Leadership Final Exam Study Guide Chapters: 12.26.15

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

ANS: A Acquisition of a role is time dependent and involves application of life experiences to each role and interpretation of the role within one's own value system. As roles become more complex, an individual may take longer to assimilate the components of each role. REF: Page 281 TOP: AONE competency: Business Skills

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

ANS: A Anecdotal notes compiled consistently over the entire rating period are a much more equitable method of providing an accurate summary of the employee's performance. REF: Page 285 TOP: AONE competency: Business Skills

12. After a major flu vaccination campaign, an agency bills a private insurance company for allowable costs for administration of each vaccination according to the schedule established by the insurance company for reimbursement. This is an example of which major payment method? a. Cost-based reimbursement b. Charges c. Contractual allowance d. Prospective reimbursement

ANS: A Because the agency is submitting costs after the campaign is completed and in accordance with an established schedule of allowable costs, a retrospective, cost-based reimbursement payment method is being utilized. If a desire for profit was indicated, then the answer would be "charges." REF: Page 214 | Page 215 TOP: AONE competency: Business Skills

2. The difference between a nurse practitioner's charge of $45 for an office visit and the insurance company's payment of $34 is: a. A contractual allowance. b. A profit. c. A flat rate. d. Revenue.

ANS: A Because the amount that is allowed for an office visit is less than the amount that the NP charges, this is known as a contractual allowance or discount. If the amount allowed were more than what the NP charges, then a profit would be realized. All of the answers represent sources of revenue. REF: Page 215 TOP: AONE competency: Business Skills

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

ANS: A Behavioral questions seek demonstrated examples of behavior from the candidate's past experiences; behavioral-based interviewing can be a strong predictor of a future employee. REF: Page 282 TOP: AONE competency: Business Skills

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

ANS: A Choosing the right individual is the challenge for managers and involves finding qualified candidates who will work well within your culture. REF: Page 281 TOP: AONE competency: Business Skills

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

ANS: A Commitment, a sense of control, and satisfaction are linked to clear role expectations and a feeling that contributions are valued. REF: Page 280 | Page 281 TOP: AONE competency: Business Skills

13. Physicians in a small urban hospital are reluctant to discharge older adult patients because many of the patients lack private insurance and the resources to travel distances for follow-up care. The hospital administration pressures the physicians to discharge patients sooner and to be more consistent with the number of hospitalization days specified within the DRGs. Which of the following would most likely prompt the action of administrators? a. The hospital is incurring a deficit related to a gap between the PPS and the DRGs and costs of care. b. Local home care services are expressing concern about the increased acuity of patients being discharged into their care. c. The resource-based relative scale for physicians does not account for the increased length of stay. d. Acute care patients are being denied entry to the hospital because of the increased stay of patients.

ANS: A Length of stay (LOS) is the most important predictor of healthcare costs and extra days are a cost to the organization in terms of both the extra days and decreased patient volume. The situation, as outlined, does not indicate that there is a bed shortage and therefore, there is no evidence that other patients are being denied access to services or that additional patient volume is not being captured. The hospital would be concerned about the impact on its income because of the additional, uncompensated care costs incurred for patients who exceed the usual length of stay explicitly calculated under PPS and the DRGs. REF: Page 215 | Page 219 TOP: AONE competency: Business Skills

MULTIPLE CHOICE 1. The nurse manager schedules evaluations of staff members using a newly developed performance appraisal tool. The development of a performance appraisal tool should include: a. Organizational mission, philosophy, and position requirements. b. A generalized overview of the duties of a position. c. A skills checklist and accreditation requirements. d. An ordinal scale that ranks all employees.

