Cherry Chapter 22, Ch 20. Ch 21., Cherry & Jacob Ch 17. Nursing Leadership & Management

*When considering the philosophy and values of a health care facility, ____is the highest priority.

*Compassion* is the highest priority when providing care and comfort to people in need of respectful and dignified treatment at all times. REF: p. 303, Box 17-4

*The ___ management style encourages staff involvement in the decision-making process.

*Democratic/Participative* The Democratic/Participative manager encourages staff participation in decision making. Involves staff in planning and developing new ideas and programs while believing in the best in people. This manager communicates effectively, and provides regular feedback and so builds responsibility in people. Works well with competent, highly motivated people. REF: p. 300, Box 17-3

*32. Match the following actions with the appropriate responsibility regarding the delegation of nursing interventions: 1. UAP's statement, "I'll notify you of Mr. Smith's BP as soon as I take it so you can decide whether he gets his medication." 2. RN discusses the way the LPN handled a patient complaint 3. RN initially observes a newly hired LPN is changing a simple dressing a. Appropriate supervision b. Evaluation and reassessment c. Effective communication

1. C. Effective communication 2. B. Evaluation and reassessment 3. A. appropriate supervision

*What interventions will a nurse manager implement when coaching a newly licensed nurse regarding the way a patient's complaint was handled? (Select all that apply) A. Ask, "What will you do differently the next time this situation occurs?" B. Begin the discussion with a personal interpretation of the situation C. Focus on how to achieve the "ideal situation" D. Approach the conversation in a nonjudgmental fashion E. Use close ended questions to help focus the conversation on the situation

A, B, D Effective coaching includes discussing situations in a neutral way—avoid judgmental language that will put the other person on the defensive, encouraging the other person to provide his or her perspective about the situation and to reflect on his or her performance through open-ended questions. Being realistic by focusing on what is actually achievable.REF: p. 307, Box 17-6

*Which characteristics are expected to be represented in a health care facility's mission statement? (Select all that apply) A. Commitment to professional excellence B. Providing the most economical health care services C. Ethical treatment of all patients and staff D. Teamwork to deliver quality care E. Utilization of innovated service delivery methods

A, C, D, E Appropriate philosophies and values include the commitment to professional and individual excellence, with support for personal and professional growth, ethical and fair treatment for all through a commitment to relationships based on fairness and trust with our patients and our employees. Teamwork is consistently demonstrated as we work together to provide ever-improving quality care. Compassion is our highest priority; we will always provide care and comfort to people in need with a respectful and dignified treatment at all times. Innovation in service delivery is accomplished by investing in the development of new and better ways to deliver health care.REF: p. 303, Box 17-4

*Which skill is most important for a nurse to possess when attempting to exercise or earn informal power within an organization? A. Ability to persuade others B. Expert level nursing knowledge C. Understanding of management goals D. Willingness to compromise with everyone in the team

A. Informal leadership is exercised by the person who has no official or appointed authority to act, but is able to persuade and influence others. The informal leader may have considerable power in the work group and can influence the group's attitude and significantly affect the efficiency and effectiveness of workflow, goal setting, and problem-solving. The other options represent skills that either relate to actual nursing care (expert nursing knowledge and cooperation) or management (goals).REF: p. 297-298

*Which of the following activities engaged in by a nurse manager would be expected to have the greatest impact on patient care? A. Role modeling effective communication between all levels of staff B. Conducting a survey to identify factors affecting staff job satisfaction C. Providing all nursing staff with opportunities to influence unit policies D. Providing all staff members with written copies of organizational policies

A. Positive role modeling is an effective tool the nurse can use to create a positive team spirit and promote high-quality patient care. Positive role modeling simply means that the nurse performs the job in such a way that he or she demonstrates ideal performance as a professional nurse; others hopefully will follow the example. The other options are more related to the working climate and control of staff performance.REF: pp. 306-307

*32. Match the nursing model most utilized in the following nursing care settings? 1. Functional 2. Case Management 3. Team 4. Total a. Emergency department b. Medical surgical unit c. Critical care d. Home health

ANS: 1. Functional -- a. Emergency Dept 2. Case Management-- d. Home health 3. Team-- b. Medical-surgical unit 4. Total -- c. Critical care

Quality is defined by the ____________.

ANS: patient Quality is based on the perspective of the consumer or, in this instance, the patient.

While taking a shower, a patient pushes the emergency light. When the nurse arrives, the patient complains of feeling dizzy and unsteady. The nurse turns to reach for the patient's walker and the patient falls, hitting the right side of the face resulting in loss of vision in the right eye. This scenario represents a _______ event.

ANS: sentinel A sentinel event is an occurrence that results in death or serious illness and requires immediate investigation.

*25. A _____________ is a measurable condition that results from interventions that can be either positive or negative in nature.

ANS: *patient outcome* Patient outcome is a measurable condition that results from interventions by the health care team; a change in a person's health after treatment; outcomes may be positive such as improved mobility or improved lab values or negative such as infections, falls, or death. p. 366

*27. The active process of directing, guiding, and influencing the outcome of an individual's performance of an activity or task is referred to as ___________________.

ANS: *supervision* Supervision is the active process of directing, guiding, and influencing the outcome of an individual's performance of an activity or task. p. 352

The staff on a nursing unit notes that patient satisfaction varies from month to month. They plot the degree of patient satisfaction each month for 1 year to determine when the periods of greatest dissatisfaction are occurring. The staff uses which type of graph? a. Time plot b. Pareto chart c. Flowchart d. Cause-and-effect diagram

ANS: A A run plot, or time plot, graphs data in time order to identify any changes that occur over time.

The surgical team arrives in the operating room and one member states, "Everyone stop. Let's identify the patient and operative site. Now does anyone have any questions or concerns?" This process is known as: a. time-out. b. a critical pathway. c. special cause variation. d. lean methodology.

ANS: A A time-out occurs in the operating room to ensure the entire surgical team identifies the patient, operative site, and possible concerns or questions about the procedure.

9. According to the unit's policy for call-ins, a nurse is suspended for 3 days because of excessive call-ins that occur within 15 minutes of shift change. The nurse states, "You are unfair to me." Which theory would disprove the nurse's statement? a. Authoritative b. Closed systems c. Open systems d. Trait

ANS: A Autocratic/authoritative management style revolves around the assumption that authority confers the right to issue commands within an organization on the basis of impersonal rules and rights, by virtue of the management position rather than any trait ascribed to the person who occupies that position. Other characteristics include the following: Impersonal rules govern the actions of superiors over subordinates, *all personnel are chosen for their competence and are subject to strict rules that are applied impersonally and uniformly*, and a system of procedures for dealing with work situations is in place **(e.g. this unit had a policy about call-ins). Represents the systems theory of the organization. DIF: Application REF: p. 300, Box 17-3

3. Nurses on a unit provide personal hygiene, administer medications, educate the patient and family about treatments, and provide emotional support. These nurses provide patient care based on which nursing delivery system? a. Total patient care b. Partnership nursing c. Team nursing d. Functional nursing

ANS: A In total patient care nurses provide all aspects of patient care. p. 370

7. Florence Nightingale is attributed with being intelligent (she developed statistical methods to evaluate health care), dependable (she often worked long hours to care for the injured), and ambitious (she fought against society's perception of nursing). Those who depict her as a leader on the basis of these qualities are practicing which leadership theory? a. Trait b. Chaos c. Bureaucracy d. Organizational

ANS: A Leadership trait theory describes the intrinsic traits of leaders and is based on the assumption that leaders were born with particular leadership characteristics. Other traits found to be associated with this leadership theory include intelligence, alertness, dependability, energy, drive, enthusiasm, ambition, decisiveness, self-confidence, cooperativeness, and technical mastery. DIF: Comprehension REF: p. 298

*30. When considering supervisory responsibilities, the registered nurse (RN) must recognize that: a. When two RNs work together to move a client, neither nurse is in a supervisory position. b. Supervision is required only when staff is new to the unit, the patient, or the task. c. All supervision is done with the RN being immediately available to the staff. d. A charge nurse is actually supervising only the LPNs and UAPs on the unit.

