Exam 2 LDR alternative questions

18. The principle that requires nurses to uphold a professional code of ethics, to practice within the code of ethics, and to remain competent is which of the following?

c. Fidelity ANS: C Fidelity refers to promise keeping or upholding one's promise to practice as a reasonable and prudent nurse would do and in an ethically competent manner.

Hospital Magnet™ decides against creating a separate department to lead and monitor quality activities because: a.Total organizational involvement is critical to QI. b.Data generated by a single, separate department are generally flawed. c.Monitoring and commitment to QI can come only from senior-level managers. d.Staff resent suggestions for improvement that originate outside of their unit.

A Decentralized approaches are effective in developing unit-level solutions, as well as commitment to strategies and implementation of changes.

Hospital ABCD is a Magnet™ hospital. This designation has been applied to Hospital ABCD because it: a.Facilitates active staff participation in decision making related to quality nursing care. b.Has implemented a graduate nurse orientation program. c.Espouses commitment to excellence in patient care. d.Is establishing career ladders for nurses.

A Magnet™ hospitals are particularly successful in implementing excellence in patient care through use of standards, evidence, and participatory decision making in quality improvement. Organizations that cannot pursue Magnet™ status can implement strategies such as career ladders.

Examples of sentinel events include (select all that apply): a.Forceps left in an abdominal cavity. b.Patient fall, with injury. c.Short staffing. d.Administration of morphine overdose. e.Death of patient related to postpartum hemorrhage.

A, B, D, E Sentinel events are serious, unexpected occurrences involving death or physical or psychological harm.

A busy neurologic ICU and step-down unit most likely would use which patient classification system? a. Factor evaluation b. Prototype evaluation c. Hybrid system d. AHRQ system

ANS: A A factor evaluation system is considered more objective than a prototype evaluation system. It gives each task, thought process, and patient care activity a time or rating. Some patient types with a single healthcare focus, such as maternal deliveries or outpatient surgical patients, would be appropriately classified with a prototype system. Patients with more complex care needs and a less predictable disease course, such as those with pneumonia or stroke, are more appropriately evaluated with a factor system. REF: Page 258 TOP: AONE competency: Business Skills

You have hired Chelsea as a new staff member on your unit. Although she is an experienced ICU nurse, this is her first educator role. A month into her new position, she confides that she feels really incompetent in her new position and bursts into tears. Your response is based on application of your understanding of: a. Role acquisition. b. Role conflict. c. Role complexity. d. Performance appraisal.

ANS: A Acquisition of a role is time dependent and involves application of life experiences to each role and interpretation of the role within one's own value system. As roles become more complex, an individual may take longer to assimilate the components of each role.

The validity of comments and ratings related to performance is enhanced by: a. Maintenance of anecdotal notes over the entire evaluation period. b. Quantity of information gathered for appraisal purposes. c. Agreement of the employee with the ratings and comments. d. Whether or not other individuals have contributed to the observations.

ANS: A Anecdotal notes compiled consistently over the entire rating period are a much more equitable method of providing an accurate summary of the employee's performance

As a manager, you are interested in developing behavioral questions for an interview. Knowing that there is team conflict at times on your unit, which of the following questions would satisfy your interest in behavioral questions? a. "Tell me about a time you were involved in a conflict related to a project. What was your role in the conflict? In the resolution of the conflict?" b. "If you were to employ one strategy for managing conflict, what would it be?" c. "What is your preferred style of conflict resolution?" d. "How effective are you in working in a group? In dealing with conflict?"

ANS: A Behavioral questions seek demonstrated examples of behavior from the candidate's past experiences; behavioral-based interviewing can be a strong predictor of a future employee.

The biggest challenge in the recruitment of staff is: a. Finding well-qualified candidates who can function well within your particular work culture. b. Recruiting individuals with the appropriate qualifications and experience. c. Screening out candidates who are unable to function well within a team. d. Determining if candidates have had previous negative experiences in a work environment.

ANS: A Choosing the right individual is the challenge for managers and involves finding qualified candidates who will work well within your culture.

A survey of staff satisfaction is conducted. The survey indicates that staff members are satisfied, are loyal to the organization, and feel that they have reasonable control in their individual responsibilities. The findings best exemplify: a. Clarity in roles and valuing of contributions. b. Satisfaction but not empowerment. c. Effective coaching of new staff. d. Role attachment.

ANS: A Commitment, a sense of control, and satisfaction are linked to clear role expectations and a feeling that contributions are valued.

As the unit manager, you post the staffing plan and compliance reports. This initiative is aimed at: a. Maintaining unit morale. b. Complying with national requirements. c. Demonstrating patient outcomes. d. Inviting staff participation in decision making.

ANS: A Hospitals are responsible for monitoring the extent to which actual staffing matches the staffing plans, making revisions as necessary. The Joint Commission accreditation reviews staffing plans against any obvious staffing deficiencies and patient care concerns. Posting of the staffing plan is required in some states so that staff may view it. Adequate staffing, as demonstrated through a staffing plan, and compliance reports contribute to staff morale.

To maintain patient safety, studies suggest that scheduling should avoid: a. Rotating shifts. b. Weekends. c. 8-hour shifts. d. Mandatory overtime.

ANS: A Rotating shifts and overtime past 12 hours (mandatory or not) are being shown to increase nurse error and jeopardize patient safety.

A nurse manager must also consider a number of internal variables that will affect staffing patterns. An internal variable to be considered is: a. Organizational staffing policies. b. State licensing standards. c. American Nurses Association. d. Consumer expectations.

ANS: A State licensing standards outline what a nurse can do. Internal policies determine what a nurse may do in a particular setting as well as the amount of flexibility that is allowed to manage times of high and low volumes, as well as changes in acuity. Organizational policies can put the nurse manager in a situation where patient safety cannot be maintained or financial obligations met.

Which of the following would be most in line with Hersey and Blanchard's concepts? a. The team of caregivers on day shift are familiar with their roles and with the patients. The nurse manager decides to work on the unit budget in her office. b. After a year of working on the unit, Shari, an LPN, is still hesitant about many policies and procedures. The charge nurse decides to challenge Shari with more difficult patients. c. The nursing supervisor asks one of her charge nurses to lead a technology integration project. The supervisor continuously demands involvement in decisions that the charge nurse is making in the project. d. Team members complain that Alysha, an RN, is unmotivated, and that she refuses assignments that are complex or difficult. The charge nurse suggests that Alysha is relatively new and that she needs time to adjust.

ANS: A The Hersey and Blanchard framework suggests that when ability (skills, job knowledge) and willingness are strong, the involvement of the delegator is less.

An outpatient clinic advertised for RN positions. Before authorizing an open position, the nurse manager should: a. Review the position description and performance expectations for the opening. b. Place an ad in the local newspaper and on the telephone job line. c. Review all current applications on file. d. Look for employees within the system who might best fill the position.

ANS: A The position description provides the basis for this position within the organization and communicates expectations for the role. When applying for a position, researching the facility and position description will help an applicant gain insight into the organization; therefore, the position description should be current and communicate expectations.

The nurse on the 7-7 shift is assigning a component of care to an unlicensed nursing personnel (UNP) employee. The night nurse should remain: a. Accountable. b. Responsible. c. Authoritative and liable. d. Responsible and task-oriented.

ANS: A When a registered nurse delegates care to a UNP, responsibility is transferred; however, accountability for patient care is not transferred. Thus, "accountability rests within the decision to delegate while responsibility rests within the performance of the task" (Anthony and Vidal, 2010, p. 3).

A nurse manager uses many sources of data when planning the unit's workload for the year. Which of the following data must be considered in the planning? a. Hours of operation of the unit b. Trends in acuity on the unit c. Maximum work stretch for each employee d. Weekend requirements

ANS: B Acuity levels are determined through classification systems, which determine the nursing resources required.

Anecdotal notes: a. Should be completed only when there are performance concerns. b. Can be used to support and justify fairness in termination discussions. c. Are unnecessary if the evaluation instrument is thorough. d. Need to be completed at the end of a performance period.

ANS: B Anecdotal notes should be kept consistently throughout the evaluation period and should reflect both negative and positive behaviors if they are to provide an accurate assessment of performance. Anecdotal notes provide documentation to support rating scales and narrative evaluation summaries.

You ask Evelyn, a new UNP, to check what is left in Mrs. N.'s inhaler when Evelyn makes visits to Mrs. N. and also to check whether Mrs. N. is receiving any positive effect from the medication. Evelyn reports for 3 weeks that Mrs. N. is using the inhaler and that there is enough medication left in the device. The day of her last visit to Mrs. N., Mrs. N. is admitted to the hospital in severe respiratory distress. When she is admitted, she tells the physician that she has not been using the inhaler for 4 weeks. Determination of Evelyn's educational preparation and certification is related to the concept of: a. Accountability. b. Authority. c. Role performance. d. Assignment.

