CNL Exam

A new nurse on the medical/surgical unit approaches you with concerns about one of her patients. She states the patient has not turned on the lights or television all day and did not order breakfast or lunch. She had to ask the patient what meal they wanted and place the order. This nurse states she is concerned about the change in the patient's behavior. Looking at the patient's chart, you realize this patient is Jewish and it is Saturday. What is your best response to the nurse?

"The patient may be following their religious practices and we need to support this"

A client is ordered 35 milligrams of Codeine phosphate by subcutaneous injection. 50 milligrams in 1 milliliter of liquid for SC Injection is available. How many milliliters will you administer?

0.7 mLs

Several near misses were identified by ICU nurses who had mistaken invasive lines for intravenous ports for medication administration. You have completed an analysis of the issue. Your recommendations include:

1. A double-check system for medication administration 2. To facilitate a critical incident reporting structure that fosters a "without blame" unit culture 3. A visual signal on all ports not intended for intravenous drugs 4. All of the above

Calculate the drip rate for1 liters of IV Fluids to be given over 5 hours via a tubing set which delivers 10 drops/ml.

33 gtts/min

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 would like to assess first. Which patient should this nurse assess first?

60-year-old s/p liver biopsy

Your hospital just completed a study comparing outcomes in rehospitalization rates for CHF patients who either received predischarge teaching from an 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?

<.05 -Value less than 0.05 is a significant statistical finding

What is the first essential key to implementing a change in a microsystem?

A clear vision of what outcomes are to be accomplished

Your team is looking at the delays in the discharge process. Your cause and effect diagram includes:

A fishbone diagram

One of the nurses on your unit was involved in a medication error. She revealed the error to both you and the nurse manager and documented the error in the online safety event reporting system. You meet with her and begin the process of identifying causes that led to this event, so the risk for future medication errors can be minimized. As evidenced by these actions, what is the culture of your hospital?

A just culture

Your unit has recently had an increase in fall rates. When you compare what other units in your department are doing, you identify that each unit is using a different fall risk assessment tool. You research each tool and identify which one has the strongest evidence-based research in preventing patient falls. This tool is later standardized throughout the hospital. What is this an example of?

A. Applying tools for risk analysis

The CNL has the potential to be a powerful catalytic role that advances patient - and - family-centered care in a constantly changing healthcare arena. What key messages helps support this?

Achieving a high level of education and practicing to the full extent of it

When is an RCA performed?

After a serious safety event has occurred

Strategies for advancing evidence based practice in health care settings include: 1. Skill building workshops 2. Evidence-based practice poster presentations 3. Evidence-based practice rounds 4. All of the above

All of the above

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

All of the above

As the CNL on a Cardiothoracic step-down unit, what is the one recommendation you would make to decrease the chance of readmission of your patient population? A) Visiting nursing for all patients B) All follow-up appointments scheduled prior to patient discharge C) Pharmacy to visit with each patient prior to discharge home to review medications D) All patients should be enrolled in a cardiac rehab program

All patients should be enrolled in a cardiac rehab program

The CNL nursing informatics competencies include all the following except:

An understanding of Excel spreadsheets

Sam is a homeless 59-year-old male admitted with CHF. He arrives alone and crying. His vitals are BP 173/96, HR 83, O2 86%, and temperature 98.9°F. During your assessment, you notice multiple bruises and lacerations. His clothes are torn and soiled. According to Maslow's Hierarchy of Needs, what should you do first?

Apply O2

In assessing your organization for evidence-based practice environmental readiness, you would evaluate all of the following except:

Are the nurses expressing an interest in evidence-based practice?

Which of the following is not part of the PDSA change model? 1. Plan 2. Do 3. Assess 4. Study

Assess

You, the CNL, work on an infectious disease unit in the hospital. Your patients tend to have long lengths of stays, sometimes weeks to months. During your 5Ps assessment, you discovered that the nursing staff is not satisfied with handoff communication. They feel like important information is often left out of report. As a leader of this team, the most appropriate next step would be to:

Assess the current communication handoff process

As the CNL on a medical unit, which of the following interventions would you support to reduce the readmission rate on your unit?