ANS: A One RN is working with another RN in a collegial relationship, and neither RN is in the position of supervising the other. Each RN is responsible and accountable for his or her own practice. However, the RN in a supervisory or management position (e.g., team leader, charge nurse, nurse manager), as defined by the health care organization, will be in a position to supervise other RNs. Appropriate supervision is a responsibility of any delegation of task, not just when the staff is unfamiliar with the patient, the task, or the unit. Supervision may be categorized as on-site, in which the nurse is physically present or immediately available while the activity is being performed, or off-site, in which the nurse has the ability to provide direction through various means of written, verbal, and electronic communication.REF: pp. 361-362

1. The task of completing and signing the initial assessment on a newly admitted patient who is about to undergo minimally invasive procedures on an outpatient basis can be delegated to: A. The registered nurse (RN). B. The licensed practical/vocational nurse (LPN/LVN). C. Unlicensed assistive personnel (UAP). D. All levels of staff, because the information is about the past and cannot change.

ANS: A Only the RN can perform and sign the admission assessment, although some components such as monitoring vital signs may be delegated. p. 357

16. A nurse groups patients with criteria such as: "high risk for falls", "infection protocols", and "special communication needs" to determine the mix and number of staff needed on a telemetry unit. The nurse is using: A. a patient classification system to determine safe staffing levels. B. diagnostic-related groups for Medicare billing. C. case management to coordinate care. D. clinical pathways to determine care.

ANS: A Patient classification systems group patients according to care needs to determine safe staffing levels. p. 367

According to the Quality Chasm report: a. health care providers should be proactive rather than reactive to patient needs. b. common needs rather than individual preferences should be the priority. c. medical information should be confined to the primary care provider. d. specialized providers or case managers should control health care decisions.

ANS: A Quality is based on predicting patient needs rather than reacting to needs.

15. A staff nurse provides care based on intuition and always seems to be in control of her personal and professional life—serving on the board of the state nurses association, serving as the nursing unit's representative on the ethics committee, and coaching her daughter's softball team. Many of the staff observes how she manages time and provides care. This nurse's power comes from which type of power? a. Referent b. Legitimate c. Information d. Connection

ANS: A Referent power comes from the followers' identification with the leader. Referent leaders are admired and respected and able to influence other nurses because of their desire to emulate her. DIF: Comprehension REF: p. 297

A team of experienced nurses work together to develop algorithms that are converted into checklists to ensure standardization of commonly performed procedures. The focus of this team is primarily on which Institute of Medicine (IOM) competency? a. Safety b. Timely c. Equitable d. Patient-centered care

ANS: A Standardization contributes to safety and improves individual performance of care providers.

3. Which task is most likely to be considered in a state's practice act as appropriate to delegate to an LPN/LVN if the patient 's condition is stable and competence in the task has been established? A. Administer an enema for an elective surgery patient. B. Administer an antiarrhythmic medication IV while interpreting the patient's rhythm on the cardiac monitor. C. Develop a plan of care for a stable patient admitted for observation after a head injury. D. Teach a patient how to instill eye drops for glaucoma.

ANS: A The RN who is delegating must consider the following: (1) the delegatee's current workload and the complexity of the task, (2) whether the staff member is familiar with the patient population and with the task to be performed, and (3) whether the RN is able to provide the appropriate level of supervision. The delegation decision-making tree would also support the delegation of this task. pp. 357-358, Box 20-3

19. A nurse is concerned about the risk of delegating tasks to licensed practical nurses and unlicensed assistive personnel. What is the best way for the nurse to determine competency of an inexperienced delegatee? A. Actually observe the delegatee perform the assigned task. B. Ask the delegatee how many times he/she has performed the task. C. Ask the patient if the care provided was satisfactory. D. Ask other nurses if they feel the delegatee is competent.

ANS: A The best way for the nurse to determine the competency of LPNs or UAPs is to observe them perform the task. p. 361

Regardless of the term used to describe high-quality health care, the focus of quality is: a. what the consumer needs and wants. b. economical care. c. having the greatest technologic advancement. d. services equally distributed among populations.

ANS: A The customer determines quality on the basis of his or her unique perception of high-quality care.

16. The RN instructs the LPN to "Give an enema to the patient in room 327 who is being discharged but is complaining of being constipated. Then be sure to document on the medication administration record when given." Which of the five rights was missing in this situation? The right of: A. direction and communication. B. task. C. person. D. circumstances.

ANS: A The directions were not clear. The RN did not specify which type of enema to give and what outcome to expect. And the RN gave no instructions related to reporting back. p. 360

4. An explosion just occurred at the local factory, and hundreds of employees have sustained varying degrees of injury. Which type of nursing leadership is most effective in this situation? a. Autocratic b. Democratic c. Laissez-faire d. Referent

ANS: A The dynamics of the situation demand that the leader take control and direct employees to specific actions in response to the emergency. DIF: Comprehension REF: p. 300, Box 17-3

10. The nurse manager is planning staffing levels and realizes that the first step is to: a. know the intensity of care needed by patients according to physical and psychosocial factors. b. examine the educational level of the staff. c. assess the skill level of caregivers. d. review the budget to determine the financial consequences of past staffing patterns.

ANS: A The nurse manager must determine the number and mix of health care providers according to the wide range of care requirements of individual patients. p. 367

4. A patient is admitted with hypotension, shortness of breath, flushing, and hives. All levels of staff have been trained to assess vital signs. Given budget restrictions and proper delegation rules, to which care provider would the RN delegate the task of obtaining the initial blood pressure reading? A. RN B. LPN/LVN C. Unlicensed assistive personnel (UAP) D. Use the blood pressure obtained in the ambulance, because it was assessed via electronic monitoring.

ANS: A The patient's condition is not stable; therefore, the skills of an RN are required. pp. 357-358, Box 20-3

8. A nurse manager is concerned with restocking the emergency cart, creating the staff schedule, requesting floor stock from the pharmacy, and checking the orders on patient charts. Which type of leader accurately describes this nurse? a. Transactional b. Situational c. Transformational d. Contemporary

ANS: A The transactional leader is concerned with the day-to-day operations of the facility. DIF: Comprehension REF: p. 298, Box 17-1

17. A nurse manager wants his nursing unit to be a place where all nurses want to work, where patient satisfaction is high, and care is innovative and interdisciplinary. Staff are encouraged to chair taskforces to improve quality of care and he counsels staff in areas of measuring patient outcomes. Other managers want to mimic this manager's approach to improve their own units. This nurse is which type of leader? a. Transformational b. Transactional c. Laissez-faire d. Authoritative

ANS: A Transformational leaders mentor followers through a vision and are admired and emulated. DIF: Comprehension REF: p. 298

1. In an attempt to persuade employees to bargain for another type of health insurance, a handout is circulated that describes the present employees' health care insurance as being insensitive, limiting choices of care providers, and providing inferior care. This reflects which aspect of Lewin's planned change? a. Unfreeze b. Move c. Refreeze d. Acceptance

ANS: A Unfreeze is correct because the change agent promotes problem identification and encourages awareness of the need for change. In alignment with Lewin's stages of change (unfreezing, moving, and refreezing), education and involvement are keys to successful change. People must believe that improvement is possible before they will be willing to consider change. DIF: Comprehension REF: p. 311

21. Which statement made by an RN regarding delegation indicates the need for additional teaching? *select all that apply* A. Unlicensed assistive personnel (UAP) can assess vital signs during the first 5 minutes for a patient who is receiving a blood transfusion because a reaction at this time is unlikely. B. An LPN/LVN can administer a PPD (tuberculin skin test) if there is no history of a positive PPD. C. When dopamine is ordered continuously, the LPN/LVN can administer dopamine at a low dose for the purpose of increasing renal perfusion. D. UAPs can transfer a patient who is being discharged home from the wheelchair to the bed if they have received training and demonstrated competency. E. Responsibility can be delegated to the UAP, but the delegator retains accountability.

ANS: A, B, C The statement "UAPs can assess vital signs during the first 5 minutes for a patient who is receiving a blood transfusion because a reaction at this time is unlikely" indicates the need for further teaching because the patient is at highest risk of a reaction during the first few minutes of a blood transfusion; thus the assessment skills of an RN are required. The statement "an LPN/LVN can administer a PPD (tuberculin skin test) if there is no history of a positive PPD" indicates the need for further teaching because administration of intradermal medication requires the skill of an RN. Dopamine is a vasoactive drug that can have a profound effect on a patient's blood pressure and cardiac output; administration requires the assessment and evaluation skills of an RN. pp. 357-358, Box 20-3

An interdisciplinary team is evaluating the hospital's care of patients admitted with a myocardial infarction (heart attack) compared to national standards. The team analyzes the hospital's clinical indicator, which would be: (select all that apply) a. aspirin order within 24 hours of discharge. b. patient teaching related to stopping smoking completed prior to discharge. c. beta blocker administered upon arrival. d. support of employer to modify stress in workplace. e. patient's willingness to adhere to a strict cardiac diet after discharge.

