Chapter 21. Managing Patient Care

Which of the following clients would most benefit from the case manager model of nursing care? 1 A client diagnosed with end-stage renal failure 2 A client who has a chronic wound on the left foot 3 A client newly diagnosed with type 2 diabetes mellitus 4 A postoperative client who had a cholecystectomy (gallbladder removal)

1 A case manager follows up with the client after discharge home. Case managers do not always provide direct care, but instead they work with and supervise the care delivered by other staff members. Case managers actively coordinate client discharge planning by identifying health care needs, determining the availability of services and resources, and assisting the client in choosing cost-efficient health care options. The client dealing with end-stage renal failure would most benefit from this model of care because the clients case is the most complex and will require extension discharge support.

Which of the following actions best reflects accountability for the clients care outcomes? 1 Reassessing a clients BP when the reported value is higher than usual 2 Assisting a team member in providing a client with a complete bed bath 3 Reevaluating a clients pain 30 minutes after administering pain medication 4 Asking a clients daughter to bring her fathers non-skid slippers to the hospital

1 Accountability refers to individuals being responsible for their actions. It means that a nurse accepts the commitment to provide excellent client care and the responsibility for the outcomes of the actions in providing that care. Reassessing an abnormally high BP is the best example of nursing accountability because it shows the nurse being responsible for the accuracy of the assessment. The remaining options better reflect nursing responsibility.

The nurse on the unit is determining which activities may be delegated to assistive personnel. Assuming that the nurse assistant is competent, which one of the following activities may be safely delegated by the registered nurse? 1 Vital signs on a stable client 2 An admission history on a new client 3 Initial transfer of a postoperative client 4 Administration of medications prepared by the nurse

1 An institutions policies and procedures and job description for assistive personnel provide specific guidelines in regard to which tasks or activities can be delegated. The nurse should match tasks to the delegates skills, such as delegating vital signs to a nurse assistant. It would not be appropriate to delegate an admission history on a new client to a nurse assistant. The RN should perform this task. Initial transfer of a postoperative client should not be delegated to a nurse assistant, as the client would be considered unstable. The RN should perform this task. The nurse should not delegate medication administration to a nurse assistant, even if the nurse prepared it. The nurse assistant is not licensed to administer medication.

A nurse who performs a skin assessment while bathing an immobile client would be displaying: 1 Efficiency 2 Leadership 3 Organization 4 Effectiveness

1 Effective use of time means doing the right things, whereas efficient use of time means doing things right. The nurse is showing efficiency by combining various nursing activitiesin other words, doing more than one thing at a time. Organization is a general term that may include efficiency, while leadership is the ability to manage people and resources.

In anticipation of a nursing shortage, the nursing management in a facility are investigating a nursing care delivery model that involves staff members working under the direction of a registered nurse leader. This model is called: 1 Team nursing 2 Primary nursing 3 Functional nursing 4 Total patient care nursing

1 In team nursing a registered nurse leads a team that is composed of other RNs, LPNs or LVNs, and nurse assistants or technicians. The team members provide direct client care to groups of clients, under the direction of the RN team leader. Nurse assistants are given client assignments rather than being assigned particular tasks. Primary nursing is a model of care delivery whereby an RN assumes responsibility for a caseload of clients over time. Typically the RN selects the clients for his or her caseload and cares for the same clients during their hospitalization or stay in the health care setting. Functional nursing is task-focused, not client focused. In this model, tasks are divided, with one nurse assuming responsibility for specific tasks. Total patient care is a model of care where an RN is responsible for all aspects of care for one or more clients. The RN may delegate aspects of care but retains accountability for care of all assigned clients.

The most important responsibility of a nurse manager is to: 1 Foster an environment that enables staff to provide quality nursing care 2 Provide leadership and role modeling for nursing and ancillary staff 3 Evaluate the delivery of nursing care in regard to its effect on client outcomes 4 Create a unit attitude of cooperative engagement directed toward positive client outcomes

1 Perhaps the most important responsibility of the nurse executive is to establish a vision for nursing that enables managers and staff to provide quality nursing care. The remaining options are means by which the manager can affect the proper environment.

