Chapter 3

In order to organize services needed to achieve specific client outcomes, hospital administrators should consider what type of client care delivery system? 1. Functional nursing 2. Differentiated practice 3. Case management 4. Primary nursing

3 Rationale 1: Functional nursing does not focus on specific outcomes. Rationale 2: Differentiated practice does not focus on specific outcomes. Rationale 3: Case management organizes client care by major diagnoses and focuses on attaining predetermined outcomes within a specific time frame. Rationale 4: Primary nursing does not focus on specific outcomes.

Regardless of which delivery system or combination of delivery systems is appropriate, which skill is required for effective use? 1. Flexibility 2. Strict adherence 3. Persistence 4. Resistance to change

Correct Answer: 1 Rationale 1: Flexibility is a skill imperative when choosing a delivery system(s) for nursing care. The system must meet client and staff needs and organizational and unit-specific goals, as well as remain within cost constraints. If not, flexibility allows for change to occur to alter the system as necessary to achieve the desired effects. Rationale 2: Strict adherence to a set of rules or structure is not appropriate in todays health care environment, where adaptability is essential. Rationale 3: The nurse should be persistent in learning new roles, but persistence is not the best answer to this question. Rationale 4: Resistance to change is not a desirable skill in todays health care environment.

The nurse manager tells a newly hired nurse that the unit practices functional nursing. What should the new nurse expect? 1. One nurse has responsibility for all the medications on the unit. 2. One nurse has responsibility for all the needs of three clients. 3. One charge nurse and one respiratory therapist have responsibility for all clients. 4. One nurse and one nursing assistant have responsibility for ten clients.

Correct Answer: 1 Rationale 1: Functional nursing breaks down client care into tasks assigned to the appropriate professional or skilled caregivers. This may result in one nurse (the med nurse) administering all the medications on the unit. Rationale 2: Total patient care is given by one nurse assigned to a few clients. Rationale 3: Team or modular nursing uses a variety of skilled caregivers to provide care to an assigned group of clients. Rationale 4: Team or modular nursing uses a variety of skilled caregivers to provide care to an assigned group of clients.

A long-term-care facility is considering implementing total patient care. Prior to implementing this system, what must be available? 1. Enough RN staff to provide all the care to the residents 2. A group of licensed assistants who are good at taking direction 3. A strong nurse manager 4. RNs willing to assume 24-hour accountability for the care provided to residents

Correct Answer: 1 Rationale 1: Total patient care means that all the care for the clients or residents is provided by the RN. Rationale 2: Unlicensed assistants are not used in total patient care. Rationale 3: While a strong nurse manager is always desirable, it is not strictly necessary to implement total patient care. Rationale 4: 24-hour accountability is a part of primary nursing, not total patient care.

One of the nurse competencies of the synergy care delivery model is moral agency. Which action is an example of that trait? 1. The nurse commits a medication error and reports it to the charge nurse. 2. The nurse collaborates well with the rest of the health care team. 3. The nurse is able to think ahead to the clients next need. 4. The nurse who does not have good baseline knowledge of a clients disease process researches it on a day off work.

Correct Answer: 1 Rationale 1: Moral agency is doing the right thing. Reporting a medication error is the right thing to do. Rationale 2: Collaboration is a desirable characteristic but does not describe moral agency. Rationale 3: Systems thinking is a desirable characteristic but does not describe moral agency. Rationale 4: This is a description of clinical inquiry, not moral agency.

What is the primary belief behind the evolution of the clinical microsystem as a nursing care delivery system? 1. Those who deliver the nursing care make the most educated decisions for a particular unit. 2. Clinical decisions are best made by the clients who are served by a particular unit. 3. Clinical decisions are best made by nursing leaders for all units within that particular hospital. 4. Nurses working in a particular service area are best suited to make decisions for the clients in that area.