ANS: A, B, C Clinical indicators are measurable items that reflect the quality of care provided and demonstrate the degree to which desired clinical outcomes are accomplished. National benchmarks are established according to guidelines related to quality care for patients admitted with heart attack and include: aspirin within 24 hours of admission, angiotensin receptor blocker at discharge, stop smoking instruction given, and beta blocker administered upon arrival and discharge. These are all measurable.

*26. What factors will be focal considerations when a facility begins developing its own set of clinical pathways? (Select all that apply.) a. The facility's most commonly treated diagnoses b. The most costly diagnoses treated by the facility's staff c. Accepted standards of specialized nursing care d. Dietary and physical therapy are viewed as principal contributors e. Physician input as a primary source of decision making

ANS: A, B, C Clinical pathways most often are developed for the health care facility's most common or costly diagnoses. Clinical pathways should also be based on accepted standards of practice as recommended by specialty nursing organizations. The success of clinical pathway development and implementation depends on input and support from all disciplines, including physicians, involved in using the pathway and caring for the patient. pp. 374-375

23. A nurse responsible for staffing a medical-surgical unit must consider: (select all that apply) a. the patient census. b. physical layout of the unit. c. complexity of care required. d. educational level of all staff. e. task preferences of the nurses.

ANS: A, B, C, D The primary considerations for staffing a specific nursing unit are the number of patients; the level of intensity of care required by those patients (commonly referred to as patient acuity); contextual issues, such as architecture, geography of the environment, and available technology; level of preparation and experience of the staff members providing the care; and the quality of the nurses' work life. pp. 367-368

23. Which functions can be delegated only to another RN with appropriate experience and training? *select all that apply* A. Assessment of skin integrity on the third day of hospitalization B. Evaluation of patient teaching related to turning, coughing, and deep breathing exercises C. Nursing judgment related to withholding medication based on vital signs D. RNs do not delegate to other RNs, they delegate only to licensed practical nurses or unlicensed assistive personnel E. Formulation of nursing diagnosis "potential for fall"

ANS: A, B, C, E Activities like assessing skin integrity—which include the core of the nursing process and require specialized knowledge, judgment, and/or skill—can be delegated only to another RN. Activities like evaluating patient teaching—which include the core of the nursing process and require specialized knowledge, judgment, and/or skill—can be delegated only to another RN. Activities like deciding to withhold medication based on vital signs—which include the core of the nursing process and require specialized knowledge, judgment, and/or skill—can be delegated only to another RN. Activities like formulating a nursing diagnosis—which include the core of the nursing process and require specialized knowledge, judgment, and/or skill—can be delegated only to another RN. pp. 361-362

*25. Which situations demonstrate effective delegation by the RN to the LPN? *Select all that apply* A. RN asks the LPN, "Do you have any concerns about your assignment for today?" B. LPN asks, "Where will you be if I need help with the dressing I've been assigned?" C. RN adjusts the LPN's assignments when a patient's condition becomes unstable D. LPN states, "I'll do whatever is necessary to keep my patients free of pain." E. RN assumes responsibility for ambulating a patient when he reports, "I'm feeling dizzy."

ANS: A, B, C, E The RN is responsible for communicating effectively with the LPN concerning responsibilities and accountability regarding patient care. *Asking the LPN if she/he has any concerns demonstrates effective communication*. Appropriate supervision is demonstrated by the LPN's when a question about support is asked. Evaluation and reassessment is demonstrated by the RN adjusting assignments and assuming a responsibility when the patients' conditions change. The LPN's statement about doing whatever is necessary demonstrates a possible risk for actions outside the established job description, competency, and standard of care on the part of the LPN. p. 360, Box 20-4

22. Which factors would be considered in the first steps in developing an effective patient classification system? (select all that apply) a. Planned procedures b. Ethnic diversity of patients c. Clinical competency of staff d. Educational level of nurses e. Age of patients

ANS: A, B, E The first step in developing a patient classification system is to understand the intensity of care needs, which requires identifying specific patient characteristics and care requirements. p. 368

A patient with complicated diabetes is scheduled for a below the knee amputation at 7 AM. The surgical team adheres to the 2012 National Patient Safety Goals by implementing which protocols? (select all that apply) a. The surgical team asks the patient to verify his or her name, type of surgery, and limb to be removed. b. Ask each member of the surgical team to provide a copy of licensure and, if applicable, certification to patient and family. c. The surgical team uses the chart number and name/hospital number to ensure they have the correct patient. d. Mark the procedure site with "X" and again ask the patient to verify correct site. e. After arrival in the operating room, perform a "time-out" for final identification of patient and operative site along with agreement of what procedure is scheduled.

ANS: A, C, D, E The 2012 National Patient Safety Goal includes universal precautions to ensure patient safety and prevent sentinel events. Methods to identify patient and surgical procedure are required.

*24. Which statements reflect common nurse practice acts policies? *Select all that apply* A. Only nursing tasks can be delegated, not nursing practice B. The LPN practices professional nursing C. The RN can delegate only what is within the scope of nursing practice D. The RN must evaluate patient outcomes resulting from the delegated activity E. The LPN works under the supervision and direction of the RN

ANS: A, C, D, E The common policies reflected in nurse practice acts include: only nursing tasks can be delegated, not nursing practice, the RN can delegate only what is within the scope of nursing practice, the LPN or LVN works under the direction and supervision of the RN, the RN must evaluate patient outcomes resulting from the delegated activity. The LPN or LVN and UAP do not practice professional nursing. REF: p. 355, Box 20-1

20. Registered nurses who are entering the workforce will have expanded leadership responsibilities that include: (select all that apply) a. serving on interdisciplinary care teams. b. being competent to work in several areas independently when dictated by a patient census. c. attending a meeting to plan advanced training for unlicensed assistive personnel. d. evaluating outcomes of care that are reported to a standing committee. e. managing units with higher acuity, shorter length of stay, and more diverse patients and staff.

ANS: A, C, D, E The new nurses will be placed in many situations that require leadership and management skills for example: managing a group of assigned patients, serving on a task force or committee, acting as team leaders or charge nurses, and supervising unlicensed assistive personnel and licensed vocational/practical nurses. Diverse patients have comorbidities and require complex interventions delivered during shorter stays with an ever-increasing diverse staff. DIF: Application REF: pp. 296-297

21. While participating in a task force to proactively plan for nursing care delivery over the next 20 years, a nurse learns that dramatic changes will occur as a result of: (select all that apply.) A. the increase in the number of minimally invasive procedures being performed for disease treatment. B. care provided for patients over an extended period in acute care settings. C. the reduction in the number of nurses and other health care professionals who are available to provide care. D. the widespread illiteracy and decreased self-efficacy of the aging patient population. E. the need to focus on social and environmental influences, educational level, and individual characteristics and values of the patient. F. the devaluing of nursing as a means of improving patient outcomes.

ANS: A, C, E Invasive surgical procedures are being replaced by laparoscopic procedures. The demand for nurses and other health care professionals cannot keep pace with the increased need for health care required by the growing older population. Care will focus on the unique lifestyles and values of a diverse population. p. 376

*32. When considering nursing care what events are associated with the term "churning" and responsible for up to 70% of nursing care on a typical 20 bed medical-surgical unit (Select all that apply.) a. Seven patients have been written discharge orders by their physicians b. Five patients will have initial visits from physical therapy staff c. Twelve patients have needs that require assistance with bathing and elimination d. Five patients will be admitted for scheduled surgeries tomorrow AM e. Two patients are in the ER department with orders to be admitted as soon as a bed is available

ANS: A, D, E Fast-paced patient turnover in acute care settings; the rapid discharge and admission cycle is now referred to as "churning" and is estimated to range from 25% to 70% on a typical medical-surgical unit. The remaining options reflect standard unit care. p. 376

7. A patient is admitted with pneumonia. The case manager refers to a plan of care that specifically identifies dates when supplemental oxygen should be discontinued, positive-pressure ventilation with bronchodilators should be changed to self-administered inhalers, and antibiotics should be changed from intravenous to oral treatment, on the basis of assessment findings. This plan of care is referred to as a: a. patient classification system. b. clinical pathway. c. patient-centered plan of care. d. diagnosis-related group (DRG).