ANS: A Performance appraisal tools and processes should reflect the organizational mission and philosophy, as well as position requirements. REF: Page 286 TOP: AONE competency: Business Skills

16. Of the following, which is the most effective strategy that a nurse manager could employ to reduce unnecessary costs in specific healthcare settings? a. Training nurses on accurate documentation of supplies used for patient care b. Reducing the number of overtime hours worked by staff c. Reducing the number of staff on a unit d. Making decisions for patients about which care is important to their health

ANS: A Reducing overtime hours needs to be carefully assessed against the reasons for overtime (e.g., staff overload, recent illnesses, increased acuity) in terms of whether this reflects an ongoing or temporary situation and therefore whether it is a necessary variance or not. Reducing staff may or may not be effective, depending on the services being provided. Making decisions for the patient misses an important opportunity to invite the patient into discussion about patient priorities and needs and relative costs of options, which may lead to improved adherence with regimens and less waste of resources. An effective approach to cost containment is ensuring that supplies are accurately accounted for and charged in a timely manner. REF: Page 219 TOP: AONE competency: Business Skills

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

ANS: A The Hersey and Blanchard framework suggests that when ability (skills, job knowledge) and willingness are strong, the involvement of the delegator is less. REF: Page 493 TOP: AONE competency: Business Skills

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

ANS: A The position description provides the basis for this position within the organization and communicates expectations for the role. When applying for a position, researching the facility and position description will help an applicant gain insight into the organization; therefore, the position description should be current and communicate expectations. REF: Page 281 | Page 282 TOP: AONE competency: Business Skills

15. Because of the complexity of reimbursement systems and its implications for the services available to patients, the nurse has a key role in: a. Advocacy for patients with regard to services required and services utilized. b. Increasing the volume of services and decreasing the number of patients served. c. Accomplishing more with each visit and decreasing the volume of services used. d. Decreasing the volume of services used and the number of return visits.

ANS: A The specific strategies employed by organizations and nurses to contain costs and increase revenues depend on the reimbursement system(s) within which the organization operates and therefore on whether the volume of services is increased or whether the volume of services is decreased by placing greater emphasis on efficacy in each visit and reducing the number of return visits. Because of the complexity of the reimbursement environment, the nurse is placed in a position of advocacy in terms of what the patient needs and how those needs can be best met within the funding structures. REF: Page 218 TOP: AONE competency: Knowledge of the Health Care Environment

9. An example of an initiative that may reduce total healthcare costs would be: a. Offering nurse practitioner-led clinics that educate parents about nonpharmacologic strategies for managing ear infections. b. Educating seniors about the comparative costs of medications that are prescribed to them. c. Lowering copayments for prescription drugs for seniors. d. Advocating for more readily available MRI services to ensure early diagnosis.

ANS: A Total healthcare costs are a function of prices that are established for various services and the volume or quantity of services used. Utilization of high-tech diagnostic services and lowering of copayments have been implicated in increasing total healthcare costs (thus C and D would not be correct), as well as attitudes and behaviors of consumers of health care. In general, consumers prefer to "be fixed" when something goes wrong rather than to practice prevention. Many consumers still believe that the physician knows best, so they do not seek much information related to costs and effectiveness of different healthcare options. When information is sought, it is not readily available or understandable. Also, consumers are not accustomed to using other, less costly healthcare providers, such as nurse practitioners. REF: Page 213 TOP: AONE competency: Business Skills

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

ANS: A When a registered nurse delegates care to a UNP, responsibility is transferred; however, accountability for patient care is not transferred. Thus, "accountability rests within the decision to delegate while responsibility rests within the performance of the task" (Anthony and Vidal, 2010, p. 3). REF: Page 496 TOP: AONE competency: Professionalism

MULTIPLE RESPONSE 1. An example of a care activity that would likely not be delegated by an RN to a UNP is (select all that apply): a. Teaching self-catheterization to a patient with paraplegia who has limited English. b. Basic care for a patient with a head injury who is rapidly deteriorating. c. One-to-one observation with a suicidal patient. d. Assessment of patients being admitted through the Emergency Department. e. Basic hygienic care for a patient who is post MI and stable.

ANS: A, B, D Functions such as assessment, diagnosis, planning, and evaluation cannot be delegated. In addition, stability, critical thinking, time, and safety are factors that are considered in assessing whether or not to delegate care to a UNP. Teaching self-catheterization to a patient with limited English requires critical thinking; basic care for a patient who is rapidly deteriorating exemplifies concern with stability; and assessment of patients through Emergency is related to the factor of time. An exception to safety and stability in which patients may be delegated to UNPs is when patients are placed on suicide precautions. REF: Page 487 | Page 499 TOP: AONE competency: Knowledge of the Health Care Environment

MULTIPLE RESPONSE 1. During the performance appraisal session, the manager should (select all that apply): a. Maintain a relaxed and professional manner. b. Inquire about the employee's personal life and how it is affecting performance. c. Allow the employee to express opinions orally and in writing. d. Plan to give specific examples only for poor performance.

