Leadership Exam 3

20. 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 b. Business c. Industry d. Outpatient clinics

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.

23. 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. b. Ask the client if he has any questions. c. Draw a picture to show the incision. d. Not intervene.

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.

9. Jane has transferred from the ICU to the CCU. She is very set in the way she makes assignments and encourages her new peers to adopt this method without sharing the rationale for why it is better. This is a good example of a process and procedure that creates which type of conflict? a. Organizational b. Intrapersonal c. Interpersonal d. Disruptive

C Interpersonal conflict transpires between and among nurses, physicians, members of other departments, and patients.

16. One day, at coffee, your co-worker suggests that you and she sit with unit members of the hospital research committee. She suggests that this would be an excellent way to get to know people who share her interest in research. Her actions are an example of: a. Mentorship. b. Politics. c. Networking. d. Empowerment.

C Meeting individuals outside the normal workgroup to share ideas and gain support and encouragement is an example of networking.

18. A rural-urban health consortium enables physicians in a rural remote setting to consult with specialists in care through electronic conferencing, which includes consultation using intranet radiology images. This system may be in which phase of electronic medical technology adoption, according to the Healthcare Information and Management Systems Society (HIMSS)? a. 0 b. 1 c. 3 d. 6

D According to the HIMSS, this healthcare organization may be in phase 6, which includes the capacity to transmit all radiology images through intranet or another secure source. Level 1 refers to the installation of major ancillary clinical systems (such as radiology) and level 3 to the retrieval of radiology images from picture archives and communication systems.

23. A necessary, basic condition for successful integration of clinical information systems is: a. Software. b. Standard medical nomenclature. c. Confirmatory evidence from nursing-led studies. d. Strong interdisciplinary cultures.

D An integrated clinical information system draws on specific knowledge from many involved disciplines that interface at the patient. Successful integration of clinical information systems requires that the various disciplines work together collaboratively to transform the data into meaningful knowledge.

1. The staff members in a local Emergency Department are experiencing stress and burnout as the result of excessive overtime. The staff decides to unionize to negotiate for better working conditions. The increase in unionization within health care may be attributed to the: a. Movement from being blue-collar workers to being knowledge workers. b. Excess profits in health care. c. Level of risk that exists for health care. d. Number of people who are involved in health care.

D As technology replaces unskilled workers, fewer workers are available for trade-union organizing, which has led to declines in union memberships. Nurses represent a large pool of workers who may be available for union organizing in the face of the declining pool available elsewhere.

15. 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.

25. As part of an information technology implementation team, you are implementing a clinical decision support system. Particular considerations for successful implementation of this project include: a. Ensuring that the system is reliable. b. Ensuring that patient information is reliable. c. Developing unique identifiers for individuals. d. Developing rules that support inferences.

D Clinical decision support systems provide support for novice nurses, in particular, as they enable entry of real-time data from patient situations and inferences that apply the logic that expert nurses would use. These inferences require rules to be developed for the system.

21. Which of the following exemplifies the predominant conflict management style of nurse managers? a. Elizabeth, the head nurse on neurology, finds that Tom, the RN nurse on nights, is irritable in relation to any suggestions or new ideas, and so she comes in to work after Tom leaves the unit. b. The technology committee has recommended a clinical system for implementation on the nursing unit. Staff is anxious about the change. Tim, the head nurse, asks staff for ideas on how to meet the technology goals and to meet staff needs. c. During management meetings, George, the head nurse on nephrology, dominates meetings and decisions. Lee, the head nurse on the cardiac step-down unit, begins to miss the management meetings. d. Ann, RN, asks her head nurse if she can go on the permanent evening shift. The head nurse, Rajib, agrees, as long as Ann agrees to be involved in assisting to mentor evening staff in the use of the new clinical information system.

D Compromise involves trading and negotiation and is the predominant conflict management style of managers.

19. Factors that influence the ease with which conflict is resolved include all except which of the following? a. Level of interdependence of the parties b. Interprofessional collaboration. c. Expression of ones own needs and ideas. d. Avoidance of the issue or concern.

D Conflict involves a level of interdependence and is a condition for conflict but not necessarily for continuance of the conflict. Expression of ones ideas and concerns is considered assertive and effective in resolving conflict if the concerns and needs of the other are also considered. Interprofessional collaboration has been shown to be effective in resolving conflict. Avoidance tends to prolong and sometimes escalate conflict.

14. As the head nurse involved in leading determination of which patient surveillance systems to acquire for your unit, one of your aims is to avoid adverse events through the implementation of appropriate technology. This particular aim recognizes that: a. Human error is significant in contributing to adverse events. b. Documentation of patient data is often illegible and therefore, misinterpreted. c. Data systems provide backup documentation with adverse events that staff cannot provide. d. Physiologic monitoring systems enable detection of early changes before an adverse event occurs.

D Data about adverse events suggests that a majority of physiologic abnormalities are not detected early enough and may be present hours before the event actually occurs. Physiologic monitoring aids in early detection of changes.

11. Sondra, a new graduate, recently began a position as a registered nurse in a rural hospital, where she is the youngest and newest staff member. Although she has limited experience, she has a strong knowledge base, is confident, and was considered to have strong entry-level skills on graduation. Sondra meets with her former instructor and confides that she is very frustrated that others do not seem to accept her leadership. What might you suggest that would help Sondra to understand what is happening in terms of power and influence? a. As a new graduate, it is unlikely that she has acquired the experience and knowledge of other staff, including aides and practical nurses. b. Rural settings tend to be closed systems and therefore are, not welcoming of those who are not from their community. c. Morale on her unit can be improved by engaging in shared decision making. d. Identify the informal leaders on her unit and how they affect care decisions.

D Developing organizational savvy includes identifying the real decision makers and those persons who have a high level of influence with the decision makers. Recognize the informal leaders within any organization may have more power than the formal leader because of more knowledge of the organization, more informational power, or more expertise.

1. 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: a. The overload of staff nurses. b. Resistance to change by staff. c. A change in reporting systems. d. Fewer clinical leaders to remove barriers to care.

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.

7. After consulting with practice environments about quality and safety concerns in health care, the Dean of Health Programs at U.S. University develops: a. A nursing program that emphasizes the development of a strong disciplinary identity. b. Programming that stresses discipline-based research. c. Partnerships with health care to develop software for the reporting of adverse events. d. An interdisciplinary program for nurses, pharmacists, and medical practitioners that emphasizes collaborative learning teams.

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.

14. Collective action is effective in: a. Ensuring that needs of nurses are placed ahead of other disciplines. b. Defining nursing as a profession. c. Advising patients of the needs of nurses. d. Amplifying the influence of individuals.

D Individuals may have limited influence in achieving various purposes such as advancement of quality care or of the profession, whereas collective action helps to define and sustain individuals in achieving the desired purposes.

24. 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 a. Re-visit reporting standards for medication errors in your organization. b. Ensure that medication errors are consistently reported. c. Provide staff with additional education related to safe practice in medication administration. d. Involve RN staff in determining reasons for errors and practice solutions to increase the safety of medication administration.

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.

22. As a nurse manager, one challenge is to orient new staff to your agencys policies and procedures, as well as to provide training across various shifts. A cost-effective and effective learning strategy would be: a. Development of new learning modules and software to support document retrieval. b. E-mail distribution to staff home e-mail addresses regarding important policies. c. Preparation of DVDs that can be viewed on computers at the nursing station during down times. d. Linking policies and procedures to the network for access when required at the point-of-care.

D Knowledge technology consists of systems that generate or process knowledge and provide clinical decision support (CDS). The clinical knowledge embedded in computer applications can range from simple facts and relationships to best practices for managing patients with specific disease states, new medical knowledge from clinical research, and other types of information. The most accessible and cost-effective approach would be utilization of what is already available in the work environment, such as the systems that provide CDS.

7. In a nurse managers meeting, strategies for ways to help retain staff are discussed. One strategy for assisting nurses in developing collective action skills is: a. Accepting the practice of going along to get along. b. Attending as many workshops as practical. c. Spending as much time as possible in clinical settings. d. Taking the opportunity to work with a mentor.

D Mentoring facilitates development and adoption of positive interaction and other skills that facilitate good decision making. Optimism, trust, and decision making are important in collective action and shared decision making and contribute to job satisfaction and lower turnover in staff.

24. In trying to achieve Magnet status, the chief nursing officer establishes a shared governance model to help nurses experience job satisfaction. However, some nurses who have enjoyed working with less autonomy resist this change and begin to criticize and make rude comments about managers who embrace this model, as well as colleagues who support it. The comments are largely ignored because those who are making them are well established nurses who are often vocal about their displeasure with the organization. Organizational conflict is arising from which of the following? a. Staffing practices b. Increased participation in decision making c. Allocation of resources d. Tolerance of incivility

D Organizational conflict arises from discord related to policies and procedures (such as staffing policies and practices and allocation of resources), personnel codes or conduct or accepted norms of behavior (such as incivility), and patterns of communication. A major source conflict in organizations stems from strategies that promote more participation and autonomy of staff nurses.

17. 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.

3. A nurse belongs to several professional organizations, serving on a state-level committee of one group and on two task forces at work. The nurse is committed to a range of health issues and knows the state senator from the nurses district, as well as the name of the representative in Washington, DC. This nurse exemplifies which level of political activism in nursing? a. Gladiator b. Buy-in c. Self-interest d. Political astuteness

D Political involvement is a professional responsibility and nurses perspectives of the critical issues for improving the healthcare system can shape the policy agenda of the nations political leadership. This nurse exemplifies several of the skills associated with political astuteness.

7. 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.

15. Sarah is a nurse manager in a surgical unit. She is concerned about a conflict between Lucy (a staff nurse) and one of the maintenance personnel. Sarah explains to Lucy that unsatisfactory resolution of the conflict is typically destructive and will result in: a. Decreased frustration between the maintenance worker and her. b. A good relationship with the maintenance department. c. Eventual resolution of the problem without further intervention. d. Decreased productivity on her part.

D Research by Saltman et al. (2006) determined that productivity decreases with destructive conflict, whereas constructive conflict strengthens relationships.