ANS: B Authority refers to the right to do and may be designated by law, educational preparation, or job description.

During staff development programs, staff nurses verbalize their frustration about their workloads and having to delegate so many tasks to others. One of the main reasons that delegation has emerged as an issue is because of: a. The amount of paperwork required to complete care. b. The complexity of client care. c. Earlier discharge practices. d. The numbers of other disciplines present on a given unit.

ANS: B Complexity of client care, a multilevel nursing model (registered nurses, mixed with LPNs/LVNs, and UNPs), and community-based care provide many challenges in determining the care required and outcomes desired and/or mandated, and in matching needs with various abilities and authority of regulated and unregulated healthcare providers. The nurse manager should ensure that staff is clinically competent and trained in their roles in patient safety.

Functions such as "delegates tasks to assistive personnel" that are outlined in a position description for an RN Team Leader would be considered: a. Active delegation. b. Passive delegation. c. Passive accountability. d. Active responsibility.

ANS: B Delegation of functions that are normally considered part of or an essential part of the practice of a licensed person through a position description is considered passive delegation.

The day shift nurse asks an LPN/LVN to complete a component of care for a client. The day shift nurse is engaging in what function? a. Delegating b. Assigning c. Sharing d. Authorizing

ANS: B Delegation refers to transfer of responsibility for work; the day shift nurse retains accountability for the outcomes of patient care.

During a performance appraisal, Joanne, the nurse manager, indicates that Alysha has difficulty mentoring students on the unit. Alysha responds that this is not her responsibility. In responding to Alysha, Joanne needs to consider: a. Alysha's level of confidence. b. Whether mentoring is included in the position description. c. Whether mentoring is an essential component of the position description. d. Whether mentoring can be accurately observed and measured.

ANS: B Employees must have clear role expectations, clearly understand what is expected of their performance, and understand the ramifications of not meeting those expectations. Position descriptions provide written guidelines detailing the roles and responsibilities of a specific position within the organizational context.

Which of the following strategies might be effective in empowering staff? a. Communication book in which new information on policies and processes is communicated and mistakes are highlighted. b. Monthly staff meetings during which a portion of the agenda is devoted to sharing ideas and presentations on best practices for implementation on the unit. c. Once-yearly summative evaluations based on what the manager best likes about the individual. d. Focus on discussion of errors in care with direction as to how errors are to be prevented in the future.

ANS: B Empowerment is a process that acknowledges the values and judgments of others and trusts their decisions. It allows freedom for making decisions while retaining accountability and provides an environment that is safe in which to explore.

With delegation, responsibility and accountability remain with the: a. Physician. b. Professional who delegates. c. Individual who receives the delegation. d. Individual who previously performed the task.

ANS: B Even though the delegatee (the one who receives the delegation) receives direction from the professional who delegates a task and must have the authority to complete it, the delegator retains accountability for the overall outcome and completion of the activity. The delegatee has responsibility (obligation to engage in the task) and authority for the task.

John, a new graduate, reviews the employee evaluation for his new position. The first section requires that he list his own specific objectives to be accomplished. This is an example of: a. The traditional rating scale. b. Learning goals, or management by objectives. c. A forced distribution scale. d. A behavior-anchored rating scale.

ANS: B In management by objectives, the employer and the employee jointly establish clear and measurable objectives for the next performance period.

A nurse staffing plan takes into account: a. Specific nurse-to-patient ratios per shift. b. Participation of nurses in projecting staffing needs. c. Compensation and benefits for each level of staff. d. The occupancy load of a unit.

ANS: B Nurse staffing plans employ nursing judgment and flexibility that is based on acuity, nurse experience, and unit configuration rather than set nurse-to-patient ratios. The American Nurses Association has opted to support the nurse staffing committee as the approach to ensure safe staffing. In 2013, national legislation was introduced that requires all acute care hospitals to establish a committee made up of 55% direct care RNs.

Joanne, a new nurse manager, writes certain assumptions regarding the organization's objectives into her budget. Her supervisor tells her that the objectives implied in her assumptions are not entirely consistent with the organization, and that she needs to clarify these objectives with her supervisor. Joanne apologizes and says she had more latitude with the budget where she previously worked. This is an example of: a. Role complexity. b. Role ambiguity. c. Role conflict. d. Time-dependent roles.

ANS: B Role ambiguity in the workplace creates an environment for misunderstanding and hinders effective communication. Without clear expectations of performance, missteps in performance can occur.

The chief nursing officer establishes a shared governance model to help empower the nursing staff, thus empowering the organization. Common characteristics of empowered organizations are: a. Shared values, high salaries, and a human focus. b. Shared values, flexibility, and a human-capital focus. c. Commitment to communication, high salaries, and flexibility for evaluations. d. Creation of community and of effective stress management in the midst of divergent goals.

ANS: B Shared governance involves valuing the contributions of each member of the team, releasing the need to control, and understanding that accountability rests with members of the team.

Staff members on your unit raise concern that there is rising acuity on the unit and lack of responsiveness in addressing these needs through appropriate staffing. They point to increased incidences of adverse and sentinel events on the unit. To address this concern, your hospital organization would do best to: a. Implement a patient classification system immediately. b. Participate in databases that compare the outcomes and staffing levels versus those of institutions similar to yours. c. Provide increased numbers of staff to the unit. d. Ignore such concerns because acuity is variable.

ANS: B Staff morale suffers both when acuity models indicate a gap between staffing and acuity and when there is no model but perceived acuity that is not being addressed. A truer approach is to monitor patient outcomes and participate in national databases that measure staffing levels through comparison with like institutions.

You ask Evelyn, a new UNP, to check what is left in Mrs. N.'s inhaler when Evelyn makes visits to Mrs. N. and also to check whether Mrs. N. is receiving any positive effect from the medication. Evelyn reports for 3 weeks that Mrs. N. is using the inhaler and that there is enough medication left in the device. The day of her last visit to Mrs. N., Mrs. N. is admitted to the hospital in severe respiratory distress. When she is admitted, she tells the physician that she has not been using the inhaler for 4 weeks. This incident is an example of: a. Incompetence of the UNP. b. Failure to follow through. c. Skills but no motivation. d. Lack of accountability.

ANS: B The nurse should maintain open lines of communication and seek information, and the UNP should know how, when, and what to report. Communication of delegation of tasks includes specific information about what is being delegated, expected outcomes, and deviations (which includes what immediate action needs to be taken). This two-way communication and follow-through allows patient care to be altered, if necessary, in a timely manner.

John's performance was satisfactory during the first month, but after that time, he was found to be very inconsistent in the provision of nursing care. One month before the end of the rating period, he cared for a very wealthy and influential client, who is best friends with the clinical manager. This client donated new furniture for the staff lounge in John's name to show appreciation for his care. John's subsequent performance appraisal resulted in outstanding ratings in all areas. This is an example of: a. A performance rating based on justifiable evidence. b. A bias related to recent events. c. The impact of personality on the appraisal of performance. d. The effective use of a behaviorally anchored rating scale.

ANS: B To gain and to provide an accurate evaluation of performance over time, anecdotal notes need to be maintained throughout the evaluation period. This process assists in avoiding bias related to recent or sensational events that make a particularly strong impression.

A particular classification system assigns revenue according to the functional capacity of patients and the progression of patients during their stay in rehabilitation units. More independent patient activities, such as prompted voiding, require higher staff utilization than dependent activities but do not result in increased staff resources. This is an example of: a. Bureaucracy. b. Concern related to the validity of classification systems. c. Inadequate reliability of classification systems. d. Inappropriate subjectivity in making judgments about staffing.

ANS: B Validity of categories and implications for staffing levels are in question in this situation because staffing levels are not reflective of the levels of

A factor evaluation system: a. Utilizes financial data to determine number of staff-to-patient ratios. b. Utilizes DRGs to determine acuity on a unit. c. Combines interventions and time required for interventions to determine levels of care required. d. Combines financial resources and nursing interventions to determine patient contact hours.

ANS: C A factor evaluation system considers tasks, thought processes, and patient care activities and gives them a time or rating. These are then used to determine the number of patient care hours required.

An important aspect of managing the costs on a unit is to plan accurately for staffing needs. Nurse managers use staffing plans to: a. Assign staff on the unit on a daily basis. b. Ensure that days off are planned for the staff. c. Outline the number of individuals by classification on a per-shift basis. d. Predict the numbers and classifications of float staff needed to augment regular staff.