ANS: A, C During a performance appraisal, it is important to provide examples of both strong and problematic performance and to provide opportunities to express opinions. The supervisor needs to maintain a relaxed professional manner. REF: Page 287 TOP: AONE competency: Business Skills

3. The chief nursing office continues to seek ways to improve healthcare services to clients and to save the hospital money. However, with the federal guidelines of paying agencies based on capitation, the chief nursing office faces a challenge. Capitation provides incentives for healthcare providers to control costs by: a. Providing fewer services to fewer clients. b. Using fewer services per client. c. Using high-technology treatments. d. Requiring second opinions.

ANS: B In a capitated environment, a single fee is paid for all services provided. To be financially viable under this reimbursement model, organizations would be interested in decreasing the volume of services used and increasing the volume of patients. High-technology treatments and second opinions may increase the number of services used. REF: Page 218 TOP: AONE competency: Business Skills

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

ANS: B A combination of several methods is probably superior to any one method. The primary success of any performance appraisal lies in the skills and communication abilities of the manager. REF: Page 286 TOP: AONE competency: Business Skills

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

ANS: B A combination of tools is likely superior to any one method in any situation. REF: Page 286 TOP: AONE competency: Business Skills

23. As an experienced nurse manager who is new to an organization, it would be important to: a. Know the difference between operating and capital budgets. b. Understand the budget timetable and level of involvement expected of individual managers in budget preparation. c. Know why a budget is essential to the well-being of an organization. d. Understand what factors drive up healthcare costs in the healthcare system.

ANS: B Although all of the answers reflect knowledge that is critical to budgeting for nurse managers, an experienced nurse manager would likely be already familiar with general knowledge related to budgeting. The nurse manager, however, would need to become familiar with budget timetables and level of involvement expected in this specific organization because these elements of budgeting vary from work environment to work environment. REF: Page 225 | Page 226 TOP: AONE competency: Business Skills

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

ANS: B Anecdotal notes should be kept consistently throughout the evaluation period and should reflect both negative and positive behaviors if they are to provide an accurate assessment of performance. Anecdotal notes provide documentation to support rating scales and narrative evaluation summaries. REF: Page 285 TOP: AONE competency: Business Skills

7. A staff nurse regularly works two 12-hour shifts each week and one 8-hour shift every other week. How many FTEs is this position? a. 0.6 b. 0.7 c. 0.8 d. 1

ANS: B Assuming that a full-time RN works 2080 hours/year (40 hours 52 weeks), the nurse works (24 hours 52 weeks + 8 hours 26 weeks)/2080, which is 0.7 FTE. REF: Page 223 TOP: AONE competency: Business Skills

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

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

4. In a nurse managers' meeting, the chief nursing officer encourages the managers to brainstorm ways to reduce costs. Nurse managers have the greatest impact on reducing costs by managing: a. Supplies. b. Staffing. c. Fixed costs. d. Medication costs.

ANS: B Because staffing constitutes the largest portion of any healthcare budget, managing the mix and numbers of staff required for patient care to meet identified outcomes will have the largest impact on budgets. REF: Page 220 TOP: AONE competency: Business Skills

22. A nurse manager is planning to request three new infusion pumps at a cost of approximately $1500 each. What would BEST support the capital request? a. Number of patient care hours anticipated for the year b. Cost comparisons; how much and how often infusion pumps are used; condition of existing pumps c. Outline of cost for each pump d. Estimation of total cost; no further details

ANS: B Complete well-documented justifications are needed because the competition for limited resources is stiff. Justifications should be developed using the principle of any business case and should include, at minimum, projected amount of use; services duplicated or replaced; safety considerations; need for space, personnel, or building renovation; effect on operational revenues and expenses; and contribution to the strategic plan. REF: Page 225 TOP: AONE competency: Business Skills

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

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

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

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

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

ANS: B Delegation refers to transfer of responsibility for work; the day shift nurse retains accountability for the outcomes of patient care. REF: Pages 494-496 TOP: AONE competency: Knowledge of the Health Care Environment