Begin discharge planning and teaching on the day of admission

Which terms are most important to the topic of ethics?

Beneficence, nonmaleficence, and justice

You are a CL 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?

Capital budget

The concept that an organization is in a continued state of change describes which organizational theory:

Chaos theory

When incorporating evidence-based practice interventions into your health care setting, it would be best to:

Choose the interventions you think would work for your setting and perform a rapid cycle test to evaluate the impact

Patient satisfaction scores in the emergency department (ED) have shown a downward trend over the past three quarters. As a clinical nurse leader (CNL) in the ED, your focus is to:

Compare desired outcomes with national and state standards

The manager of the medical unit where you work has just shared some data with you. She is concerned because the 30-day readmission rate for COPD patients is 15%. Your next step should be to:

Compare your hospital's 30-day readmission rate with other like hospitals on the CMS website

When CNLs are in school they learn that the best theory used to understand a rapidly changing, unpredictable healthcare environment is called?

Complexity Theory

Which most demonstrates advocacy toward a patient? a) Led interdisciplinary rounds on a group of patients b) Consulted a diabetic instructor for a patient who was found to have an HgB A1C of 13.1 c) Met with the trauma team of physicians to update patient plans of care d) Conducted an in-service with the nursing staff on how to reduce falls for the unit

Consulted a diabetic instructor for a patient who was found to have an HgB A1C of 13.1

In an effort to reduce central line infections, you have done some research and found evidence-based guidelines that you would like to implement at your organization. Your next step would be to:

Convene a team meeting to discuss the problem and impact of central line infections

An elderly patient is admitted to your unit with a diagnosis of UTI. Which of the following is generally not a symptom of a UTI in the elderly?

Decrease appetite

You are working with a team to reduce patient waiting time for transport to diagnostic imaging. An effective goal would be to:

Decrease waiting time for diagnostic imaging by 5% *Improvement goals must be specific and measurable

After careful review of unit processes, you have determined that the self meal order program was introduced 3 months ago. With this program, patients have the ability to order meals when they are ready to eat rather than eating at predetermined times set by the hospital. This change has altered the timing of medications previously given with meals. What does the CNL do to improve the process?

Develop an interdisciplinary team, including unit staff, nutritionist, diabetic educator, and meal service team members to investigate the self meal order program

Which of the following is not a part of the epidemiological triad? 1. disease 2. host 3. environment 4. agent

Disease

What can variation in practice procedures lead to?

Errors

As a member or leader of a team, a CNL remembers essential qualities of the CNL role and therapeutic use of self, genuineness, warmth, empathy, maturity, and self-awareness. These qualities support the CNL role in:

Establishing trust and promoting inter professional communication within the team

Which type of evidence would you prefer to review and share with a team when trying to support whether an evidence-based intervention should be implemented on your unit?

Experimental

The results of a quarterly report identify an increase in patient falls on the telemetry unit. Your first action will be to:

Gain an understanding of patient care practices on the telemetry unit

A lack of compliance with deep vein thrombosis (DVT) prophylaxis has been identified in retrospective chart reviews of all ischemic stroke patients in your organization. As a CNL on the neurological unit, your primary goal will include:

Gaining an understanding of how DVT prophylaxis is initiated on each stroke patient on your unit

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:

Incidence

A team approach utilizing the integration of many different roles working toward common patient and family goals describes the objective of which type of team:

Interdisciplinary team

Per the epidemiology report, your unit's hand hygiene scores have steadily decreased over the past 3 months. When reporting these metrics at a staff meeting, most of the staff replies saying, "It's the doctors fault, we always wash our hands." How do you work to change the culture of the unit?

