b. Trends in acuity on the unit ANS: B Acuity levels are determined through classification systems, which determine the nursing resources required.
A client requires an appendectomy. The surgeon explains the procedure and asks the client to sign the consent. The patient speaks very little English and looks worried. As a nurse, you would: a. Suggest that an interpreter explain the procedure to the client and answer any questions.
a. Suggest that an interpreter explain the procedure to the client and answer any questions. The Five Steps to Safer Patient Care identifies that encouraging patients to ask questions when there are doubts and concerns and ensuring understanding before surgery is performed are ways in which nurses can support patients in having greater influence in their own care. In this situation, asking an interpreter to help enables access to information for the patient and active assessment of his understanding.
As a patient care advocate, you regularly coach patients on how to stay safe in health care by educating them about: a. The need to understand and record all medications being taken.
a. The need to understand and record all medications being taken. The Five Steps to Safer Health Care for patients include keeping a list of medications that patients are taking.
5. The IOM Health Professions Education report highlighted patient safety concerns as: . b. A result of disciplinary silos.
b. A result of disciplinary silos. The IOM Health Professions Education report (2004) highlighted the education of health disciplines in silos as a major concern in patient safety and endorsed five recommendations.
2. A small rural hospital has been designated as a critical access hospital. It has 40 beds and an average occupancy of 34 beds. To prepare the staffing, the chief nursing officer computes the occupancy as being:
b. 85%. ANS: B A way to assess a unit's activity level is to calculate the percentage of occupancy. Formula: daily patient census (rounded) divided by the number of beds in the unit The occupancy level is calculated as 34/40, or 85%.
22. To project staffing needs and to avoid understaffing, it is important that nurse managers consider which of the following?
b. Average nonproductive hours ANS: B To avoid understaffing, average nonproductive or benefit hours need to be taken into account, so the unit is properly staffed when staff members are off.
13. A particular classification system assigns revenue according to the functional capacity of patients and the progression of patients during their stay in rehabilitation units. More independent patient activities, such as prompted voiding, require higher staff utilization than dependent activities but do not result in increased staff resources. This is an example of:
b. Concern related to the validity of classification systems. ANS: B Validity of categories and implications for staffing levels are in question in this situation because staffing levels are not reflective of the levels of activity required for patient care.
12. Staff members on your unit raise concern that there is rising acuity on the unit and lack of responsiveness in addressing these needs through appropriate staffing. They point to increased incidences of adverse and sentinel events on the unit. To address this concern, your hospital organization would do best to:
b. Participate in databases that compare the outcomes and staffing levels versus those of institutions similar to yours. ANS: B Staff morale suffers both when acuity models indicate a gap between staffing and acuity and when there is no model but perceived acuity that is not being addressed. A truer approach is to monitor patient outcomes and participate in national databases that measure staffing levels through comparison with like institutions.
17. A nurse staffing plan takes into account:
b. Participation of nurses in projecting staffing needs. ANS: B Nurse staffing plans employ nursing judgment and flexibility that is based on acuity, nurse experience, and unit configuration rather than set nurse-to-patient ratios. The American Nurses Association has opted to support the nurse staffing committee as the approach to ensure safe staffing. In 2013, national legislation was introduced that requires all acute care hospitals to establish a committee made up of 55% direct care RNs.
The NQF provides a model for advancement of healthcare quality that could be used in healthcare organizations. The use of this model by the Centers for Medicare & Medicaid Services specifically affects the interaction between adverse events and: b. Funding.
b. Funding. The Centers for Medicare & Medicaid Services (CMS) have adopted a policy based on the NQF's "never events." The CMS will no longer pay for patient conditions or events that result from poor practice while patients are under the care of a health professional
8. Scheduling is a function of implementing the staffing plan by assigning unit personnel to work specific hours and specific days of the week. To retain nursing staff, the nurse manager must schedule:
c. A variety of scheduling options. ANS: C Creating a flexible schedule with a variety of scheduling options that leads to work schedule stability for each employee is one mechanism likely to retain staff, which is within the control of nurse managers.
11. A factor evaluation system:
c. Combines interventions and time required for interventions to determine levels of care required. ANS: C A factor evaluation system considers tasks, thought processes, and patient care activities and gives them a time or rating. These are then used to determine the number of patient care hours required.
16. In evaluating weekend mortality rates, the head nurse on the cardiac unit is surprised to find that they are higher than on weekdays. In exploring the reasons for this apparent anomaly, the head nurse focuses on:
c. Communication with on-call providers. ANS: C Studies to date of off-peak hours (weekends and nights) are limited, but those that have been done indicate increased mortality during weekends and nights, when staff work with fewer and often less experienced staff and when there may be strained communication among on-call healthcare providers.
4. An important aspect of managing the costs on a unit is to plan accurately for staffing needs. Nurse managers use staffing plans to:
c. Outline the number of individuals by classification on a per-shift basis. ANS: C A nurse manager needs to manage financial resources by developing staffing plans. Staffing plans plan for minimum number of professional nurses required on a unit at a given time or to the amount of minimum staffing in an extended-care facility or prison, based on regulatory guidelines.
3. To prepare staffing schedules, a nurse manager needs to calculate paid nonproductive time. When calculating paid nonproductive time, the nurse manager considers:
c. Vacation time, holiday time, and sick time. ANS: C Nonproductive hours are hours of benefit time and include vacation, holiday, and personal or sick time.