The student nurse is seeking to learn skills associated with priority setting. In discussing different priorities of care, an example of a second-order priority is: 1 The need to urinate 2 An obstructed airway 3 The side effects of a medication 4 Activities of daily living in the home environment

1 Second-order priority needs are actual problems for which the client or family has requested immediate help, such as a full bladder. An obstructed airway is a first-order priority need because it is an immediate threat to a clients survival or safety. Side effects of a medication is an example of a third-order priority need. It is a relatively urgent actual or potential problem that the client or family does not recognize. Activities of daily living in the home environment is a fourth-order priority need. It is an actual or potential problem with which the client or family may need help in the future.

A client has reported all of the following; which should be given priority by the nurse? 1 Pain 2 Hunger 3 Anxiety 4 Constipation

1 When a client has diverse priority needs, it helps to focus on the clients basic needs; pain will exacerbate the clients anxiety and interfere with eating and thus should be attended to first. While a concern, constipation is the lowest priority problem.

Which of the following are recognized competencies for an entry-level nurse? (Select all that apply.) 1 Views clients holistically 2 Utilizes the nursing process 3 Participates in life-long learning 4 Exhibits nursing professionalism 5 Delegates client care appropriately 6 Exhibits expert nursing knowledge

1, 2, 3, 4, 5 All provided options are recognized competencies for entry-level nurses except the ability to practice with expert nursing knowledge. This will be acquired with time and experience.

To achieve Magnet status, the nursing staff of a hospital must exhibit: (Select all that apply.) 1 A client first mentality 2 Autonomy of personal practice 3 Strong involvement in life-long learning 4 Ability to use state of the art technology 5 Strong nurse-health care provider collaboration 6 Clinical competence through earned certifications

1, 2, 3, 5, 6 All provided options are characteristics required of the nursing staff for recognition as a Magnet hospital except for expertise with state of the art technology.

The advantages of team nursing include: (Select all that apply) 1 Fosters team cooperation 2 Allows for ancillary staff autonomy 3 Strengthens the RN-client relationship 4 Facilitates decision making at the clinical level 5 Encourages collaboration between team members 6 Provides management experience for team leaders

1, 4, 5, 6 An advantage of team nursing is the collaborative style that encourages each member of the team to help the other members. This model has a high level of autonomy for the team leader and is an example of decision making occurring at a clinical level. Team nursing can limit the actual time the RN spends with the clients; ancillary staff are not afforded autonomy regardless of the nursing care model because their work must be supervised by the RN.

The primary benefit of achieving Magnet status is the nursing staff is empowered to make innovative changes that: 1 Promote nursing autonomy 2 Positively affect client care outcomes 3 Enhance the perception of the nursing profession 4 Strengthen the collaborative RN/MD relationship

2 A Magnet hospital empowers the nursing team to make changes and be innovative. This culture and empowerment combine to produce a strong collaborative relationship among team members and so ultimately improves client quality outcomes. The remaining options are outcomes of the Magnet status but not the primary benefit.

The primary reason the nurse asks for help when changing a clients complicated dressing is to: 1 Foster efficient client-oriented interventions 2 Facilitate a comfortable, safe dressing change 3 Minimize the amount of time spent on a specific task 4 Engage in collaborative learning with other health care professionals

2 A nurse should never hesitate to have staff assist, especially when there is an opportunity to make a procedure or activity more comfortable and safer for the client. While it is possible that having help with a task can be a learning experience as well as making the task more efficient and less time-consuming, it is not always the case and not the primary reason for asking for assistance.

When the oncology units interdisciplinary team meets every Monday morning at 0830 to discuss the units individual clients, the group is best displaying: 1 Staff education 2 Collaborative practice 3 Team communication 4 Nursing shared governance

2 Collaboration of health care team members is required to help meet the complex needs of clients in health care settings. Such collaborative interaction may strengthen individual members knowledge and communication skills. Nursing shared governance is a process directed towards the standard of nursing care among a particular groups of professional nurses.