ANS: C A nurse manager needs to manage financial resources by developing staffing plans. Staffing plans plan for minimum number of professional nurses required on a unit at a given time or to the amount of minimum staffing in an extended-care facility or prison, based on regulatory guidelines.

Which of the following might best conclude an interview? a. "Thank you for your interest. Someone will be in touch with you soon." b. "Before you go, we will make sure that we have your contact information. Thank you for coming." c. "I will be in contact with all candidates by telephone by next Friday. It has been a pleasure to meet you." d. "We have several excellent candidates so I am not sure about the outcome of the interview, but I will let you know. Thank you for coming."

ANS: C An employment interview should always conclude with information as to how and when follow-up to the interview will occur.

Scheduling is a function of implementing the staffing plan by assigning unit personnel to work specific hours and specific days of the week. To retain nursing staff, the nurse manager must schedule: a. All weekends off. b. All holidays off. c. A variety of scheduling options. d. Rotating shifts.

ANS: C Creating a flexible schedule with a variety of scheduling options that leads to work schedule stability for each employee is one mechanism likely to retain staff, which is within the control of nurse managers.

Ali, an RN on your unit, is consistently late to work and makes remarks such as "Do you really want me to do that?" when patients and care are assigned to her. You have spoken with her frequently about her: a. Ability. b. Skills. c. Attitude. d. Personal issues.

ANS: C Hersey and Blanchard explained followership in terms of ability and willingness. Attitude refers to willingness or reluctance to perform work.

An RN colleague, who is a long-standing and collaborative member of your team, is performing a complex and novel dressing for the first time for the patient to whom she has been assigned. Which of the following would be the most appropriate communication with her? a. "How do you usually do this kind of dressing?" b. "The dressing needs to be done today and tomorrow with the supplies on this cart." c. "Here is what you need for the dressing, and I will show you what needs to be done." d. "I know you know what you are doing. Let me know if you have any problems."

ANS: C If a situation involves a new task and the relationship is ongoing (two individuals who will usually continue to work together), the delegator explains what to do and how to do it. Hersey described the leader's behavior as explaining or persuading, which, is characterized as "selling." The RN who is assigned to the patient is an experienced nurse and team member, but is new to this specific situation. In situations where the nurse is experienced but the task is new, explain (and demonstrate) what needs to be done.

The unit manager is working in a large metropolitan facility and is told that two UNPs are to be assigned to work with her. Delegation begins with: a. Acknowledging the arrival of the second UNP on the unit. b. Providing clear directions to both UNPs. c. Matching tasks with qualified persons. d. Receiving reports from the prior shift.

ANS: C In delegating to the UNPs, the nurse must consider what cannot be delegated, as well as the factors of safety, time, critical thinking, and stability of patients.

To prepare staffing schedules, a nurse manager needs to calculate paid nonproductive time. When calculating paid nonproductive time, the nurse manager considers: a. Work time, educational time, and holiday time. b. Paid hours minus worked hours. c. Vacation time, holiday time, and sick time. d. Paid hours minus meeting time.

ANS: C Nonproductive hours are hours of benefit time and include vacation, holiday, and personal or sick time.

In a job interview for a staff position, which of the following indicates your knowledge of patient safety? a. "Will I be able to get overtime hours on your unit?" b. "If there is an opportunity to work extra shifts, I would really like that." c. "Is there a strategy in place to reduce the number of overtime hours on the unit?" d. "I see no reason why I wouldn't be able to work overtime."

ANS: C Overtime, whether voluntary or mandatory, to fill staff vacancies is seen as a risk to both patients and nurses because it is more likely to lead to compromised decision making and technical skills because of fatigue.

Which of the following exemplifies accountability? Karen, the nurse manager on 5E: a. Consistently submits her budgets on time. b. Gets along well with her staff and with other managers. c. Outlines her rationale for reduction of RN coverage on nights to the Nursing Practice Committee after serious patient injury. d. Actively solicits ideas regarding scheduling from her staff.

ANS: C Reliability, dependability, and obligation to fulfill the roles and responsibilities of the nurse manager are consistent with responsibility. Accountability refers to being answerable for actions and results

In evaluating weekend mortality rates, the head nurse on the cardiac unit is surprised to find that they are higher than on weekdays. In exploring the reasons for this apparent anomaly, the head nurse focuses on: a. Availability of diagnostic personnel. b. Availability of physicians. c. Communication with on-call providers. d. Acuity level of patients.

ANS: C Studies to date of off-peak hours (weekends and nights) are limited, but those that have been done indicate increased mortality during weekends and nights, when staff work with fewer and often less experienced staff and when there may be strained communication among on-call healthcare providers.

County Hospital has position descriptions for all staff, including RN Team Leaders. Sarah, a team leader on the rehab unit, assesses the needs of the patients in her area, assesses the skills and backgrounds of each of the individuals on her team, and then assigns and delegates the appropriate care provider to each patient and task. Sarah's activity in the example described is termed: a. Passive delegation. b. Passive accountability. c. Active delegation. d. Active responsibility.

ANS: C When a position description contains functions that are considered to be the normal practice of the person in that role, then it is considered a passive delegation act. When Sarah decides what is best for the patients in her care in terms of who should perform the care and then holds the person accountable, she is engaging in active delegation.

County Hospital has position descriptions for all staff, including RN Team Leaders. Sarah, a team leader on the rehab unit, assesses the needs of the patients in her area, assesses the skills and backgrounds of each of the individuals on her team, and then assigns and delegates the appropriate care provider to each patient and task. Sarah provides Colleen, her RN colleague with details regarding the patients to whom Colleen has been assigned on the day shift. This is an example of: a. Accountability. b. Responsibility. c. Assignment. d. Delegation.

ANS: C When an RN assigns care to another RN, it is termed an assignment and not delegation, because both accountability and responsibility are transferred.

The final section of a performance appraisal is a rating scale. This scale is very detailed and relates to competency standards specific to surgical clients. The scale is a summary of performance directly observed or documentation reviewed and is specific to client care situations in which the employee has been involved. This type of evaluation is most commonly known as: a. A traditional rating scale. b. Management by objectives/learning goals. c. A forced distribution scale. d. A behaviorally anchored rating scale.

ANS: D BARS contain both quantitative (rating scales) and qualitative data. They are specific to situations and positions.

A nurse manager in the ICU works with his staff to develop an appraisal instrument that includes quantitative data and respects standards for an RN working on that unit. This type of appraisal is a: a. Rating scale. b. Collaboratively based appraisal system. c. Narrative instrument. d. Behaviorally anchored rating scale.

ANS: D Behaviorally anchored rating scales (BARSs) describe performance quantitatively and qualitatively.

In delegating to a UNP in a home health setting, which of the following represents the most appropriate delegation communication? a. "You will be taking care of Mrs. S., who needs assistance with her bath." b. "You will need to help Mrs. S. get into and out of her shower. Ensure that you check the condition of her feet, and let me know if you have any concerns when you check in." c. "I am not sure that you know how to do this, but I am giving you Mrs. S. She is quite obese and needs skin care." d. "Mrs. S. needs help to get into and out of her bathtub. Her bath will need to be completed by 10:00. When you are helping her to dry, please check between her toes and toenails, and phone me by 10:30 if you notice nail discoloration or redness."

ANS: D Delegation communication includes what is being delegated (and what is not), outcomes, specific deadlines (if applicable), specific reporting guidelines (what, when), and who may be consulted. Communication also includes conveying recognition of the authority to do what is expected.

Your healthcare organization has a decentralized system for scheduling. As part of this process, after you have developed a draft schedule, you may need to: a. Seek budgetary approval. b. Balance personal schedules against institutional needs. c. Negotiate the schedule with unit staff. d. Submit the schedule to a centralized staffing office for review.

ANS: D In a decentralized model, you may be completely responsible for approving all schedule changes and for development of the schedule, or you may need to submit a draft to a centralized office for review and determination of supplemental staff. Balancing personal schedules and negotiation describes staff self-scheduling models.

The night nurse understands that certain factors need to be considered before delegating tasks to others. These factors include the: a. Complexity of the task and the age of the delegatee. b. Potential for benefit and the complexity of the task. c. Potential for benefit and the number of staff. d. Complexity of the task and the potential for harm.

ANS: D In delegating tasks to others, the nurse considers factors such as stability of the patient, safety of the situation and of the patient, time and intensity involved, and level of critical thinking required to achieve desired outcomes.

A nurse manager must consider a number of external variables when preparing the personnel budget and projecting the unit's staffing needs. An external variable to be considered is: a. Organizational staffing policies. b. Staffing models. c. Changes in services that will be offered. d. Department of Health licensing standards.

ANS: D Licensing regulations of the state can determine staffing models. Staffing regulations can dictate the number of professional nurses required on a unit at any given time.