ANS: B A clinical pathway is a plan that specifies the timing and sequencing of major patient care activities and interventions by the interdisciplinary team for a particular diagnosis, procedure, or health condition. pp. 374-375

Patients with heart failure have extended lengths of stay and are often readmitted shortly after they have been discharged. To improve quality of care, a type of "road map" that included all elements of care for this disease and that standardized treatment by guiding daily care was implemented. This road map is referred to as a(n): a. benchmark. b. critical pathway. c. algorithm. d. case management.

ANS: B A critical pathway determines the best order and timing of interventions provided by health care team members for a particular diagnosis.

A nurse is assisting with the delivery of twins. The first infant is placed on the scale to be weighed. The physician requests an instrument stat. The nurse turns to hand the instrument to the physician, and the infant falls off the scale. When evaluating the incident, the nurse and her manager list contributory factors such as the need for two nurses when multiple births are known, and the location of the scale so far from the delivery field. These nurses are performing a(n): a. standardization of care. b. root cause analysis. c. process variation. d. analysis of a deployment flowchart.

ANS: B A root cause analysis is a process by which factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event, are identified. The purpose of root cause analysis is to identify improvements that can be implemented to prevent future occurrences.

A nurse is removing a saturated dressing from an abdominal incision and must cut the tape to remove the dressing. The nurse accidentally cuts the sutures holding the incision, and evisceration occurs. In quality improvement, this incident is best identified as a: a. root cause. b. sentinel event. c. variation in performance. d. causal factor.

ANS: B A sentinel event is an unexpected occurrence that could result in serious physical or psychological injury to the patient, including the possibility of returning to surgery and a prolonged length of stay.

A nurse is preparing to administer a medication by using the vastus lateralis site and is unfamiliar with the process. A step-by-step reference that shows how to complete the process is called a: a. deployment flowchart. b. top-down flowchart. c. Pareto chart. d. control plot.

ANS: B A top-down flowchart shows the sequence of steps in a job or process such as medication administration.

6. A patient is admitted with coronary artery disease and is scheduled for coronary artery bypass grafting (CABG). According to the clinical pathway the patient should be extubated and discharged from critical care the day after surgery. During surgery the patient's oxygen saturation decreased drastically as a result of chronic tobacco abuse. Subsequently, the patient remained on the ventilator an additional 2 days postoperatively. According to the clinical practice guideline for CABG, this situation represents a: a. patient outcome. b. variance. c. goal. d. standard.

ANS: B A variance is a deviation from the planned path. p. 375

7. An RN delegates to the unlicensed assistive personnel (UAP) the task of performingblood pressure checks for a group of patients on a nursing unit. The UAP accepts the task and is responsible for: A. delegating the task to another UAP if he or she does not have the time or skill to complete the task. B. keeping the RN informed of any abnormal blood pressure readings. C. calling the physician when the patient's vital signs are not within established parameters. D. informing the dietary department to initiate a low-sodium diet for patients who are hypertensive.

ANS: B After accepting the assignment, the UAP is responsible for completing the task and reporting any patient concerns to the RN. p. 354

*29. The most basic factor contributing to the effective supervision of unlicensed assistive personnel (UAP) is the nurse's: A. ability to communicate effectively with others. B. confidence in his or her ability to delegate appropriately. C. experience managing other members of the health care team. D. ability to teach UAPs the necessary skills for their assigned tasks.

ANS: B Because RNs are becoming increasingly responsible for delegation and supervision in today's health care system, it is imperative that they have confidence in their delegation skills and understand the legal responsibility that they assume when delegating to and supervising licensed personnel and UAP. RNs must know what aspects of nursing and health care can be delegated. Although the other options support their supervision of UAP, the basic component is appropriate delegation. p. 353-354

19. A nurse plans care knowing when specific recovery milestones are expected. The nurse is providing care via: a. patient classification systems. b. clinical pathways. c. functional nursing. d. case management.

ANS: B Clinical pathways plans patient care activities and interprofessional interventions and desired patient outcomes within a specified time period for a particular diagnosis or health condition. p. 366

4. A hospital converts to a system of care delivery in which RNs, LPNs, and unlicensed assistive personnel (UAP) are responsible for implementing a specific task, such as medication administration or personal hygiene, for the entire nursing unit. This type of delivery system is: a. total patient care. b. functional nursing. c. team nursing. d. primary nursing.

ANS: B In functional nursing members of the team are assigned specific tasks such as assessment or medication administration. pp. 370-371

*29. The implementation of a "Medication Nurse" is an example of what nursing care delivery model? a. Total patient care b. Functional c. Primary d. Team

ANS: B In the functional nursing method of patient care delivery, staff members are assigned to complete certain tasks for a group of patients rather than care for specific patients. In total patient care, nurses are responsible for planning, organizing, and performing all care for specific clients. In team nursing, the RN functions as a team leader and coordinates a small group (generally no more than four or five) of ancillary personnel to provide care to a small group of patients. In primary nursing, the RN, or "primary" nurse, assumes 24-hour responsibility for planning, directing, and evaluating the patient's care from admission through discharge. pp. 370-371

A hospital is concerned that the number of medication errors has increased significantly in the past year. A project revealed four causes of medication errors. The above chart was used to help staff and administration know where to focus efforts to reduce errors. Which process improvement tool is used in this situation? a. Run chart b. Pareto chart c. Flowcharts d. Cause-and-effect diagrams

ANS: B Pareto charts are used to prioritize areas to reduce medication errors. Eighty percent of all errors were caused by interruptions, so this should be the area of priority.

9. A nurse manager is mentoring a novice nurse manager in determining staffing needs. The mentor explains, "We must determine the acuity level of the patient by: a. assessing patient satisfaction with nursing care." b. quantifying the amount and intensity of care required." c. examining the skill mix and educational preparation of the staff." d. determining the number of hospital days required by the patients."

ANS: B Patient acuity is measured by determining the amount and intensity of care required. p. 367

18. A patient has decided to stop hemodialysis because his renal failure progresses and he wishes to spend more time with family. Palliative care will continue, and the approach will be discussed with the patient and family as needed and at change of shift. The care delivery model in this situation is termed: a. partnership. b. patient-centered. c. case management. d. total patient care.

ANS: B Patient-centered care models entail the health care team partnering with the patient and family to ensure that patients' wants, needs, and preferences are the priority while allowing the patient and family to participate in decisions and educational needs. p. 373

8. The nurse manager determines that four RNs, five LPN/LVNs, and two unlicensed assistive personnel (UAP) are required per shift to meet the needs of the patient population on the unit, according to acuity and census. The nurse manager is concerned with: a. assignments. b. staffing. c. output. d. productivity.

ANS: B Staffing is the activity of determining that an adequate number and mix of health care team members are available to provide safe, high-quality patient care. p. 367

Nurses working on an orthopedic unit use personal digital assistants (PDAs) to review medications prior to administration to reduce potential drug interactions. Software is also installed that provides video clips of common procedures performed by nurses. Nurses on this unit are best demonstrating which QSEN competencies? a. Patient-centered care b. Informatics c. Teamwork d. Quality improvement

ANS: B Technology (PDA) is used to aid decision making and reduce errors.

14. A task force is considering factors that contribute to high-quality safe staffing. Which statement reflects an understanding of the American Nurses Association's (ANA) recommendations? a. Because patient needs remain constant on a daily shift, staffing needs at the beginning of the shift should be sufficient to provide safe, high-quality care. b. Staffing should allow time for the RN to apply the nursing process so decisions result in high-quality, safe patient outcomes. c. Patient acuity levels affect staffing by increasing the need for unlicensed personnel to provide routine basic care rather than increasing RNs in staff mix. d. RN staffing is not cost-effective; thus is it important for staffing models to limit the number of RNs assigned per shift.

ANS: B The ANA recommends that nurses have time to exercise professional judgment. p. 367

A nonprofit organization that distributes to governmental agencies, the public, business, and health care professionals knowledge related to health care for the purpose of improving health is the: a. Institute for Safe Medication Practices. b. Institute of Medicine. c. National Committee for Quality Assurance. d. The Joint Commission.

ANS: B The Institute of Medicine is a nonprofit organization whose mission is to advance and disseminate to the government, the corporate sector, the professions, and the public scientific information that will improve human health.