12. Mrs. Hill, aged 68, was hospitalized after a stroke. The speech therapist recommended that oral feeding be stopped because of her dysplasia. During visiting hours, Mr. Hill fed his wife some noodles. The nurse noticed this and stopped Mr. Hill from feeding his wife, telling him it was the doctors decision. An hour later, the nurse returned and found Mr. Hill feeding his wife again. The nurse tried to stop him again. Mr. Hill refused and claimed that the clinical staff was trying to starve his wife; he also threatened to get violent with the nurse. The nurse decided to walk away and documented the event in Mrs. Hills chart. The outcome as depicted by Thomas conflict stages can be considered to be: a. Compromising. b. Confronting. c. Constructive. d. Destructive.

D Resolution was absent because the nurse did not have time to effectively deal with the issues in the conflict. This can lead to negativity, increased frustration, and further distancing between individuals or groups, including between patients and nurses.

20. Which of the following healthcare employees is MOST at risk for violence? a. Becky, working in a well-lit area with stable psychiatric patients and other staff members nearby. b. Sarah, who works in a busy emergency room. Access to the emergency patient units is allowed by security staff and alarm systems are in place in patient units. c. Sharon, who works evening shifts. Workstation is behind a shatterproof glass, and an alarm can be reached easily from her computer. d. Donna, who works the evening shift, cleans rooms each night in the administrative wing and business offices, which are largely empty. The wing is near an outside access door.

D Staff who work in isolated, poorly lit areas are at higher risk of violence, which would describe Donnas work conditions. In addition, if the business office contains money, this could make it a desirable target for criminals. While Becky and Sarah work in high-risk areas (mental health and the emergency room), the nearby presence of colleagues, the availability of alarms, and good lighting help to reduce the risk.

21. Which of the following is the best example of skilled negotiation? a. Linda, the manager on pediatrics, takes a proposal to her supervisor, outlining the benefits of a walk-in preoperative area for children. b. Kim, RN, asks for leave to pursue a semester of full-time study in her graduate program. She proposes to accept less popular rotations during peak vacation time, in return. c. George, the head nurse in ER, asks for additional staff for his department and points out the benefits of being able to keep patients for longer periods. d. Jerry speaks with his supervisor about his supervisors concerns related to bedside reporting before presenting a proposal to change this process.

D Successful negotiators are well informed about not only their own positions but also those of the opposing side. Negotiators must be able to discuss the pros and cons of both positions. They can assist the other party in recognizing the costs versus the benefits of each position.

5. The clinic nurse has just accessed a clients chart on the computer. The resident comes over and asks her to stay logged on because he needs to add a note to that clients chart. She should say: a. No problem. Just log me off when youre done. b. Ill put the note in for you. What do you want to say? c. Just make sure that you sign your note because its under my password. d. Im sorry, but you will have to enter the information using your own password.

D System users must never share the passwords that allow them access to information in computerized clinical information systems. Each password uniquely identifies a user to the system by name and title, gives approval to carry out certain functions, and provides access to data appropriate to the user. All users must be aware of their responsibilities for the confidentiality and security of the data they gather and for the security of their passwords.

2. The nursing manager of a surgical unit has been asked by administration to evaluate client outcomes post cardiac catheterization. Using data about client outcomes post cardiac catheterization for the past 6 months so as to modify practice is an example of: a. Information. b. Cost-effective care. c. Meeting standards. d. Evidence-based practice.

D Technology enables evidence-based practice by collecting good clinical knowledge, translating nursing knowledge into reference materials that can be accessed at the point-of-care, and, potentially, assisting nurses to take action based on best evidence for practice

10. 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? a. Careful screening of nursing staff for substance use and abuse b. Increased RN staffing on the unit c. Salary and benefits that reflect nursing accountabilities d. Increase in the percentage of baccalaureate-prepared nurses to 80%

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.

11. 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? a. Employ a centralized decision-making approach. b. Use simulators for initial practice to build confidence. c. Bring in a nurse consultant who is familiar with the technology. d. Use early adopters among the staff as leaders and role models in implementation.

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.

24. 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.

18. In looking at an organizational chart for her institution, Jennifer notes that nursing is led at the senior level by a non-nurse executive. Jennifer expresses concern that this is a reflection of how nursing is viewed within the organization. Jennifers comments reflect: a. A concern that resource allocation will be made on a business and not a professional model. b. The dissatisfaction that occurs when lack of autonomy is given to nurses. c. Concern with the nonadvancement of nursing practice in the institution. d. An awareness of how organizational culture is reflected in organizational structure.

D The organizational chart reflects the formal structure of the organization and can reflect predominant beliefs, values, and relationships in the organization. Exclusion at senior executive levels of nurse leaders may reflect institutional beliefs about how resources are allocated, the degree of autonomy given to staff, and involvement of key groups in decision making.

25. As a senior manager, you notice that there have been several resignations on a unit where a new charge nurse has been hired. You suspect that the new charge nurse may be demonstrating bullying behaviors, but staff say little about their relationship with the charge nurse. Your decisions about intervention would be based on which assumptions? a. The staff nurses would tell you if the charge nurse was engaging in relational violence. b. It would be unusual for leaders to engage in violence and bullying behavior. c. Bullying is primarily related to feelings of marginalization and jealousy among peers. d. Initiating confidential exit interviews will assist in determining if leader violence or bullying is occurring.

D To understand if violence or intimidation is a reason for leaving, organizations should conduct exit interviews with the assurance that the information will remain confidential if an employee fears retaliation. This is an important step in gauging if the problem is bullying or intimidation by managers. Johnson (2009) found that 50% of respondents indicated that they were bullied by their manager or director. The researcher suggested that when management is part of the problem, victims have a harder time feeling they have adequate support to end the negative cycle of violence. Lack of support leads many victims of bullying to decide that the best alternative is to leave the organization and to give this advice to others who find themselves in similar situations (Johnson, 2009).

23. Which of the following is NOT a factor in patient- and/or family-generated violence in healthcare settings? a. Feelings of vulnerability b. Anxiety about treatments or diagnoses c. Feelings of powerlessness or loss of control d. Staff rudeness

D Unlike in other settings, hospital violence differs in that it is usually the result of patients or their family members feeling frustration or anger. This is usually related to feelings of vulnerability, stress, and loss of control that accompany illness. Other factors such as the location, size of the facility, and type of care provided also increase the risk for violence.

12. Residents in a new long-term care facility attend a large dining hall for meals. In reviewing reports of aggression and violence, you note that behaviors such as hitting, or attempting, to hit staff are increasing. Further investigation suggests that this behavior occurs most often at mealtimes. A possible intervention would be to: a. Seat residents with the highest potential for violence next to those with the lowest potential for aggression. b. Feed residents earlier in the day. c. Restrain residents who are violent or aggressive during mealtimes. d. Establish a smaller dining area that is away from the main area that is for residents who have potential for aggression/violence.

D Violence and aggression are more likely during times of increased activity, such as mealtimes. Reducing activity levels through interventions such as a separate dining area may reduce incidents of violence and aggression.

16. 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.

13. 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.

12. In accomplishing the goal of breakfast for children in elementary school, Leanne is particularly effective in approaching businesses with the needs that the group has determined and articulating the ways that the group has found for businesses to participate. Leanne is exemplifying: a. Leadership. b. Followership. c. Professionalism. d. Knowledge of context.

B Effective followership involves active and loyal involvement in an agenda that has been established. In this role, Leanne is supporting and operationalizing the agenda and strategies that have been established within the group.

13. You note that Unit 64 has had a high turnover rate of staff during the past year. In investigating this situation, an important source of data might include: a. Employee evaluations. b. Level of experience of staff. c. Exit interviews with staff. d. Selection processes and decisions.

C Exit interviews may assist in identifying issues such as workplace violence, bullying, and intimidation by managers.

13. Politics is usually: a. Confined to legislatures. b. Seen in dysfunctional workplaces. c. Found in all social organizations. d. A representation of self-interest.

C Politics involves social interaction among organizations and as such, politics permeates in all organizations, workplaces, legislatures, professions, and even families.

9. The chief nursing officer understands that to be able to compare data across client populations and sites, it is important that nurses use: a. Similar settings. b. Information systems. c. Knowledge systems. d. Structured nursing languages.

D Data are standardized and use structured terminology, which enables cross-site comparisons

13. Awareness and use of power have been challenging for nurses in general because of: a. Incidences of punishment by authority figures. b. Too little time in the workplace to collectively develop power strategies. c. Lack of cohesiveness and unity among nurses. d. A tradition of obedience to authority.

D Rituals and traditions such as the Nightingale Pledge have emphasized the need for the good nurse to be obedient to authority. This prevailing attitude has made it difficult for nurses, who typically spend considerable time in the workplace and who have opportunity through their work in teams to develop cohesiveness and unity, to develop awareness and use of power.

19. As a nurse manager representative on a clinical information system selection team, you would be particularly concerned if the favored system: a. Involves screen displays that are best configured for non-clinical users. b. Requires an upgrade to servers in the facility. c. Requires staff orientation and training during implementation of the software. d. Minimizes the amount of data entry necessary.

A An ideal hospital information system should include as much instrumentation as possible to minimize data entry. As a clinical end user, you would expect orientation and training on how the screen display can be configured so as to suit the purposes and preferences of users in clinical areas.

17. Sarah determines, in partnership with her patient, that current medications are not enabling her patient, a married account executive with fibromyalgia, to continue with her employment and family responsibilities. After searching for additional information on fibromyalgia, Sarah finds nonpharmacologic interventions that are supported through credible evidence. Sarah suggests that the patient, her physician, and she meet to discuss the medications and possible options and a plan of care for the patients discharge. This action exemplifies which of the four historical concepts identified by Lewis and Batey? a. Authority b. Responsibility c. Communication of conflict d. Autonomy

A Authority refers to the use of professional status and power to act in the patients best interests. In this example, Sarah is using her professional status and power to set up a conference in which her patient, the prescribing physician, and she can discuss what is not working for the patient and potential options.

16. A recent nursing graduate in a busy emergency department triages a patient who has sustained a large, deep puncture wound in his foot while working at a construction site. He is bleeding and is in pain. The nurse enters the triage data that she has obtained from the patient into a computerized, standard emergency patient classification system. After she enters the assessment data, she notices an alert on the computer screen that prompts her to ask the patient about the status of his tetanus immunization. What system of technology is involved in generating the alert? a. Clinical decision support b. WL technology c. Computerized provider order d. Electronic health record

A Clinical decision support (CDS) is a clinical computer system, computer application, or process that helps health professionals make clinical decisions to enhance patient care. The clinical knowledge embedded in computer applications or work processes can range from simple facts and relationships to best practices for managing patients with specific disease states, new medical knowledge from clinical research, and other types of information.