In the past year, you have noticed an increase in patient falls on your unit. In reading studies related to staffing and patient outcomes, you realize that you will need to plan for: a. Higher patient care hours. b. Safer facilities. c. Institution of a patient classification system. d. An increased number of RN positions.

ANS: D Lower fall rates are shown to be related to higher total nursing hours and a higher percentage of nursing hours supplied by RNs.

A strategy to increase RN staff retention at Valley Hospital includes: a. Better compensation and benefits. b. Clearer position descriptions. c. Lay-offs of nursing assistants. d. Adequate staffing to meet acuity levels.

ANS: D Over the past decade, a significant amount of research has been done in the United States to evaluate links among nursing staffing, workloads, skills mix, and patient outcomes. An analysis of this research demonstrates that ensuring adequate staffing levels has been shown, among other things, to improve nurse retention and job satisfaction.

The turnover rate for RNs in the ICU is high. You discuss this situation with existing staff and you find out that because of the rapid turnover, new staff are frequently required to assume full responsibilities soon into the position and before training is completed. In considering approaches that will reduce turnover rates, the staff and you decide to implement: a. An employee recognition program. b. Coaching for new staff. c. A new performance appraisal system. d. A committed orientation and training program.

ANS: D Retention of new nursing personnel begins on the day of their hire. This includes an effective, appropriate orientation and training program, which has a measurable impact on reducing turnover.

You have hired a new RN to replace a well-respected and experienced nurse in your outpatient department. The new RN recently graduated and is nervous about stepping into a role that was previously filled by someone who was so competent. You recognize anxiety and set up regular, frequent meetings during which you explore how she is dealing with her anxiety, provide feedback, and discuss strategies/ideas that will enhance her performance. What development approach are you using? a. Performance appraisal. b. Counseling. c. Empowerment. d. Coaching.

ANS: D The overall evaluative process can be enhanced if the manager employs the technique of coaching. Coaching is a process that involves the development of individuals within an organization. This coaching process is a personal approach in which the manager and the employee interact on a frequent and regular basis with the ultimate outcome that the employee performs at an optimal level.

A key advantage that a nurse manager has in terms of delegating is that: a. Clients receive less attention because too many staff make it difficult to coordinate care. b. Nurses report less pressure to perform necessary tasks themselves. c. Administration can predict overtime more accurately. d. Team skills can be used more effectively.

ANS: D The use of multilevel healthcare providers enables healthcare organizations and nursing to provide patient-centered care, with a focus on abilities and skills that can be employed to perform "what is needed now." As tasks become more complicated, delegating skills to others enables the nurse to effectively deliver a complex level of care.

You are working in a home health service and have three unlicensed nursing personnel (UNPs) assigned to your team. You have worked with two of them for 2 years; the third is new. The two experienced UNPs have patients with complex illnesses for whom they provide basic care. The third member of the team has been assigned to patients with less complex illnesses. Your best approach to supervising their care is to: a. Remain in the office and ask each UNP to check in with you upon arrival at their first patient care site. b. Ask another RN to supervise the two experienced assistants so you can be with the new person full time. c. Meet the new staff member at the first patient care site and ask the others to call if anything is unusual. d. Meet the new staff member at the first patient care site and call the others with questions to determine whether anything is unusual.

ANS: D When ability and willingness are strong, the involvement of the delegator is less (Hersey and Blanchard).

Leslie, a UNP, transfers a patient while using improper technique. The patient is injured, and as a result, a suit is launched in which both Sarah (the delegator) and Leslie (the delegatee) are named. Sarah is named in the suit because she: a. Retains accountability for the care of the patient. b. Worked the same shift as Leslie. c. Has passive accountability for delegation. d. Retains accountability for the outcomes of care for the patient.

ANS: D Whenever care is provided by someone other than a registered nurse, accountability for care remains with the manager/delegator even though others provide aspects of care.

Healthcare organization X is committed to improving patient outcomes and, as part of the QI process, examines its executive structure and organizational design. This approach recognizes: a.The importance of decentralized structure in QA. b.That structure influences nurse burnout and participation in quality improvement initiatives. c.The need to ensure sufficient supervisory staff to respond in a corrective manner when mistakes occur. d.That a narrow hierarchy ensures accountability for errors and outcomes.

B Common organizational characteristics of Magnet™ hospitals include structure factors (e.g., decentralized organizational structure, participative management style, and influential nurse executives) and process factors (e.g., professional autonomy and decision making, ongoing professional development/education, active quality improvement initiatives). ANCC Magnet™ designated hospitals and other high-reliability organizations in the United States and Europe generally have lower burnout rates, higher levels of job satisfaction, and provide higher levels of quality care resulting in greater levels of patient satisfaction (Aiken et al., 2012; Kelly, McHugh, & Aiken, 2011).

The nurse educator of the pediatric unit determines that vital signs are frequently not being documented when children return from surgery. According to quality improvement (QI), to correct the problem, the educator, in consultation with the patient care manager, would initially do which of the following? a.Talk to the staff individually to determine why this is occurring. b.Call a meeting of all staff to discuss this issue. c.Have a group of staff nurses review the established standards of care for postoperative patients. d.Document which staff members are not recording vital signs, and write them up.

B Leadership must identify safety shortcomings and must locate resources at patient care levels to identify and reduce risks. One method of doing this is to invite all staff into a discussion related to solutions to an identified concern. This approach encourages teamwork.

The outcome statement "Patients will experience a ten percent reduction in urinary tract infections as a result of enhanced staff training related to catheterization and prompted voiding" is: a.Physician-sensitive and nonmeasurable. b.Measurable and nursing-sensitive. c.Precise, measurable, and physician-sensitive. d.Patient care-centered and nonmeasurable.

B Nursing-sensitive outcomes refer to outcomes that are affected by nursing activity and are precise, measurable, and patient-centered.

A nurse manager wants to decrease the number of medication errors that occur in her department. The manager arranges a meeting with the staff to discuss the issue. The manager conveys a total quality management philosophy by: a.Explaining to the staff that disciplinary action will be taken in cases of additional errors. b.Recommending that a multidisciplinary team should assess the root cause of errors in medication. c.Suggesting that the pharmacy department should explore its role in the problem. d.Changing the unit policy to allow a certain number of medication errors per year without penalty.

B Quality management stresses improving the system, and the detection of staff errors is not stressed. If errors occur, reeducation of staff is emphasized rather than imposition of punitive measures such as disciplinary action or blaming.

Before beginning a continuous quality improvement project, a nurse should determine the minimal safety level of care by referring to the: a.Procedure manual. b.Nursing care standards. c.Litigation rate of unsafe practice. d.Job descriptions of the organization.

B Standards establish the minimal safety level of care. Procedure manuals provide information about how standards are to be achieved.

A new graduate is asked to serve on the hospital's quality improvement (QI) committee. The nurse understands that the first step in quality improvement is to: a.Collect data to determine whether standards are being met. b.Implement a plan to correct the problem. c.Identify the standard. d.Determine whether the findings warrant correction.

C Before further action (data collection, decision making related to correction, and implementation of a plan) can occur, it is necessary to identify the standards against which data collection and decision making will occur. Institutions may or may not adopt standards that are already established by organizations such as the ANA.

The nurse manager is concerned about the negative ratings her unit has received on patient satisfaction surveys. The first step in addressing this issue from the point of view of quality improvement is to: a.Assemble a team. b.Establish a benchmark. c.Identify a clinical activity for review. d.Establish outcomes.

C In theory, any and all aspects of clinical activity could be improved through the QI process. However, QI efforts should be concentrated on changes to patient care that will have the greatest effect.

The chief executive officer asks the nurse manager of the telemetry unit to justify the disproportionately high number of registered nurses on the telemetry unit. The nurse manager explains that nursing research has validated which statement about a low nurse-to-patient ratio? It: a.Promotes teamwork among healthcare providers. b.Increases adverse events. c.Improves outcomes. d.Contributes to duplication of services.

C Studies related to staffing and patient outcomes suggest that patient outcomes are improved with a low nurse-to-patient ratio and especially with a low registered nurse-to-patient ratio.

As a nurse manager, you know that the satisfaction of patients is critical in making QI decisions. You propose to circulate a questionnaire to discharged patients, asking about their experiences on your unit. Your supervisor cautions you to also consider other sources of data for decisions because: a.The return rate on patient questionnaires is frequently low. b.Patients are rarely reliable sources about their own hospital experiences. c.Hospital experiences are frequently obscured by pain, analgesics, and other factors affecting awareness. d.Patients are reliable sources about their own experiences but are limited in their ability to gauge clinical competence of staff.

