Chapter 11. Building Nursing Management Skills

8. What are critical points to communicate during a shift report or hand-off communication? a. Patient name, current physical status, activities that have contributed to current status, problems that have occurred during the shift, nursing care to address problems, and a readback or response b. Patient name, room number and date of birth, changes in current orders, provider's visits, laboratory tests that have been completed, and physical activity of the patient c. Patient name, health care provider, diagnosis, review of all current orders, family visits and involvement in care, review of history leading to hospitalization, and current status of the patient d. Physician orders for past 24 hours, patient name and date of birth, medical and social history prior to hospitalization, and review of health problems since hospitalization

ANS: A According to the I-SBAR-R tool—Identification (patient name), Situation (current physical status), Background (activities that contributed to current status), Assessment (problems that occurred during shift), Recommendation (nursing care to address problems), Readback or Response (receiver acknowledges information)—these are critical areas. All of the other options contain items that are not critical to a shift report.

5. The nurse manager is updating unit staff on findings by The Joint Commission. Which of the following statements shows an understanding of untoward events in the hospital setting? The primary cause of untoward events is a. "unclear, ineffective communication." b. "unclear chain of communication for reporting." c. "ineffective reporting of the untoward event." d. "lack of consistent supervision of nursing staff."

ANS: A Ineffective communication was identified as the root cause for nearly 70% of all sentinel events reported. The majority of those untoward events involved communication failure. The other options were not identified as the majority of all sentinel events.

18. A nurse is working with a nurse aide to care for a group of patients. Which of the following activities would be inappropriate to delegate to the nurse aide? a. Providing discharge instructions to a patient b. Refilling water containers c. Obtaining a lift to help a patient out of a chair d. Feeding a patient who is unable to feed himself

ANS: A It is the nurse's responsibility to provide discharge instructions to patients and to assess their understanding of them. This task cannot be delegated to the nursing assistant. Refilling water containers, obtaining a lift to help a patient out of a chair, and feeding patients are all tasks that can be delegated to the nursing assistant.

9. The charge nurse is assigning patient care activities to the nursing care team. In supervising the team, what is the most effective activity to determine that the nursing care has been completed satisfactorily? a. Have hourly checks with personnel to determine how effectively nursing care is being completed. b. Review with personnel at the end of the shift regarding the status of patients and how care was delivered. c. Discuss with each person the status of their assigned patients and what type of nursing care each will require. d. Schedule routine patient care rounds to evaluate the patients and the nursing care that has been completed.

ANS: A Supervision entails providing direction, evaluation, and follow-up by the nurse regarding the nursing care assigned. The only way the nurse can determine whether the care has been done satisfactorily is to monitor the task (hourly checks with personnel) and evaluate the patient. Waiting until the end of the shift could lead to problems not being assessed early to prevent complications. Discussing with the health care provider about the patient is a good practice, but determining the outcome of the care is what needs to be evaluated not just telling them what type of care is required. Scheduling rounds allows the nurse to evaluate the patient; however, communication with the nursing team is important to determine if care is administered satisfactorily.

20. A nurse is discharging a patient who primarily speaks German. Which action(s) should the nurse take to communicate effectively with the patient? (Select all that apply.) a. Contact interpreter services to interpret discharge instructions to the patient. b. Provide discharge instructions for the patient that are written in German. c. Ask the patient to repeat the discharge instructions back to the interpreter as he understands them. d. Forego the interpreter because you are just showing him how to change a dressing. e. Give the patient discharge instructions that are written in English.

ANS: A, B, C The nurse should contact interpreter services and request a German-speaking interpreter. The nurse should provide all discharge instructions with the help of the interpreter and ask the patient to repeat back what he has heard. By using a Team STEPPS strategy "check back," the nurse can ensure that the patient understands the discharge instructions what he needs to do for himself when he leaves.

25. The nurse manager is in charge of a busy nursing unit. Today the nurse manager is planning to evaluate the work of nurses on the unit. Which of the following actions would help complete this task in an effective manner? (Select all that apply.) a. Provide feedback as necessary to staff. b. Verify the tasks are being performed according to standards of practice. c. Allow nurses to complete all tasks, even if performed incorrectly. d. Provide directions with clear expectations of how the task is to be performed. e. Evaluate the performance of the task by the staff.