In anticipation of a nursing shortage, the nursing management in a facility is investigating a nursing care delivery model that involves the division of tasks, with one nurse assuming the responsibility for particular tasks. This model is called: 1 Total patient care 2 Functional nursing 3 Team nursing 4 Primary nursing

2 Functional nursing is task-focused, not client-focused. In this model, tasks are divided, with one nurse assuming responsibility for specific tasks. Total patient care is a model of care where an RN is responsible for all aspects of care for one or more clients. The RN may delegate aspects of care, but retains accountability for care of all assigned clients. In team nursing a registered nurse leads a team that is composed of other RNs, LPNs or LVNs, and nurse assistants or technicians. The team members provide direct client care to groups of clients, under the direction of the RN team leader. Nurse assistants are given client assignments rather than being assigned particular tasks. Primary nursing is a model of care delivery whereby an RN assumes responsibility for a caseload of clients over time. Typically the RN selects the clients for his or her caseload and cares for the same clients during their hospitalization or stay in the health care setting.

When the nurse gathers all the equipment needed for a particular procedure and arranges the clients room for proficient implementation of the procedure, the nurse is displaying: 1 Multitasking 2 Organization 3 Effectiveness 4 Professionalism

2 The well-organized nurse approaches any planned procedures by having all of the necessary equipment available and making sure the client is prepared. It always is wise to have the work area organized and preliminary steps completed before asking co-workers for assistance. Multitasking is dealing with more than one task at a time while being effective means doing the right things correctly. Being professional means showing the characteristics of performing the expected tasks of the profession.

As the nurse starts to perform a procedure, a peer says, Ive done that before. Would you like me to help? The peers leadership style is described as: 1 Directing 2 Coaching 3 Democratic 4 Laissez-faire

2 This situational leadership style is described as coaching. The peer is willing to explain the procedure and provide the opportunity for clarification. Directing is a highly directive style of leadership where leaders provide specific instructions and close supervision. A laissez-faire style of leadership is where the leader intervenes as little as possible in the direction of others. The laissez-faire style of leadership is described as nondirective, permissive, ultraliberal. A democratic leadership style encourages group discussion and decision making. The democratic leadership style is described as participative and consultative.

To meet the needs of assigned clients and the responsibilities associated with the position, nurses need to be aware of time management techniques. The time management skills for the nurse include: 1 Meeting all of the clients needs in the early morning hours 2 Anticipating possible interruptions by therapists and visitors 3 Leaving each day unplanned to allow for adaptations in treatments 4 Completing client assessments and treatments individually at separate times

2 To manage time, the nurse must anticipate when care will be interrupted for medication administration and any diagnostic testing, and the nurse should also determine the best time for planned therapies such as dressing changes, client education, and client ambulation. Meeting all the needs in the early morning hours would be unrealistic. Some activities have specific time limits in terms of addressing client needs and some activities follow scheduled routines according to hospital policy. The nurse may also have to work around other schedules, such as if the client had a test ordered for the morning. Therefore, the nurse cannot expect to meet all of the clients needs at a specified time of day. Because the nurse has a limited amount of time with clients, it is essential to remain goal-oriented and make a plan for using time wisely. Time management involves using client goals as a way to identify priorities. The nurse in reviewing the care requirements organizes his or her time so the activities of care and client goals can be achieved. A nurse should complete the activities started with one client before moving on to another.

Clinical nursing decisions are best made using: 1 Clinical pathways 2 Accurate assessment data 3 Previous nursing knowledge 4 Interdisciplinary collaboration

2 When beginning an assignment with a client, the first nursing activity involves a focused but complete assessment of the clients condition. This information enables the nurse to make an accurate clinical decision as to the clients health problems and required nursing therapies. The remaining options support the clinical decision-making process.

Indicators in a quality improvement program that evaluates the manner in which care is delivered are: 1 Structure indicators 2 Team indicators 3 Process indicators 4 Client indicators

3 A quality indicator for evaluating the manner in which care is delivered is a process indicator. Structure indicators evaluate the structure or systems for delivering care; an example is adherence to checking if emergency carts are adequately stocked. There is no team indicator. Client indicators would actually be outcome indicators. Outcome indicators evaluate the end result of care delivered.