D Patients are reliable and motivated sources of their own experience but often do not have sufficient knowledge of clinical procedures to provide feedback about clinical competence.

The nurse gives an inaccurate dose of medication to a patient. After assessment of the patient, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication understands that: a.The error will result in suspension. b.An incident report is optional for an event that does not result in injury. c.The error will be documented in her personnel file. d.Risk management programs are not designed to assign blame.

D QM stresses improving the system, and the detection of staff errors is not stressed. If errors occur, reeducation of staff is emphasized rather than imposition of punitive measures such as disciplinary action or blaming.

At Hospital Ajax, there has been a 20% increase in instruments and sponges being left in patients during surgery and surgeries on the wrong limbs. These are known as: a.Sentinel events. b.Medically sensitive events. c.Nurse-sensitive events. d.Never events.

D The NQF and CMS define never events as errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients and that indicate a real problem in the safety and credibility of a healthcare facility. Examples of never events include surgery on the wrong body part, foreign body left in a patient after surgery, mismatched blood transfusion, major medication error, severe pressure ulcer acquired in the hospital, and preventable postoperative deaths.

In designing a quality, safe healthcare environment, the primary emphasis needs to be on:

The patient. ANS: D Focusing on the patient moves care from concern about who controls care to a focus on what care is provided to and with patients, which was an aim identified in the IOM report Crossing the Quality Chasm.

2. With regard to nursing practice, nurse managers are held responsible for (select all that apply):

a. Practicing within legal guidelines established under state law and nurse practice acts. b. Ensuring that nursing staff under their supervision are currently licensed to practice. ANS: A, B Nurses are responsible for knowing and practicing under state law and nurse practice acts. Managers are responsible for monitoring staff practice and ensuring that staff hold current, valid licensure.

19. Mr. M. complains to you that one of your staff asked him details about his sexual relationships and financial affairs. He says that these questions were probing and unnecessary to his care, but he felt that if he refused to answer, the nurse would be angry with him and would not provide him with good care. Mr. M.'s statements reflect concern with:

a. Privacy. ANS: A Privacy protection includes protection against unwarranted intrusion into the patient's affairs.

8. One means of ensuring that nurses floated to other patient care areas in healthcare organizations are qualified to work in those areas is:

b. Cross-educating staff members to other areas of the institution. ANS: B Nurses should be floated to units as similar as possible to their own to decrease the potential for liability. Negotiating cross-training, a proactive approach to temporary staffing problems, reduces the potential for liability.

23. While walking past a patient's room, you overhear one of the RN staff telling a patient that the patient has no right to refuse chemotherapy treatment because the family and the doctor think the treatment is the best option for the patient. This patient is 40 years of age and alert. When you meet later to discuss what you heard with the RN, it is important to:

b. Discuss that statute law provides for patient autonomy and refusal of treatment. ANS: B Statute law states that the patient must be given sufficient information, in terms he or she can reasonably be expected to comprehend, to make an informed choice. Inherent in the doctrine of informed consent is the right of the patient to informed refusal. Patients must clearly understand the possible consequences of their refusal.

22. A member of a patient's family calls the nurse manager of the palliative care unit to express concern that a member of the family, who died on the weekend, had requested analgesics from the RNs on duty. An RN came with the analgesic nearly 45 minutes later, just after the patient had died. The manager is aware that the unit was especially busy that weekend because many patients were seriously ill, staff had called in ill, and the staffing manager was unable to completely replace staff who were absent. The manager is deeply troubled that the family member had to die in pain because it violates what she knows should have been done. This manager is experiencing:

b. Moral distress. ANS: B Moral distress is experienced when nurses cannot provide what they perceive to be best for a given patient. Examples of moral distress include constraints caused by financial pressures, limited patient care resources, disagreements among family members regarding patient interventions, and/or limitations imposed by primary healthcare providers.

21. In a telehealth organization, a nurse who is licensed in New York and Pennsylvania provides teaching to a patient who resides in Pennsylvania. The patient charges that the teaching failed to provide significant information about a potential side effect, which led to delay in seeking treatment and untoward harm. Under which state nurse practice act and standards would this situation be considered?

b. Pennsylvania ANS: B Under the law, the state in which the patient resides and not the state where the nurse holds his or her license determines the state nurse practice act that is considered.

13. The parents of a toddler who dies after being brought to the ER launch a lawsuit, claiming that the failure of nurses to pursue concerns related to their son's deteriorating condition contributed to his death. The senior nurse executive is named in the suit:

b. Under the doctrine of respondeat superior. ANS: B Known as vicarious liability, the doctrine of respondeat superior makes employers accountable for the negligence of their employees, using the rationale that the employee could not have been in a position to have caused the wrongdoing unless hired by the employer.

The IOM Health Professions Education report highlighted patient safety concerns as:

b. A result of disciplinary silos. ANS: B The IOM Health Professions Education report (2004) highlighted the education of health disciplines in silos as a major concern in patient safety and endorsed five recommendations.

To increase safety in patient care areas of the Valley Hospital, the executive begins by:

c Ensuring that the senior nursing officer attends the board meetings. ANS: C The IOM report (2004) highlighted the importance of the attendance of the senior nurse executive at board meetings to be a key spokesperson on safety and quality issues.

20. To satisfy duty of care to a patient, a nurse manager is legally responsible for all of the following except:

d. Supervising the practice of the physician. ANS: D Legally, the nurse manager is accountable to nursing practice standards, standards for nurse administrators, and hospital policies and procedures.

As the manager on an acute care medical unit, you note that the incidence of medication errors has increased since the implementation of staffing changes. As part of your strategy to reduce errors, it is important to

d. Involve RN staff in determining reasons for errors and practice solutions to increase the safety of medication administration. ANS: D Keeping Patients Safe: Transforming the Work Environment of Nurses (2004) identified many past practices that had a negative impact on nurses, and thus on patients, and recommended the inclusion of nurses in direct care in decision making involving their practice. Future of Nursing: Leading Change, Advancing Health (2010) also emphasizes the role of nurses as leaders in changes that improve health.

An example of an effective patient outcome statement is: a.Eighty percent of all patients admitted to the Emergency Department will be seen by a nurse practitioner within 3 hours of presentation in the Emergency Department. b.Patients with cardiac diagnoses will be referred to cardiac rehabilitation programs. c.The hospital will reduce costs by 3% through the annual budget process. d.Quality is a desired element in patient transactions.

A Patient outcomes must be measurable, specific, and patient-centered.

In determining the relationship between injury-producing falls and proposed preventive measures as part of the QI process, a QI team might turn to which of the following for confirmatory evidence? a.NDNQI b.NANDA c.NIOSH d.AHRQ

A The National Database of Nursing Quality Indicators is a national, nursing quality measurement program from the American Nurses Association that provides hospitals with unit-level performance reports with comparisons to national averages and rankings.

A nurse is explaining the pediatric unit's quality improvement (QI) program to a newly employed nurse. Which of the following would the nurse include as the primary purpose of QI programs? a.Evaluation of staff members' performances b.Determination of the appropriateness of standards c.Improvement in patient outcomes d.Preparation for accreditation of the organization by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

C The primary purpose of QI is improvement of patient outcomes, which relates to prevention of error, quality patient care, and patient satisfaction.

To achieve nurse-sensitive care standards developed by the NQF, you advocate for which of the following in your health facility?

Evidence-based practice to reduce the prevalence of pressure sores. ANS: A The National Quality Forum (NQF) outlines nursing-centered intervention measures related to prevalence of pressure sores, ventilator-associated pneumonias, volunteer turnover, nursing care hours per day, and skill mix of staff.

17. Which ethical principle is primarily involved in informed consent?

b. Autonomy ANS: B Autonomy refers to the right to choose freely, which is inherent in informed consent.

Through the QI process, the need to transform and change the admissions process across administrative and patient care units is identified. In this particular situation, what method of data organization will be most effective? a.Flowchart b.Histogram c.Narrative d.Line graphs

A Flowcharts are useful in identifying and visualizing sequential steps, such as the admissions process.

A nursing unit is interested in refining its self-medication processes. In beginning this process, the team is interested in how frequently errors occur with different patients. To assist with visualizing this question, which organizational tool is most appropriate? a.Histogram b.Flowchart c.Fishbone diagram d.Pareto chart

A Histograms are bar graphs that are useful in outlining and identifying frequency.

A nursing-led classification system that has led to greater reliability and standardization in data utilized for QI processes is: a.NANDA. b.AHRQ. c.NIOSH. d.Nursing process.

A NANDA has been developed by nurses and uses standardized terminology that enables study of health problems across populations, settings, and caregivers.