11. An RN delegates to an experienced LPN/LVN the task of administering oral medications to a group of patients. The LPN/LVN accepts the assignment, and the RN knows that the LPN/LVN has had the training and has acquired the skills needed to complete the task. The RN then observes the LPN/LVN recording a patient's medication administration just before entering the patient's room. The priority intervention by the RN is to: A. check the patient's drug packages to ensure that the correct drugs were given. B. stop the LPN/LVN immediately and discuss the possible consequences of his actions in a nonjudgmental manner. C. contact the nurse manager and ask that the LPN/LVN's license is suspended. D. call the pharmacy and ask for replacement medications for the patients.

ANS: B The LPN/LVN has the competency but violated one of the rights of medication administration and is practicing unsafe care. The RN's responsibility requires that he or she intervene and identify concerns with the LPN/LVN. p. 363

15. A nursing unit is comparing team nursing to the partnership model and finds that: a. with the partnership model, an RN does not have to be part of the mix. b. leadership abilities of the RN is a major determinant of effectiveness of care for both models. c. the RN teaches the LPN/LVN or unlicensed assistive personnel (UAP) how to apply the nursing process in team nursing. d. with team nursing the RN cares for the patient while the team members work with the family or significant others.

ANS: B The RN leads regardless of whether partnership model or team nursing is practiced. p. 371 |p. 372

6. A student nurse is concerned about delegation practices and wonders why hospitals employ unlicensed assistive personnel (UAP) and LPN/LVNs. The student nurse refers to the National Council of State Boards of Nursing and learns that the role of these personnel is to: A. supplement the staffing pattern when an RN is not available. B. aid the RN by performing appropriately delegated care tasks. C. replace the RN when the health care facility provides long-term care. D. provide patient teaching, allowing more direct care to be provided by the RN.

ANS: B The UAP and LPN/LVN can increase productivity of the RN by performing those tasks that fall within their scope of practice. p. 353

5. The nurse who is responsible for following the patient from admission through discharge or resolution of illness while working with a broad range of health care providers is called a: a. nurse manager. b. case manager. c. coordinator of patient-centered care delivery. d. team leader in team nursing care delivery.

ANS: B The case manager, in collaboration with an interdisciplinary team, oversees the use of health care services by clients throughout a course of illness. p. 373

Each month data on admission assessments that are based on the following standard are entered: "All patients will be assessed by an RN within 2 hours of admission." The target goal for this standard is 97% compliance. Data are displayed on a graph that shows number and time of admission assessments and compliance variation limits. This pictorial representation is: a. Pareto chart. b. control chart. c. deployment chart. d. top-down flowchart.

ANS: B The control chart is a run chart that has a centerline and added statistical control limits that help to detect specific types of change needed to improve a process.

3. The first step in the nursing process and in the problem-solving process is to: a. Identify the problem. b. Gather information. c. Consider the consequences. d. Implement interventions.

ANS: B The nursing process, which is familiar to nurses who address patient care needs, can be applied to all management activities that require decision making and problem-solving. As in the nursing process and the problem-solving process, one must first gather information about the problem or situation. DIF: Comprehension REF: pp. 309-310

12. A patient is admitted for a hysterectomy, and the RN develops and implements the plan of care but also delegates to the LPN/LVN the responsibility of administering oral medications. While off duty, this RN receives a call requesting a change in the plan of care because the patient has developed deep vein thrombosis. The nurse who originally planned the care is practicing which type of nursing care delivery? a. Modular b. Primary c. Team d. Functional

ANS: B The primary nurse assumes 24-hour responsibility for planning, directing, and evaluating the patient's care from admission through discharge but may delegate or provide primary care during the shift when present. p. 372

17. Which of the following situations would be appropriate for the supervisory level of initial direction and/or periodic inspection? A. Experienced RNs work together to provide care for a group of patients newly diagnosed with meningitis. B. The RN assigns the LPN tasks within her scope of practice and checks back during the shift to ensure the tasks are completed correctly. C. A new graduate nurse is assigned care to a male patient with a hematocrit of 11.0 g of hemoglobin per deciliter and is receiving a blood transfusion. The charge nurse checks on the patient status every 15 to 30 minutes and asks the graduate to explain "next steps." D. No supervision is necessary since both are registered nurses.

ANS: B When a working relationship is established and competencies of the delegate established, the delegator may check in during intermittently during the shift. p. 361

*33. What are the primary foci for nurses caring for patients currently being admitted to acute care facilities that make traditional nursing models less effective? (Select all that apply.) a. Rescue b. Stabilization c. Prevention d. Transition e. Rehabilitation

ANS: B, D Because acute care settings now admit only the most seriously ill or injured individuals with a focus on stabilization and transition, the traditional models of nursing care may no longer apply. In the past, nurses provided care based on comprehensive knowledge of the patients' needs, which were learned by caring for the patients over an extended period. Now nurses may have an entirely new group of patients to care for every shift or even more than once during a shift. The remaining options while concerns are not typically the focus of the acute care nurse. p. 376

A nurse educator is explaining to licensed staff that health care is no longer safe and describes The Quality and Safety for Nursing (QSEN) recommended competencies for educating nursing professionals. These include: (select all that apply) a. advanced health assessment techniques. b. patient-centered care. c. prescriptive pharmacology content. d. quality improvement. e. safety.

ANS: B, D, E Patient-centered care is a recommended competency, along with teamwork and collaboration, evidence-based practice, and informatics. Quality improvement is a recommended competency, along with patient-centered care, teamwork and collaboration, evidence-based practice, and informatics. Safety is a recommended competency, along with patient-centered care, teamwork and collaboration, evidence-based practice, and informatics.

*26. Which statement made by the RN demonstrates a lack of effective delegation to a LPN? *Select all that apply.* A. "Have you ever cared for a postoperative patient who experienced a total mastectomy?" B. "If you begin that complex dressing change while I'm off the floor, get someone to help you." C. "Don't change the patient's catheter until you are sure the correct one has arrived on the unit." D. "Which mandatory competency testing session are you planning to attend?" E. "Remember the patient is depressed so don't say anything to make her more sad."

ANS: B, E Not being available to provide effective supervision and addressing the issue in such a general manner is not a demonstration of effective delegation. Assigning a patient whose emotional state is unstable is not reflective of effective delegation. Evaluating the staff member's competency to perform a task or care for a patient with a particular set of needs and the requirement of mandatory competency testing is a factor in effective delegation. It is necessary to assure that the staff member has the resources including supplies to accomplish the assigned task.REF: p. 360, Box 20-4

Nurses, physicians, and social workers finalize the plan of care and coordinate discharge for a homeless person who will need wound care and follow up over the next 4 weeks. Each member contributes based on his or her area of expertise but also recognize other members' strengths. Which of the QSEN competencies are being demonstrated? a. Quality improvement b. Evidence-based practice c. Teamwork and collaboration d. Patient-centered care

ANS: C An interdisciplinary team is working to prevent hand-off errors on discharge.

Which of the following occurrences would be classified as a sentinel event? a. A postpartum patient who elects to breastfeed only twice daily develops mastitis. b. A newly diagnosed diabetic patient self-injects insulin in the abdominal area rather than the upper thigh as instructed by the patient educator. c. A nurse assisting with the delivery of twins places the "Twin 1" name tag on the second-born twin, causing the first-born twin to undergo surgery that was scheduled for the other twin. d. A nurse administers 3 units of regular insulin rather than 3 units of NPH insulin subcutaneously, resulting in a drop in the patient's serum glucose from 160 to 100 mg.

ANS: C Any procedure performed on a wrong person or organ constitutes a sentinel event.

Institute for Healthcare Improvement (IHI) proposed a process for quality improvement with steps known as "PDCA." When explaining the steps to a group of nurses interested in improving the process of medication reconciliation for heart failure patients with high rates of recidivism, the instructor states: a. P stands for process. Following a top-down flowchart provides the steps for reviewing patient medications taken at home compared to those prescribed during hospitalization. b. D stand for deviation, which is an alteration in the expected drugs ordered. c. C is for check if the process for change worked. Was there an improvement in accurate reconciliation? And what was learned? A stands for algorithm, which includes all steps of the process. d. A stands for algorithm, which includes all steps of the process.

ANS: C C stands for check if the change improved the process and what was learned.