To increase safety in patient care areas of the Valley Hospital, the executive begins by: c. Ensuring that the senior nursing officer attends the board meetings.
c. Ensuring that the senior nursing officer attends the board meetings The IOM report (2004) highlighted the importance of the attendance of the senior nurse executive at board meetings to be a key spokesperson on safety and quality issues.
Mary, an 85-year-old patient with cognitive impairment and gross instability, wanders continuously. Lately, she has fallen twice, and the family demands that she be restrained. As the unit manager, you have initiated a least restraint practice. An appropriate action in this situation would be: c. Initiating a multidisciplinary and family meeting to focus on Mary's needs.
c. Initiating a multidisciplinary and family meeting to focus on Mary's needs. Crossing the Quality Chasm emphasizes the importance of rendering care with the client (client-centered) rather than to the client. In this situation, the patient includes family in transparent discussions about quality needs and takes a team approach that involves healthcare professionals, the family, Mary's needs, and evidence associated with safe practice.
15. A strategy to increase RN staff retention at Valley Hospital includes:
d. Adequate staffing to meet acuity levels. ANS: D Over the past decade, a significant amount of research has been done in the United States to evaluate links among nursing staffing, workloads, skills mix, and patient outcomes. An analysis of this research demonstrates that ensuring adequate staffing levels has been shown, among other things, to improve nurse retention and job satisfaction.
14. In the past year, you have noticed an increase in patient falls on your unit. In reading studies related to staffing and patient outcomes, you realize that you will need to plan for:
d. An increased number of RN positions. ANS: D Lower fall rates are shown to be related to higher total nursing hours and a higher percentage of nursing hours supplied by RNs.
5. A nurse manager must consider a number of external variables when preparing the personnel budget and projecting the unit's staffing needs. An external variable to be considered is:
d. Department of Health licensing standards. ANS: D Licensing regulations of the state can determine staffing models. Staffing regulations can dictate the number of professional nurses required on a unit at any given time.
1. The number of adverse events such as falls and pressure ulcers on your unit is increasing. An ideal staffing plan to address this issue would include which of the following? Increasing the:
d. Number of RNs and number of RNs with experience on the unit. ANS: D A number of studies have identified that adverse events such as falls and pressure ulcers can be reduced by increasing the number of RNs on a unit (relative to other personnel) and utilizing experienced RNs. Overtime and 12-hour shifts are linked to greater incidence of errors.
23. Your healthcare organization has a decentralized system for scheduling. As part of this process, after you have developed a draft schedule, you may need to:
d. Submit the schedule to a centralized staffing office for review. ANS: D In a decentralized model, you may be completely responsible for approving all schedule changes and for development of the schedule, or you may need to submit a draft to a centralized office for review and determination of supplemental staff. Balancing personal schedules and negotiation describes staff self-scheduling models.
After consulting with practice environments about quality and safety concerns in health care, the Dean of Health Programs at U.S. University develops: d. An interdisciplinary program for nurses, pharmacists, and medical practitioners that emphasizes collaborative learning teams.
d. An interdisciplinary program for nurses, pharmacists, and medical practitioners that emphasizes collaborative learning teams. Health Professions Education identified that education related to health disciplines in silos leads to compromised communication and inability to function as an integrated whole for patient-centered care.
In preparation for redesignation as a Magnet Hospital, how would you prepare? d. Ensure that there are empirical data to support review of patient outcomes, actions taken, and results of actions.
d. Ensure that there are empirical data to support review of patient outcomes, actions taken, and results of actions. Through the MagnetTM model, organizations must demonstrate how they provide excellence in five areas. Between designation and redesignation as a MagnetTM organization, greater emphasis is placed on empirical quality results.
10. As a nurse manager on the West Surgery Unit, you are interested in increasing patient safety and reducing morbidity and mortality on your unit. Which of the following recommendations would be consistent with the IOM The Future of Nursing report? d. Increase in the percentage of baccalaureate-prepared nurses to 80%
d. Increase in the percentage of baccalaureate-prepared nurses to 80% The Future of Nursing advocates for having 80% of the nursing population at a baccalaureate-prepared level. This recommendation reflects research that suggests that improved mortality and morbidity rates occur with a better educated workforce.
As the manager on an acute care medical unit, you note that the incidence of medication errors has increased since the implementation of staffing changes. As part of your strategy to reduce errors, it is important to d. Involve RN staff in determining reasons for errors and practice solutions to increase the safety of medication administration.
d. Involve RN staff in determining reasons for errors and practice solutions to increase the safety of medication administration. Keeping Patients Safe: Transforming the Work Environment of Nurses (2004) identified many past practices that had a negative impact on nurses, and thus on patients, and recommended the inclusion of nurses in direct care in decision making involving their practice. Future of Nursing: Leading Change, Advancing Health (2010) also emphasizes the role of nurses as leaders in changes that improve health.
In designing a quality, safe healthcare environment, the primary emphasis needs to be on: d. The patient.
d. The patient. Focusing on the patient moves care from concern about who controls care to a focus on what care is provided to and with patients, which was an aim identified in the IOM report Crossing the Quality Chasm.
On the West Surgery unit, you want to institute a new system for checking armbands that evidence suggests may increase safety in medication administration. The system involves technology. Which of the following strategies may assist with rapid adoption of the technology and system? d. Use early adopters among the staff as leaders and role models in implementation.
d. Use early adopters among the staff as leaders and role models in implementation. The Institute for Healthcare Improvement (IHI) is dedicated to rapid improvement in patient care through a variety of mechanisms such as rapid cycle change. Rapid cycle change diffuses innovation and changes quickly through early adopters who share information and energy over time and act as role models for others.