To reduce reliance on overtime hours, an organization develops a strategy for floating nurses during staff shortages. To maximize patient safety and reduce costs, the healthcare organization: a. Develops a centralized pool of float nurses. b. Assigns nurses from less busy units to ones with increased acuity levels. c. Floats nurses only between units on which the nurses have been cross-trained. d. Assigns float nurses to basic care only.

ANS: A A centralized pool usually includes experienced nurses who maintain a broad range of competencies. Other approaches are less satisfying for nurses, are less efficient, and may be less safe.

The difference between staffing and scheduling is that staffing: a. Puts the right person in the right position. b. Puts the right person in the right time and place. c. Refers to the number of nursing hours per patient per day. d. Looks after interpretation of benefits and compensation.

ANS: A Nursing staffing involves planning for hiring and deploying qualified human resources to meet the needs of a group of patients. Scheduling, on the other hand, is a function of implementing the staffing plan by assigning unit personnel to work specific hours and days of the week.

The nurse manager schedules evaluations of staff members using a newly developed performance appraisal tool. The development of a performance appraisal tool should include: a. Organizational mission, philosophy, and position requirements. b. A generalized overview of the duties of a position. c. A skills checklist and accreditation requirements. d. An ordinal scale that ranks all employees.

ANS: A Performance appraisal tools and processes should reflect the organizational mission and philosophy, as well as position requirements.

On your unit, despite efforts to build a strong sense of team, conflict between some of the staff is ongoing. Nonetheless, you want to proceed with developing a systematic and effective performance appraisal system. Which of the following approaches would be most appropriate for you to implement? a. Peer review b. A combination of tools c. Anecdotal notes d. Rating scale

ANS: B A combination of tools is likely superior to any one method in any situation.

Sue, a nurse manager, discusses her concerns about the hospital's employee appraisal system with her work group, noting that it includes only one rating scale and that it means nothing unless the manager has effective relationship skills. Sue's concerns reflect which best practices associated with performance appraisal? a. Rating scales are too generalized to be considered valid or reliable. b. The effectiveness of appraisal is enhanced by a combination of methods and effective communication skills. c. BARS is considered superior to simple rating scales in terms of performance appraisal. d. Rating scales need to be designed by users to be well accepted.

ANS: B A combination of several methods is probably superior to any one method. The primary success of any performance appraisal lies in the skills and communication abilities of the manager.

A small rural hospital has been designated as a critical access hospital. It has 40 beds and an average occupancy of 34 beds. To prepare the staffing, the chief nursing officer computes the occupancy as being: a. 90%. b. 85%. c. 75%. d. 60%.

ANS: B A way to assess a unit's activity level is to calculate the percentage of occupancy. Formula: daily patient census (rounded) divided by the number of beds in the unit The occupancy level is calculated as 34/40, or 85%.

To project staffing needs and to avoid understaffing, it is important that nurse managers consider which of the following? a. Maximum productive hours b. Average nonproductive hours c. Minimum benefit hours d. Maximum vacation time

ANS: B To avoid understaffing, average nonproductive or benefit hours need to be taken into account, so the unit is properly staffed when staff members are off.

During a fire drill, the nurse manager becomes very assertive and directive in her communications with staff. This type of situational leadership depends on: a. Supportive behavior by the leader and immature followers. b. The development level of the followers and the type of behavior of the leader. c. Well-developed followers combined with a strong leader who acts quickly. d. The leader's ability to evaluate personnel and communicate that evaluation.

ANS: B When abilities, relationships, and/or time is limited (as in a crisis situation), the leader assumes a bigger role in guiding and in making decisions (Hersey and Blanchard and "telling" behavior).

19. You ask Evelyn, a new UNP, to check what is left in Mrs. N.'s inhaler when Evelyn makes visits to Mrs. N. and also to check whether Mrs. N. is receiving any positive effect from the medication. Evelyn reports for 3 weeks that Mrs. N. is using the inhaler and that there is enough medication left in the device. The day of her last visit to Mrs. N., Mrs. N. is admitted to the hospital in severe respiratory distress. When she is admitted, she tells the physician that she has not been using the inhaler for 4 weeks. Before assigning Evelyn to Mrs. N.'s care, the most appropriate action of the care coordinator would have been to: a. Determine Evelyn's educational background and preparation for this role. b. Ask Evelyn if she has worked with inhalers before and to describe what she knows about them. c. Advise that if Evelyn has any questions about what to do with the inhaler, she should come to the coordinator. d. Advise Evelyn that working the inhaler is not really complicated and that she should ask the patient how to check medication levels in the inhaler.

ANS: B When delegating tasks, in addition to specifying the task to be completed, outcomes, priorities, timelines, deviations, report time frames, monitoring, and resources, asking the delegatee to give examples of each is helpful in ensuring that communication is clear and has been understood. Preparation of UNPs lacks consistency; therefore, the safest practice is to determine the knowledge and skill level of the UNP in relation to the skill and the patient before delegating.

Which of the following indicates safe delegation? a. The nurse supervisor for a large urban acute care department asks the unit manager to accept two new acutely ill patients, which the manager does. The unit is short two staff, and the replacement is inexperienced. b. A unit manager agrees to release a staff from her unit to Unit B. The staff member she agrees to release is experienced on Unit B and is agreeable to the change. The unit manager's unit is fully staffed and patients are stable. c. The nurse supervisor asks the head nurse for Unit A to make do without a replacement for an ill staff member because Unit A was originally overstaffed anyway. Patient acuity levels are very high on Unit A and two staff are orientating. d. The nurse supervisor asks the charge nurse on Unit B to cover Unit F, which is two floors up, because the charge nurse for Unit F is ill. The charge nurse for Unit B is an experienced manager but has no experience with the nursing care required on Unit F.

ANS: B When span of control (number of individuals for whom a manager is responsible) is compromised by geographic factors such as lack of proximity, instability in patients' conditions, or lack of experience, the span of control that is being delegated may lead to unsafe care.

Your institution has identified a recent rise in postsurgical infection rates. As part of your QI analysis, you are interested in determining how your infection rates compare with those of institutions of similar size and patient demographics. This is known as: a.Quality assurance. b.Sentinel data. c.Benchmarking. d.Statistical analysis.

C Benchmarking is a widespread search to identify the best performance against which to measure practices and processes.

In determining the fit of a candidate with the culture on your unit, which of the following interview questions might be asked? a. "Could you review your resume for us, highlighting your certifications and experience?" b. "If we were to ask your references, what would they list as your strengths? Weaknesses?" c. "We have a number of older adult patients on this unit. If you noticed another staff member addressing one of these patients impatiently, how would you respond?" d. "Tell us about your work and academic experiences and qualifications."

ANS: C The nurse manager wants the most qualified individual for the position who also fits the culture of the organization. Asking behavioral questions in the interview allows you to assess how a candidate may function in real-life situations and to assess if this behavior is compatible with the culture on the unit.

The nurse manager is setting up the room assignments for the unit. She has one critical patient on the unit, who is going to require more care than the others. Before delegating a task, a nurse manager should: a. Delegate the admission assessment to the LPN. b. Review the employee's performance assessment for the most recent period. c. Assess the amount of guidance and support needed in a particular situation. d. Create a task analysis of critical behaviors for the individual.

ANS: C To delegate effectively, the nurse manager must assess the abilities required in the situation and the abilities that staff have to anticipate the amount of direction, monitoring, explanation, and independence that can be assumed.

John notes that the next section is specific to the organizational philosophy and has a four-point ordinal scale that describes performance from "always meets expectations" to "does not meet expectations." This type of evaluation is most commonly known as: a. A behavior-anchored rating scale. b. Management by objectives/learning goals. c. The forced distribution scale. d. A graphic rating scale.

ANS: D Graphic rating scales are commonly used in evaluation and reflect generalizations rather than specific behaviors.

The number of adverse events such as falls and pressure ulcers on your unit is increasing. An ideal staffing plan to address this issue would include which of the following? Increasing the: a. Total number of staff on the unit. b. Staff and RN hours per patient. c. Total number of staff, and implementing 12-hour shifts. d. Number of RNs and number of RNs with experience on the unit.

ANS: D A number of studies have identified that adverse events such as falls and pressure ulcers can be reduced by increasing the number of RNs on a unit (relative to other personnel) and utilizing experienced RNs. Overtime and 12-hour shifts are linked to greater incidence of errors.

You are a member of a team assigned to care for 15 general medical/surgical clients. You have all worked well together in the past in this same type of care. If you are assigned to coordinate this team's work, your best strategy, based on the Hersey and Blanchard model, would be to: a. Have a list of tasks to be accomplished and tell each member of the team what he or she must do. b. Encourage people to discuss their frustrations in providing this care. c. Ignore them—they've done it before. d. Provide minimal direction and let them come to you with questions.

