NU371 Week 10 PrepU: Quality Improvement

A bedridden client is scheduled to receive subcutaneous injections of heparin at 8:00 a.m. and 8:00 p.m. each day. The client's medication administration record would present these times as o 0800 and 2000 o 0800 and 1200 o 800 and 2200 o 0800 and 2200

o 0800 and 2000 · 8:00 a.m. is 0800 in military time and 8:00 p.m. is 2000.

Which is a classic sign of hypovolemic shock? o Bradypnea o Pallor o Dilute urine o High blood pressure

o Pallor · The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing.

What dual purpose does an audit serve? o education and confidentiality o quality assurance and reimbursement o knowledge and quality o communication and evaluation

o quality assurance and reimbursement · Audits of client records serve a dual purpose: quality assurance and reimbursement. Audits have no role in communications, evaluation, knowledge, quality, education, or confidentiality,

Which statement regarding health care reform trends is most accurate? o "Systems are in place to pay for performance and penalize hospitals for excessive readmissions." o "Spending on medical services will rise to almost 32% of the U.S. gross domestic product by 2021." o "The United States is second in the world in total health care dollars spent annually." o "Distinctive to the United States is the dominance of the public element over the private one."

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

A nurse on a neurologic unit is working on performance improvement with a stroke-management team. The nurse identifies a gap between the time a client enters the emergency department (ED) and the time that client is admitted to the intensive care unit (ICU) for aggressive treatment. The nurse meets with the team to develop a change strategy based on indicators. Which statement by a team member shows a need for further teaching regarding performance management? o "We can collaborate with staff from the ED and the ICU to formulate strategies and implement change." o "We can discipline the ED staff for not getting the clients to the ICU fast enough." o "We can review ED staffing to see if shortages affect ICU admission." o "We can use statistics gathered in the ED during triage to determine the average time for admission to the ICU."

o "We can discipline the ED staff for not getting the clients to the ICU fast enough." · Using statistics and other indicators, such as ED staffing information, to develop a change strategy is part of performance management. Disciplining staff doesn't reflect a strategy based on indicators. Collaborating with staff from other areas results in performance improvement, not performance management.

A nurse is reviewing the medical records of several patients and their risk for health problems. The nurse determines that the patient with which body mass index (BMI) would have the lowest risk? o 23 o 28 o 18 o 31

o 23 · Patients with a BMI of 23 would have the lowest risk for health problems. Those with a BMI of 18 might have the increased risk associated with poor nutritional status. Those with a BMI of 28 are considered overweight, and those with a BMI of 30 to 39 are considered obese. Both of these groups have an increased risk for health problems.

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents? o Care plan and client's record o Critical pathway and care plan o Client's record and occurrence report o Occurrence report and critical pathway

o Client's record and occurrence report · An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences.

A nurse on a night shift entered an elderly client's room during a scheduled check and discovered the client on the floor beside the bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? o following up on the incident with other members of the care team o protecting the nurse and the hospital from litigation o gauging the nurse's professional performance over time o identifying risks and ensuring future safety for clients

o identifying risks and ensuring future safety for clients · Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action and they are not commonly used to communicate within the interdisciplinary team.

A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving o A-positive blood to an A-negative client. o O-negative blood to an O-positive client. o B-positive blood to an AB-positive client. o O-positive blood to an A-positive client.

o A-positive blood to an A-negative client. · An acute hemolytic reaction occurs when there is an ABO or Rh incompatibility. For example, giving A blood to a B client would cause a hemolytic reaction. Likewise, giving Rh-positive blood to an Rh-negative client would cause a hemolytic reaction. It's safe to give Rh-negative blood to an Rh-positive client if there is a blood type compatibility. O-negative blood is the universal donor and can be given to all other blood types. AB clients can receive either A or B blood as long as there isn't an Rh incompatibility.

The RN develops an outcome standard of "client will ambulate with an assistive device 60 feet with assistance twice a day" for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement? o Implementation o Planning o Assessment o Evaluation

o Planning · Establishing the outcomes and actions will help the client achieve the overall goals of care. Assessment is the careful observation and evaluation of a client's health status by the collection of data. Implementation is putting the plan into action, and evaluation is determining the client's responses to the care provided.