Accountability is a critical aspect of nursing care. An example of a specific decision-making process of accountability is demonstrated by: 1 Selecting the medication schedule for the client 2 Implementing discharge teaching plans that meet individual needs 3 Evaluating the clients outcomes following implementation of care 4 Promoting participation of all staff members in regular unit meetings

3 Accountability refers to individuals being responsible for their actions. It involves follow-up and a reflective analysis of ones decisions to evaluate their effectiveness. Selecting the medication schedule for the client is an example of taking responsibility. Implementing discharge teaching plans that meet individual needs is an example of autonomy. Promoting participation of all staff members in unit meetings is an example of decentralized management and of promoting authority.

A unit manager on a busy multi-service medical nursing unit decides to take responsibility for the direct client care of one of the many new admissions. Later the manager decides she is too busy to give adequate client care. Which of the following situational leadership styles does the nurse manager need to apply? 1 Coaching 2 Supporting 3 Delegating 4 Directing

3 Delegation is transferring responsibility for the performance of an activity or task while retaining accountability for the outcome. To be more efficient in providing adequate client care, the manager needs to use delegation. Coaching would not be the situational leadership style to apply. The manager does not have time to explain decisions and provide the opportunity for clarification. Supporting would not be the situational leadership style of choice. The manager does not need to share ideas and facilitate decision making of other employees at this time. Directing is a highly directive style of leadership. The manager needs to delegate, not provide specific instructions and close supervision.

Which of the following statements made by a nurse related to the organization of client care requires follow-up by the mentor? 1 I had my LPN bring the Foley catheterization supplies into the room so theyd be there when I got there. 2 I delegated all the stable vital signs to my nursing assistant and the treatments to the LPN. 3 I was taking vitals on one client, dangling a second client while I had the third expelling an enema. 4 Organization was never a strength of mine, but I believe Im getting better at completing all my clients care.

3 Good time management involves completing one task before starting another. If possible, complete the activities started with one client before moving on to the next. Care will then become less fragmented, and the nurse will be better able to focus on what is being done for each client. As a result, it is less likely that errors will be made. The remaining options are not reflective of poor management and so do not need follow-up.

Which statement best reflects the major limitation of the team nursing model? 1 The team really needed an extra pair of hands today. 2 It complicates things when you have a different team each day. 3 Getting our two new admissions stabilized took up all of my time today. 4 My nursing assistants need to be in-serviced on how to do a bladder scan.

3 One of the limitations to the model is that the team leader does not spend a large amount of time with clients. Depending on the mix of staff members, this sometimes means that clients see an RN infrequently. Risks exist if an RN is unable to make necessary client assessments and be involved in important clinical decision making. The remaining options refer to less frequent problems inherent to the team nursing model.

The nurse is prioritizing care for two postoperative abdominal surgery clients; the first is 15 hours postoperative and the second is ready for discharge. Which of the interventions should be accomplished first? 1 Discharge pain control 2 First day dangling and ambulation 3 First day post op coughing and deep breathing 4 Discharge teaching regarding the dressing change

3 The first clients goals center on restoring physiological function impaired as a result of the stress of surgery. The second clients goals center on adequate preparation to assume self-care at home. Physiological interventions, particularly those affecting breathing, should receive priority. Dangling and ambulation may be addressed after the second client is readied for discharge.

Which of the following actions is the best example of a nurse exercising nursing authority? 1 Assigning team responsibilities to individual team members 2 Evaluating a team members ability to perform a bladder scan 3 Readjusting a clients turning schedule to provide hourly repositioning 4 Determining that a client will not be ambulated based on assessment findings

4 Authority refers to legitimate power to give commands and make final decisions specific to a given position. Canceling a clients ambulation is the best example because it shows critical thinking in determining the appropriateness of an intervention. The remaining options are better examples of nursing responsibility.