Investigate the barriers to hand hygiene and collaborate with staff to reduce these barriers

Jen is an obese patient admitted with COPD and CHTN. Part of her social history is that she smokes 2 ppd. Her CNL, Erika, makes a goal for her to decrease by one cigarette a day until there are no more by August 1st. This goal will not work because

Jen should help make the goal

When trying to implement a change in the outpatient family clinic, which group of staff should the CNL focus on more?

Late majority

Which group presents the highest challenge in attaining buy-in for a new innovation?

Late majority

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:

Lateral integration

You are the CNL on a busy medical-surgical unit. One of your patients, Mr. Thompson, a Type 2 diabetic, has been on your unit for 5 days following a right foot amputation due to necrosis. He has been on IV antibiotics and has now been afebrile for 24 hours. Mr. Thompson, 67 years old, lives alone, but his son lives two miles away and says he will be able to check on his dad at least daily once he is discharged home. In preparation for discharge, you realize Mr. Thompson will need someone to assist him with his dressing changes and to check his vital signs for several days. You think he will also need outpatient physical therapy. You discuss with the physician your thoughts on discharging Mr. Thompson home with home health. The physician agrees with your plan of care, so you consult the case manager to set up home health and outpatient physical therapy. You also consult with the physical therapist for recommendations on home needs. You assist with making follow- up appointments for Mr. Thompson. Mr. Thompson is able to be discharged home the next day. This is an example of which CNL role?

Lateral integration of care

As the CNL on a medical-surgical unit, you are asked to participate in a root cause analysis of a group of sentinel events that have occurred recently throughout the hospital. Your team determines that a lack of effective communication in emergent situations is the root problem. Now what?

Lead the team in researching evidence-based practice improvements to implement a better way of communicating during emergencies

The CNL role was developed to:

Lead, guide, director other nursing staff to provided patient-centered care

One morning as you, the CNL, are walking into the nurses' lounge, you hear a lot of talk about a nurse who has called out sick that day. The nurses are griping about how this nurse always calls out, especially on Fridays. The best response is to:

Listen to what the nurses have to say, and then address that it is not our business to discuss someone else's personal life. That nurse's sick days and disciplinary action are up to that nurse and the manager. Ensure they have adequate staffing to make up for the sick call/help to adjust assignments

Julie, a CNL, hears that another hospital does hourly rounding and thinks this is a great idea to reduce falls on her unit. She meets with her interdisciplinary team and they decide to try this on their unit. She informs the rest of the staff and makes a start date. What did Julie forget to do?

Look at the latest evidence/literature review

A patient asks the CNL about the regulations on abortion in North Carolina. What should the CNL do?

Look up the regulation in North Carolina and share them with the patient

When conducting a literature review, the publication that would provide a comprehensive summary of research on that topic would be:

Meta-analysis

A 5Ps assessment was completed by each CNL in the hospital. As a CNL, you know this is an assessment of the:

Microsystem

Individual consults by many different health disciplines represent which type of approach:

Multidisciplinary

From which database would the CNL collect the most useful nursing-sensitive indicator metrics: A) NDNQI B) Hospital Compare C) TJC D) NQF

NDNQI

In your role as a CNL, you have implemented some practice changes on your unit that have resulted in an overall reduced LOS for the pneumonia patients. The cost savings will be reflected in which budget:

Operating budget

Before beginning data collection, what is the primary key factor to determine?

Operational definitions of data

Currently Medicare is moving from a fee-for-service model to a:

Pay-for-performance model

What is the best way for the CNL to analyze systems and outcome datasets to anticipate individual client risk and improve quality care?

Perform a FMEA

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 failure and identify which of the following has a primary symptom of right-sided heart failure?

Peripheral edema

Medicaid covers which population:

Poor and disabled

You are using failure mode and effect analysis (FMEA) to anticipate the risk of medication errors in the ICU related to invasive lines. You begin your FMEA analysis with:

Process mapping

After completing unit audits, you have noticed the nurses are not completing AIR cycles documentation with pain management (AIR: assessment, intervention, reassessment). What should be done to improve documentation?