16. A staff nurse states, "I really enjoyed having dinner with the Chief of Medical Staff and the President of the hospital. We hope to meet again soon." Which source of power does this nurse possess? a. Expert b. Legitimate c. Connection d. Reward

ANS: C Connection power results from knowing or associating with power people such as the upper administration. DIF: Comprehension REF: pp. 297-298

*30. An emergency department nurse will likely provide care according to which care delivery model? a. Team b. Primary c. Functional d. Total care

ANS: C Emergency departments often use functional approaches to care because emphasis is on efficient assessment and immediate treatment. The team model is often used in medical-surgical units while the primary care model can be used in long-term care facilities. Some aspects of home health nursing function under the total care model. p. 375

*28. Which factor has the greatest impact on whether safe delegation of nursing tasks is possible? a. The level of competency displayed by the unlicensed assistive personnel (UAP) b. Whether the client is experiencing an acute or a chronic medical health issue c. Whether the client's physical condition is considered stable at the time d. The degree of trust shared between the nurse and the client

ANS: C Generally the more stable the patient, the more likely delegation is to be safe. However, it is also important to remember many tasks that can be delegated may also carry with them a nursing responsibility. The other options are to be considered but they are not as impactful as is the physical condition of the client at the time tasks are being delegated. p. 355

13. When deciding which staffing option to use on a nursing unit that will open soon, the manager realizes that: a. continuity of care is enhanced and errors are reduced when nurses provide care over longer shifts and consecutive workdays, such as 12-hour shifts on 3 consecutive days per week. b. the use of part-time nurses provides the variability needed to meet diverse patient needs. c. satisfaction of the staff equates to satisfaction of patients. d. nurses provide the same level of care, regardless of the work environment.

ANS: C High nurse satisfaction is generally equated with high patient satisfaction and positive patient outcomes. p. 368

14. A nurse moves from California to Arkansas and due to having 20 years of experience as a registered nurse is immediately placed in charge of the telemetry unit. The staffing consists of LPNs and two unlicensed assistive personnel. The RN is unsure of the scope of practice of the LPNs and reviews the nurse practice act for Arkansas, which lacks clarity on some tasks. The RN should: A. query the state nursing association to determine their stance on the role of LPNs. B. ask the LPNs on the unit to list what tasks they routinely performed. C. contact the state board of nursing to determine legal scope of practice for LPNs. D. refer to California's nurse practice act because the scope of LPNs/LVNs is consistent across the United States.

ANS: C If the nurse practice act lacks clarity, the state board of nursing can provide guidance. pp. 354-355

18. A hospital recently learned that their scorecard did not meet the national benchmark for patient satisfaction and brought in a professional change agent to determine what their issues were and how they could improve their score. The agent collected data and recommended that nurses participate in interdisciplinary walking rounds and allow the patient and family to be participants. Nurses now round every shift and perform "huddles to update the team" as needed throughout the shift as part of best practices. *Random visits are made to nursing units to ensure all nurses are participating and patients are interviewed for their involvement. This stage of Lewin's change is:* A. Unfreeze. B. Moving. C. Refreeze. D. Resistance.

ANS: C In the refreezing stage, change becomes status quo and the agent reinforces until the change is part of the daily process as in the above situation. DIF: Comprehension REF: p. 311

2. Customer satisfaction is primarily based on: a. access to modern, up-to-date facilities. b. availability of an extensive menu selection. c. personal interactions with employees. d. having to undergo fewer invasive procedures.

ANS: C Interactions between employees and patients/families actually affect clinical outcomes, functional status, and even physiologic measures of health. p. 369

*27. The nurse responsible for unit staffing recognize that client care is most affected positively by: a. A mix of high- and low-acuity client needs. b. Units that implement the job-sharing model. c. Nurses who report high levels of job satisfaction. d. Nursing staff that hold advanced nursing degrees.

ANS: C Nurses who are satisfied with their work generally provide higher-quality, more cost-effective care. Staffing systems should consider the quality of work life for the nursing staff as important as the quality of patient outcomes. Although the other options are factors to be considered, they are all influenced by whether the staff is satisfied with their work environment. pp. 368

10. An RN is counseled by the nurse manager regarding inappropriate delegation when the: A. RN instructs the nursing assistant to greet ambulatory surgery patients and show them to their rooms. B. nursing assistant informs the RN that she has not been trained to collect a sputum specimen and the RN states, "I will show you this time and you can show me the next time." C. RN assigns the float LPN/LVN the task of completing a plan of care for a stable patient who was admitted for routine replacement of a feeding tube. D. LPN/LVN who has demonstrated competence is asked to perform a dressing change for a patient before she is discharged home.

ANS: C Only an RN can initiate and complete a new plan of care; this does not fall within the scope of practice of the LPN/LVN. The RN has violated one of the five rights of delegation. p. 357

The number of IV site infections has more than doubled on a nursing unit. The staff determine common causes include the site is cleaned using inconsistent methods, dressing frequently becomes wet when patient showers, IV tubing is not changed every 48 hours per protocol, and inadequate hand washing of RN prior to insertion. A bar graph demonstrates the frequency in descending order, with 80% of infections being attributed to inadequate hand washing. The quality tool used is a: a. cause-and-effect diagram. b. run chart. c. Pareto chart. d. flowchart.

ANS: C Pareto charts are bar graphs that show causes contributing to a problem in descending order so the leading cause is easily recognized.

*28. When considering clinical pathways, the nurse recognizes that an outcome is: a. The result of a collaborative intervention of the healthcare team. b. An event that can prevent or help a patient reach wellness. c. The end result of interventions provided by the health care team. d. An unexpected event that determines a need to change the plan of care

ANS: C Patient outcomes are the end result of interventions by the health care team. Interprofessional intervention is the collaborative effort by all disciplines. Variance is any event that may alter the patient's progress through the clinical pathway. Triggers alert the caregiver that an unexpected event has occurred and a change in the plan of care may be indicated. p. 374-375

15. An RN makes the following assignments at the beginning of the shift. Which assignment would be considered high-risk delegation? A. A novice RN is assigned a patient with diabetes mellitus requiring mixing of regular and NPH insulin. B. An LPN is assigned an older adult with pneumonia and who requires dressing changes on a foot wound. C. An unlicensed assistive person is assigned the task of assisting a patient with late stages of Huntington's disease to ambulate a short distance in the hallway. D. A float RN from the oncology unit is assigned a patient with a white blood cell count of 4000 mm3

ANS: C Risk of falling is great in later stages of Huntington's disease due to chorea movements. pp. 359-360

6. Managers who exhibit an authoritative behavioral style are most likely to use which source of power? a. Informal b. Expert c. Coercive d. Reward

ANS: C Seven primary sources of power are known. Coercive power is based on fear of punishment or failure to comply. Coercive power fits well into the authoritative behavioral style because authoritative managers indictate the work with much control, usually ignore the ideas or suggestions of subordinates, and provide little feedback or recognition for work accomplished. DIF: Application REF: p. 300, Box 17-3

5. An RN with excellent assessment and psychomotor skills would derive power on the basis of which source? a. Rewards b. Coercion c. Expert d. Legitimate

ANS: C Seven primary sources of power are known. Expert power is based on knowledge, skills, and information. DIF: Comprehension REF: p. 297

11. A hospital is concerned with nurse retention and realizes that job satisfaction is a major influence. To enhance employee satisfaction related to staffing, the management team: a. negotiates for additional agency nurses. b. hires more part-time employees. c. includes participatory management into staffing decisions. d. uses "float" nurses to cover vacancies.

ANS: C Staffing methods that include staff participation and enhance staff autonomy have been demonstrated to play a major part in ensuring employee satisfaction. p. 368

A nurse is asked to "float" to a telemetry floor and is to place a patient on telemetry monitor. The nurse is unfamiliar with placement of EKG leads and would consult which type of chart to learn the correct placement?

ANS: C The Pareto chart is used to prioritize interventions that caused the majority of the problems.

*33. After first having a strong understanding of the standards of practice that govern delegation, the registered nurse must know the: a. patient care tasks that are being considered for delegation. b. expected outcomes of the care to be delegated. c. the condition and needs of the patient whose care is being delegated. d. skill and knowledge level of the staff member who is being delegated to

ANS: C The RN must then know the client whose care is being delegated. The client's condition and stability must be determined before tasks and outcomes can be determined or consideration be given to the skill level of the staff being delegated to. p. 358

20. Care delivery using the team-based approach is used on a telemetry nursing unit. The team consists of one registered nurse (RN), two licensed practical nurses (LPNs), and one unlicensed assistive personnel (UAP). Staff have been charged to improve quality of care while ensuring cost containment. Which assignments would meet both criteria? A. The RN administers all medications to all patients. B. The LPN performs sterile dressings and IV tubing changes on all central lines. C. The experienced UAP places telemetry electrodes and attaches to cardiac monitor. D. The RN administers an enema to a stable patient who has an order "administer a fleet enema PRN when no bowel movement in 2 days."

