COURSEPOINT Chapter 1

A nurse manager is making a decision based on a problem with a staff member. What would be the optimal end product of the decision? A. A chosen course of action B. An alternative problem C. A restatement of the solution D. An action that guarantees success

A Rationale: Decision making implies there are at least two options that have been presented as possibilities for action. At a minimum, the choices are act and don't act. The ultimate end product of the decision-making process is a chosen course of action. An alternative problem is not a positive outcome. Actions do not always guarantee success nor does a restatement of the solution.

A nurse is educating a patient who is scheduled to undergo an open cholecystectomy how to turn, cough, and deep breathe in order to prevent complications after the procedure. What phase of the nursing process is the nurse providing? A. Implementation B. Evaluation C. Planning D. Assessment

A Rationale: Implementation of the plan is the active portion of the plan of care and the nursing process. Education of the patient is essential in order to prevent potential complications. The nurse will then evaluate the effectiveness of this plan. Assessment occurs in gathering the data in order to make a diagnosis, and then the plan will be developed in order to determine the needs be met.

After receiving report, which client should the nurse see first? A. A patient who was admitted with kidney stones and is crying with back pain. B. A patient who is scheduled for surgery this afternoon and is requesting a shower. C. A patient admitted with chest pain who has been pain-free since admission and is now requesting breakfast. D. A patient who is to receive one unit of packed RBCs today and needs an IV restarted.

A Rationale: The client with kidney stones has an actual, current problem of acute pain that needs to be assessed and treated as prescribed. The client admitted with chest pain is not reporting any symptoms indicating an actual problem, although this may be a potential problem. Restarting an IV prior to a blood transfusion is not an urgent priority at this time based on the information provided. Even if the blood were already on the unit, the client who is having episodes of back pain should be assessed first.

Which of the following strategies should nurse leaders use to promote evidence-based practice? A. Staying current with professional issues B. Limit evidence-based research to nurses C. Do not take risks D. Use one reliable professional resource

A Rationale: Nurse leaders should stay current within their perspective specialties in the nursing profession. Ongoing professional development is required by all nurses; the use of multiple resources that provide insight into current evidence-based findings is encouraged and best practice. Risk taking and collaborating with other members of various professions assist nurses with discovering evidence-based approaches.

A nurse manager is having a difficult time making a decision about reprimanding a staff nurse who has exceeded the absentee policy. Why would the manager's values cause personal conflict in making this decision? A. Values remain unchanged over time B. Values often collide with one another C. Not all values are of equal worth D. Some values are not realistic or healthy

B Rationale: Belief systems may limit the options you are willing to support. Similarly, background, or preferences, may limit the degree of risk in terms of time, money, or possibility of failure you are willing to take on. Values often collide with one another and it's best to minimize the impact of values and personal preference by being aware of what your values and preferences are, and whether they are playing a part in limiting a decision that could serve the greater good.

A nurse manager is using the decision-making model "SWOT" to determine whether it is feasible to add another on-call team in perioperative services. What words does the acronym "SWOT" represent? A. Significance, Wellness, Operating, Timing B. Strengths, Weaknesses, Opportunities, Threats C. Strengths, Worth, Options, Timing D. Superiority, Work, Opportunity, Threats

B Rationale: SWOT stands for Strengths, Weaknesses, Opportunities, and Threats. This decision-making model is typically reserved for strategic planning.

The nurse should plan to see which patient first when planning morning care? A. A 12-year-old who is 24 hours postoperative from an appendectomy awaiting orders for a full diet and discharge. B. A 12-year-old who was admitted for chemotherapy via a central venous catheter. C. A 15-year-old who is scheduled for discharge this morning pending teaching regarding prednisone therapy for an allergic reaction. D. An 11-month-old who is receiving oral rehydration therapy for an admission of dehydration with orders to progress to a regular diet.

B Rationale: The first patient to be seen should be the patient currently receiving chemotherapy, which is a priority ongoing treatment with many associated risks and side effects. The patient with dehydration taking oral rehydration fluids, the patient requiring prednisone teaching, and the patient post-appendectomy are all stable with no information given that suggests a new or acute problem requiring an immediate assessment.