A group of nurses are participating in being the first group of staff to use a new electronic pain assessment tool. The group is discussing whether or not the system is easy to use. During the discussion, the group mentions that "the shortcuts provided are really helpful and save valuable time." The informatics nurse specialist interprets this statement as reflecting which concept? o Forgiveness o Naturalness o Efficient interactions o Effective use of language

o Efficient interactions · The statement reflects efficient interactions. One of the most direct ways to facilitate efficient user interaction is to that minimize the number of steps it takes to complete tasks and to provide shortcuts for use by frequent and/or experienced users. Forgiveness means that a design allows the user to discover it through exploration without fear of disastrous results. Naturalness refers to how automatically "familiar" and easy to use (intuitive) the application feels to the user. Effective use of language involves the use of concise, unambiguous language with terminology that is familiar and meaningful to the end users in the context of their work.

A client diagnosed with a myocardial infarction (MI) is being moved to the rehabilitation unit for further therapy. Which statement reflects a long-term goal of rehabilitation for the client with an MI? o Ability to return to work and a pre-illness functional capacity o Prevention of another cardiac event o Improvement in quality of life o Limitation of the effects and progression of atherosclerosis

o Improvement in quality of life · Overall, cardiac rehabilitation is a complete program dedicated to extending and improving quality of life. Immediate objectives of rehabilitation of a client with an MI patient are to limit the effects and progression of atherosclerosis, to return the client to work and a pre-illness lifestyle, and to prevent another cardiac event.

A hospital is revising its quality improvement program. The goal of the program is to improve quality in the facility. Which of the following are major premises of the program? (Select all that apply) o Focus on unit nurses o Leadership commitment o Empowerment o Focus on the organizational mission o Customer orientation

o Leadership commitment o Empowerment o Focus on the organizational mission o Customer orientation · Focus is not on unit nurses in a quality improvement program. It is focused on client care and the other choices noted above.

The RN is orienting a new nurse who suggests a different way to perform a procedure. What is the RN's most appropriate reaction? o Consult with the client's physician for appropriateness. o Listen to the new nurse's suggestion and evaluate its usefulness. o Remind the new nurse of the facility's policy and procedure. o Consult with another experienced nurse for input.

o Listen to the new nurse's suggestion and evaluate its usefulness. · It is appropriate for health care professionals to be constantly evaluating whether the client's needs are being met in the best way. The experienced nurse should listen to the ideas of the new nurse and decide if the approach would be beneficial to the client. If the nurse's initial reaction is to quote policy and procedure, it does not allow for the exchange of ideas with the new nurse. It would not be necessary to consult with another experienced nurse or with the client's physician.

An informatics nurse specialist is interviewing several nurses who have participated in testing a new electronic assessment tool. The nurses report that the tool "feels so familiar, like we know exactly what it is that we're supposed to do." The nurse specialist interprets this as indicating which concept? o Naturalness o Simplicity o Forgiveness o Consistency

o Naturalness · Naturalness refers to how automatically "familiar" and easy to use (intuitive) the application feels to the user. Consistency involves the user's ability to apply prior experience to a new system. The more that users can apply prior experience to a new system, the lower the learning curve, the more effective their usage, and the fewer their errors. Simplicity involves design and refers to everything from lack of visual clutter and concise information display to inclusion of only functions that are needed to effectively accomplish tasks. Forgiveness means that a design allows the user to discover it through exploration without fear of disastrous results.

A nurse manager has asked the staff to create a plan to improve patient outcomes. In the past, the staff have not met deadlines. How can the nurse manager use transactional leadership style to ensure that the deadline is met? o Ask politely. o Demand efficiency. o Offer 2 days of paid vacation. o Give extensions as needed.

o Offer 2 days of paid vacation. · The transactional leadership style involves a task and reward system. Paid vacation is a reward for meeting the deadline. Asking politely, demanding efficiency, and giving extensions are not rewarding behaviors.

An informatics nurse is involved in testing an update to a clinical information system. Numerous caregivers are using the system at the same time. The testing is being done to see if the system can handle the large amount of users at one time. The nurse is involved with which type of testing? o Function o Unit o User-acceptance o Performance

o Performance · Performance testing is more technical and ensures proper functioning of the system when there are high volumes of end users or care providers using the system at the same time. In other words, can it handle the load? Unit testing is the initial testing that occurs and serves to check if everything is in the right place and that nothing was left out. Function testing uses test scripts to validate that a system is working as designed for one particular function. User-acceptance testing is the final phase of testing where the nurse (or other system end user) "test-drives" the new system or new functions of the EHR to ensure it's working as designed.