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

ANS: B Employees must have clear role expectations, clearly understand what is expected of their performance, and understand the ramifications of not meeting those expectations. Position descriptions provide written guidelines detailing the roles and responsibilities of a specific position within the organizational context. REF: Page 280 | Page 281 TOP: AONE competency: Business Skills

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

ANS: B Empowerment is a process that acknowledges the values and judgments of others and trusts their decisions. It allows freedom for making decisions while retaining accountability and provides an environment that is safe in which to explore. REF: Page 284 TOP: AONE competency: Knowledge of the Health Care Environment

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

ANS: B Even though the delegatee (the one who receives the delegation) receives direction from the professional who delegates a task and must have the authority to complete it, the delegator retains accountability for the overall outcome and completion of the activity. The delegatee has responsibility (obligation to engage in the task) and authority for the task. REF: Page 488 TOP: AONE competency: Professionalism

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

ANS: B In management by objectives, the employer and the employee jointly establish clear and measurable objectives for the next performance period. REF: Page 286 TOP: AONE competency: Business Skills

MULTIPLE CHOICE 1. The chief nursing office of a Magnet™ hospital has conducted a study of ways to improve healthcare services. Healthcare services that add value for clients: a. Accomplish healthcare goals. b. Minimize costs. c. Decrease the number of services used. d. Use high-technology treatments.

ANS: B Models of reimbursement affect which services and approaches (e.g., decreasing the number of services used) might be financially viable and add value for clients. It is critical to determine and advertise the value of nursing care. Services that add value are of high quality, affect health outcomes positively, and minimize costs. REF: Page 217 TOP: AONE competency: Business Skills

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

ANS: B Role ambiguity in the workplace creates an environment for misunderstanding and hinders effective communication. Without clear expectations of performance, missteps in performance can occur. REF: Page 280 TOP: AONE competency: Business Skills

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

ANS: B Shared governance involves valuing the contributions of each member of the team, releasing the need to control, and understanding that accountability rests with members of the team. REF: Page 284 TOP: AONE competency: Leadership

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

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

14. Within a healthcare environment, where the gap between revenues and costs can mean the difference between sustainability of an organization and nonsustainability of an organization or services, it is critical for nurse managers to: a. Maintain a clear vision of how to trim healthcare costs. b. Balance value-added services against costs and revenues. c. Consistently delete programs that are of high cost. d. Implement programs that bring in additional revenues.

ANS: B To achieve and maintain financial viability, nurse managers must be able to think strategically financially and in terms of nursing care. Cutting costs by deleting programs and bringing in additional revenue through new programs and services are not in themselves strategic unless the decisions made lead to quality care, have positive outcomes, and are efficient in terms of cost. REF: Page 217 TOP: AONE competency: Business Skills

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

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

8. After reviewing her monthly budget report, the nurse manager sees that she has a negative variance, which prompts her to change the staffing schedule. A negative or unfavorable variance in a monthly expense report may result from: a. Overestimation of inflation. b. Higher than expected client acuity. c. Net revenue exceeding net expenses. d. Not replacing staff who called in sick.

ANS: B Variance reflects the difference between what was projected and the actual performance in a budget. When the variance is negative or unfavorable, the amount spent is more than what was budgeted (expenses exceed revenue); this may be a result of higher acuity. To help managers interpret and use variance information better, some institutions use flexible budgets that automatically account for census variances. REF: Page 226 | Page 227 TOP: AONE competency: Business Skills

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

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

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

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

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

ANS: B When span of control (number of individuals for whom a manager is responsible) is compromised by geographic factors such as lack of proximity, instability in patients' conditions, or lack of experience, the span of control that is being delegated may lead to unsafe care. REF: Page 492 TOP: AONE competency: Knowledge of the Health Care Environment

2. During the budgeting process, nurse managers are typically responsible for which of the following? (Select all that apply.) a. Determining inflationary rates for the upcoming year b. Developing unit operation objectives c. Justifying capital equipment requests d. Predicting cash flow e. Negotiating budget with other managers and administration

ANS: B, C, E Although involvement in budget processes will vary from institution to institution, these are typical responsibilities for nurse managers during the budget process. REF: Page 225 | Page 226 TOP: AONE competency: Business Skills