The nurse in the emergency department should see which of these four patients first? A. A patient who cannot bear weight without pain who has a bruised, edematous ankle after playing basketball. B. A patient reporting a headache, photosensitivity, and a stiff neck. C. A patient with an elevated temperature, sore throat, and upper respiratory symptoms. D. A patient requesting ice chips for a sore throat and an earache.

B Rationale: The patient reporting a headache, photosensitivity, and a stiff neck has an actual, current problem; the nurse is expected to recall that those symptoms may suggest meningitis. The patients with a potential ankle injury, sore throat, and upper respiratory symptoms are not as urgent a priority based on the information provided, as well as the knowledge that meningitis is a critical, time-sensitive clinical emergency.

The director of a busy outpatient department is meeting with staff to ask for input and make decisions about the feasibility of a freestanding unit. What issue by the nurse manager can stop the entire process if not rectified? A. Having resources available to make informed decisions. B. Keeping the objective and expectations for the group undefined. C. Allowing the group to participate in the discussion and be free to voice opinions. D. Encouraging each other to have respect for the values of the team.

B Rationale: When a manager fails to establish a clear objective and expectations for the group, chaos will occur and the decision will be stalled. Allowing to the group to participate and be able to freely voice opinions, and to encourage respect of various values in team members are positive ways to keep the group moving. Making resources available prior to the meeting will allow the staff to make informed decisions.

A staff nurse is having difficulty with problem-solving in patient care and the nurse manager is counseling the nurse. What suggestions by the nurse manager may assist the staff nurse in improving problem-solving skills? (Select all that apply.) A. Ask closed-ended questions B. Slow down thinking C. Systematize data collection D. Override bias E. Combine personal and professional feelings

B, C, D Rationale: There is a higher potential for choosing the option that will serve the greatest good when you can identify how your values, beliefs, preferences, and tendencies show up in your thinking. This knowledge allows differentiation of your bias from the facts. Ask open-ended and not closed-ended questions to obtain vital information prior to making a decision. Separate personal from professional feelings.

Which of the options below correctly correlate the decision-making model to the nursing process? (Select all that apply.) A. Plan: Identify the decision, collect data B. Implement: Choose alternative, implement alternative C. Evaluate: Evaluate decision-making steps D. Assess: Identify criteria for decision, identify alternatives

B, E Rationale: The Assess step in the simplified nursing process more accurately correlates to identifying the decision to be made and collecting data in the decision-making process. The Plan step in the nursing process more correlates to identifying the criteria for the decision and identifying alternatives in the decision-making process.

A root cause analysis (RCA) is a process during which participants: A. Include consideration of all relevant literature related to the incident B. Identify the individuals who are at fault in the incident. C. Identify risk points before, during, and after the event and the impact on the incident D. Identify one primary factor that may have contributed to the event

C Rationale: An RCA focuses on an in-depth review of all possible system factors that contributed to an event, exploring one factor at a time. The goal of an RCA is to delve deeper into problems that have occurred to find out the root cause of why the problem occurred. This often means that RCA reveals more than one root cause. The RCA process builds on the idea of risk analysis to identify points where a process could fail. There is no review of the literature or focus on individual staff performance during an RCA.

When a new nurse executive identifies the goal of creating a "just culture" environment in their healthcare organization, the staff understands that such an environment is characterized by a culture where: A. Constant questioning of the status quo is encouraged to prevent errors. B. Each department reviews the work processes of another department. C. The focus is on system processes that caused an error, not on individual blame. D. All team members share culpability for an error committed by one member of the team.

C Rationale: In a "just culture" health care organization, each staff member is accountable for understanding and ensuring that all processes and interactions are patient oriented. This shifts the focus away from a punitive or "blaming" culture and moves the focus towards a "middle ground" with health care staff and systems. This new thinking is designed to help change an organization's culture by placing less emphasis on errors and outcomes, and more emphasis on system design and the management of behavioral choices. In this model, errors and outcomes are the outputs to be monitored; system design and behavioral choices are the inputs to be improved.