ANS: D According to the Hersey and Blanchard model, when ability (skills, job knowledge) and willingness are strong, the role of the delegator is less ("delegating behavior").

As part of orientation to your unit, you decide to administer Kolb's Learning Style Inventory (LSI) to new staff. The most likely reason for your decision is that the use of Kolb's LSI: a. Reduces the cost of orientation. b. Determines if there is fit between learner and organizational values. c. Develops the strengths of the new staff member. d. Enables individualization of learning to the learner's needs.

ANS: D Administration of Kolb's LSI enables identification of the learning styles of new employees, which assists in focusing the implementation of orientation goals and in individualizing learning to the needs and learning style of the employee.

Sally is an experienced nurse on the unit and is very experienced with ICP monitoring. She is assigned David, a patient who has been admitted with a severe head injury. In communicating with Sally, you would: a. Provide a detailed explanation of what she needs to do with ICP monitoring. b. Tell her when she needs to provide an update about David's status. c. Ask her to tell you what she knows about ICP monitoring and share expectations about reporting. d. Advise her that you are available if she needs you.

ANS: D You and Sally have a well-established relationship and Sally has the expertise to work effectively with David; therefore, you would need to provide little guidance but would need to communicate that you are available if needed. Hersey refers to this leader behavior as "delegating."

After consulting with practice environments about quality and safety concerns in health care, the Dean of Health Programs at U.S. University develops:

An interdisciplinary program for nurses, pharmacists, and medical practitioners that emphasizes collaborative learning teams. ANS: D Health Professions Education identified that education related to health disciplines in silos leads to compromised communication and inability to function as an integrated whole for patient-centered care.

With the rise of violence in the psychiatric department, the nurse manager decides that she should work with the risk manager in violence prevention. The nurse manager should: a.Request all staff to accept new risk management practices. b.Hold staff accountable for safe practices. c.Document inappropriate behavior. d.Hire more police security.

B Active involvement of staff in risk management activities is key to prevention of adverse events. Nursing has a primary role in leadership in optimizing patient outcomes, preventing patient care issues, and mitigating adverse events. Accountability for safety can be one aspect of performance evaluations.

A new RN staff member asks you about the difference between QA and QI. You explain the difference by giving an example of QI. a."Last year, the management team established new outcomes that addressed issues such as medication errors." b."At a staff meeting last year, two of our staff commented on the number of recent falls and asked, 'What can we do about it?'" c."A process audit was done recently to determine how much time was being spent on patient documentation." d."Errors are reported on our new computerized forms, and I follow up with staff to make sure that they understand the seriousness of their error."

B In QI, followers invest in the process by continually asking "What makes this indicator important to measure?" "What has been done to improve it?" "What can I do to improve it?"

Patient perceptions are useful in: a.Determining disciplinary actions in QI. b.Establishing the competitive advantage of QI decisions. c.Providing one source of data for QI initiatives. d.Establishing blame for poor-quality care.

C Customers define quality and patient dissatisfaction as useful indicators of which areas are of greatest concern to patients and of what matters then to nurses and organizations. Patient perceptions guide areas of inquiry; however, they do not establish what disciplinary decisions will be made.

A method commonly used in Quality Assurance to monitor adherence to established standards is: a.A Pareto chart. b.Brainstorming. c.Patient interviews. d.Chart audit.

D Chart audits are a common method of addressing process standards. Chart audits over time yield trend charts.

During review of back injuries, it is determined that a large number of injuries are occurring in spite of mechanical lifts being used. Furthermore, it is determined that some lifts are outdated. In addressing this concern, the unit manager:

Meets individually with nurses who are observed to be using the lifts incorrectly to review the correct procedure. ANS: A The IOM report (2004) points to the need to involve nurses in decisions that affect them and the provision of care.

12. As a charge nurse, you counsel your RN staff member that he has satisfied his duty of care by notifying a child's physician of his concerns about deterioration in the child's status at 0330 hours. The physician does not come in. The child dies at 0630 hours. As the charge nurse, you could be held liable for:

a. Professional negligence. ANS: A Professional negligence can be asserted when there is failure to do what a reasonable and prudent nurse would do in the same situation. In this situation, the charge nurse might have advocated further for the patient in light of the evident seriousness of the child's condition.

9. A colleague asks you to give her your password access so that she can view her partner's healthcare record. This request violates the patient's right to:

a. Privacy. ANS: A Privacy refers to the right to protection against unreasonable and unwarranted interference with the patient's solitude. Privacy standards limit how personal health information may be used or shared and mandate safeguards for the protection of health information. Institutions can reduce potential liability in this area by allowing access to patient data, either written or oral, only to those with a "need to know." Persons with a need to know include physicians and nurses caring for the patient, technicians, unit clerks, therapists, social service workers, and patient advocates. Others wishing to access patient data must first ask the patient for permission to review a record.

16. Three gravely ill patients are candidates for the only available bed in the ICU. As the supervisor, you assign the bed to the patient with the best chance of recovery. This decision reflects which of the following ethical principles?

a. Beneficence ANS: A Beneficence refers to doing what's good for the patient; in this situation, doing what's good means providing care to the patient with the best likelihood of recovery.

MULTIPLE RESPONSE 1. One of your staff nurses asks for your advice because a patient refuses to sign a consent for surgery. The patient says that he won't sign because he doesn't understand the nature of the surgery. You advise that (select all that apply):

a. Consent must not be coerced. b. The patient has a right to choose not to consent. d. Witnessing a consent is related only to the voluntary nature of the signature. ANS: A, B, D Consent must be voluntary and not coerced; the patient must understand what he is signing, must have legal capacity, and must understand the consequences of refusal. Witnessing a consent means attesting to the voluntary nature of the patient's signature.

5. A staff nurse who was fired for reporting patient abuse to the appropriate state agency files a whistleblower lawsuit against the former employer. Reasons that the court would use in upholding a valid whistleblower suit claiming retaliation include that the nurse:

a. Had previously reported the complaint, in writing, to hospital administration. ANS: A An employer is unable to fire an employee who, in good faith, reports what is believed to be a violation of a law, rule, or state or federal law.

11. A nurse on your inpatient psychiatric unit is found to have made sexually explicit remarks toward a patient with a previous history of sexual abuse. The patient sues, claiming malpractice. Which of the following conditions may not apply in this situation?

a. Injury ANS: A By virtue of employment, the nurse owes a duty of care to the patient; this care has been breached by a nurse, who would be expected to know that this behavior violates usual standards of care. The resultant injury, the fifth malpractice element, must be physical, not merely psychological or transient. In other words, some physical harm must be incurred by the patient before malpractice will be found against the healthcare provider, which is not evident in this situation where the action did not involve physical harm.

4. An individual in a wheelchair is applying for the position of receptionist in an outpatient clinic. The nurse manager understands that the Americans with Disabilities Act of 1990 requires that employers:

a. Make reasonable accommodations for persons who are disabled. ANS: A The purposes of the ADA are to eliminate discrimination against persons with disabilities and to provide consistent, enforceable standards to address discrimination in the workplace.

Which of the following would managers and staff review annually in order to ensure compliance with the Joint Commission (TJC) to improve patient safety?

a. Appropriateness of charting terms and abbreviations ANS: A The Joint Commission issues setting-specific patient goals annually, as well as a list of "do-not-use" terms, abbreviations, and symbols and sentinel events.

Which of the following patients would be at greatest risk in a healthcare visit (select all that apply)?

a. Clyde requires an anticoagulant. He tells the nurse about his medications. He does not include an herbal supplement. c. Sarah is a new parent who finds that nurses on the children's unit are very helpful. She is eager to accept all suggestions, including those that she does not yet understand. d. Claude is booked for bowel surgery. His doctor explains about the colostomy. Later, Claude tells his wife that he really doesn't know what the doctor meant by colostomy. ANS: A, C, D Safer health care involves the patient as an active consumer who keeps and brings a list of all medications, including natural remedies, and questions if there are doubts, concerns, or lack of understanding.

The SBAR approach to patient safety encourages:

a. Consistency in assessment and practices. ANS: A The use of SBAR (Situation, Background, Assessment, and Recommendation) checklists are designed to decrease omission of important information and practices.

You notice that Sally, a student on your unit, is giving information to an anxious young teen who seems very uncertain about preparation for an upper GI series. After Sally leaves the room, you ask her how she thought her conversation with the patient went and:

a. Encourage her to ask the patient if he has questions or concerns about the procedure. ANS: A The Five Steps to Safer Health Care for Patients includes the step of asking questions if there are doubts or concerns. The nurse can encourage patients to take a larger role in care by taking these steps and by providing patients with coaching in the steps.