ANS: C The UAP, when properly trained, can place patients on telemetry. This meets quality and cost containment goals because the LPN and RN have higher salaries. pp. 353-354

14. A director of nursing (DON) asks the staff to list how their nursing unit can help the organization meet its goal to "provide quality patient care with attention to compassion and excellence." An ad hoc committee is formed to develop a timeline of identified actions. *The DON coaches the committee to reach desired outcomes. This DON is demonstrating which additional role of leadership and management?* a. Transactional b. Clinical consultant c. Corporate supporter d. Autocratic

ANS: C The manager is embracing the mission of the organization (corporation) by supporting the achievement of goals noted in the mission statement. DIF: Comprehension REF: p. 311

A patient is ordered a low-protein, low-calorie diet but the patient's family brings fish, lentils, and unleavened bread for a meal to observe a cultural practice. The nurse works with the dietitian to adjust the next few meals to accommodate for this variance. This situation would represent: a. a sentinel event. b. an adverse event. c. patient-centered care. d. the communication technique of "call-out."

ANS: C The nurse and dietitian are respecting patient values, preferences, and expressed needs.

2. An RN recently relocated to another region of the country and immediately assumed the role of charge nurse. When determining the appropriate person to whom to delegate, the RN knows that: A. the role of the LPN/LVN is the same from state to state. B. the LPN/LVN can be taught to perform all the duties of an RN if approved by the employer and if additional on-the-job training is provided. C. he or she must review the state's nurse practice act for LPN/LVNs, because each state defines the role and scope of practice of the LPN/LVN. D. The Joint Commission has certified and established roles for the LPN/LVN.

ANS: C The scope of practice of the LPN/LVN varies significantly from state to state; RNs should know the LPN/LVN nurse practice act in the state in which they practice and should understand the legal scope of practice of the LPN/LVN. p. 354

2. One difference between a leader and a manager is that: a. A leader has legitimate authority. b. A manager motivates and inspires others. c. A manager focuses on coordinating resources. d. A leader focuses on accomplishing goals of the organization.

ANS: C The terms leadership and management are often used interchangeably, and it is difficult to discuss one without discussing the other. However, these roles have specific traits unique to themselves. The manager is the coordinator of resources (time, people, and supplies) needed to achieve outcomes. The leader uses influence to guide and inspire others. DIF: Comprehension REF: p. 296

9. An LPN/LVN has transferred to a nursing unit and arrives for the first day. The RN checks with the LPN/LVN often throughout the shift to provide support and determine if assistance is needed. The RN is providing which level of supervision? A. There is no supervision because at times the LPN/LVN is not with the RN. B. Periodic inspection is being used. Because the LPN/LVN is licensed, the RN is relieved of the need to evaluate care. C. Continual supervision is being provided until the RN determines competency. D. Initial supervision is being provided because this is the LPN/LVN's first day on the unit.

ANS: C This level of supervision is required when the working relationship is new, the task is complex, or the delegatee is inexperienced or has not demonstrated an acceptable level of competence. p. 362

22. A nursing administrator who is considering the feasibility of an all-RN staff reviews the report, Keeping Patients Safe: Transforming the Work Environment of Nurses (2003) and determines that RNs: *select all that apply* A. are more costly and less efficient than LPNs. B. have little or no effect by being proactive but instead are reactive to patient care errors. C. have a positive effect on patient outcomes when managing patient care. D. are effective overseers of patients' overall health condition. E. lack the training to be effective delegators.

ANS: C, D RNs are effective at coordinating care that results in improved patient outcomes. RNs are valuable monitors of a patient's health status—a practice that results in improved patient outcomes. p. 353

21. A nurse asks, "What is meant by 'internal' customers?" The correct response is: (select all that apply) a. insurance companies b. accreditors such as The Joint Commission c. X-ray technicians d. clinical pharmacist e. chief financial officer

ANS: C, D, E Internal customers are employees of an organization at all levels. An x-ray technician, a clinical pharmacist, and a chief financial officer are all examples of an internal customer. DIF: Comprehension REF: p. 308

18. A registered nurse (RN) is assigned as charge nurse for the first time. She knows to consult the state board of nursing to determine scope of practice for licensed practical nurses (LPN) and unlicensed assistive personnel (UAP). She also realizes there are common policies which exist in most state practice acts that include: A. the RN is held accountable for the decision to delegate, but responsibility rests only with the delegatee. B. the RN may only delegate tasks that are not in the scope of practice of the LPN if the delegatee is certain they are competent to perform the task. C. since the LPN is licensed, they practice professional nursing. D. to determine what tasks can be safely delegated, the RN must first assess the patient.

ANS: D The stability of the patient must be determined prior to delegation. Even routine tasks such as taking vital signs that are often delegated may need to be performed by the RN when the patient's condition is critical. pp. 354-355, Box 20-1

An organization's emergency preparedness task force meets to discuss how it should react in case of a terrorist attack and develops a disaster evacuation plan that details how each department will assist individuals in reaching safety. This type of diagram is referred to as a: a. Pareto chart. b. control chart. c. top-down flowchart. d. deployment chart.

ANS: D A deployment flowchart would show the detailed steps involved in the process and the people or departments that are to be involved at each step to assist individuals in reaching safety.

During the night, a patient fell in the bathroom and sustained a hip injury. The patient was very upset because of being unable to attend a granddaughter's wedding in 2 days. The team looked at the process and determined that the patient had been medicated with a narcotic, had urinary urgency so had not taken the time to put on shoes, failed to turn on the light because the door to the hall let in some light, and stumbled over a towel that had been placed to collect water leaks caused by construction that was in progress to replace damaged sinks. Which factor was a special cause variation? a. Failure to take time to put on shoes due to urgency b. Unsteady gait due to narcotic administration c. Poor lighting that led to decreased vision d. Improper construction that caused the leak and towel placement

ANS: D A special cause variation is an uncommon variation that is unstable and unpredictable, is not under statistical control, and is related to a clearly identified single source, which in this scenario is the construction project.

11. Which action represents the key management function of strategic planning? a. Determining that all nurses on the unit understand the current organizational philosophy b. Evaluating the communication process between the pharmacy and the nursing departments c. Monitoring data from the quality management initiative related to the last three orientation programs d. Developing a 5-year plan that will incorporate the clinical nurse leader as a part of all nursing units

ANS: D A strategic plan is a written document that details organizational goals, allocates resources, assigns responsibilities, and determines time frames. The strategic plan generally looks 3 to 5 years into the future. DIF: Application REF: pp. 301-302

12. Which statement related to delegation is correct? A. The practice of unlicensed assistive personnel (UAP) is defined in the nurse practice act. B. Nursing practice can be delegated only when the LPN/LVN and UAP have received adequate training. C. Supervision is not required when routine tasks are delegated to a competent individual. D. The RN must be knowledgeable about the laws and regulations that govern nursing practice, as well as those that have no clearly defined parameters, such as for UAP.

ANS: D Accountability remains with the RN, and he or she is responsible for knowing what tasks can be delegated and what is defined as nursing practice. p. 354

1. Accrediting agencies such as The Joint Commission address staffing by: A. imposing maximum staffing levels. B. requiring a specific staff mix. C. stipulating nurse-patient ratios. D. looking for evidence that patients receive satisfactory care.

ANS: D Accrediting agencies do not address minimum staffing levels; however, they do look for evidence that patients receive adequate care, and this can occur only with adequate staffing. p. 369

19. A manager just finished the last annual performance review of the staff, reviews the unexpected expenditures for the month due to use of agency nurses, and shares the latest quality indicators with the staff nurses. This manager is performing which management function? a. Directing b. Planning c. Organizing d. Controlling

ANS: D Controlling is the final management function. It includes performance evaluations, financial activities, and tracking outcomes of care to ensure quality. DIF: Comprehension REF: p. 307

Which of the following statements concerning the Institute of Medicine (IOM) competencies is correct? a. Each competency is mutually exclusive. b. The competencies focus on individual efforts to reduce errors. c. Physicians lead the team to achieve each competency. d. The competencies address both individual and system approaches to transform care.