9. In the Emergency Department waiting room, you notice a patient sitting, with his head in his hands, who has been waiting for about 5 hours for relief of his headache. When you approach him to ask him how he is doing, he says, I cant believe that I have to wait this long for help! Do you know what it is like to be in pain for 10 hours? Your response to him would be: a. It is frustrating to wait when you are in pain and when you are expecting to receive relief right away. b. Dont talk to me. If you are going to be rude, then you will not receive treatment here. c. We are very busy and dont have enough staff to deal with problems such as yours. d. Perhaps you should go elsewhere. We do not have time for you here, as many more sick patients are waiting.

A Empathizing helps the other person to know and feel that he has been understood and is powerful in de-escalating a situation that has potential for aggression and violence.

5. A nurse manager must implement a 2% budget cut on the nursing unit. Which approach should the manager use to most effectively empower the staff of the unit? a. Discuss the guidelines for the budget cuts with the staff, making the decisions with those who participate. b. Inform the staff of the budget cuts in a series of small group meetings and accept their ideas in writing only. c. Provide the staff with handouts about the budget cuts and let them make recommendations in writing. d. Hold a series of mandatory meetings on the budget cuts, asking staff for ideas on the cuts.

A Empowerment is the process of exercising ones own power to facilitate the participation of others in decision making and taking action so they are free to exercise power It means releasing authority and enabling others to have accountability, for participation and decisions.

20. 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.

24. A unit manager watches a new RN graduate interacting with a patient. When the RN comes out of the room, the unit manager says, I dont know what they taught you in your nursing program, but if I see you do that again, I will write you up. This example demonstrates: a. Coercive use of power. b. Appropriate application of control. c. Use of informatory power. d. Use of power to provide coaching.

A Influence is the process of using power. Influence can involve the punitive power of coercion, as is used in this example.

12. 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.

24. You are hired as a new manager. When the offer of employment is made, you agree to at-will employment. Later, you become very concerned about the policies and practices of your organization and their impact on patient care. You speak with your supervisor several times about your concerns, but no action is taken. In considering your next steps, you: a. Consider your increased vulnerability under the terms of your employment. b. Recognize that your supervisor is more vulnerable than you are because of her more senior position. c. Are more likely as a leader to take action because you are well protected from repercussions by federal and state regulations. d. Contact your union to discuss your concerns and review your options.

A Managers of at-will employees have greater latitude in selecting disciplinary measures for specific infractions. State and federal laws do provide a level of protection; however, an at-will employee may be terminated at any time for any reason except discrimination. At-will employees, in essence, work at the will of the employer. Nurses in these positions need to know their rights and accountability.

10. As a new nurse manager who has inherited a unit with high nurse turnover and complaints of patient dissatisfaction, your first course of action would be to: a. Determine levels of nurse engagement on the unit. b. Review the personnel files of nurses who have resigned. c. Interview upper management about their vision for the unit. d. Meet with your staff to clarify your vision for the unit.

A Multiple studies demonstrate that a healthcare organization that provides a climate in which nurses have authority and autonomy has better patient outcomes, retains nurses at a higher rate, is more cost-effective, and has evidence of greater patient satisfaction than an organization in which such a climate does not exist (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Dunton, Gajewski, Klaus, & Pierson, 2007). Organizational assessment assists in identifying the reasons for high nurse turnover and patient complaints.

10. Leaders in nursing must advocate for information and knowledge systems that support nursing practice. This is best accomplished by: a. Participating in organizational information technology committees. b. Submitting written requests for needed information systems. c. Requesting budgetary funds needed for systems. d. Sending staff nurses to conferences that discuss cutting-edge technologies.

A Nurse leaders and direct care nurses must be members of the selection team, participate actively, and have a voice in the selection decision. The information system must make sense to the people who use it and fit effectively with the processes for providing patient care.

3. Mr. Cruiser has been surfing the Web. He is looking for healthcare information on low back pain. He shows the clinic nurse a Webpage he thinks is great and tells her that he has been following the exercises recommended by the author. He wants to know what she thinks about the site. When the clinic nurse evaluates this site, she discovers that its author is a personal trainer. No credentials are listed. In several testimonials on the page, people (their pictures are included) say how wonderful they feel after having done these exercises. The exercises all have animated demos when you click on the pertinent highlighted text or icon. They seem easy to follow. The site was posted five years earlier and was last updated three years before. The clinic nurse advises Mr. Cruiser to: a. Avoid this site. b. Check with his primary healthcare provider. c. Continue with the exercises. d. Contact the author for additional exercise and feedback.

A Patients need coaching as to how to use and decipher information that is available through the Internet. In this situation, the provider on the site lacks credibility because no credentials are listed, and the information is not current.

13. In an ICU, you order new devices to measure heart rhythm and rate, respiratory rate, oxygen levels, and intracranial pressure. These devices involve: a. Biomedical technology. b. Telecommunications. c. Retrieval of patient history information. d. Internet.

A Physiologic monitoring devices and patient surveillance systems involve biomedical technology.

21. As a manager, the development of your decision-making skills related to safe patient care is facilitated by: a. Regular reflection on decisions. b. A culture of perfectionism. c. Recognition of who should be held responsible for individual errors. d. A culture of trust between the staff and you.

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.

6. 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. b. Rules and decisions are made through centralized processes. c. You monitor the performance of each staff member closely. d. Preference is given to increasing staff numbers rather than staff credentials.

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.

13. 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. b. Advise her to consider providing the patient with more information. c. Suggest that she leave some brochures on the procedure with the patient. d. Suggest that she also provide teaching to the adolescents parents.

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.

16. 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 b. Nursing hours per patient c. Acuity of patient admissions d. Wait times for care

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.

5. Nursing labor management partnerships: a. Engage nurses at all levels in problem solving for better patient care. b. Require unions and management to negotiate in good faith regarding hours of work and wages. c. Have been shown to have negligible effects on nurse turnover and patient outcomes. d. Have typically resulted in increased polarization of nurses and management, leading to formation of collective bargaining units.

A The development of a nursing labor management partnership is an approach that can be used in most professional nursing environments. This process recognizes nurses as leaders on all levels and provides formal and informal mechanisms for professional nurses to work together to achieve shared goals through collaboration and shared decision making or decentralized decision making. A study of a nursing labor management partnership suggested that nurse satisfaction was higher, turnover was lower, and more time was available for patient care.

7. After using a mediator to resolve a conflict between the nurse manager and two staff nurses, the chief nursing officer decides to: a. Observe to make sure the conflict has been resolved. b. Fire both staff nurses. c. Reassign both staff nurses. d. Reassign the nurse manager.

A The nurse leader should follow up to determine if the conflict has been resolved because, in professional practice environments, unresolved conflict among nurses is a significant issue that results in job dissatisfaction, absenteeism, and turnover, as well as in decreased patient satisfaction and poorer quality in patient care.

14. A nurse educator is giving a workshop on conflict. During the sessions, he makes various statements regarding conflict. All of the statements are true except: a. Conflict can decrease creativity, thus acting as a deterrent for the development of new ideas. b. Horizontal violence involves those with similar status but little power in the larger context. c. Interprofessional collaboration reduces unresolved conflicts. d. All conflicts involve some level of disagreement.

A The opposite is true because research has shown that conflict, like change, increases creativity and allows for the development of new ideas.

18. Joe and Carol, two of the RNs on Unit 22, are discussing recent incidents on the unit that have involved patients and visitors uttering threats or making demeaning remarks to staff during evening hours. Joe observes that unless someone shoots at him, he is not concerned because words cant hurt you. Joes remarks: a. Illustrate common misperceptions about the nature of violence. b. Accurately depict the difference between violence and aggression. c. Are partially correct because verbal remarks do not cause injury. d. Reveal possible issues that Joe relates to violence in his personal life.

A Violence and aggression involve verbal and nonverbal and covert and overt behaviors, and all forms are capable of producing short- and long-term injury that may have an impact on productivity, work performance, work attendance, and patient care.

15. 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. b. Decision-making processes. c. Sufficient staffing for safe care. d. Increased numbers of baccalaureate-prepared RNs.

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

1. Martin, the unit manager, receives complaints from community agencies that patients who have been discharged from his unit seem to lack understanding about their disorder and immediate strategies for managing elements of their care. Martin checks the patient teaching sheets and notes that the sheets are initialed by staff. He calls the agencies and indicates that teaching has been done. Potential outcomes of Martins actions include (select all that apply): a. Poor morale on the unit. b. Disruption in community relationships. c. Corruption of patient-staff relationships. d. Patient outcomes for quality care are met.

ABC Kupperschmidt (2004) points out that when accountability is not accepted, then relationships suffer, professional practice is diminished, and self-esteem suffers.

1. As a nurse manager, you want to institute point-of-care devices on your unit. The rationale that you provide to support the point-of-care devices includes (select all that apply): a. Reduction in incidents of medication error. b. Immediate documentation of care. c. Comparison of patient data with previous data. d. Immediate access to staffing schedules.

ABC Point-of-care devices that allow documentation of assessment, care, and teaching at the bedside reduce the gap in time between care and documentation, thereby reducing error, increasing accuracy, and improving communication of care. Medication devices and patient databases enable accurate clinical decision making.

7. Caroline asks family members to leave while she cares for the 16-year-old victim of a recent car accident. The father screams at her and tells her that she has no right to ask his family to leave, and that if she continues to do so, he will throw her out of the room. Caroline is shaken and tells her head nurse, who tells her that this kind of thing is just part of the job. The guidance of the head nurse: a. Is reasonable. No physical violence was involved. b. Is related to why statistics on violence in health care are likely underreported. c. Acknowledges the deep distress and fear of the family. d. Acknowledges the concern of the nurse.

B A common perception is that incidences such as these, which do not involve physical injury or harm, but rather threats, are part of the job. Because of underreporting, data related to violence and aggression in the workplace may not be reflective of its true incidence.

9. 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

11. 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

7. At a newly built outpatient surgical center, an integrated information system has been purchased. The chief nursing officer creates a series of staff development classes to orient the staff to this new system. One of the advantages of an integrated information system is that client-care data from all sites can be stored in and retrieved from a: a. Nursing information system. b. Central data repository. c. Nurse expert system. d. Handheld device.