Correct Answer: 1 Rationale 1: The clinical microsystem method allows those who are involved in the smallest unit of care to make the decisions for that unit. Rationale 2: Clinical decisions should be made by professional health care providers, with client input. Rationale 3: Decision making from the top is not reflected in the clinical microsystem structure. Rationale 4: Clinical microsystems involve a core team of caregivers, not all the nurses working in a particular service area.

The nurse executive is reviewing client satisfaction surveys. Which trend would the nurse evaluate as indicating the nursing care delivery system in use is not effective? 1. Sixty percent of respondents replied with the name of an unlicensed assistant when asked the name of the RN who cared for them. 2. Seventy percent of respondents accurately listed their discharge medication. 3. Eighty-eight percent of respondents reported that invasive interventions were performed by an RN. 4. Thirty percent of respondents reported that their nurse sometimes seemed rushed.

Correct Answer: 1 Rationale 1: This response may indicate that the RN is not able to provide the skilled care needed. There may be a lack of RN presence in patient care. Rationale 2: This statistic indicates the RN is providing discharge instructions, which is correct use of RN knowledge. Rationale 3: Most invasive procedures are done by RNs, so this indicates correct use of skill sets. Rationale 4: The nurse will sometimes be rushed. This low percentage is likely not an indicator of problems.

Question 12 Type: MCSA Which is the most important consideration in choosing a structure for nursing care? 1. Client need 2. Efficiency 3. Cost 4. Timeliness

Correct Answer: 1 Rationale 1: While all four options are important, client need takes precedence over the others because nursing provides a service to the client. Rationale 2: Efficiency can be improved by choosing the correct nursing care delivery system, but this is not the most important consideration. Rationale 3: Costs can be contained by choosing the correct nursing care delivery system, but this is not the most important consideration. Rationale 4: Timeliness of care can be improved by choosing the correct nursing care delivery system, but this is not the most important consideration.

A nursing team consists of an RN, two LPNs, and two UAPs. Which work would be completed by the RN? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Reviewing the clients plan of care with the UAPs 2. Discussing the clients increasing shortness of breath with the LPN 3. Updating the care plan of a client who will undergo surgery tomorrow 4. Administering oral medications to clients 5. Calling the physician to discuss the clients response to a new treatment

Correct Answer: 1,2,3,5 Rationale 1: The RN team leader is responsible for conducting the nursing care conference and reviewing the clients plan of care with the team. Rationale 2: The RN team leader guides the client care and helps to resolve any problems that may occur. Rationale 3: Developing and updating nursing care plans is the work of the RN team leader. Rationale 4: Typically the team leader is involved in indirect client care activities. Rationale 5: Communicating and collaborating with physicians is generally the responsibility of the team leader.

As the RN team leader, identify potential disadvantages of using team nursing to deliver care to assigned clients. Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Continuity of care may suffer. 2. Client/staff communication may be an issue. 3. There is little cost savings to the institution. 4. Delegation is necessary. 5. Not as many professional staff are required.

Correct Answer: 1,2,4 Rationale 1: Continuity of care may suffer when care is given by more than one person. Rationale 2: Team nursing requires excellent communication skills in all team members, who must communicate with clients, families, and each other. Rationale 3: Team nursing does save on personnel costs. Rationale 4: The RN must be careful to delegate only tasks that are appropriate for the skill level and licensure of the designated personnel. The RN is ultimately responsible for all client care. Rationale 5: Team nursing does reduce the numbers of professional staff required.

Which statement by a newly licensed nurse indicates an understanding of why it is necessary to structure nursing care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. It helps to coordinate care to a group of clients. 2. It organizes care responsibilities. 3. It ensures that the staff doesnt get overtime. 4. It improves physician efficiency. 5. It provides skilled care by skilled staff.

Correct Answer: 1,2,5 Rationale 1: Structure is necessary to ensure that care is coordinated. Rationale 2: Structure is necessary to ensure that all care responsibilities are covered. Rationale 3: While structure may make nursing care more efficient, it does not ensure that no overtime will be necessary. Rationale 4: The objective of structuring nursing care is not to ensure physician efficiency. Rationale 5: Structuring nursing care helps to assign nurses with certain skills to clients whose care requires those skills.