A nurse makes a decision using intuitive judgment regarding a patient's rapid change in condition. What action should the nurse take after the decision? A. Quantify information B. Examine alternatives visually and compare each against the same criteria C. Use evidence-based data to validate the decision D. Plot a decision over time

C Rationale: After the nurse makes a decision based on intuitive action, an evaluation of the action should be made using evidence-based data to support and validate the decision that was made. It would not be beneficial to compare the action to a replica of the decision. The decision is not able to be plotted over time since it was intuitive.

A nursing staff is presently using disposable biopsy forceps in the endoscopy suite, and the nurse manager is questioning the cost-effectiveness of this practice. What would be an appropriate decision-making model to find a cost-efficient solution? A. SWOT B. Consequence tables C. Decision grid D. Intuitive judgment

C Rationale: Decision grids are visual models that allow comparison of "apples to apples". By listing alternative options as well as different criteria, a decision grid leaves a clear comparison of alternatives. Intuitive judgment would best be used when a decision has to be made immediately using intuition. A SWOT analysis is used when strategic planning is necessary. This situation would not require a consequence grid since it is a simple comparison of cost.

Which of the following is a decision-making tool often used by today's nurse leaders/managers for program/unit evaluation? A. Program outcomes B. Review techniques C. Flow charts D, Quarterly reports

C Rationale: Flow charts are used to develop critical pathways in the health care arena. The critical pathway shows what steps must occur in order to progress to the final step. These charts were first used by the U.S. Navy programs, originally called PERT, which stands for program evaluation and review technique. The other choices are elements of program evaluation and are not considered actual tools.

The nurse manager may use which quality assurance or performance improvement technique to identify underlying process flaws in the reporting of suspected child or elder abuse? A. Small group process B. People at fault process C. Root cause analysis D. Cause and effect

C Rationale: Root cause analysis is a quality assurance or performance improvement technique that is used to identify the underlying root causes of a problem, or in this case the lack of understanding of an important process of child/elder abuse reporting. Root cause analysis focuses on process flaws and NOT on people who have erred or made a mistake. A cause-and-effect diagram may be used for root cause analysis, but it in itself is not a quality assurance or performance improvement technique. Although small groups participate in quality assurance or performance improvement activities, small groups are not a performance improvement technique.

A nurse is caring for a patient that suddenly becomes short of breath and has a decrease in oxygen saturation to 86%. The nurse places the patient on 4 L of oxygen via nasal cannula and elevates the head of the bed. What decision tree would the nurse have used in this situation? A. Consequence tables B. A decision grid C. Intuitive judgment D. SWOT

C Rationale: Use intuitive judgment when time is of the essence. This model calls on your ability to recognize patterns and similarities by combining common sense and your professional training and experience. Science is finding that intuition is actually more than "knowing without knowing how" and is in fact a mental shortcut that happens so quickly you may not be able to articulate the dots your brain connected. A decision grid allows the comparison of "apples to apples". SWOT stands for Strengths, Weaknesses, Opportunities, and Threats. This decision-making model is typically reserved for strategic planning. A consequence table is a balance between the decision grid and decision tree.

A nurse educator determines that the present classroom environment is ineffective in promoting critical thinking. What methods could the educator employ in the classroom to improve critical thinking? (Select all that apply.) A. Study guides B. Lecture C. Problem-based learning exercises D. Case studies E. Simulation

C, D, E Rationale: Case studies, simulation, and problem-based learning exercises are strategies that have been developed to vicariously improve problem solving and decision making. Case studies are stories that impact learning. Simulation allows for opportunities for problem solving. Problem-based learning exercises are opportunities to analyze real-life learning. Lecture and study guides are considered passive learning and are the least effective methods to develop critical-thinking and problem-solving skills.