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

ANS: C An employment interview should always conclude with information as to how and when follow-up to the interview will occur. REF: Page 282 TOP: AONE competency: Business Skills

17. In preparing her budget, a nurse manager determines that she needs to budget for six FTE RN positions in the upcoming year. Based on a 40-hour week, this means that the nurse manager has determined that the budget will provide for _____ hours. a. 12,480 productive b. 10,820 productive c. 12,480 paid d. 10,800 patient care

ANS: C From the information given, it is not possible to determine how many nonproductive hours (vacation, holiday, sick time, education) the nurse manager has accounted for in her budget calculations and therefore whether the total number of hours (40 hours 52 weeks 6 staff = 12,480 paid hours) is productive (paid time that is worked) or nonproductive hours. 12,480 accurately reflects the total number of hours of work paid per year. REF: Page 223 TOP: AONE competency: Business Skills

18. In preparing her budget, a nurse manager determines that she needs to budget for six FTE RN positions in the upcoming year. The nurse manager determines that RN 1 has 5 weeks of vacation and 3 days of education, and has averaged 3 sick days a year. RN 2 has 6 weeks of vacation, has asked to attend a 3-day conference and a 2-day workshop, and has no history of sick time. RN 3 is new, and you anticipate 3 weeks of orientation, as well as 4 weeks of vacation. RN 4 has 6 weeks of vacation and has an ongoing health condition, so you anticipate 2 weeks of sick time, as well as 3 days for education. RN 5 has 5 weeks of vacation, has no education planned, and averages 5 sick days per year. RN 6 has 6 weeks of vacation, has no educational opportunities planned, and has been off ill for 4 weeks. How many hours of productive paid time can be anticipated for the budget? a. 12,480 b. 11,200 c. 10,848 d. 10,688

ANS: C From the information given, there are 32 weeks of vacation (40 hours 32 weeks = 1280 hours), 11 days of education (11 days 8 hours = 88 hours), 15 days of orientation (15 days 8 hours = 120 hours), and 18 days of sick time anticipated (18 days 8 hours = 144) or 1280 + 88 + 120 + 144 = 1632 hours of nonproductive time. This will leave 10,848 hours of productive time available, based on the information available and the fact that the manager is not anticipating sick time for RN 6 in the upcoming budget year. REF: Page 223 TOP: AONE competency: Business

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

ANS: C Hersey and Blanchard explained followership in terms of ability and willingness. Attitude refers to willingness or reluctance to perform work. REF: Page 493 TOP: AONE competency: Communication and Relationship-Building

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

ANS: C If a situation involves a new task and the relationship is ongoing (two individuals who will usually continue to work together), the delegator explains what to do and how to do it. Hersey described the leader's behavior as explaining or persuading, which, is characterized as "selling." The RN who is assigned to the patient is an experienced nurse and team member, but is new to this specific situation. In situations where the nurse is experienced but the task is new, explain (and demonstrate) what needs to be done. REF: Page 493 TOP: AONE competency: Knowledge of the Health Care Environment

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

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

11. An older adult couple with limited means and on Medicare is considering options after the hospitalization of Mrs. A. with a fractured hip. Mrs. A. is stable but requires assistance with bathing, transfer, and mobility, and this will present stress for Mr. A., who was hospitalized with a mild myocardial infarction last year. Considering their means and health concerns, which of the following might be the best option? a. Hospice care b. Custodial nursing home care c. Home care d. Hospital care

ANS: C Of the options presented, C is the best alternative . Custodial nursing care is not covered under Medicare and therefore, the financial burden of this option may cause further stress for the couple. Medicare Part A is an insurance plan for hospital, hospice, home health, and skilled nursing care that is paid for through Social Security. Because Mrs. A. is stable and not terminal, she does not require hospice care. The assistance provided through home care is covered under Medicare and provides assistance for needs such as those of Mrs. A. REF: Page 214 TOP: AONE competency: Knowledge of the Health Care Environment

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

ANS: C Reliability, dependability, and obligation to fulfill the roles and responsibilities of the nurse manager are consistent with responsibility. Accountability refers to being answerable for actions and results. REF: Page 488 TOP: AONE competency: Professionalism