B Computer information systems manage large volumes of data, examine data patterns and trends, solve problems, and answer questions. In other words, computers can help translate data into information from both within and among organizations. Data from all patient encounters with the healthcare system are stored in a central data repository, where they are accessible to authorized users. Patient information in a centralized database is organized, legible, and easily retrievable from a variety of sources and reflects a variety of data.

4. A primary care clinic in a small urban center sees a high volume of cardiology patients. Patients who attend the clinic have smart cards that they use at hospitals, clinics, and emergency departments within that region of the state. A primary benefit of the smart card for these patients would be: a. Rapid and accurate treatment in emergency situations. b. Reduced wait times to see specialists. c. E-mail notification of test results. d. Readily available information regarding medications.

B Credit cardlike devices called smart cards store a limited number of pages of data on a computer chip and serve as a bridge between the clinician terminal and the central repository of the electronic health record (EHR), making patient information available to the caregiver quickly and cheaply at the point-of-service. Smart cards provide information to healthcare providers regarding the patients demographic and contact information, allergies, immunizations, lab results, and past patient care encounters and are presented at the point-of-service.

1. Your healthcare organization places a high value on workplace safety and integrates this into all aspects of administrative and patient care processes. As a unit manager, you thoroughly endorse this direction, and during the selection and hiring of new staff, you consistently: a. Refuse to hire applicants who are pushy during interviews. b. Thoroughly follow up with all references before offering a position. c. Ask applicants during the interview if drug or alcohol abuse is a problem. d. Refuse to interview applicants with sporadic work histories.

B Determining if current employees pose a danger in the workplace is a critical factor that is often overlooked. In addition to personal and psychological factors, behaviors can be observed in employees that may be related to violence or aggression in the workplace (Paludi, Nydegger, & Paludi, 2006). The most obvious indicator is a previous history of aggression and substance abuse. Screening potential employees through drug testing, background checks, and references can help reduce the risk of hiring someone who may pose a danger in the workplace.

19. Government and third-party payers announce reduction of compensation for the delivery of patient services. Hospital STV has a flat organizational structure. After the funding announcements, senior officials at the hospital meet and make decisions regarding cost containment of new revenue streams. This action is consistent with: a. The practice of leaving financial decisions with senior officials who understand the total context of funding. b. A tendency to concentrate decision making during economic downturns at the top administrative level. c. A need to make expedient decisions that are likely to be poorly received by staff. d. Ensuring that decisions with regard to cost are made equitably across all departments.

B During times of economic downturn, decisions tend to become very centralized to avoid risk. History demonstrates that increasing the breadth of input during these times is more effective than narrowing it.

21. On Unit 62, the nurses and the unit manager have been involved in shared decision making related to the model of nursing care delivery that the unit will adopt. All individuals have participated and been involved in decision making and implementation of changes. When issues arise during implementation, it is expected that: a. Accountability resides entirely with the unit manager. b. Individual expertise will be utilized to provide solutions, but that responsibility for the change is shared. c. No one really has any accountability or responsibility for the changes. d. This will contribute to widespread skepticism among the staff about the probability of success.

B High-performing organizations provide for participation by all stakeholders, and each stakeholder shares responsibility and risk. This kind of environment is more satisfying for nurses and is characterized by optimism and trust.

10. 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?

16. A patient who has a history of involvement with drugs and weapons comes up to you in the hallway and asks you a question regarding directions in treatment. When you respond, he moves closer in to you and puts both hands up on either side of your neck. No one else is in the hallway. Your best response at this point is to: a. Yell at him to stop. b. Calmly ask the patient to remove his hands. c. Hit the patient in the midsection. d. Use pepper spray.

B In a potentially violent situation, it is important to look and behave in a calm and confident manner, even if you do not feel calm or confident. The person that you are de-escalating will notice and take his cues from you.

1. A nurse manager was orienting new staff members to computerized charting. To understand computerized charting, staff members must understand informatics. The three core concepts in informatics are: a. Hardware, software, and printers. b. Data, information, and knowledge. c. Decision making, data gathering, and reporting. d. Wireless technology, voice recognition, and handheld devices.

B Informatics is the application of technology to all fields of nursing to facilitate and extend nurses decision-making abilities and to support nurses in the use, storage, and linkage of clinical information to provide effective and efficient patient care.

7. Two nurses approach their manager about a conflict regarding the next months schedule. The nurses are talking loudly and at the same time. The manager most effectively uses communication skills to resolve the conflict by: a. Taking both nurses aside, separately and then together, and charging them with resolving the problem without her direct intervention. b. Listening to each nurse speak to the other without interruption and asking clarifying questions to help them resolve the issue themselves. c. Separating the nurses, instructing each to decide how the problem can be resolved, and meeting with them the next day. d. Calling an emergency scheduling committee meeting and asking volunteers to resolve the conflict between the two nurses.

B Negotiation involves the presentation of an opening position with each party, then moving on until they achieve a mutually agreeable result or until one or both move away from a failed negotiation. Negotiation occurs when one party has something that the other party values, such as a desired schedule.

22. 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 carecentered and nonmeasurable.

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

15. Nurses on the dialysis unit notice that changes in labeling of fluids have meant several alarming near misses in terms of wrong administration of fluids. They take this concern to the unit manager. As an advocate of nurse autonomy, the most appropriate response in this situation would be to: a. Ensure that the nurses are aware of the reasons for the change and how the decision was made about the new labels. b. Discuss concerns about the labels and develop potential solutions that take into account changes that can be made at the local level and those that need system intervention. c. Suggest that the staff wait until they have become more familiar with the labels before taking further action. d. Tell the staff that you will notify the pharmacy about these concerns and leave it up to the pharmacy to decide what should be done.

B Participation in decision making regarding ones practice is an appropriate expectation for professional nurses, provides for greater autonomy and authority over practice decisions, contributes to supporting the professional nurse, and is a major component of job satisfaction (Kramer et al., 2008; Pittman, 2007). Autonomy is encouraged through supportive management and through unit-level support of changes without the need for complex, multilevel approval of changes that can be made locally.

3. 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.

21. A nurse manager is excited by the possible use of speech recognition (SR) systems for documentation of patient care, especially during crisis situations when staff members need to focus on performing rapid assessments and implementation of procedures. She learns, however, that SR systems would be impractical at this point. What would lead to this conclusion? a. SR systems are not available outside pilot projects. b. The type of speech required for voice recognition is unlikely to occur in a pressured situation. c. The hands-free function has not been perfected in SR technology. d. Wireless communications are prone to unreliability in transmission.

B Speech recognition systems rely on staccato-like speech, pauses between words, and programming for each user, any and all of which would be unlikely in a pressured crisis situation. SR is being used primarily for therapeutic purposes and in situations where data entry is stable.

6. 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.

14. 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: a. Staffing. b. Funding. c. Composition of executive councils. d. Composition of consumer-based councils.

B The Centers for Medicare & Medicaid Services (CMS) have adopted a policy based on the NQFs 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.

5. The IOM Health Professions Education report highlighted patient safety concerns as: a. A normal risk in professional practice. b. A result of disciplinary silos. c. A reflection of frontline staff. d. Related to systems errors.

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.

20. The institution where you are a nurse manager has resisted the adoption of a new document management software, citing cost as a concern. You meet with other nurse managers who are in favor of the software and prepare a proposal to take to the senior executive with the goal of persuading the executive to adopt the software. This is an example of: a. Collaboration. b. A coalition. c. Networking. d. Policy building.

B The formation of temporary groups to achieve particular goals involves the development of coalitions.

6. The chief nursing officer plans a series of staff development workshops for the nurse managers to help them deal with conflicts. The first workshop introduces the four stages of conflict, which are: a. Frustration, competition, negotiation, and action. b. Frustration, conceptualization, action, and outcomes. c. Frustration, cooperation, collaboration, and action outcomes. d. Frustration, conceptualization, negotiation, and action outcomes.

B Thomas (1992) determined that conflict proceeds through these four stages in this particular order.

10. Two nurses on a psychiatric unit come from different backgrounds and have graduated from different universities. They are given a set of new orders from the unit manager. Each nurse displays different emotions in response to the orders. Nurse A indicates that the new orders include too many changes; Nurse B disagrees and verbally indicates why. This step in the process is which of the following in Thomas Stages of Conflict? a. Frustration b. Conceptualization c. Action d. Outcomes

B Thomas Stages of Conflict include conceptualization, which involves different ideas and emphasis on what is important or not or about what should occur.

22. Sarah is involved in intervening when a patient attempts to harm herself on the unit. During the interaction, the patient slaps Sarah across the face. As a head nurse, it is important that you: a. Offer Sarah immediate education and training in self-defense. b. Assist with follow-up documentation and offer access to counseling. c. Provide access to a lawyer. d. Encourage Sarah to see the incident as a normal part of care.

B Training should be conducted on a regular basis and cover a variety of topics, including policies and procedures for reporting, record-keeping, and for obtaining medical care, counseling, workers compensation, or legal assistance after a violent episode or injury.

4. Delaney, one of your staff nurses, confides that Marjorie, another nurse, has been actively telling others that you are incompetent and do not know what you are doing in relation to patient care, and that you lie to the staff about attempts to get more staffing. Delaney says that Marjorie is derogatory towards her in front of others and tells her that she better shape up. Through telephone calls and conversations during breaks, she is recruiting other staff to her position. Delaney confides that most of the staff find you fair, honest, and knowledgeable. Marjories behavior can best be characterized as: a. Political action. b. Bullying. c. Building alliances. d. Disgruntlement.

B Workplace bullying involves aggressive and destructive behaviors such as running a smear campaign, engaging in put-downs, and excluding team members from socialization opportunities.

15. You note that Unit 64 has had a high turnover rate of staff during the past year. In addressing the staff turnover rate, you are: a. Confirming the high correlation between managerial incompetence and violence. b. Demonstrating awareness that workplace violence, if present, has significant costs. c. Aware that staff and manager experiences contribute to high turnover. d. Aware that violence is a rare but present factor in the workplace.

B Workplace violence and aggression contribute to staff turnover and toxic work environments. Loss of the organizational investment required to train new staff and departure of experienced staff can increase operating costs and reduce the quality of care.