As a manager in a new nursing home, where might you consult for guidance and evidence to support the development of safe patient practices?

a. Hospitals ANS: A Practices that were once mostly studied in hospital settings are now scrutinized for implementation in other settings, such as outpatient clinics, rural settings, and nursing homes.

If you are supporting the steps in the AHRQ document "Five Steps to Safer Health Care," you would ensure that:

a. Patients are actively encouraged to make decisions related to care. ANS: A The Agency for Healthcare Research and Quality (AHRQ) outlines "Five Steps to Safer Health Care," which suggests that safe, patient-centered care is facilitated by assisting patients to become active partners in their own care.

Sarah is a second-year nursing student. The clinical instructor overhears Sarah telling a patient that she "always" checks patients' bracelets before giving medication and she is not sure how the nurses on the unit "get away with" not making more errors than they do. The clinical instructor pulls Sarah aside and explores with her how her communication might affect the patient and what it reflects about her beliefs related to the team. The actions of the clinical instructor reflect competencies outlined by:

a. QSEN. ANS: A The Quality and Safety Education for Nurses (QSEN) project provides resources related to competencies that prelicensure and graduate students need to develop to serve as safe practitioners. These competencies include leading and managing, teamwork and collaboration.

As a manager, the development of your decision-making skills related to safe patient care is facilitated by:

a. Regular reflection on decisions. ANS: A Reflection on how well decisions were enacted enables knowledge of the complexity of situations and ramifications of the decisions made. Reflection enables elimination of strategies and methods that are inappropriate in meeting needs and aids in narrowing choices of best actions to take.

In accordance with changes by the Joint Commission (TJC), Pleasant Valley Hospital amends its safety practices and policies to emphasize:

a. Safety goals specific to Pleasant Valley. ANS: A When the TJC, a not-for-profit organization that accredits healthcare organizations, changed its focus from processes to outcomes, it emphasized patient safety and issues setting-specific annual patient safety goals.

A client requires an appendectomy. The surgeon explains the procedure and asks the client to sign the consent. The patient speaks very little English and looks worried. As a nurse, you would:

a. Suggest that an interpreter explain the procedure to the client and answer any questions. ANS: A The Five Steps to Safer Patient Care identifies that encouraging patients to ask questions when there are doubts and concerns and ensuring understanding before surgery is performed are ways in which nurses can support patients in having greater influence in their own care. In this situation, asking an interpreter to help enables access to information for the patient and active assessment of his understanding.

As a patient care advocate, you regularly coach patients on how to stay safe in health care by educating them about:

a. The need to understand and record all medications being taken. ANS: A The Five Steps to Safer Health Care for patients include keeping a list of medications that patients are taking.

7. To reduce the incidence of falls in a skilled nursing unit, the nurse manager contacts the risk manager. Risk management is a process that attempts to identify potential hazards and:

b. Eliminate these risks before anyone else is harmed. ANS: B Risk management involves taking proactive steps to identify and eliminate risks and liability.

The NQF provides a model for advancement of healthcare quality that could be used in healthcare organizations. The use of this model by the Centers for Medicare & Medicaid Services specifically affects the interaction between adverse events and:

b. Funding. ANS: B The Centers for Medicare & Medicaid Services (CMS) have adopted a policy based on the NQF's "never events." The CMS will no longer pay for patient conditions or events that result from poor practice while patients are under the care of a health professional.

6. In keeping with standards of The Joint Commission (TJC), the nurse manager organizes an orientation for new staff members. As part of the orientation, the nurse manager reviews the employee handbook. Employers may be bound to statements in the employee handbook:

c. Based on the employee's or the employer's expectations ANS: C The handbook is an implied contract and frames the employment contract.

15. You volunteer at a free community clinic. A 13-year-old girl claims to have been diagnosed with SLE and presents with chlamydia. The team leader at the clinic advises that:

c. Care can be provided as long as consent is voluntary and information about treatment and options is provided. ANS: C All states have a legal age for consent; generally, this age is 18. However, emancipated minors, minors seeking treatment for substance abuse, and minors seeking treatment for communicable diseases can provide their own consent.

The Rehabilitation Unit at Pleasant Valley Hospital has a high number of falls. Which of the following interventions might assist to reduce the number of falls on the unit?

c. Encouraging involvement of nurses in education related to falls and safety ANS: C The IOM (2010) emphasizes the need for nurses to engage in lifelong learning and to use evidence and best practices to inform practice and ensure safety.

10. On your nursing unit, you employ LPNs, RNs, and advanced practice nurses. You will need to be familiar with at least:

c. At least one nursing practice act. ANS: C In all states, you will need to be familiar with at least one nursing practice act. In some states, there may be two nursing practice acts if RNs and LPNs/LVNs come under different licensing boards.

3. A patient refuses a simple procedure that you believe is in the patient's best interest. The two ethical principles that are directly in conflict in such a situation are:

c. Autonomy and beneficence. ANS: C Autonomy refers to the freedom to make a choice (e.g., refuse a procedure), and beneficence to doing good (performing a procedure that will benefit the patient).

2. A staff nurse in the area that you manage has excelled in the delivery of patient education. You are considering implementing a new job description that would broaden her opportunity to teach patients and orient new staff members to the value of patient education. The ethical principle that you are most directly reinforcing is:

c. Paternalism. ANS: C The principle of paternalism allows one person to make partial decisions for another and is most frequently deemed to be a negative or undesirable principle. Paternalism, however, may be used to assist persons to make decisions when they do not have sufficient data or expertise. Paternalism becomes undesirable when the entire decision is taken away from the employee.

Mary, an 85-year-old patient with cognitive impairment and gross instability, wanders continuously. Lately, she has fallen twice, and the family demands that she be restrained. As the unit manager, you have initiated a least restraint practice. An appropriate action in this situation would be:

c. Initiating a multidisciplinary and family meeting to focus on Mary's needs. ANS: C Crossing the Quality Chasm emphasizes the importance of rendering care with the client (client-centered) rather than to the client. In this situation, the patient includes family in transparent discussions about quality needs and takes a team approach that involves healthcare professionals, the family, Mary's needs, and evidence associated with safe practice.

1. The manager in the coronary care unit believes that the most important ethical considerations in performance evaluations are that they include the employee's good qualities and that they give positive direction for professional growth. This belief is an example of:

d. Nonmaleficence. ANS: D Nonmaleficence refers to "doing no harm." For a nurse manager following this principle, performance evaluation should emphasize an employee's good qualities and give positive direction for growth. Destroying the employee's self-esteem and self-worth would be considered doing harm under this principle.

14. During a staff shortage, you hire an RN from a temporary agency. The RN administers a wrong IV medication that results in cardiac arrest and a difficult recovery for the patient. Liability in this situation:

d. May depend on the patient's belief regarding the employment relationship. ANS: D Apparent agency may apply here because your liability and that of your institution could be established if it can be shown that the patient believes that the RN was an employee of yours and of your institution.

In preparation for redesignation as a MagnetTM Hospital, how would you prepare?

d. Ensure that there are empirical data to support review of patient outcomes, actions taken, and results of actions. ANS: D Through the MagnetTM model, organizations must demonstrate how they provide excellence in five areas. Between designation and redesignation as a MagnetTM organization, greater emphasis is placed on empirical quality results.

In an effort to control costs and maximize revenues, the Rehabilitation Unit at Cross Hospital reduced the number of its managers and increased the number of units for which each manager was responsible. Within a year, the number of adverse events on the units had doubled. This may be attributable to:

d. Fewer clinical leaders to remove barriers to care. ANS: D Eliminating barriers to the implementation of best practices is the role of managers and leaders. When there are insufficient resources for leadership to encourage a culture in which evidence-based practice is embraced, frontline nurses recognize this as a stumbling block for delivering quality care.

As a nurse manager on the West Surgery Unit, you are interested in increasing patient safety and reducing morbidity and mortality on your unit. Which of the following recommendations would be consistent with the IOM The Future of Nursing report?

d. Increase in the percentage of baccalaureate-prepared nurses to 80%. ANS: D The Future of Nursing advocates for having 80% of the nursing population at a baccalaureate-prepared level. This recommendation reflects research that suggests that improved mortality and morbidity rates occur with a better educated workforce.

On the West Surgery unit, you want to institute a new system for checking armbands that evidence suggests may increase safety in medication administration. The system involves technology. Which of the following strategies may assist with rapid adoption of the technology and system?

d. Use early adopters among the staff as leaders and role models in implementation. ANS: D The Institute for Healthcare Improvement (IHI) is dedicated to rapid improvement in patient care through a variety of mechanisms such as rapid cycle change. Rapid cycle change diffuses innovation and changes quickly through early adopters who share information and energy over time and act as role models for others.