A new graduate nurse plans to administer early morning medications after receiving change-of-shift report. Which medication should the nurse administer first? A. An antipyretic to a client who has a temperature of 37.9° C (100.7° F) B. An antidiarrheal for a client who had one watery stool in the last hour C. A narcotic to a client who has a pain level of 6 on a 1 to 10 scale D. A scheduled IV antibiotic for a client who has resolving pneumonia

D Rationale: It is critical for the patient with resolving pneumonia to receive ongoing antibiotics to prevent a relapse. This is the priority as compared to the other clinical situations; a pain level of 6/10, one watery stool, or a low-grade temperature are not as concerning as administering an antibiotic, which must be kept on the same medication schedule for optimum therapeutic blood levels. The other medications should certainly be administered, but the exact timing is less critical.

A nurse manager is holding a meeting to discuss a sensitive issue with the staff. A previous meeting was held regarding the same issue and it ended in a negative manner. What action can the manager take in order to minimize the impact of leader/group style mismatch? A. Use a decision-making model. B. Ensure adequate gender role participation. C. Have more extroverts than introverts in the meeting. D. Appoint a leader as a participant.

D Rationale: In order to minimize the impact of leader/group style mismatch, the manager should be aware of the needs of the group. Someone with an appropriate leadership style should be appointed as a participant. This person should be aware of the group's needs and be vocal when necessary. Using a decision-making model may be an appropriate step after utilization of the leader to facilitate positive participation in the group. Gender role does not play a part in minimizing the impact of leader/ group style mismatch. Having more extroverts than introverts can be a negative factor in a meeting as the extroverts can dominate.

Which step in the problem-solving process assists the nurse leader to prioritize the problem or issue? A. Identifying bias B. Identifying stakeholders C. Identifying causative factors D. Identifying the problem

D Rationale: Nurse leaders should first identify/define the problem, issue, or situation to assist them in establishing priorities. It has been noted that one of the most common causes of failure to resolve issues is incorrectly identifying the problem.

A nurse manager schedules a meeting with the staff to discuss policy changes. What does the manager hope to achieve by having some upper left-brain dominant staff members lend their input? A. Holistic input B. An intuitive side C. Creativity D. Logical and rational analysis

D Rationale: Some people tend to be more "left-brain oriented" and prefer progressing in a logical, linear manner. Being analytical is a major characteristic of left-brain thinkers. Left-brain users are great at designing data, gathering processes, and analyzing the data. Creativity, intuitive, and holistic are characteristics of right-brain-dominant people.

A nursing instructor is discussing ways to improve critical thinking during a clinical rotation with a student. The student asks the nurse what critical thinking is. What is the best response by the nursing instructor? A. It is a simple approach to decision-making. B. It is narrower in scope than decision making. C. It is a synonym for the problem-solving process. D. It requires reasoning and creative analysis.

D. Rationale: Critical thinking is a broad term for the process of making meaning of information through evaluation and judgment and may be independent of decision making and problem solving. You can increase your critical thinking ability by questioning everything—especially initial assumptions. One of the best initial questions to ask when problem solving is: "Is this really a problem?"

Using first impressions to guide the decision-making process is a common flaw and considered a pitfall in using decision-making tools. TRUE OR FALSE

TRUE Rationale: A common flaw in using the decision-making process is one's own tendency to base decisions on a "first impression." This is also referred to as confirmation bias. To make an informed and rational decision, the nurse leader should rely on evidence and data collection.

The nurse is admitting a new patient and is collecting data through obtaining a health history and physical assessment. What phase of the problem-solving process is the nurse focusing on with the patient? A. Assessing B. Evaluating C. Planning D. Implementing

A Rationale: Collecting data about a suboptimal situation through interview, research, and observation using visual aids like process or logic flow diagrams is part of the assessing phase of the nursing problem-solving process. This is just like collecting data about the patient through interview, obtaining their health history, and conducting a physical examination. The planning phase is when outcomes are developed. Implementation will occur afterwards, and then the activities as well as the outcomes will be evaluated in the last stage of the process.