1. As a new manager in the ED, you meet with each of the staff to ask about their priorities and what they think is going well in the department or what is of concern to them. Almost all of the staff express frustration and distress at being treated rudely or disrespectfully by patients, staff from other departments, and physicians and complain that they feel that nurses in the ED are not valued. With the staff, you brainstorm to raise the profile of nurses. Which of the following strategies would be most effective? (Select all that apply.) a. Requesting increased compensation b. Speaking positively about ones work c. Dressing and grooming in a clean and neat manner d. Using titles (e.g., Mr., Mrs., Ms.) and last names e. Submitting a written complaint to senior administration regarding rude behaviors f. Developing a code of conduct for the ED staff.

BCDF Demonstrating a positive and professional attitude about being a nurse to nursing colleagues, patients and their families, other colleagues in the workplace, and the public facilitates the exercise of power among colleagues while educating others about nurses and nursing. A powerful image is an important aspect of demonstrating this positive professional attitude and includes how we identify ourselves, how we dress, whether we are punctual for commitments, and whether we speak positively about our work. Bullying and incivility are negative expressions of power that can affect patient outcomes. The Joint Commission standard demands that leaders ensure that a code of conduct is implemented to ensure patient safety and a culture of quality.

12. You document your patients vital signs into a bedside documentation device and are able to compare your patients vital signs with patients who have similar diagnoses and similar medications, and who are of a similar age. You are accessing: a. E-mail. b. Telecommunications. c. A database. d. Technology.

C A database is a collection of data elements stored and organized together for the purposes of interpreting information such as vital signs.

25. Susan, an RN in the ED, would like to pursue leadership roles in her career. She is frustrated that others in her working environment seem to pay little attention to her creative ideas or place her in informal leadership positions. As her colleague, you want to provide her with helpful feedback. Which of the following statements will provide feedback as to how she might communicate power and demonstrate that she is capable of handling other leadership responsibilities? a. I find your soft voice and manners very reassuring and calming to patients. b. Try using a wider vocabulary and big words so that people will think that you are knowledgeable. c. At times, you tend to slump and avoid eye contact when you are talking with colleagues and families. d. Dont worry about what others think of you. If you feel like saying something, say it, even if it hurts other peoples feelings.

C A powerful image comes from thinking of oneself as powerful and effective, and this is communicated through posture, maintaining eye contact, treating others with courtesy and respect, and using a firm, confident voice with vocabulary that is appropriate (which does not necessarily involve using big-sounding words).

4. A manager relies on his director (immediate supervisor) for advice about enrolling in graduate school to prepare for a career as a nurse executive. The director may exercise what kinds of power in the relationship with the manager in this advisory situation? a. Expert, coercive, and referent b. Reward, connection, and information c. Referent, expert, and information d. Reward, referent, and information

C Because the director is in a leadership role, he comes with knowledge or expertise that is required to assume a leadership role, and he has information that he is willing to share, which gives him the power of information. The employee sees him as credible and seeks his advice, which gives him referent power.

1. A new graduate is asked to serve on the hospitals 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.

23. 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.

11. Mrs. Hill, aged 68, was hospitalized after a stroke. The speech therapist recommended that oral feeding be stopped because of her dysplasia. During visiting hours, Mr. Hill fed his wife some noodles. The nurse noticed this and stopped Mr. Hill from feeding his wife, telling him it was the doctors decision. An hour later, the nurse returned and found Mr. Hill feeding his wife again. The nurse tried to stop him again. Mr. Hill refused and claimed that the clinical staff was trying to starve his wife; he also threatened to get violent with the nurse. The nurse decided to walk away and documented the event in Mrs. Hills chart. According to Thomas Four Stages of Conflict, in which stage could the nurse have been more effective? a. Frustration b. Conceptualizing c. Action d. Outcomes

C By walking away, the nurse is engaged in an action or a behavioral response, which is the action stage of conflict that is outlined in the four stages of conflict (Thomas, 1992). In this stage, the nurse might have used more effective strategies, such as clarifying Mr. Hills views on feeding his wife and engaging in dialogue with Mr. Hill to clarify his concerns and attempt to reach a common goal.

11. In an inner-city area, a group of nurses meet and develop a plan to negotiate with local businesses to support a breakfast program for young elementary schoolchildren. This is an example of: a. Community development. b. Collective bargaining. c. Collective action. d. Shared governance.

C Collective action refers to activities undertaken by a group of people with common interests and, in this example, by a group of nurses who are interested in the welfare of children in their community.

22. 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: a. Setting up a nursing team meeting to review practices. b. Calling the family to inform them of the practice. c. Initiating a multidisciplinary and family meeting to focus on Marys needs. d. Restraining Mary to satisfy the familys wishes.

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, Marys needs, and evidence associated with safe practice.

19. 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.

2. The Emergency Department nurses decision to organize for the purpose of collective bargaining is being driven by a desire to: a. Establish the staffing pattern that will be used. b. Determine the hours that one is willing to work. c. Create a professional practice environment. d. Protect against arbitrary discipline and termination.

C Historically, nurses were reluctant to unionize. However, concern with safety of care and quality of care, especially when tension is present in a work environment, makes unionization more desirable. U.S. Supreme Court rulings have provided for RN-only units and protection to practice according to what the profession and licensure status require nurses to do.

6. While working with an aggressive patient, it is important for the nurse to: a. Speak firmly. b. Call the individual by name. c. Place herself between the patient and the door. d. Ignore threats against her.

C In situations where a patient may become aggressive, it is important to ensure that you are not trapped in the room.

8. 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

20. In Hospital STV, senior administration is strongly oriented toward fiscal and social conservatism. The nursing department is deeply concerned with the provision of quality to the community, which includes a high number of poor and unemployed. To accomplish the goals of the nursing department, resources need to be allocated that administration is not able to allocate. Nursing and administration: a. Are engaged in shared governance. b. Are involved in an irreconcilable conflict of interests. c. Represent separate subcultures in the institution. d. Represent union and nonunion conflict.

C Institutions can have several subcultures, which are represented by unique features and distinct ideologies. Subcultures can be congruent and can support healthy relationships in the organization, or they may be separated and characterized by tensions that may be irreconcilable and destructive. From the information given in this scenario, it is not evident that shared governance, union presence, or irreconcilable differences are present.

3. In which of the following situations would you, as the head nurse, be concerned about potential safety issues? a. Jordan comes to your office to complain about inadequate staffing on the unit. He says that he is concerned because he attributes a recent incident to the staffing levels. b. Henry, a long-standing RN on the unit, has begun to miss work regularly. He calls in but is vague about his reasons for the absences. c. Carla, RN, has just ended an abusive relationship with Jake, RN, and he will not leave her alone. You are meeting with Jake today because colleagues on nights have reported that Jake seems to have been intoxicated last night and the previous night. d. Sarah is very quiet and says almost nothing in team meetings. Lately, she has been much more animated since becoming friendly with a couple of other RNs on the unit.

C Jake seems at most risk for violence because of his alcohol use and history of aggression. In the other situations, Jordan is expressing a legitimate concern and is behaving assertively; Henry may have health concerns or other issues that are private and interfering with his work life; and Sarahs change in behavior is likely related to a higher level of comfort with work and colleagues.

22. Lee, the head nurse in ER, has attempted to meet Jillian, one of her staff RNs, for several days to discuss concerns about Jillians relationships with her team members. Lee hopes to offer Jillian coaching so that Jillians relationships can be more satisfying for Jillian and her team members. Each time Lee and Jillian set a time to meet, Jillian phones in sick. In this situation, Lee and Jillian are demonstrating: a. Similar conflict management strategies. b. Escalation of conflict. c. Avoidance and compromise strategies. d. Competing and compromise strategies.

C Jillian is demonstrating avoidance by staying away from meetings to discuss her team relationships, and Lee is demonstrating compromise by offering coaching in return for Jillians being able to engage in more satisfying relationships.

17. Despite the implementation of bar-code medication administration (BCMA) on your busy medical unit, you notice that the number of medication errors has not significantly decreased. Which of the following reasons might explain the lack of change in errors? a. A number of new medications have been introduced into the hospital pharmacy that are not yet recognized in the CDS. b. There have been an unusually high number of patients on the unit who have been unable to confirm their identity at the time of medication administration. c. Lack of staff understanding and support for BCMA has led to overrides or failures to scan bar codes during busy times. d. Clinical data that have been entered into the system to guide administration of the medications are outdated.

C Most errors related to technology involve mislabeled bar codes on medications, mistakes at order entry because of confusing computer screens, or issues with management of information. Errors also are related to dispensing devices and human factors, such as failure to scan bar codes or overrides of bar-code warnings.

17. Kala, a unit manager, in discussing a role the CEO would like her to perform, makes the following statement, I will sit on the hospital taskforce on improving morale if you send me to the hospitals leadership training classes next week, so I can further develop my skills and thus be more effective. Which of the following conflict management styles is Kala using? a. Collaborating b. Avoiding c. Negotiating d. Accommodating

C Negotiation involves an exchange of concessions (membership on a committee in return for attendance at a workshop) or trading. This strategy supports a balance of power.

8. A nurse manager recognizes the need to expand her professional network as she begins a job search for a middle-management position. Which of the following actions is least likely to expand her job-searching network? a. Reviewing her address book or card file for names and phone numbers of former colleagues who are now in middle-management positions b. Making an appointment to meet with a former instructor from her graduate program in nursing administration c. Making a long overdue return call to a former colleague who is now a chief nurse executive d. Attending a state-level conferences for nurse managers and executives and volunteering to help with professional organizations informal luncheons and receptions

C Networking is the result of identifying, valuing, and maintaining relationships with a system of individuals who are sources of information, advice, and support. Many nurses have relatively limited networks within the organizations where they are employed. Active participation in nursing organizations is the most effective method of establishing a professional network outside ones place of employment.

2. 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.

6. A home health nurse has been assigned to cover a 300-square-mile area of remote Montana. Mrs. Baker has just been discharged home following bowel surgery and has a new colostomy. She will need daily contacts for at least two weeks and then regular weekly contact following that week. Because it is not possible to visit Mrs. Baker in person every day and see all of the other clients, the nurse gives her a laptop computer with net meeting software installed. Each morning, both dial in at an agreed-upon time and discuss her progress. The home health nurse assesses whether or not the client needs to be seen that day and is able to view the colostomy site. This type of technology is called: a. Distance learning. b. Knowledge software. c. Telecommunications. d. Biomedical technology.