A hospital is considering implementing the use of critical pathways and case management. Which statements by a nurse would indicate to the nurse manager that more education should be provided? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. If we use critical pathways, we wont have physical therapy to help us ambulate clients. 2. If a client is not able to follow the critical pathway, a variance will be written. 3. The critical pathway lists discharge outcomes but wont help us with day-to-day guidance of care. 4. Once the client is on a critical pathway, we must follow it until discharge. 5. Using critical pathways will help us reduce length of stay and costs to the client.

Correct Answer: 1,3,4 Rationale 1: Critical pathways are designed to direct the care of many disciplines. There is no reason to believe that physical therapy will no longer be available to help with client ambulation. Rationale 2: Variances are written when the client is not making progress according to the critical pathway. Rationale 3: The critical pathway orients staff to the outcomes that should be achieved by the client each day. Rationale 4: If the client has variance from the critical pathway, it may be revised. Rationale 5: Critical paths use resources appropriate to the care needed, and thereby reduce cost and length of stay.

What should the nurse executive consider when planning the nursing care delivery system of a new hospital? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. How to optimize use of nursing knowledge 2. The system used by competing hospitals 3. How to ensure that clients receive optimal care 4. Skill sets likely to be present in the nurses who will be employed at the hospital 5. What groups of nurses are available for employment

Correct Answer: 1,3,4,5 Rationale 1: Optimizing the knowledge of the available nurses is an important component of deciding on a nursing care delivery system. Rationale 2: The system used by competing hospitals is not of great importance in choosing the system for a new hospital. Rationale 3: The provision of safe and effective nursing care is the most important of all considerations. Rationale 4: Optimizing nursing skills is an important consideration when choosing a nursing care delivery system. Rationale 5: The nurse executive must consider who is available to fill the nursing positions in the organization. Creating a system that requires employing numbers of nurses or nurses with particular specialties or education levels will not be effective if those nurses are not available to employ.

Question 6 Type: MCMA The hospital administration is considering adopting primary nursing as its model of nursing care delivery. Disadvantages of this method are that Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The client may have multiple primary nurses if transfers within the facility are necessary. 2. Physician satisfaction is decreased. 3. Staff nurses cannot be held legally liable for care provided outside their work hours. 4. It requires a knowledge-based nursing practice model. 5. All persons caring for the client must have excellent communication skills.

Correct Answer: 1,3,5 Rationale 1: If a client requires transfer between units, a new primary nurse will be assigned in each unit. In some cases, this could result in multiple primary care nurses during one hospitalization. Rationale 2: Physician, nurse, and client satisfaction is generally increased with primary care. Rationale 3: The premise of primary nursing is that the nurse holds 24-hour-a-day accountability for client care. Legally, nurses cannot be accountable for care provided outside their work hours. Rationale 4: Requiring a knowledge-based nursing practice model is seen as an advantage of primary nursing. Rationale 5: Excellent communication must exist between the primary nurse and associate nurse. This is often difficult.

A nursing unit has just completed a 6-month trial of using team nursing to provide care. The overwhelming opinion of the staff is that the experiment was a disaster. What are the most common reasons team nursing is not successful? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. There are problems with delegation. 2. There are problems with the skill set of the UAPs on the teams. 3. The LPNs on the team do not accept their position of being in the middle. 4. Communication on the team or with the nurse manager is flawed. 5. RNs and LPNs struggle with who is in control and has the power on the team.