A nurse is reading a journal article about health information technology and the need for this technology to demonstrate meaningful use. Which information would the nurse anticipate reading about as reflective of meaningful use? Select all that apply. o Reduction in privacy breaches of client information o Increased health disparities o Reduced health of populations o Greater client engagement o Improvement in health care quality

o Reduction in privacy breaches of client information o Greater client engagement o Improvement in health care quality · Meaningful use would be reflected by improved quality, safety, efficiency, and reduced health disparities; engagement of clients and family; improved care coordination and population and public health; and maintenance of privacy and security of client health information.

Which tool is often used by case managers? o Standards of care o Service cost measurement o Outcome criteria o Bottom line

o Standards of care · Case managers usually make use of tools such as critical pathways, practice guidelines, and standards of care to help them plan and coordinate care. Insurance companies measure the costs of services provided to a case manager's patients as a means of assessing the case manger's effectiveness. One of the complaints about case management is that the "bottom line" will become more important than quality. For this reason, and because they are in the best position to collect outcome data, case managers usually are integral members of hospital-based and insurance-based quality improvement programs.

A client has been admitted in the emergency care unit with conditions of respiratory distress and pneumonia. The client's condition worsens and requires mechanical ventilation. While visiting this client in the hospital, the family observes members of the health care team washing their hands upon entering and leaving the room. By implementing recommended hand hygiene measures, which organization's goals is the health care team supporting? o The Joint Commission o The National Council of State Boards of Nursing (NCSBN) o Institute of Medicine (IOM) o Agency for Healthcare Research and Quality (AHRQ)

o The Joint Commission · One of The Joint Commission National Patient Safety Goals (NPSGs) prioritizes the reduction of health care-associated infections. The NCSBN prioritizes matters related to public health, safety, and welfare, including the development of licensing examinations in nursing. The IOM emphasis relates to ensuring that patient care is safe, effective, patient centered, timely, efficient, and equitable. The AHRQ highlights patients' satisfaction with care.

Which characteristic is the most important indicator of high-quality nursing practice? o The nurse follows the policies and procedures of the institution. o The nurse is organized and efficient in client care. o The nurse considers the individual needs of clients. o The nurse takes measures to ensure accurate medication administration.

o The nurse considers the individual needs of clients. · The personal, compassionate, caring side of a nurse is the most important indicator of quality nursing care. Considering the individual needs of the clients demonstrates the nurse's belief in the importance of the client. Being organized and efficient, following policies and procedures, and ensuring accurate medication administration are important parts of nursing care but are mainly task oriented.

A nurse is evaluating nursing care and client outcomes by using a retrospective evaluation. Which action would the nurse perform in this approach? o The nurse devises a post discharge questionnaire to evaluate client satisfaction. o The nurse interviews the client while the client is receiving the care. o The nurse reviews the client chart while the client is being cared for. o The nurse directly observes the nursing care being provided.

o The nurse devises a post discharge questionnaire to evaluate client satisfaction. · Evaluations can be conducted concurrent with care (by using direct observation of nursing care, client interviews, and chart review to determine whether the specified evaluative criteria are met) or retrospectively (post discharge questionnaires, client interviews by telephone or face to face, or chart review to collect data).

A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. After stabilizing the client, the nurse informs the physician. The physician advises the nurse to prepare an incident report. What is the purpose of an incident report? o To evaluate the immediate care provided by the nurse to the client o To evaluate the quality of care provided and assess the potential risks for injury to the client o To determine the nurse's fault in the incident o To provide information to local, state, and federal agencies

o To evaluate the quality of care provided and assess the potential risks for injury to the client · An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. Incident reports determine how to prevent hazardous situations and serve as a reference in case of future litigation. Accurate and detailed documentation often helps to prove that the nurse acted reasonably or appropriately in the circumstances. It may not always serve as a method of determining the nurse's fault in the incident. The document does not evaluate the immediate care provided to the client but states the actions taken.