Provide staff with a self-audit sheet as a way to review their own documentation during their shifts

Ongoing risk reduction and patient safety efforts are an important component of:

Quality Improvement (QI)

You are considering using a new type of Foley catheter in your setting when the sales representative mentions a study that the manufacturer conducted that showed a reduction of catheter-associated infections with the use of the new device. Which type of study would be most convincing of this new product's potential value:

Randomized controlled trial

How can the CNL make the greatest impact on the health care organization?

Representing the microsystem

You are working in a unit that has recently seen an influx of patients with substance related disorders. The nurses on the unit are complaining that frequently these patients are "drug seeking" and often signing out against medical advice in order to receive drugs elsewhere. What is an intervention that a CNL may implement to improve the treatment for this patient population?

Research on whether the hospital uses an evidence based tool that may help with the assessment of patients for alcohol addiction and/or withdrawal

All of the following are components of evidence-based practice and clinical decision making except:

Research utilization

You have evaluated the fall rate for the previous 12 months on the medical-surgical unit where you work as a CNL. You find that your fall rate is above the national benchmark. Your next step is to:

Review current hospital policy and find out what fall prevention strategies are currently being used on the unit

A process improvement project charter or establishment of specific aims can help a project group to avoid which difficulty:

Scope creep

Your unit has worked hard to maintain a very low fall rate. There has now been a sharp increase over the last 2 months. In looking at control chart data related to falls, you see that all of these falls occur on the night shift. What is the most likely reason for this shift?

Special cause

Which of the following actions illustrates the CNL professional value of altruism?

Sponsoring a meeting with the monitor technicians to understand their barriers in the cardiac monitoring process

To confirm a scope of practice question, the CNL should consult which administrative body guidelines:

State Nursing Practice Act

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 Tuckerman and Jensen's model is represented by members communicating their feelings, but still viewing themselves as individuals rather than part of the team?

Storming

You are trying to reduce admission time to your unit from the emergency department. You have completed several PDSA cycles and have reduced the time by 21 minutes. But in the most recent PDSA, the time actually increased by 6 minutes. What stage of the PDSA cycle should the team go to in order to plan the next steps?

Study

Advocacy can be a challenging role for the CNL, as sometimes a patient or the healthcare proxy makes a decision with which the CNL does not agree. If a well-informed decision is made to refuse or stop care, the CNL should:

Support the right of the patient/proxy to refuse care

A patient admitted to the hospital in hypertensive crisis is now receiving care at what level of prevention:

Tertiary

One of your patients, a widow, is reaching end of life. The physician has adamantly suggested to the patient's family to plan for death and to make the decision to remove life support, as he feels it is futile at this point and most likely causing more agony to the patient. The patient has three children, and they cannot agree on a decision. The oldest daughter feels that they should abide by the doctor, as he knows best. The middle child does not agree with "killing" his mother. The youngest child just wants to be with her mother and cannot make a decision. You decide the best thing to do now is hold a patient-care conference. Whom do you invite?

The family, the team of physicians, the primary nurse, the case manager, the chaplain, an ethics committee member, and the social worker

The result of a workflow diagram of a clinician illustrates an excessive amount of walking to obtain supplies. Reducing the waste of motion adds value-added time that ultimately benefits:

The patient

What is the purpose of a fishbone diagram?

To identify the cause and effect of multiple factors that lead to a result

The manager on the unit where you work really encourages the staff to learn and grow professionally as individuals and as a group. Several of the staff have earned advanced degrees and moved onto other roles in the hospital. Her goals always seem to be aligned with the organization's vision. This is what type of leadership style:

Transformational leadership

Survey results of the nursing staff reflect poor perceptions and a discomfort with addressing spiritual issues with patients. The ultimate success of focused staff education can be measured by:

Trending quarterly patient satisfaction scores pertaining to spiritual care during hospitalization

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?

Unfreezing

Who can function as an important ally to the CNL in engaging frontline staff in a major initiative?