C Telecommunications and systems technology facilitate clinical oversight of health care via telephone or cable lines, remote monitoring, information links, and the Internet. Patients sitting in front of the teleconferencing camera can be diagnosed, treated, monitored, and educated by nurses and physicians. EKGs and radiographs can be viewed and transmitted.

To increase safety in patient care areas of the Valley Hospital, the executive begins by: a. Asking the community what the safety issues are. b. Consulting with a management expert about staffing schedules. c. Ensuring that the senior nursing officer attends the board meetings. d. Instituting improved practices to reduce needle-stick injuries.

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.

8. Nurses need to know how to operate a computer, compare data across time, and look for patterns in client responses to treatments. These are examples of: a. JCAHO standards. b. Information systems. c. Informatics competencies. d. Requirements for nursing licensure.

C The Quality and Safety Education for Nurses (QSEN) project identified informatics competency as a necessary component of the knowledge, skills, and attitudes for quality patient care. Nurses are anticipated to be able to use information and technology to communicate, manage knowledge, mitigate error, and support decision making. Nurses must utilize hospital database management, decision support, and expert system programs to access information and analyze data from disparate sources for use in planning for patient care processes and systems.

17. Jenny tells you that she is always able to tell when others are about to become violent because they yell. Your response to Jenny is based on your understanding that: a. Her perception is accurate. b. Yelling is more likely associated with aggression. c. Violence is signaled by a variety of behaviors. d. She is mostly accurate in her thinking.

C The STAMP Assessment Components and Cues outline a wide variety of verbal and nonverbal cues that might signal the potential for violence.

15. A 39-year-old patient awaits a kidney transplant. Because he must immediately arrange to get to the hospital when a donor kidney is available, it is important that he can be reached anywhere and at any time. To ensure that he receives the message, what type of technology is most effective? a. Internet b. Telecommunications c. WL pager d. CDS

C Wireless (WL) communication is an extension of an existing wired network environment and uses radio-based systems to transmit data signals through the air without any physical connections. Patients awaiting organ transplants are provided with WL pagers so that they can be notified if a donor is found.

11. You are in the process of designing a patient education program that will provide education and monitoring for patients with hypertension. To support your planning, you draw out and present patient data from: a. A clinical database. b. Biomedical technologies. c. E-mail. d. Internet sources.

A Clinical databases are collections of elements organized and structured for the processing, organization, and presentation of data for interpretation as information, which, in this particular instance, includes outpatient data.

3. The Emergency Department staff decides to use a collective bargaining model for negotiation rather than a traditional trade union model. A traditional trade union model is characterized by: a. Positional conflict. b. Management support of labors initiatives. c. A spirit of trust between management and labor. d. An ability to resolve complaints.

A Collective bargaining encompasses management support of labors initiative, a spirit of trust between labor and management, and resolution of problems. It replaces the positional conflict that has been associated with traditional trade unions. Models such as the interest-based problem solving (IBPS) model seek to avoid positional conflicts such as those between labor and management that do not take into account the opposing party in any way.

24. To improve outcomes on the stroke recovery unit, the unit manager leads an evidence-based practice (EBP) project. The goal of this project is to: a. Enable detection of variations in clinical outcomes from well-researched standards that are supported by confirmatory evidence. b. Gain quick access to literature based on studies of patients and families who have experienced stroke. c. Develop a list of articles that could be accessed to address clinical issues and problems with stroke patients. d. Advance the development of staff who are able to conduct independent nursing research on stroke outcomes.

A Several intelligent clinical information systems are in place that collect good data and then translate nursing knowledge, such as well-researched standards, into reference materials at the point-of-care. In addition, computer applications assist nurses to take action and provide patient care based on the best evidence for practice.

22. Senior executives at Hospital A determine that the hospital will engage in a strategic planning process after changes in healthcare funding and concerns expressed in the community about care that is being delivered at the hospital. The senior executives decide on a participatory process in which staff are widely consulted regarding input about the organization and the external environment and are actively invited to be part of decisions related to the mission statement, goals, and objectives. For true shared governance to be seen as part of this approach: a. It must be evident in the outcomes of the process that staff and senior executives have partnered on the decisions. b. Stakeholders must be assured of the value of their input even though final decisions rest with senior executives. c. Publications must clearly outline how staff input was solicited and obtained. d. Staff must be reassured that significant concerns will be kept in mind even if they have not been addressed in planning documents.

A Shared governance demands participation in decision making. When partnership, equity, and ownership are not involved, then shared governance has not occurred, and publication and expressions of appreciation for input will not be seen as representative of shared governance.

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. b. Bringing their own linens and other personal items to the hospital. c. Washing hands frequently while in a healthcare environment and using a hand sanitizer. d. Following closely the directions and orders of healthcare providers.

A The Five Steps to Safer Health Care for patients include keeping a list of medications that patients are taking.

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: a. Meets individually with nurses who are observed to be using the lifts incorrectly to review the correct procedure. b. After consultation with the staff about the review, orders new lifts to replace older ones that are malfunctioning. c. Blames the system for inadequate funding for resources. d. Reviews the system of reporting incidents to ensure that appropriate reporting is occurring.

A The IOM report (2004) points to the need to involve nurses in decisions that affect them and the provision of care.

14. 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.

18. 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. b. IHI. c. DNV/NIAHO. d. AHRQ.

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.

19. The SBAR approach to patient safety encourages: a. Consistency in assessment and practices. b. Continuing education. c. Multidisciplinary approaches. d. Patient feedback.

A The use of SBAR (Situation, Background, Assessment, and Recommendation) checklists are designed to decrease omission of important information and practices.

17. In preparation for redesignation as a MagnetTM Hospital, how would you prepare? a. Commit staff resources over a 6-month period to updating procedure manuals. b. Educate staff through meetings and training sessions regarding appropriate answers to questions. c. Prepare a manual that outlines orientation procedures and ensure that all safety issues are addressed. d. Ensure that there are empirical data to support review of patient outcomes, actions taken, and results of actions.

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.

19. Becky, RN, works as a staff nurse in mental health; Sharon works as a data entry clerk in Admissions; Sarah is an emergency room physician; and Donna is a housekeeper in geriatrics. Which of these four is most at risk for violence and aggression? a. Becky b. Sarah c. Sharon d. Donna

A Healthcare workers, especially nurses, experience a disproportionately high rate of violence, compared to personnel in other industries. Nurses are the primary target of violence in healthcare settings, especially those who work in emergency room, mental health, and geriatrics. Hader (2008) found that nurses experienced their colleagues as primary targets of violence 79.7% of the time.

21. 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.

20. When assessing the appropriateness of adopting WL PDAs for a nursing unit, you need to consider the advantages, which include: a. Lower cost relative to PCs. b. Small display screen. c. Font size. d. Speed of operation.

A PDAs offer a lower-cost method of documentation and communication than PCs, as well as easy portability. Disadvantages of PDAs include small screen size, suboptimal readability, and slowness in situations when speed is most needed.

18. 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.

12. To achieve nurse-sensitive care standards developed by the NQF, you advocate for which of the following in your health facility? a. Evidence-based practice to reduce the prevalence of pressure sores b. Implementation of informatics at the bedside c. Staff-manager conferences to review reporting of adverse medical events d. Patient councils to review food, recreation, and nurse-patient relations

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.

23. Nurses in an Emergency Department, in an inner-city neighborhood characterized by high levels of violence, are concerned with low levels of security presence in their department. Security levels have recently been decreased and the nurses question why this has occurred. An appropriate action would be to: a. Provide nurses with information about rationale for recent changes in security staffing. b. Refer the matter to the head of security and let her deal with it. c. Provide mentors who can help nurses diffuse aggressiveness. d. Accept the security levels as a consequence of funding realities.

A Workplace advocacy is an umbrella term encompassing activities within the practice setting. Workplace advocacy includes an array of activities undertaken to address the challenges faced by nurses in their practice settings. The focus of these activities is on career development, employment opportunities, terms and conditions of employment, employment rights and protections, control of practice, labor-management relations, occupational health and safety, and employee assistance. The objective of workplace advocacy is to equip nurses to practice in a rapidly changing environment. One manifestation of workplace advocacy is ensuring that relevant information is shared about decisions that affect practice so that further data gathering and decision making (in this instance about security levels and nurse safety) is informed.

1. 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.

ABDE Sentinel events are serious, unexpected occurrences involving death or physical or psychological harm.

1. In designing a new healthcare facility, it is particularly important to pay close attention to safety elements related to violence and aggression in which of the following settings? (Select all that apply.) a. Emergency b. Psychiatry c. Gerontology d. Maternal-child

ABC Although the potential for violence and aggression exists in all healthcare settings, emergency, psychiatric, and geriatric settings are at particular risk for violence.

1. 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. b. George is very shy and withdrawn. He asks the nurse to leave him alone. c. Sarah is a new parent who finds that nurses on the childrens 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 doesnt know what the doctor meant by colostomy.

ACD 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.

8. While making rounds, a night supervisor finds a unit with a low census and too many staff members. The night supervisor is performing as a statutory supervisor when he or she: a. Assigns nurses to care for specific clients. b. Develops a protocol for unlicensed personnel. c. Recommends transferring a nurse to another service. d. Teaches a nurse to use a new piece of equipment.

C The night supervisor is acting in accordance with the National Labor Relations Act, which would enable the supervisor to assign nurses to care.

2. 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? a. Determining who is responsible for the falls b. Strengthening unit policies to avoid inappropriate admissions c. Encouraging involvement of nurses in education related to falls and safety d. Ensuring that patients are appropriately restrained if they are at risk for falls

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.

22. Amy has worked in the dialysis unit on staff for about 12 years. She is frequently consulted by other nursing staff regarding protocols and policies on the unit. What type of power is Amy using? a. Position power b. Expert power c. Personal power d. Competency power

B According to the types of power outlined in the text, Amy is most likely evidencing expert power in that she is being consulted regarding areas of knowledge and competency on the unit and is at the same level, potentially, in the hierarchy as her colleagues.

9. The Emergency Department staff members are concerned that working long hours without rest puts patient safety at risk. One staff member decides that she will risk her job and become a whistleblower. Whistle-blowing is an appropriate recourse when management: a. Disregards due process when disciplining a nurse. b. Delays responding to repeated efforts to provide safe care. c. Hires nurses who are not a part of the union during a strike. d. Refuses to bargain in good faith with the elected bargaining agent.