Which of the following statements best reflects the autocratic style of leadership? 1 Lets discuss this case study thoroughly and decide on a plan of action as a group. 2 Ill try to pair you in comparable work teams, and lets evaluate the success of this approach in 2 weeks. 3 Everyone knows their work assignment, so lets not meet together unless we have an unexpected crisis. 4 Ill consider each of your requests, and then Ill give you the guidelines for establishing new acuity ratings for our clients.

4 Ill consider each of your requests, and then Ill give you the guidelines for establishing new acuity ratings for our clients reflects the autocratic style of leadership. The leader is making the decision. Lets discuss this case study thoroughly and decide on a plan of action as a group reflects the democratic style of leadership. The leader encourages group discussion and decision making. Ill try to pair you in comparable work teams, and lets evaluate the success of this approach in 2 weeks reflects the delegating style of leadership. Responsibility and implementation are being turned over to the group, but the leader remains accountable. Everyone knows their work assignment, so lets not meet together unless we have an unexpected crisis reflects the laissez-faire style of leadership. There is much freedom, and the leader assumes a hands off approach.

One advantage of a decentralized management structure for nursing units over a centralized structure is that: 1 Communication pathways are simplified 2 Staff are not responsible for defining their roles 3 Managers handle all of the difficult decision making 4 Each staff member is accountable for evaluating the plan of care

4 In decentralized management, decision making is moved down to the level of staff. It requires workers to be empowered to accept greater responsibility for the quality of client care provided. This means that each staff member is accountable for evaluating the plan of care. Communication pathways are not simplified. If decentralized decision making is in place, professional staff have a voice in identifying the RN role. Each RN on the work team is responsible for knowing his or her role and how it is to be implemented on the nursing unit. In decentralized management, there is autonomy. In other words, there is freedom to decide and act. The nurse manager does not necessarily handle the difficult decisions. Those staff members who are best informed about a problem or issue make decisions on the basis of knowledge.

Which of the following statements best reflects the nurses understanding of team nursing? 1 The team provides the client care and I provide the leadership and decision making. 2 I will manage the complex care and delegate the remaining care to my LPN and ancillary assistants. 3 Everyone on the team has responsibilities and is accountable to me regarding the effective execution of that care. 4 I delegate the care of the clients to the appropriate team members and I am responsible for coordinating and directing that care.

4 In team nursing a registered nurse (RN) leads a team that is made up of other RNs, licensed practical nurses (LPNs) or licensed vocational nurses (LVNs), and nurse assistants or technicians. The team members provide direct client care to groups of clients under the direction of the RN team leader. In this model, nurse assistants have client assignments rather than being assigned particular nursing tasks. The remaining options fail to provide an inclusive definition of team nursing.

It is necessary for the nurse manager to delegate tasks to the staff. Which of the following is a requirement of the delegation process? 1 Working alongside the staff to evaluate their care 2 Functioning from a laissez-faire style of leadership 3 Obtaining the employees voluntary acceptance of the task 4 Communicating the work assignment in understandable terms

4 When delegating, the nurse should always provide unambiguous and clear directions by describing a task, the desired outcome, and the time period within which the task should be completed. The nurse manager does not necessarily have to work alongside staff to evaluate their care. The nurse manager can often evaluate staff performance in client outcomes. A laissez-faire style of leadership is not a requirement for delegation. Tasks should be delegated to those who are capable, not necessarily to those who are willing.

A threshold of 90% is identified for an outcome indicator in the quality improvement program. Which of the following situations indicates a need for further review of the quality improvement plan? 1 The waiting time for clinic appointments has decreased 96%. 2 Clients with renal dialysis expressed a 95% satisfaction with their care. 3 In 93% of clients, subjective expressions of postoperative pain have decreased. 4 Wound infections are evident in 92% of clients after care of their IV access ports.

4 Wound infections are exceeding the designated threshold, indicating a need for further review of the quality improvement plan. Waiting time for clinic appointments has decreased, meeting the threshold. Satisfaction with care meets the threshold. Expressions of pain have decreased, meeting the threshold.