20. In preparing a budget, the nurse manager needs to anticipate the cost of benefits (e.g., health, life insurance, pension and retirement plans). Based on the usual cost of benefits, how much should a nurse manager include for a total full-time salary cost of $312,000? a. $78,000-$93,600 b. $62,400-$78,000 c. $46,800-$93,600 d. $31,200-$46,800

ANS: C The average cost of benefits is approximately 25% to 30% of a full-time employee's salary. In this example, the correct response is obtained by multiplying the total full-time salary cost by .25 and .30. REF: Page 224 TOP: AONE competency: Business Skills

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

ANS: C The nurse manager wants the most qualified individual for the position who also fits the culture of the organization. Asking behavioral questions in the interview allows you to assess how a candidate may function in real-life situations and to assess if this behavior is compatible with the culture on the unit. REF: Page 280 | Page 281 TOP: AONE competency: Business Skills

6. A nurse manager approves two staff nurses to attend a national conference. When reviewing the budget, the nurse manager looks at which line item? a. Cash budget b. Capital budget c. Operating budget d. Supply and expense budget

ANS: C The operating budget includes a personnel budget, which takes into account productive and nonproductive paid work hours. Education hours are covered under nonproductive paid work hours in the operating budget. REF: Page 223 TOP: AONE competency: Business Skills

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

ANS: C To delegate effectively, the nurse manager must assess the abilities required in the situation and the abilities that staff have to anticipate the amount of direction, monitoring, explanation, and independence that can be assumed. REF: Page 499 TOP: AONE competency: Knowledge of the Health Care Environment

24. A nurse manager discovers that the actual number of visits per patient in a home health service is 3.8 visits per day when the standard is 5 visits per day. Based on this information, the nurse manager: a. Concludes that the complexity of care in each visit has arisen. b. Concludes that patient volume has been decreased. c. Decides that more information is needed before a conclusion can be reached. d. Initiates a training session regarding the importance of ensuring that visits are made.

ANS: C Variance from measures of productivity or ratio of outputs to inputs does not necessarily offer an explanation of whether or not care was delivered as needed. Before proceeding to any further conclusion, the nurse manager will need to investigate reasons for the decreased output. REF: Page 227 TOP: AONE competency: Business Skills

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

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

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

ANS: C When an RN assigns care to another RN, it is termed an assignment and not delegation, because both accountability and responsibility are transferred. REF: Pages 494-496 TOP: AONE competency: Knowledge of the Health Care Environment

MULTIPLE CHOICE 1. You are a member of a team assigned to care for 15 general medical/surgical clients. You have all worked well together in the past in this same type of care. If you are assigned to coordinate this team's work, your best strategy, based on the Hersey and Blanchard model, would be to: a. Have a list of tasks to be accomplished and tell each member of the team what he or she must do. b. Encourage people to discuss their frustrations in providing this care. c. Ignore them—they've done it before. d. Provide minimal direction and let them come to you with questions.

ANS: D According to the Hersey and Blanchard model, when ability (skills, job knowledge) and willingness are strong, the role of the delegator is less ("delegating behavior"). REF: Page 493 TOP: AONE competency: Knowledge of the Health Care Environment

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

ANS: D Administration of Kolb's LSI enables identification of the learning styles of new employees, which assists in focusing the implementation of orientation goals and in individualizing learning to the needs and learning style of the employee. REF: Page 283 TOP: AONE competency: Business Skills

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

ANS: D BARS contain both quantitative (rating scales) and qualitative data. They are specific to situations and positions. REF: Page 286 TOP: AONE competency: Business Skills

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

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

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

ANS: D Delegation communication includes what is being delegated (and what is not), outcomes, specific deadlines (if applicable), specific reporting guidelines (what, when), and who may be consulted. Communication also includes conveying recognition of the authority to do what is expected. REF: Page 499 TOP: AONE competency: Knowledge of the Health Care Environment

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

ANS: D Graphic rating scales are commonly used in evaluation and reflect generalizations rather than specific behaviors. REF: Page 286 TOP: AONE competency: Business Skills