ANS: A, B, D, E The nurse manager should provide directions with clear expectations, intervene if the task is being performed incorrectly, verify that the tasks are being performed according to standards of practice, evaluate the performance of the task, and provide feedback as necessary. Following these steps will help the nurse manager effectively evaluate staff.

22. Which action(s) can the nurse take during report to ensure patient safety? (Select all that apply.) a. Give report at the bedside. b. Give report while the nurse is finishing up charting on another patient, so that the new nurse doesn't have to wait. c. Use I-SBAR-R during shift change report. d. Focus on giving report, not on answering telephones. e. Be prepared for report.

ANS: A, C, D, E To ensure patient safety during change of shift the nurse should be prepared, give report at the bedside if possible, use I-SBAR-R, and focus on giving report and not on other distractions such as answering the telephone. The nurse should not multitask because this increases the incidence of errors.

17. The charge nurse is determining which activities to delegate to the nursing assistant. Which of the following would not be appropriate for the charge nurse to delegate to the nursing assistant? a. Changing soiled linen b. Taking a blood pressure on someone receiving blood c. Removing a urinary catheter d. Assessing a patient's lung sounds

ANS: D When delegating care, the charge nurse must remember that she cannot delegate nursing judgment. Therefore, in this scenario, the nurse cannot delegate the task of assessing lung sounds. This is a task that must be performed by the nurse. Taking blood pressures, removing a urinary catheter, and changing bed linens are all activities that can be delegated.

13. The nurse is reviewing I-SBAR-R with a coworker at the end of the shift. Which statement indicates that they are discussing the Situation component? a. The nurse states the patient's name using two identifiers. b. The nurse states that the patient was hospitalized for a broken tibia and that surgery is scheduled for later today. c. The oncoming nurse acknowledges the info that has been received. d. The nurse states an opinion on what is happening with the patient.

ANS: B In the Situation component of I-SBAR-R, the nurse states what is going on with the patient. In this situation, the patient was hospitalized with a broken tibia, and surgery is planned for later today. The Identification component involves stating the patient's name, the Assessment component involves the nurse discussing what the nurse thinks is happening with the patient, and the Read-Back or Response component involves that the oncoming nurse repeating what the nurse has heard from the nurse who is reporting at the end of the shift.

3. A nurse is assigned to care for five patients. The nurse is concerned about the ability to care for this many patients. The nurse needs to a. delegate one of the patients to someone else. b. prioritize the needs of the patients and determine the sickest patient. c. procrastinate and hope that someone will offer assistance. d. do the easiest patients first to allow more time for sicker patients.

ANS: B It is important to determine the least stable patient when planning care for multiple patients. Plan and complete the care for the patient who requires multiple treatments or complex nursing care. This patient is most likely to experience physiological problems if the nurse does not address his or her needs. The others are cared for in the priority order determined by their stability and needs. Procrastination and caring for the easiest patient first are not reflective of assessing patient needs and administering patient care management effectively.

2. The instructor has suggested that the student nurse could improve organizational skills and manage time better by scheduling selected nursing activities in the daily assignment. Which activity should be scheduled? a. Suctioning the tracheostomy tube of a patient b. Administering medications c. Assessing patient knowledge of colostomy care d. Assisting a patient with personal hygiene

ANS: B Medications are the most time sensitive issues in nursing care delivery. Scheduling is predetermined by the physician's order. Assessment of a patient's understanding of colostomy care can be done at any time. Personal hygiene needs can be met around non-time-sensitive issues (medications, treatments) in managing the patient care. Suctioning a tracheostomy should be performed when the patient needs it; it is not scheduled.

16. The nurse wants to anticipate patient needs in order to increase patient satisfaction and decrease the use of call bells in the assigned section. What actions can be taken to achieve this? a. Tell patients to turn on their call bells if they need something. b. Perform hourly rounding on each patient. c. Check on the patient every 2 to 3 hours. d. Check on the patient only when medication needs to be administered.

ANS: B Performing hourly rounding encourages the nurse to anticipate the patient's needs, thereby increasing patient satisfaction and decreasing call bell usage. Although checking on the patients every 2 to 3 hours is appropriate, it is not the best answer because hourly rounding provides increased patient satisfaction and reduction of call bells. The nurse needs to check more frequently on the patient rather than wait until the nurse sees the patient when medications are administered.