The Institute of Medicine (IOM) would consider which behaviors as an indicator of quality care? (Select all that apply.) A. The use of nationally developed and approved patient education materials B. The implementation of a shared governance nursing model C. A hospital requiring annual retraining for all staff in CPR and AED use D. Nurses returning to school to obtain a baccalaureate degree in nursing E. Nurses taking population-specific classes to keep their professional knowledge updated

A, C, D, E Rationale: According to the IOM, for care to be considered high quality, it must be consistent with current professional knowledge. Staying current in professional knowledge in today's information-laden world is difficult and costly but must be done in order to provide evidence-based care. While a shared governance model may result in greater nurse satisfaction, it is not identified as an indicator of quality care.

A nurse has a difficult decision to make regarding patient care. What should the nurse do to influence a positive outcome? (Select all that apply.) A. Gather data and input from a variety of sources. B. Make a quick decision and act on it immediately C. Identify a number of different options. D. Slow down the thinking process E. Understand the repercussions of each option.

A, C, D, E Rationale: Critical thinking, questioning, researching, and obtaining multiple perspectives are all skills that can help during your decision-making process. Gathering data and input from different sources can help the nurse make a more informed decision, as would taking the time to consider the options that are available. It is important to be aware of the consequences of decision making and the actions taken. Making a quick decision and acting on it does not always lead to a positive outcome.

A nurse manager is mentoring a new facilitator. What decision-making models can the manager suggest to the facilitator that will help minimize the impact of an unskilled facilitator? (Select all that apply.) A. Decision tree B. Logic model C. Payoff table D. Consequence table E. Decision grid

A, C, D, E Rationale: The nurse manager can lessen the impact of an unskilled facilitator by using a decision-making model like a decision grid, decision tree, consequence table, payoff table, or SWOT analysis tool. The systemized nature and predictability of using a model will help guide the discussion to a conclusion. As a leader, working with a skilled facilitator first and gradually moving into a facilitation role will help you learn the skills first-hand and ease into the role with confidence. The logic model would not be appropriate in this situation since it is a model that is used to present schematics or pictures of how a program should operate.

According to Marquis and Huston (2021), there are other critical elements that nurse managers/leaders use to complete the decision-making process. From the following choices, select those that are considered crucial to problem-solving and decision-making. A. Develop a realistic timeline B. Delay making a decision as long as possible C. Objectives clearly define D. Generate an alternative solution E. Think logically F. Carefully gather pertinent data

A, C, E, F Rationale: Rather than generating just one alternative solution, generate as many alternatives as possible to increase the chance that the final course of action is sound. In addition, it is important to make a decision and act decisively, remembering that ineffective decisions can be changed.

The charge nurse is making assignments for the next shift. Which patient should be assigned to the new graduate nurse who has just successfully completed her unit orientation? A. A 58-year-old with Guillain-Barre syndrome who is ventilator dependent B. A 60-year-old who needs teaching about the use of incentive spirometry C. A 38-year-old just returned from bronchoscopy with biopsy D. A 38-year-old just admitted on airborne precautions for tuberculosis (TB)

B Rationale: A new graduate nurse who has successfully completed orientation should be competent to teach a patient about the use of incentive spirometry. Patients on a ventilator, those recovering from procedures, or those with significant infection control needs (e.g., TB) should be assigned to an experienced nurse.

When making a decision about using a prn pool for added staffing, what can the nurse manager do to make the best decision? A. Make a decision and then question the facts. B. Make a decision with all of the facts. C. Don't question the first impression. D. Get multiple people to give input into the decision.

B Rationale: Always make an informed decision based on the evidence whenever possible. Question the first impression. Look underneath the initial judgment to see if something else may be going on. Getting input from others is wise, but too many conflicting opinions can make it difficult to make an accurate decision.

A nurse is using the nursing process to plan the care of a newly admitted patient that has had a stroke. What is the benefit of using the nursing process to devise a care plan? A. The patient will have the best outcome from the stroke. B. This method of problem-solving can be transferrable to non-patient problems. C. The nurse will be able to diagnose the patient's medical problem immediately. D. The process will always lead to optimal patient care.