B Whistle-blowing is often a result of organizational failure, including failure of the organization to respond to serious danger or wrongdoing created within the environment, which, in this instance, involves conditions that put the patient at risk.

4. 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.

4. The chief nursing officer utilizes the hospitals workplace advocacy to help the overwhelmed Emergency Department staff. Workplace Advocacy is designed to assist nurses by: a. Creating professional practice climates in their institutions. b. Equipping them to practice in a rapidly changing environment. c. Negotiating employment contracts. d. Representing them in labor-management disputes.

B Workplace advocacy encompasses a number of activities that enable nurses to control the practice of nursing and to address challenges that they face in the practice setting. These activities include career development, employment rights, employment opportunities, and the labor-management relationship. The aim of workplace advocacy is to proactively equip nurses to practice within a rapidly changing environment, rather than to negotiate contracts or provide representation in employment disputes.

23. Despite repeated invitations by his colleagues to become involved in regional and state nursing practice committees, Tom refuses. His reason is that nursing committees rarely get anything worthwhile done because of politics and conflicts. According to the text, Toms view of involvement: a. Is rare in nursing today. b. Reflects a fear of power. c. Reflects the essential process of power. d. Reflects empowerment and capacity to make his own decisions.

C Toms response reflects a distancing from other nurses related to discomfort with conflict associated with human interactions. The text defines human interactions within organizations as politics, a component of which is the essential process of power.

18. During a unit meeting, you notice that Vivian listens attentively when Mary is speaking and offers support and advice when Mary presents ideas to the group. You are surprised because Vivian has often confided that she does not like Mary. Vivians behavior is best described as: a. Insincere. b. Networking. c. Politically sophisticated. d. Collegial.

D Collegial behavior requires respect, not friendship.

6. During orientation of new nurse managers, the chief nursing officer stresses strategies that help nurse managers to achieve a powerful image. Which groups of behaviors best contribute to a powerful image for the nurse manager? a. Greeting patients, families, and colleagues with a handshake and a smile; listening carefully when problems arise b. For men, no facial hair, always wearing a suit and tie; for women, always wearing a suit and high-heeled shoes c. Maintaining a soft voice during times of conflict; making unbroken eye contact during interactions d. Smiling all the time; always wearing a suit, carrying a briefcase, and, if a woman, wearing no jewelry

A A powerful and positive approach is communicated through confident behaviors such as greeting others, smiling, and showing respect for the opinions of others through listening. Grooming and dress need to be clean, neat, and appropriate to the situation. Speech needs to be firm and confident.

6. A Magnet hospital surveys the staff about job satisfaction. This type of environment, in which nurses have authority and autonomy, is linked with: a. Client satisfaction with the healthcare organization. b. Organizations with a limited number of nurse managers. c. Private, specialty organizations in urban areas. d. Sophisticated academic health sciences universities.

A Autonomy and authority in decision making that is consistent with scope of practice are linked both to higher job satisfaction and to higher patient satisfaction with care. Job satisfaction is an important indicator of the quality of patient care.

3. The nurse manager is aware that conflict is occurring on her unit; however, she is focused on preparing for a state health department visit, so she ignores the problem. A factor that can increase stress and escalate conflict is: a. The use of avoidance. b. An enhanced nursing workforce. c. Accepting that some conflict is normal. d. Managing the effects of fatigue and error.

A Avoidance as a conflict-management style prolongs conflict and has a tendency to escalate conflict.

16. Staff at Valley Hospital are concerned that recent staffing cuts will affect their ability to provide quality patient care, and they express their concerns to senior management. The CEO of Valley Hospital makes the following statement: We need to contain costs because our funding has been decreased. This is a good example of which of the following conditions that propel a situation toward conflict? a. Incompatible goals b. Role conflicts c. Structural conflict d. Competition for resources

A Conflicts arise in four areas: goals, facts, approaches, and values. Conflicts among goals arise from competing priorities such as the provision of quality patient care and containment of costs.

17. The workgroup on NU 23 is marked by apathy toward the wards patients, high absenteeism, open conflict among team members, and high turnover of personnel, including managers. The underlying behavior in this situation may be characterized as: a. Powerlessness. b. Anger. c. Apathy. d. Oppression.

A Emotions such as anger and apathy result from a workplace in which powerlessness is exhibited.

25. Sandra, an RN on the surgery unit, is assisting with a procedure in the patient examination room. The physician orders a medication to be given through IV. Sandra questions the order, based on her knowledge of the patients history and of other medications that the patient has been given. The physician reiterates the order and Sandra refuses to give it. In this instance, Sandra is demonstrating: a. Autonomy. b. Accountability. c. Authority. d. Best practice.

A In this situation, Sandra is exemplifying autonomy, which is the act of making independent decisions in the best interests of the patient, based on her knowledge and experience. This is analogous to the example in the text where the workers on the manufacturing floor have the independence to say Stop the line when something is wrong. Key to the concept of autonomy is decision making and the level of independence that is given. Accountability refers to achievement of outcomes, and authority refers to the capacity to make decisions.

9. A staff nurse asks the nurse manager for a few days off for personal reasons. The nurse manager turns in the request to the human resources office with a note indicating that the staff nurse has demonstrated excellent working skills and is a valued employee. The nurse manager has used the influence of her position to help this staff member. Influence is the process of: a. Using power. b. Empowering others. c. Understanding power. d. Moving past apathy.

A Influence involves the use of power to effect certain outcomesin this situation, to arrange days off for a valued employee.

5. Sarah, a staff nurse on your unit, witnesses another nurse striking a patient. Sarah wants to remain friends with her colleague and worries that confrontation with her colleague or reporting her colleague will destroy their relationship. Sarah is experiencing which type of conflict? a. Intrapersonal b. Interpersonal c. Organizational d. Professional

A Intrapersonal conflict occurs within a person when confronted with the need to think or act in a way that seems at odds with that persons sense of self. Questions often arise that create a conflict over priorities, ethical standards, and values. Some issues present a conflict over comfortably maintaining the status quo and taking risks to confront people when needed, which can lead to interpersonal conflict.

12. Literature on oppression in nursing has: a. Verified the presence of behaviors associated with oppression within nursing. b. Suggested that oppression leads to bullying but has little or no effect on patient outcomes. c. Failed to establish that oppression is present in nursing groups. d. Indicated that nurses use oppression negatively.

A Oppressed group behavior is apparent when a population is dominated by another group and begins to take on the characteristics of the dominant group (Roberts, 1993), often bullying and abusing their peers. In the twenty-first century, bullying and incivility have become epidemic in both nursing education and clinical settings.

2. You need to terminate Gregory, who has had a long-standing history of conflict with you and the staff, and who recently was charged with theft of patient belongings. You consult Human Resources, and together, you develop a plan, which includes: a. A private meeting with Gregory, a Human Resources representative, and you to deliver the news and deliver the termination notice and all other documents that are related. b. Planning an opportunity for Gregory to return and be recognized at a staff farewell. c. Calling Gregory at home to tell him that he is fired and that his paperwork will be sent to him at a future date. d. Calling him into a meeting in your office on the ward, where assistance is available, should he become upset or agitated.

A Termination requires careful planning as to timing, privacy, safety, and how to preserve the employees dignity and avoid humiliation. Choosing a private location where colleagues are not present, and organizing all documentation that is required to be given to Gregory, achieves these goals and prevents his having to come to the organization at a future date.

10. At 3 AM, a man walks into your emergency department. He paces back and forth in the waiting area before he approaches staff to ask if he can see his wife, who is a patient on another floor. He speaks rapidly, his face is flushed, he glances around often, and he keeps his hand in his jacket pocket. A best initial response would be to: a. Assess your situation and your surroundings. b. Ask two or three staff to assist in confronting the individual. c. Ask what floor his wife is on and remind him that visiting hours are closed. d. Remain calm as there is no potential for violence here.

A The behavior of the individual (flushed appearance, furtive glances, speed of speech) and the hand in his pocket suggest the potential for violence or aggression. The first step is to quickly assess your surroundings for others who might assist and for safety alarms.

8. You are part of a multidisciplinary team that is charged with designing a workplace safety plan for your healthcare organization. This team has been established in response to increases in reports of violence and aggression. You begin by: a. Surveying staff about levels of satisfaction with the workplace and management, collegial, and patient relations. b. Offering training sessions in self-defense. c. Developing a policy that outlines zero tolerance for bullying. d. Offering education sessions on recognizing behaviors with potential for violence.

A Violence and aggression and a toxic workplace can lead to staff dissatisfaction and high staff turnover rates. Surveying staff provides a useful starting place in identifying problems such as employee dissatisfaction, bullying, and other forms of violence.

1. Nurses entering into the workforce today are faced with which of the following relationships that could create organizational conflict? (Select all that apply.) a. Nurse-physician relationship b. Nurse-nurse relationship c. Nurse-patient relationship d. Nurse-chief nursing officer relationship e. Nurse-auxiliary personnel relationships

ABCDE By nature, conflict is potentially present in all interpersonal situations. The nurse manager should create an environment that recognizes and values differences in staff, physicians, patients, and communities.

16. Martin, the unit manager, receives complaints from community agencies that patients who have been discharged from his unit seem to lack understanding about their disorder and immediate strategies for managing elements of their care. Martin checks the patient teaching sheets and notes that the sheets are initialed by staff. He calls the agencies and indicates that teaching has been done. Martins follow-up to complaints from the community is: a. Appropriate and indicates that he has assumed accountability for the actions of his staff. b. Indicative that he does not clearly understand the concept of accountability. c. Indicative of strong support for his staff and their autonomy. d. Important in clarifying the difference between his accountability and that of the community in patient care.

B Accountability refers to the achievement of desired outcomes. If community agencies are noticing that limited or no change in patient behavior has occurred despite teaching on the unit, then the staff has not achieved accountability, and he is not holding his unit responsible for the outcomes. Martin is also demonstrating lack of accountability.

2. Nurses who engage in in-fighting, seek physician support against nursing colleagues, and avoid political advocacy through membership in nursing organizations: a. Refuse to believe that they are acting like members of groups that suffer socioeconomic oppression. b. Do not understand how their failure to exercise power can limit the power of the whole profession. c. Purposefully choose to exercise their power in the workplace through indirect means. d. Suffer from learned helplessness as a result of abuse by powerful nurse executives.