The neuroscience nursing unit has developed a set of step-by-step directions of what should occur if a nursing assessment reveals the client may be exhibiting clinical manifestations of a cerebrovascular accident (CVA). Which statement about clinical practice guidelines are accurate? Select all that apply. o Once developed, practice guidelines only need to be reviewed if a national committee sends out an update on new research. o When developing a CVA set of step-by-step directions, the nursing unit should ask for assistance from experts in the neuroscience field. The potential users of the guidelines should pilot test it for further feedback. o The development of evidence-based practice guidelines require a research review from different studies to develop the most accurate diagnostic method to implement. o Step-by-step guidelines are usually developed and based primarily on "how it has always been done before." o A meta-analysis could be utilized to combine evidence from different studies to produce a more accurate diagnostic method.

o When developing a CVA set of step-by-step directions, the nursing unit should ask for assistance from experts in the neuroscience field. The potential users of the guidelines should pilot test it for further feedback. o The development of evidence-based practice guidelines require a research review from different studies to develop the most accurate diagnostic method to implement. o A meta-analysis could be utilized to combine evidence from different studies to produce a more accurate diagnostic method. · Clinical practice guidelines are systematically developed and intended to inform practitioners in making decisions about health care for CVA clients. They should be developed using research and review by experts in the clinical content. Potential users should also participate and provide feedback prior to implementation. The purpose of the guidelines is to review EBP articles and develop new practice guidelines rather that continuing practicing primarily on "how it has always been done before." Once developed, the guidelines must be continually reviewed and changed to keep pace with new research findings. A meta-analysis could be utilized to combine evidence from different studies to produce a more accurate diagnostic method or the effects of an intervention method.

A nurse enters a client's room and finds that the client is lying on the floor. The nurse makes the client comfortable on the bed and completes an assessment. The nurse then informs the health care provider and the nursing supervisor about this incident and also completes an incident report. Which actions by the nurse indicates correct knowledge of handling an incident report? o makes a copy of the incident report to give to the health care provider o makes a copy of the incident report and places it in the client's records o mentions in the client's report that an incident report was completed o completes a full incident report

o completes a full incident report · An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. It is kept separate from the medical record. The incident report is a legal document and making a copy of it is not advisable. It should not be placed in the client's records; however, the nurse can mention the incident in the client's records without mentioning the incident report.

One of the primary advantages of the managed care model is: o economic, quality care. o increased client satisfaction. o an all-RN staff. o a distinct area of care.

o economic, quality care. · The primary advantage of the managed care model is provision of high-quality care in the most efficient and economic manner. Managed care often results in decreased client satisfaction due to a lack of choice of health care provider. Managed care is provided by a diverse health care team with many different specialties and areas of care represented, not an all-RN staff or only one distinct area of care.

A healthcare agency has set a plan to apply for accreditation. A nurse on the accreditation committee has been assigned to audit clients' medical records for appropriate documentation. What information would the nurse assess in the audit? o evidence of home care and nursing follow-up for 6 weeks following discharge o evidence that nurses have set goals for improving future practice o evidence of self-reflection from nursing and other care providers about the quality of their care o evidence that nursing interventions have been evaluated in terms of the client's response

o evidence that nursing interventions have been evaluated in terms of the client's response · The medical record serves multiple purposes, including a role in accreditation. Accreditors look for evidence of evaluation following interventions. The medical record is not the correct venue for nurses' self-reflection or personal goal-setting. Many clients do not require community-based follow-up after they have been discharged.

While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct? o notifying the health care provider of the incident and the client's condition o documenting the incident factually in the client's record o submitting the incident report to the appropriate hospital administrator o making a copy of the incident report for the client

o making a copy of the incident report for the client · A nurse shouldn't copy an incident report for anyone. An incident report is a confidential and privileged document available to agency personnel for risk-management activities. After completing the report, the nurse should submit it according to facility policy. The nurse should document the incident factually in the client's record and notify the health care provider of the incident and the client's condition.

The focus of a hospital's current quality assurance program is a comparison of the health status of clients on admission and with that at the time of discharge. This form of quality assurance is characteristic of: o process evaluation. o structure evaluation. o nursing audit. o outcome evaluation.

o outcome evaluation. · Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care. Whereas the proper environment for care and the right nursing actions are important aspects of quality care, the critical element in evaluating care is demonstrable changes in client health status. Process evaluation addresses performance expectations during the various stages of the nursing process. Structure evaluation addresses the environment of care. A nursing audit focuses on the review of records.