Correct Answer: 1,4 Rationale 1: If the team leader does not delegate effectively or team members do not accept delegation well, team nursing will not be effective. Rationale 2: Problems with UAP skill sets can be overcome by education. This is not a common reason team nursing does not work. Rationale 3: While LPNs can be in the middle between the UAP and the RN, there is no indication that this is a common problem. Rationale 4: Poor communication is a common problem and can make the team approach ineffective. Rationale 5: There is no indication that this is a common issue.

he hospitals management team wishes to institute case management to improve the quality of nursing care. As a beginning step, the team is choosing specific medical diagnoses on which to focus. What criteria should the team use when choosing these diagnoses? 1. Diagnoses given to only a few clients 2. Diagnoses that carry high risk for the client and the provider 3. Diagnoses that have low reimbursement rates 4. Diagnoses that involve as few providers as possible

Correct Answer: 2 Rationale 1: Case management is used for high-volume diagnoses. Rationale 2: Case management is used with high-risk diagnoses. Rationale 3: Case management is used with high-cost diagnoses. Rationale 4: The number of providers associated with a diagnosis is not a criterion for case management.

A change in nursing care delivery system is being considered by hospital administrators. Which information should the nurse executive add to this discussion? 1. There has been little change in nursing care delivery over the last few years. 2. We must look to the nursing process for guidance in nursing care. 3. Too much time is spent deciding on a system of care. 4. Any system is okay, as long as the nurses follow it.

Correct Answer: 2 Rationale 1: Nursing care delivery systems are in continual revision as nurses strive to find the perfect system for providing care to clients with varying degrees of need. Rationale 2: The nursing process reflects nursing care and consists of assessment, planning, implementation, and evaluation. Rationale 3: A comfortable and efficient system for delivery of care is important to client outcomes. Rationale 4: The system must be safe, efficient, and effective.

The RN leader of a team overhears one of the UAPs on the team say, Ill sure be glad when I get my RN license. All they do is sit around doing paperwork. How does the RN interpret this comment? 1. As a need to be more involved in direct client care when this UAP is on the team 2. As a common disadvantage of the team approach to nursing 3. As an indication that this UAP should be reported for unprofessional behavior 4. As confirmation that UAPs are poorly educated and do not work well on teams

Correct Answer: 2 Rationale 1: The RN must focus on the work that requires RN skills. In some cases, this work consumes much of the shift. The RN should not ignore that work to placate the UAP. Rationale 2: Resentment against the team leader for not doing real nursing is a common drawback of team nursing. Rationale 3: Reporting the UAP for unprofessional behavior will not make the resentment go away and may make the situation worse. Rationale 4: There is no indication that this UAP is not educated or does not work well on a team. The UAP may not understand the roles on the team.

The nurse executive of a for-profit hospital continually works to provide an environment that is better for the nursing staff. Why is this effort so important? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. It is the most cost-effective way to manage a hospital. 2. An environment that is better for nurses is associated with lower mortality rates. 3. Nurses are more satisfied working in an environment that is better for nursing. 4. When the environment is better for nursing, it is also better for other disciplines. 5. Most of the strategies that improve the environment for nursing do not cost anything.

Correct Answer: 2,3 Rationale 1: Making the environment better for nurses may not be the most cost-effective strategy. Rationale 2: Research indicates that a better nursing environment is associated with lower mortality rates. Rationale 3: An environment that is better for nurses is associated with greater nurse satisfaction. Rationale 4: There is no evidence that improving the environment for nursing improves the environment for other disciplines. Rationale 5: There is little that can be done in a hospital environment that does not entail at least some cost.

A large metropolitan hospital uses differentiated practice as part of the structure of nursing services. Following this plan, nursing responsibilities are assigned based on which criteria? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Seniority 2. Educational level 3. Experience 4. Nurse preference 5. Affordability

Correct Answer: 2,3,4 Rationale 1: Seniority does not mean competence. Rationale 2: Differentiated practice takes education (primarily associates degree and bachelors degree) into consideration when determining nursing responsibilities. Rationale 3: Experience is considered in differentiated practice. Rationale 4: Nurse preference is taken into consideration in differentiated practice. Rationale 5: While cost containment is always an issue, in true differentiated practice it is not a primary determinant of responsibilities.