Unit champion

The hospital has a goal for patient transfers from ICU to be completed by 12 noon. Your unit has a very low percentage for meeting this hospital goal. How can you best address this problem as the CNL?

Use process mapping to determine all the possible factors that contribute to patient discharge and what barriers there are to discharge

You are the CNL at an outpatient care clinic providing care to families in the area. You have noticed it is difficult to get families to bring their children in for their immunizations, & children are often off schedule. How can the clinic best address this issue to meet the needs of their patient populations? A) Educate families on immunizations, their purpose, & their children's schedule B) Provide reminder phone calls to families the day before a scheduled appointment C) If possible, offer extended clinic hours 1 to 2 nights a week, so parents can come in after work D) Use the clinic data to determine why families are not coming to appointments

Use the clinic data to determine why families are not coming to appointments

Over the past few weeks, nurses on the 30-bed medical unit have been complaining the MD orders related to oxygen do not match what the patient is receiving. Often the patient has more than one oxygen order at the same time. This leads to confusion for nursing and respiratory care staff and could harm the patient. How can the CNL improve the practice?

Using the informatics team as support, create a hard stop in the computer that does not allow the physician to activate a new oxygen order without discontinuing the previous order

A patient on your unit is receiving an antibiotic and begins to develop a rash on their face, neck, and upper torso. You identify this to be a common adverse reaction to which antibiotic?

Vancomycin

What is the appropriate ending point of a root cause analysis (RCA)? A) When several possible reasons for the error have been identified B)When staff have identified what they think is the reason for the error C) When the list of causes is exhausted to no more possible causes D) The CNL can identify reasons for occurrence

When the list of causes is exhausted to no more possible causes

Carey, a CNL, thinks utilizing volunteers in a microsystem will benefit the staff and the patients. She performs a literature review and does not find much literature evaluating volunteers being effective in a health care setting. She decides to go ahead and implement a volunteer program and collects data to see whether this is an effective change. Should Carey have implemented this?

Yes, if there is no literature on a topic, data should be collected to evaluate the change to see whether it is effective

While admitting a patient for COPD, a nurse notices the patient has had two other admissions this month for the same diagnosis and is homeless. A key part of this admission is:

a) Consult a social worker on admission

You are trying to get literature on using music to relieve pain. One research article uses methods you forget how to interpret. You should:

ask a mentor to assist you, so you understand the data

B.L. is a 91-year-old male who was transferred to a skilled nursing facility from an acute care hospital. Upon transfer, the patient's Lasix for CHF was not transferred with the patient. Once the medication error is found and restarted, it is the CNL's job to: a) Notify hospital of error b) Notify skilled nursing facility of error c) Go back through all pathways and find where the error in this transfer process occurred d) Notify the family

c) Go back through all pathways and find where the error in this transfer process occurred

There has been disagreement regarding the suggested adoption of a patient transfer blackout period during change of shift. Staff on the inpatient units favor a 30-minute blackout period, while emergency department staff favor no blackout period. A team of stakeholders from all areas recently agreed on a universal blackout period of 15 minutes during shift change. What type of solution does this represent? a. Avoidance b. collaboration c. accommodation d. confrontation

collaboration

Your geriatric unit shows the highest average restraint episode duration in the hospital. You have been asked to lead an improvement project to reduce duration. What would be your first step?

conduct a full assessment of your unit, including all restraint-related data and processes

A Korean patient is admitted who speaks little English. An example of culturally competent care is: a)Finding a nurse who speaks some Korean b) Transferring that patient to a floor that has a Korean-speaking secretary c) Calling the patient's family to see if they speak any English d) Obtaining a Korean translator

d) Obtaining a Korean translator

A Highly Reliable Organizations (HRO) has the following characteristics:

hyper-complexity and a high degree of accountability

What type of study would not be included in evidence-based practice if the nurses were looking for quantitative research?

phenomenological *Qualitative studies and aren't directly included in the evidence based practice

By leading which unit initiative can the CNL directly impact the financial health of the entire institution?

reducing readmissions