1. During clinical experience, the student nurse is assigned a patient scheduled to undergo numerous treatments. The student decides it is not possible to complete all the needed treatments in the time scheduled for this clinical day. The student nurse consults with the clinical instructor to... a. delegate b. prioritize c. procrastinate d. do the easiest treatment first

ANS: B Plan your care of a patient who requires multiple treatments or complex nursing care by determining the priority of the patient's problems or needs so that you can provide care to the patient's highest priority needs first. Delegation would not be the most logical or appropriate choice as the student is not working over anyone. It is not always wise to do the easiest treatment first because difficult treatments may have unexpected outcomes that may challenge time management. Procrastination is never a good approach in managing patient care.

12. A nurse is working on a busy orthopedic floor and is on the phone with the floor manager when a physician comes up and gives a verbal order for pain medications on an assigned patient. The physician then leaves the unit. Which action by the nurse would be the most appropriate? a. Write down the order and administer the medication. b. Put the nurse manager on hold and ask the physician to write the order. c. Ignore the physician and continue the conversation with the nurse manager. d. Write down the order and document it as a telephone order.

ANS: B The most appropriate action would be for the nurse to put the nurse manager on hold and ask the physician to write the order. The Joint Commission states that there is a big difference between verbal and telephone orders. Verbal orders should never be accepted unless there is an emergency or the physician is in a sterile environment because there is too much opportunity for a transcribing error.

14. A nurse has received report on assigned patients and is prioritizing their care. Which of the following patients should the nurse assess first? a. A female patient who is complaining of a headache b. A patient who has just returned from surgery and has saturated his dressing c. A patient with a femur fracture that is requesting pain medications d. A male patient who needs to use the bathroom

ANS: B The nurse should assess patients using Maslow's hierarchy of needs or the ABCD system. In the situation, the patient who has saturated his postoperative dressing should be seen first because an issue with the circulatory system makes the patient a priority over the others.

19. A nurse is working on a medical-surgical unit and receives phone call from a physician who would like to give orders for a new patient. What should the nurse do to make the telephone order safer for the patient? (Select all that apply.) a. Refuse to accept the telephone order and request that the physician come to the unit to write the order. b. Accept the order and perform a "read back." c. Write down the telephone order as it is being given. d. Accept the telephone order, but write it down later. e. Ask another nurse to accept the telephone order.

ANS: B, C The nurse should accept the order, write it down and perform a read back. According to the Institute for Healthcare Improvement (2005), 50% of all medication errors have been directly attributed to the failure to communicate information at the point of transition.

21. A nurse has received an abnormal result on a critical test for an assigned patient. The nurse has been trying to reach the resident for 20 minutes but has been unsuccessful. What should be done to ensure the best care for the patient? (Select all that apply.) a. Page the resident once and document this in the chart; he will make rounds soon. b. Page the attending physician. c. Continue to provide care for the patient and document all actions in the medical record. d. Wait until the resident makes rounds to review the test results with him. e. Begin treating the patient for the test result because the nurse knows what the resident will likely order.

ANS: B, C Upon receiving the critical test result, the nurse should page the resident. The nurse should document all attempts to reach the resident and all care provided to the patient. If the resident does not call the nurse back, the nurse should page the attending physician to ensure adequate care for the patient. The nurse should not withhold the test results until the resident makes rounds or begin treating the patient without a physician's order.

24. A nurse has noticed that a coworker consistently has a negative attitude, criticizes others, and even shows aggression toward other members of the healthcare team. Which action(s) by the nurse would help to limit time with this individual? (Select all that apply.) a. Try to help the coworker deal with personal problems during work. b. Steer clear of the coworker. c. Use assertive communication. d. Learn to say "no." e. Set clear boundaries with the coworker.

ANS: B, C, D, E To limit time with this coworker, the nurse should steer clear of this coworker, use assertive communication, learn to say "no," and set clear boundaries. It would not be appropriate to help the coworker deal with personal problems during work.

23. A new nurse understands that organization is key to providing safe, effective care. Which of the following actions would help to achieve this? (Select all that apply.) a. Memorize her assignment and patient reports. b. Create a work organization sheet. c. Keep info about each patient on separate sheets of paper. d. Write down all pertinent patient info. e. Minimize distractions during report.