A registered nurse will be the case manager of a group of ten clients. What will the nurse expect as part of this assignment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The nurse will determine interventions for all the disciplines needed as part of the clients care. 2. The nurse will meet with other disciplines to agree on the choice of critical pathways for each client. 3. The nurse will work to build consensus with the physicians caring for the clients on the team. 4. The nurse will define the expected nursing outcomes for the clients on the team. 5. The nurse will collect and analyze data regarding the clients on the team.

Correct Answer: 2,3,4,5 Rationale 1: Each discipline determines its own interventions. The disciplines collaborate to design care. Rationale 2: Collaboration with other disciplines is a critical component of case management. Rationale 3: A main emphasis of case management is building consensus with physicians caring for the clients. Rationale 4: The nurse is responsible for defining expected nursing outcomes. The other disciplines involved will set expected outcomes for their work. Rationale 5: Essential baseline data, such as length of stay, cost of care, and complication information, are collected and analyzed by the nurse and other members of the team.

Which nursing interventions would be in line with the chronic care model? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Blood sugar is measured frequently in an attempt to achieve tight glycemic control. 2. The nurse provides the client with the URL for a new website dedicated to self-management of a chronic respiratory disease. 3. The nurse advocates for the client who has decided to forego further dialysis. 4. Client information is entered into an electronic medical record. 5. Information about the operating hours of a community recreation center is provided to the client with coronary artery disease.

Correct Answer: 2,3,4,5 Rationale 1: The chronic care model manages how care is delivered, not a specific disease. Rationale 2: Self-management is one of the six components of the chronic care model. Rationale 3: Decision support is one of the six components of the chronic care model. Rationale 4: Use of clinical information systems is essential to the chronic care model. Rationale 5: Use of community resources is one of the six components of the chronic care model.

The RN receives reports on eight clients in the morning. Client assignments are then delegated to an LPN and two nursing assistants. The morning is busy, with physician visits and new client orders, and the RN communicates these new orders to the LPN and nursing assistants. The RN also meets with the case manager to discuss nursing home placement for a client. What type of nursing care delivery system is in place in this hospital? 1. Critical pathways 2. Total patient care 3. Team nursing 4. Functional nursing

Correct Answer: 3 Rationale 1: Critical pathways are a set of strategies used by health care providers to attain expected outcomes. Critical pathways are not a nursing care delivery system, and there are insufficient data to determine if they are used in this scenario. Rationale 2: Total patient care is given by one nurse. Rationale 3: The RN in this case is leading a team. A variety of skilled caregivers cares for a group of clients. Rationale 4: Functional nursing breaks down the assignments into tasks.

The hospital is opening its first intensive care unit. The nurse executive should plan to staff this unit according to which model of care? 1. Functional nursing 2. Team nursing 3. Total patient care 4. Modular nursing

Correct Answer: 3 Rationale 1: Functional nursing has the disadvantages of less continuity of care and potentially less skilled personnel caring for the client. Rationale 2: Team nursing has the disadvantage of not having a professional nurse attending to all client care needs. Rationale 3: In total patient care, one nurse cares for a client and, being totally accountable for the client, can give continuous, holistic, and expert care. Rationale 4: Modular nursing is somewhat synonymous with team nursing and has the disadvantage of not having a professional nurse to attend to all client care needs.

The RN working on an orthopedic unit is caring for a postoperative client with a hip replacement who is not transferring well from bed to chair. The client is behind on the mobility training program. What action is the nurses priority? 1. Instruct physical therapy to increase treatments to four times daily. 2. Contact the family to discuss preoperative mobility problems. 3. Inform the case manager of variance in the critical pathway. 4. Discuss the problem with the clients surgeon.