ANS: D Errors and increased health care costs result from both the actions of health care workers and the nature of the system in which they deliver care.

20. An orthopedic unit is considering different types of care delivery models and staff have an opportunity to ask questions about how the models differ. The nurse manager provides an overview and uses the above visual to demonstrate which model of care delivery? a. Team b. Partnership c. Primary d. Functional

ANS: D Functional care delivery models assign tasks to each provider. In the above visual, the LPN is responsible for oral medication administration, the unlicensed assistive personnel provide hygiene, and the RN is assigned to task that require the nursing process. pp. 370-371

A group of nurses is presenting the importance of high-quality care during a system-wide meeting of medical-surgical nurses. They point out a finding of the Quality Chasm that: a. being insured has little effect on a person's longevity and the quality of care received. b. lobbyists for the drug companies are able to gain permission for the use of new drugs within 1 year of their discovery. c. although a greater number of lawsuits stem from medication errors, more people actually die from human immunodeficiency virus (HIV) and acquired immunodeficiency disease syndrome (AIDS). d. medication-related errors place a tremendous financial burden on the U.S. health care system.

ANS: D Medication-related errors for hospitalized patients cost roughly $2 billion annually.

17. A nurse makes patient care assignments as follows: RN1 has rooms 200-210; RN2 has rooms 211-221; RN3 has rooms 222-232. The two unlicensed assistive personnel have half the rooms, with one assigned to 200-215 and the second to 216-232. The care delivery model used in this situation is: a. team. b. primary. c. partnership. d. modular.

ANS: D Modular (or geographic) assignments are based on a geographic location in the nursing unit. p. 372

8. Which task is appropriate for the RN to delegate to the unlicensed assistive personnel (UAP) provided the delegatee has had experience and training? A. Evaluate the ability of a patient to swallow ice after a gastroscopy. B. Assist a patient who has a postoperative hip replacement to ambulate with a walker for the first time. C. Change the disposable tracheotomy cannula for a new postoperative tracheotomy patient if secretions are thick and tenacious. D. Obtain a sterile urine sample from a patient with a Foley catheter that is connected to a closed drainage system.

ANS: D Obtaining a sterile urine sample from a patient with a Foley catheter that is connected to a closed drainage system is not an invasive procedure, and risk to the patient is minimal, making the task appropriate for delegation. pp. 357-358, Box 20-3

5. A nurse is delegating to the newly hired nursing unlicensed assistive personnel (UAP) the task of assisting with oral hygiene, knowing that this assignment "does not require decisions based on the nursing process." The nurse is correctly using which of the five rights of delegation? A. Supervision B. Communication C. Person D. Circumstance

ANS: D Right circumstance involves the delegation of tasks that do not require independent nursing judgments. p. 360

*31. Which statement made by an unlicensed assistive personnel (UAP) would cause the registered nurse team leader the most concern? a. "The nurse will follow up to make sure the client is well cared for." b. "I wonder who I can ask about how to use this new electronic thermometer." c. "I've only been working on this unit for a month and things are still new to me." d. "It's good to know that the nurse is really the one responsible for the client's care."

ANS: D The UAP is responsible for his or her own actions. A belief that the nurse is fully responsible is a concern and needs immediate attention by the nurse. It is true that the nurse will follow up and evaluate the client's care. The statements concerning being new and asking for help are appropriate. REF: p. 354

12. A hospital's policy requires that all nurse managers must have a minimum of a bachelor's degree in nursing. A BSN nurse new to the hospital has recently been hired as nurse manager for the oncology unit. An RN who has worked on this unit for many years is unable to be promoted to a nurse manager position because of their educational status, and now they've been commenting to physicians and staff, "The new nurse manager has book sense but no leadership abilities." *What is the best approach that can be used by the new nurse manager who is attempting to gain the trust and respect of the nursing staff on the unit?* A. Send memos to all staff except the upset nurse to invite them to a luncheon. B. Ask management to transfer the upset nurse to another unit. C. Assign the upset nurse to committees that do not directly affect that nursing unit. D. Acknowledge the clinical expertise of the upset nurse and clearly explain the expectations for teamwork and open, honest communication.

ANS: D The best way for the new nurse manager to communicate with this employee, who may be an informal leader, is to show respect for the individual's clinical expertise and experience through clear and direct communication. The new nurse manager should attempt to identify the staff nurse's power as an informal leader, should involve them and other staff members in decision-making and change-implementation processes, and should clearly communicate goals and work expectations to all staff members. DIF: Application REF: pp. 297-298

13. A clinical nurse leader (CNL) enters the workforce and hopes to use her interdisciplinary skills to participate on a quality improvement committee. The coordinator of the quality group invites the CNL to join the group. Which type of power is demonstrated by the coordinator of the group? a. Coercive b. Transformational c. Laissez-fair d. Legitimate

ANS: D The coordinator of the committee has an official position within the organizational committee. DIF: Comprehension REF: p. 297

*24. When considering staffing needs, the registered nurse (RN) is primarily concerned with: a. The number of available licensed staff. b. The history of staff absenteeism. c. The availability of support staff. d. Client acuity.

ANS: D The primary considerations for staffing a specific nursing unit are the number of patients followed by the level of intensity of care required by those patients (commonly referred to as patient acuity). Knowing only the number of patients that require care is an ineffective way to plan staffing because of the wide range of care requirements needed by individual patients. The other options may in some degree affect the delivery of care but not to the degree that client acuity does. p. 367

13. During orientation, an RN learns that LPN/LVNs in the facility receive additional training to perform some tasks such as hanging continuously infusing intravenous fluids that have no additives. It is important for the RN to understand that: A. the health care facility can override the state practice act by having all LPN/LVNs and unlicensed assistive personnel (UAP) participate in on-site training. B. LPN/LVNs are licensed, and accountability for their own practice rests with each LPN/LVN. C. UAPs cannot be held responsible for their own actions or inactions. D. the nurse practice act and state regulations related to delegation override the organization's policies.

ANS: D The state's nurse practice act is the deciding factor regarding what can legally be delegated. p. 355

10. A nurse is reading about positive reinforcement with the goal of increasing staff motivation. Which action would demonstrate positive reinforcement? a. Every morning at shift change, thank each employee for an excellent job. b. Rotate a monthly "employee recognition award" among all employees on the unit. c. Wait until the annual performance review to recognize accomplishments. d. Give spur-of-the-moment recognition to an employee who has accomplished a goal.

ANS: D To be effective, positive reinforcement should (1) be specific, with praise given for a particular task done well or a goal accomplished; (2) occur as close as possible to the time of the achievement; (3) be spontaneous and unpredictable (praise given routinely tends to lose value); and (4) be given for a genuine accomplishment. DIF: Application REF: p. 306

*According to the definition, which word best describes leadership? A. Allocate B. Influence C. Evaluate D. Control

B. Leadership is the ability to guide or influence others. The other words are more applicable to the supervision of resources.REF: p. 296-297

*Which activity demonstrates the organizational Chaos Theory? A. Preparing the yearly unit budget B. Planning for unexpected staffing shortages C. Preparing a rubric to guide staff performance reviews D. Setting unit goals related to quality control of client care

B. The Chaos Theory suggests that a degree of order can be attained by viewing complicated behaviors and unpredictable situations as predictable by planning for them. The other options are not considered unpredictable.REF: pp. 301

*Which situations have been identified as positive factors in achieving job satisfaction among nurses? (Select all that apply) A. Having policy and practice decisions made by administration B. Managers taking care not to interfere when a patient focused crisis occurs C. Professional development opportunities made available at the facility D. Attention is paid to fostering excellent nurse-physician relationships E. Respect is given to and expected by all members of the health care team

C, D, E Nursing job satisfaction depends on attention being paid to professional development and advancement opportunities, support for good nurse-physician cooperation and a pleasant respectful work environment. A lack of collaborative decision making and a management team uninvolved in the daily function of the nursing units serve as negative factors.REF: p. 305, Box 17-5

*A nurse manager will likely have which of the following types of power? A. Referent B. Informal C. Legitimate D. Connection

C. Legitimate power is based on an official position in the organization. Through legitimate power, the manager has the right to influence staff members, and staff members have an obligation to accept that influence. Although a manager may have the other types of power, they are not a result of the management position alone.REF: p. 297