ANS: B, D, E To provide safe, effective care, the nurse should create a work organization sheet and write down all pertinent information regarding the patient, and minimize distractions during report. The nurse should keep all information on one sheet, so that the information does not get lost. It is unrealistic to memorize assignment and patient reports. Having patient information on separate sheets of paper can become overwhelming and is not effective work organization.

4. Which statement by the nurse manager shows understanding of what initiated the development of the team Strategies and Tools to Enhance Performance and Patient Safety (STEPPS)? a. "The increased need for health care coverage" b. "The need for more qualified nurses" c. "A need for a teamwork system focused on improving communication and teamwork" d. "The increased cost of health care"

ANS: C The Department of Defense (DoD) Patient Safety Program, in collaboration with the Agency for Healthcare Research and Quality (AHRQ), developed an evidence-based teamwork system focused on improving communication and teamwork skills in the health care industry to improve patient outcomes. The team was not created to solve health care coverage concerns, search for more qualified nurses or to decrease the cost of health care.

15. A nurse has been assigned the following patients. Which patient is a priority to assess first? a. A patient with abdominal pain b. A patient who has been NPO all morning and wants to eat c. A patient with pneumonia and O2 saturation of 88% d. A patient complaining of ear pain

ANS: C Using Maslow's hierarchy of needs or the ABCD system, the nurse should see the patient with pneumonia and low O2 saturation first. Issues involving the airway are a priority, and these patients must be seen first. Next, the nurse should see the patient with abdominal pain followed by the patient with ear pain and then the patient who is NPO and wants to eat.

10. What would be a good assignment for an experienced nursing assistant? a. Help teach patients newly diagnosed with diabetes to give themselves injections. b. Report on the quality and quantity of urine on a continuous bladder irrigation. c. Obtain a clean-catch urine specimen from a patient. d. Chart a diet for a patient with an eating disorder.

ANS: C The nursing assistant can be assigned activities that involve standard, unchanging procedures such as helping to obtain a clean-catch urine specimen from a patient. Charting, teaching, and assessing are not assigned to the nursing assistant.

11. The nurse calls a physician to come to the unit to assess a patient. Which of the following is the most effective telephone communication by the nurse? a. "This is the 4100 unit troublemaker again. You probably ought to come to the unit to see Mr. Samuels. His condition doesn't seem right." b. "This is Ann Allen on 4100. I don't quite know what to think about Mr. Samuels. I think his condition is deteriorating, and I'd like to have you see him." c. "Sorry to bother you. This may not be important, but I'm not completely comfortable with Mr. Samuel's response to care. His blood pressure has dropped, and his pulse is elevated." d. "This is Sheila Ryan on 4100 calling regarding your patient, Mr. Samuels. His BP has dropped from 130/90 at 8 am to 100/70 at 10 am. His pulse has risen from 80 to 100, and he seems restless. He received his 8 am Cardizem."

ANS: D A detailed, objective response is effective when communicating not only in person but also by telephone. Try organizing your conversation in the I-SBAR-R communication format. The other responses are subjective in nature with no descriptive assessment data to provide to the physician.

6. The nurse is receiving a phone order from a health care provider. How will the nurse make sure that the provider's order is received without error? a. Advise the health care provider that the order must be written on the chart within the next 24 hours. b. Ask the nurse in charge to come to the phone to take the order. c. Write the order without using any unclear or unapproved abbreviations. d. Repeat the order, write the order verbatim, and read it back to the provider.

ANS: D Repeat the order, write the order verbatim, and read it back to the provider are the steps recommended to confirm that the order was understood correctly, as well as communicated correctly. The question is in regard to the receiving of the order, not specifically how it is written. The nurse will write the phone order on the chart, and later the health care provider will co-sign the order. The charge nurse does not have to take the phone order; any licensed nurse can take the phone order.

7. The nurse receives report on an assigned group of patients. Which patient would the nurse assess first? a. A patient 2 days postoperative who is complaining of pain b. An older adult patient reported to have increasing lethargy and confusion c. A newly admitted patient with a serum blood urea nitrogen (BUN) of 32 mg/dL d. A hypertensive patient complaining of severe mid-sternum pain

ANS: D The patient with chest pain is at greatest risk of experiencing urgent problems and needs to be evaluated immediately. This does not mean that the nurse will not address the needs of the other patients, but the safety of the hypertensive patient is at risk if the nurse does not see him first.