B Rationale: The nursing process—using assessment, diagnosis, planning, implementation, and evaluation—is a scientific problem-solving method that is transferrable to nonpatient problems. The process leads to optimal care but is ever changing and does not always identify issues without frequent alteration. The nursing process diagnoses nursing care problems but not medical problems. It is always the plan that the patient will achieve the best outcomes, but there are many factors that are involved in this process.

Decision-making tools such as decision trees or consequence tables are in place to prevent errors in the decision-making process. TRUE OR FALSE

FALSE Rationale: Human error is always a possibility during decision making, and tools can assist nurse leaders in exploring various alternatives; however, they do not prevent a person from poor or inadequate decisions.

Rationales and justification for decisions need to be communicated to stakeholders only when there is a lack of clarity. TRUE OR FALSE

FALSE Rationale: Rationales and the justification for decisions are part of the decision-making process and must be communicated to all stakeholders to effectively implement potential solutions.

Effective decision making is a learned behavior. TRUE OR FALSE

TRUE Rationale: Effective decision making includes the ability to critically think through any given situation; the thinking process that influences decision making is one that is developed over time.

A nurse is determining whether the outcomes were met for a patient preparing for discharge with an open abdominal wound and reassessing if not met. What phase of the nursing process is the nurse performing? A. Implementing B. Planning C. Evaluating D. Assessing

C Rationale: Determining whether the optimal outcome was accomplished and reassessing if it wasn't is part of the evaluating phase. This phase equates to determining whether the patient health goals defined in the planning phase have been met in the nursing process. Assessment is the first phase of the process and involves the initial gathering of data. Planning requires the development of the outcome standards. Implementation of the plan will allow the nurse to provide the actions required to meet the outcomes.

The nurse working on a medical-surgical nursing floor should plan to assess which client first? A. A patient admitted with renal failure with a previous day's urinary output of 900 cc. B. A patient with a chest tube treating a spontaneous pneumothorax with continuous bubbling in the suction control chamber. C. A patient who is three days' postoperative for a below-knee amputation (BKA) who is tearful and refusing to get out of bed. D. A patient with diabetes and a MRSA-infected leg wound who is requesting to leave the hospital against medical advice.

A Rationale: The patient with renal failure has an actual, current problem whose symptom of decreased urine output may suggest worsening renal failure. The patient with MRSA is not a threat to others should they leave the hospital against medical advice. It is normal and expected for a patient with a BKA to experience the various stages of grief (denial, anger, bargaining, depression and acceptance) when dealing with the loss of past body image. Continuous bubbling in the suction control chamber of a chest tube is normal.

An organization's culture can affect the decision-making process. TRUE OR FALSE

TRUE Rationale:An organization's culture influences decisions made by managers/leaders because many times decisions must reflect the organization's mission and philosophy.

A nurse determines that action is justified for a patient with limited mobility after an injury. After a plan for a solution has been identified, what is the next step in the problem-solving process? A. Assessing B. Diagnosing C. Evaluating D. Implementing

D Rationale: After the planning process, the next step should be to implement; the plan should be enacted and status updates provided. Assessment is the first phase of the process and it involves the initial gathering of data. Diagnosing occurs after the assessment is provided in order to be able develop the outcomes and begin to plan for care. Evaluation occurs in the last phase to determine if the plan has been effective.

If you become aware of the elements of the decision-making process, you will develop effective decision-making skills. TRUE OR FALSE

TRUE Rationale: Developing one's own approach to decision making should be based on the six essential elements or steps of the decision-making process. These steps include establishing a positive decision-making environment, generating potential solutions, evaluating solutions, deciding between the solutions, checking the decisions, and communicating/implementing the decision.

Effective nurse leaders have developed critical thinking and decision-making skills that assist with collaborative leadership. TRUE OR FALSE

TRUE Rationale: The Marquis-Huston Critical Thinking Teaching Model describes the relationship between critical thinking and decision making; this encourages group collaboration and encourages effective interaction between leaders and their subordinates