Correct Answer: 3 Rationale 1: Ordering an increase in physical therapy is not within the scope of nursing and would not be the priority action. Rationale 2: The family may have important information about the clients mobility, but this is not the priority action. Rationale 3: The case manager tracks all variances, reports to the collaborative team, and may revise the critical pathway. Rationale 4: Discussing the problem with the surgeon is not the priority action.

At a strategic planning meeting the nurse executive recommends instituting patient-centered care as a model of care delivery in the hospital. Which statement by the hospital CEO indicates understanding of this concept? 1. We have always had the patient at the center of everything we do. 2. We cant afford to hire more RNs. 3. Im concerned about the increased time and leadership our nurse managers will have to provide. 4. I like the idea of centralizing all our care.

Correct Answer: 3 Rationale 1: Patient-centered care as a practice model is not the same as centering care around the patient. Rationale 2: There would be fewer RNs in the patient-centered care model. Rationale 3: The nurse managers role in patient-centered care requires considerable time. The nurse manager must be a strong leader. Rationale 4: Patient-centered care is actually decentralized. Many of the tasks traditionally done by a central office, such as admission, are unit based.

A group of nurses is developing a poster presentation titled Nursing Care Delivery Through the Ages for the hospitals annual Nurses Day celebration. What form of nursing care delivery should they depict as occurring prior to 1930? 1. Team nursing 2. Functional nursing 3. Total patient care 4. Primary care

Correct Answer: 3 Rationale 1: Team nursing evolved in the middle to late 1940s. Rationale 2: Functional nursing grew out of the nursing shortage caused by World War II. Rationale 3: The original model of nursing care delivery was total patient care or the case method. During the 1920s, total patient care was the typical delivery system, with much RN care being provided in the home. Rationale 4: Primary nursing was conceptualized and implemented during the late 1960s.

Which nursing care delivery situation best reflects the concept of a clinical microsystem? 1. A rural free clinic housed in a church gymnasium that is staffed by volunteer nurses and physicians 2. A walk-in clinic in a local discount store that is staffed by a nurse practitioner 3. An inpatient burn unit 4. A general medical-surgical unit in a midsized hospital

Correct Answer: 3 Rationale 1: The free clinic likely does not have the support staff, equipment, and facilitative environment necessary for a clinical microsystem. Rationale 2: A walk-in clinic in a retail outlet does not have a tightly defined population to receive care and is not likely to function as a clinical microsystem. Rationale 3: The burn unit likely has a core team of caregivers, a defined population to receive care, informational systems in place, support staff, equipment, and an environment that facilitates provision of care. Rationale 4: A general medical-surgical unit is less likely to have the components necessary to support a clinical microsystem.

A newly licensed RN is beginning a job search. This nurse would be best served by working in an organization that provides which nursing care delivery system? 1. Primary nursing 2. Total nursing care 3. Functional nursing 4. Practice partnerships

Correct Answer: 4 Rationale 1: The nurse providing primary nursing must be very autonomous. This is not the best environment for a newly licensed RN. Rationale 2: The nurse providing total nursing care must be very autonomous. This is not the best environment for a newly licensed RN. Rationale 3: In functional nursing, the RN leads the team. The newly licensed RN does not have sufficient experience for this role. Rationale 4: Practice partnerships allow for two personnel to work together in giving client care. Ideally, a senior RN can be paired with a novice RN.

A hospital is concerned about low customer satisfaction ratings and poor evaluation on quality indicators. The nurse managers are asked to implement a nursing delivery system that is cost-effective and improves both customer satisfaction and quality of care. Which nursing delivery system should the managers implement? 1. Total patient care 2. Functional nursing 3. Team nursing 4. Patient-centered nursing

Correct Answer: 4 Rationale 1: Total patient care is costly and less efficient for nursing staff. Rationale 2: Functional nursing is cost-effective but lacks continuity of care. Rationale 3: Team nursing is cost-effective but may lack continuity of care, which can cause client dissatisfaction. Rationale 4: The focus of patient-centered nursing is the promotion of efficiency, quality, and cost control.