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

ANS: D In delegating tasks to others, the nurse considers factors such as stability of the patient, safety of the situation and of the patient, time and intensity involved, and level of critical thinking required to achieve desired outcomes. REF: Page 487 | Page 499

21. A nurse manager is planning to request three new infusion pumps at a cost of approximately $1500 each. This item would typically be included in which budget? a. Operating b. Strategic c. Unit of service d. Capital

ANS: D Items that have a useful life of longer than a year, which is likely with the pumps, and that have a cost that usually exceeds $300 to $1000 (specific amount is set by the organization) are considered capital items. Operating budget items include what is used on a day-to-day basis, such as staffing. REF: Page 225 TOP: AONE competency: Business Skills

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

ANS: D Retention of new nursing personnel begins on the day of their hire. This includes an effective, appropriate orientation and training program, which has a measurable impact on reducing turnover. REF: Page 283 TOP: AONE competency: Business Skills

5. The chief nursing officer works with her nurse managers by helping them understand how to develop and implement a budget. A nurse manager can best describe a budget as a: a. Day-to-day plan for operations. b. Unit of service. c. Statement of revenues and services. d. Financial plan.

ANS: D The budget is an overall financial plan that reflects organizational assumptions, objectives, and standards, and various types of budget planning, including operational and capital budgets, which, in turn, reflect revenues and costs. REF: Page 222 TOP: AONE competency: Business Skills

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

ANS: D The overall evaluative process can be enhanced if the manager employs the technique of coaching. Coaching is a process that involves the development of individuals within an organization. This coaching process is a personal approach in which the manager and the employee interact on a frequent and regular basis with the ultimate outcome that the employee performs at an optimal level. REF: Page 285 TOP: AONE competency: Business Skills

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

ANS: D The use of multilevel healthcare providers enables healthcare organizations and nursing to provide patient-centered care, with a focus on abilities and skills that can be employed to perform "what is needed now." As tasks become more complicated, delegating skills to others enables the nurse to effectively deliver a complex level of care. REF: Page 496 TOP: AONE competency: Knowledge of the Health Care Environment

19. The primary reason for calculating productive hours paid instead of simply calculating work paid per year is that productive hours enable the manager to: a. Anticipate total costs for patient care. b. Know how much time staff will likely be unavailable because of illness. c. Determine when orientation needs to occur for new staff. d. Determine the number of hours available for patient care.

ANS: D Total hours are critical for determining the total number of hours that need to be paid for the year. Productive hours are needed to determine what hours are actually available for patient care. The number of FTEs required is determined by dividing the total patient care hours required by the number of productive hours. REF: Page 223 TOP: AONE competency: Business Skills

10. Which of the following factors is not implicated in rising healthcare costs? a. Rising expectations of consumers for cure and care b. Marketing of drugs to consumers c. Large administrative staffs to process medical billings d. Rising Medicare costs

ANS: D Unintentional injuries, socioeconomic conditions (e.g., poverty and violence), marketing of pharmaceuticals, and the rising expectations of consumers with regard to what should be done to manage health concerns all contribute to rising healthcare costs. The costs of Medicare are not considered in relation to rising costs of health care. REF: Pages 212-214 TOP: AONE competency: Knowledge of the Health Care Environment

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

ANS: D When ability and willingness are strong, the involvement of the delegator is less (Hersey and Blanchard). REF: Page 493 | Page 494 TOP: AONE competency: Knowledge of the Health Care Environment

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

ANS: D Whenever care is provided by someone other than a registered nurse, accountability for care remains with the manager/delegator even though others provide aspects of care. REF: Page 496 TOP: AONE competency: Knowledge of the Health Care Environment

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

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

MULTIPLE RESPONSE 1. Which of the following are considered variable costs? (Select all that apply.) a. Salaries for the minimum number of staff b. Utilities and rent c. Managed care d. Supplies e. Medication and treatment supplies

ANS: D, E The total fixed costs in a unit are those costs that do not change as the volume of patients changes. In other words, with either a high or a low patient census, expenses related to rent, utilities, loan payments, administrative salaries, and salaries of the minimum number of staff to keep a unit open must be paid. Variable costs are costs that vary in direct proportion to patient volume or acuity. Examples include nursing personnel, supplies, and medications. REF: Page 220 | Page 221 TOP: AONE competency: Business S