B Becoming an active, productive, collegial member of groups and teams within the workplace and in professional associations and community groups ensures that the nursing voice is heard on healthcare issues and problems and is an appropriate exercise of power.

2. Two staff nurses are arguing about whose turn it is to work on the upcoming holiday. In trying to resolve this conflict, the nurse manager understands that interpersonal conflict arises when: a. Risk taking seems to be unavoidable. b. People see events differently. c. Personal and professional priorities do not match. d. The ways in which people should act do not match the ways in which they do act.

B By definition, conflict involves a difference in perception between two or more individuals.

18. John is a circulating nurse in the operating room. He is usually assigned to general surgery, but on this day he is assigned to the orthopedic room. He is unfamiliar with the routines and studies the doctors preference cards before each patient. The fourth patient comes into the room and John prepares a site for a biopsy using a Betadine solution. The surgeon prefers another solution. He notices what John has done and immediately corrects him by rudely insulting John. Which of the following is the most appropriate approach to conflict resolution in this example? a. Collaboration b. Compromising c. Avoiding d. Withdraw

B Compromise involves negotiation or an exchange of concessions and supports a balance of power

14. Your colleague Mary, a recent graduate, announces one day that she intends to leave nursing in 3 to 4 months to pursue a position in marketing. While at your agency, she plans to give patients excellent care and to learn as much as she can, because Who knows? Nursing is a great job with a great pay and I may return someday. Marys statements most accurately exemplify which orientation to the concept of nursing? Nursing as a(n): a. Profession. b. Occupation. c. Flexible discipline. d. Career with off and on ramps.

B Concern with nursing as potentially one in a series of possibly well-paid jobs reflects a view of nursing as an occupation.

1. A group of staff nurses is dissatisfied with the new ideas presented by the newly hired nurse manager. The staff wants to keep their old procedures, and they resist the changes. Conflict arises from: a. Group decision-making options. b. Perceptions of incompatibility. c. Increases in group cohesiveness. d. Debates, negotiations, and compromises.

B Conflict involves disagreement in values or beliefs within oneself or between people that causes harm or has the potential to cause harm. Folger, Poole, and Stutman (2012) add that conflict results from the interaction of interdependent people who perceive incompatibility and the potential for interference.

1. A nurse manager is experiencing poor staff morale on her unit. While participating in a baccalaureate course, the nurse manager had learned that one of the reasons nurses lack power today is probably because of the past. In the early decades of the profession, nurses lacked power because: a. Nurses freely chose to defer to physicians and administrators with more education. b. Women lacked legal, social, and political power because of legal and cultural barriers. c. The first nursing licensure laws prohibited nurses from making most decisions. d. Nurses astutely recognized the risks of grabbing too much power too soon.

B Nursing mirrored the lack of legal, social, and political power that was prevalent in the early decades of the profession.

14. You note that Unit 64 has had a high turnover rate of staff during the past year. In selecting the appropriate action, it is important that: a. All documentation is reviewed. b. Usual processes for discipline are followed. c. Confidentiality is assured. d. An incident report is filed.

C Confidentiality is important if an employee fears intimidation or retribution from a manager.

8. A nursing instructor is teaching a class on conflict and conflict resolution. She relates to the class that conflict in an organization is important, and that an optimal level of conflict will generate: a. Creativity, a problem-solving atmosphere, a weak team spirit, and motivation of its workers. b. Creativity, a staid atmosphere, a weak team spirit, and motivation of its workers. c. Creativity, a problem-solving atmosphere, a strong team spirit, and motivation for its workers. d. A bureaucratic atmosphere, a strong team spirit, and motivation for its workers.

C Differences in ideas, perceptions, and approaches, when managed well, can lead to creative solutions and deepened human relationships. Work on conflict suggests that complete resolution of conflict is counterproductive to the achievement of organizational goals, organizational change, and cohesiveness of employees.

24. As a nurse manager, you realize that your unit has become a toxic environment in which horizontal violence and incivility has become common. In addressing the problem, you decide to implement which of the following? a. Increased education in clinical skills b. Follow-up of all reports of violence c. Training in conflict resolution and team-building d. Posting of the institutional policy on violence at the nursing station

C Encouragement to report violence in all its forms is crucial to understanding the root of the problem and implementing plans to eradicate it. Acts of good faith by organizational management in supporting staff include a policy of non-retaliation for reporting. Making sure that reporting is easier and doing an impartial investigation are critical. Addressing a toxic culture also requires training in conflict management, leadership, communication, and team-building.

5. During coffee and other breaks, Rosalie, the new RN, is shut out of conversations with the other staff. When she approaches other staff on the unit to ask questions, they turn and walk off in the other direction. The behavior of the staff is characteristic of: a. Dislike. b. Lack of trust in Rosalies abilities. c. Horizontal violence. d. Cultural incompetence.

C Horizontal or lateral violence and bullying are terms used to describe destructive behaviors towards co-workers, such as the silent treatment and shutting others out of socializing.

5. A nurse is explaining the pediatric units 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.

21. A safety and security plan is important to a healthcare organization because it: a. Lays out preventive measures in relation to violence. b. Provides direction as to changes in facilities that protect staff. c. Establishes expectations in relation to behavior and tolerance of violence. d. Establishes policies and practices that guide prevention of violence and expectations in the workplace.

D A safety plan provides overall direction in relation to what is expected, how violence is prevented, and what will occur when violence happens.

23. Which of the following best exemplifies the predominant style of conflict management for staff nurses? a. Sarah and Jonas, two RNs, disagree about the best approach to assisting a family that has complex needs. They decide that they will consult with family and together will decide what is best. b. Jennifer needs to switch a shift to attend a family function. She arranges to trade with Nancy, who wants a day off next to a 3-day break. c. Lindsay asks Melody to stay late for the third day in a row. Melody refuses, stating that she has already helped out for two days by staying late for Lindsay. d. Lara asks Stacey to switch shifts with her because Lara wants to attend a concert. Stacey would prefer not to but does to enable Lara, who is new in town, to be with her friends.

D Avoidance and accommodation are the predominant conflict management styles of nurses. Accommodating involves neglecting ones own needs while trying to satisfy the needs of another.

20. The head nurse and a staff nurse are having a conflict over how to use and apply a new procedure for dressings in the medical/surgical unit. The staff nurse wishes to use the new procedure based on newly released nursing research. The head nurse wishes to use a protocol that has been used in the department for a number of years. The head nurse later makes comments to other staff on her unit about the credibility of the staff nurse. This behavior is associated with: a. Lateral violence. b. Horizontal violence. c. Confrontation. d. Bullying.

D Bullying involves aggressive or destructive behavior or psychological harassment of a recipient who is in a position of power differential with the perpetrator (the head nurse). Bullying is closely related to lateral or horizontal violence and involves such behaviors as incivility or intimidation.

13. Jill is the head nurse on a unit in a large hospital. Two of the staff nurses are constantly arguing and blaming each other, and a resolution has not occurred in months. To solve the existing conflict, which is the most creative conflict resolution? a. Avoiding b. Competing c. Compromising d. Collaborating

D Collaboration, although time-consuming, is the most creative stance. The collaboration technique involves both sides in the conflict working together to develop an optimal outcome. This results in a win-win solution.

11. Linda, a staff nurse on nights, yells at Ali, another RN, and tells Ali that she is stupid and cant get anything right. In responding to this situation as head nurse, it is critical that you: a. Require that Linda attend anger management classes. b. Investigate to see if Ali did anything to aggravate Linda. c. Call both immediately into the office to discuss the situation. d. Respond to Linda in a way that is consistent with organizational processes and with similar situations.

D Erratic or arbitrary discipline, favoritism, or behavior that undermines the dignity of either individual undermines efforts at curbing workplace violence. Disciplinary actions must be proportionate, consistent, reasonable, and fair.

8. In designing a quality, safe healthcare environment, the primary emphasis needs to be on: a. Evidence-based practice. b. Informatics. c. Staffing. d. The patient.

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.

4. The nurse manager decides to use a mediator to help resolve the staffs conflict. A basic strategy for truly addressing this conflict is to: a. Identify the conflicting facts. b. Be determined to resolve the conflict. c. Schedule a meeting time for resolution. d. Have a clear understanding of the differences between the parties in conflict.

D It is important for each person in the conflict to clarify the conflict as I see it and how it makes me respond before all the persons involved in the conflict can define the conflict, develop a shared conceptualization, and resolve their differences.

19. Which of the following interactions is MOST consistent with the idea of networking? a. Meet with the same colleagues daily to have coffee and share concerns about the workplace and stories about colleagues. b. Join an online workplace forum to gain ideas about how to handle workplace conflict. c. Suggest that you and a new team member meet after work for coffee to review unit guidelines. d. Join a nurse executive interest group to meet other executives for support and for sharing ideas of expertise.

D Networking is the result of identifying, valuing, and maintaining relationships with a system of individuals who are sources of information, advice, and support. Many nurses have relatively limited networks within the organizations where they are employed. Active participation in nursing organizations is the most effective method of establishing a professional network outside ones place of employment. Successful networking involves sharing similar ideas and maintaining relationships within a system of individuals who serve as sources of information, advice, and support.

10. A nurse is participating in a baccalaureate course. For the class, she has to attend the legislative session regarding the new role of medication assistants. Nurses should be involved in shaping public policy primarily because: a. Involvement will enable nurses to take over the healthcare system at some point in the future. b. Other healthcare professions are less concerned about the essential needs of clients. c. Such activities are important career builders for nurses who seek top-level executive positions. d. They are closest to the front line of health care and see how it affects clients and families.

D Nurses can no longer be passive observers of the political world. Political involvement is a professional responsibility. Nurses perspectives of the critical issues for improving the healthcare system can shape the policy agenda of the nations political leadership.

15. Lucy, head nurse on the surgical unit, works with her staff to find ways in which they can work together with other disciplines to provide more effective care for patients on the unit. Lucy likely knows her power is: a. Limited, thereby necessitating involvement of others in implementing ideas. b. Restricted, which necessitates finding alternative means to achieve strong patient outcomes. c. Directed primarily toward those who are subordinate to her. d. Of unlimited capacity when shared with others.

D Those like Lucy, who share power, tend to be the strong collaborators and see power as an unlimited quantity when shared. Empowered nurses make professional practice possible, creating a culture that satisfies all nurses.