Leadership final exam practice questions

The chief nursing office of a Magnet™ hospital has conducted a study of ways to improve healthcare services. Healthcare services that add value for clients:
Minimize costs.
The chief nursing office continues to seek ways to improve healthcare services to clients and to save the hospital money. However, with the federal guidelines of paying agencies based on capitation, the chief nursing office faces a challenge. Capitation provides incentives for healthcare providers to control costs by:
Using fewer services per client
In a nurse managers’ meeting, the chief nursing officer encourages the managers to brainstorm ways to reduce costs. Nurse managers have the greatest impact on reducing costs by managing:
Staffing
The chief nursing officer works with her nurse managers by helping them understand how to develop and implement a budget. A nurse manager can best describe a budget as a:
Financial plan
A nurse manager approves two staff nurses to attend a national conference. When reviewing the budget, the nurse manager looks at which line item?
Operating Budget
After reviewing her monthly budget report, the nurse manager sees that she has a negative variance, which prompts her to change the staffing schedule. A negative or unfavorable variance in a monthly expense report may result from:
Higher than expected client acuity
An example of an initiative that may reduce total healthcare costs would be
Offering nurse practitioner-led clinics that educate parents about nonpharmacologic strategies for managing ear infections
Which of the following factors is not implicated in rising healthcare costs?
Rising Medicare costs
Physicians in a small urban hospital are reluctant to discharge older adult patients because many of the patients lack private insurance and the resources to travel distances for follow-up care. The hospital administration pressures the physicians to discharge patients sooner and to be more consistent with the number of hospitalization days specified within the DRGs. Which of the following would most likely prompt the action of administrators?
The hospital is incurring a deficit related to a gap between the PPS and the DRGs and costs of care
Within a healthcare environment, where the gap between revenues and costs can mean the difference between sustainability of an organization and nonsustainability of an organization or services, it is critical for nurse managers to:
Balance value-added services against costs and revenues
Because of the complexity of reimbursement systems and its implications for the services available to patients, the nurse has a key role in:
Advocacy for patients with regard to services required and services utilized
Of the following, which is the most effective strategy that a nurse manager could employ to reduce unnecessary costs in specific healthcare settings?
Training nurses on accurate documentation of supplies used for patient care
To prepare staffing schedules, a nurse manager needs to calculate paid nonproductive time. When calculating paid nonproductive time, the nurse manager considers:
Paid hours minus worked hours
The difference between staffing and scheduling is that staffing
Puts the right person in the right position.
To reduce reliance on overtime hours, an organization develops a strategy for floating nurses during staff shortages. To maximize patient safety and reduce costs, the healthcare organization:
Develops a centralized pool of float nurses
In the past year, you have noticed an increase in patient falls on your unit. In reading studies related to staffing and patient outcomes, you realize that you will need to plan for:
An increased number of RN positions
The number of adverse events such as falls and pressure ulcers on your unit is increasing. An ideal staffing plan to address this issue would include which of the following? Increasing the
Number of RNs and number of RNs with experience on the unit.
A nurse manager must consider a number of external variables when preparing the personnel budget and projecting the unit’s staffing needs. An external variable to be considered is:
Department of Health licensing standards
A nurse manager must also consider a number of internal variables that will affect staffing patterns. An internal variable to be considered is:
Organizational staffing policies
A strategy to increase RN staff retention at Valley Hospital includes:
Adequate staffing to meet acuity levels
In reviewing the job description of a nurse manager, the staff becomes aware that a nurse manager’s role is complex. Which of the following duties are required of a nurse manager (select all that apply)?
Responsibility for nursing benchmarks
Preparing a unit budget
Changing staffing plans based on service needs
To project staffing needs and to avoid understaffing, it is important that nurse managers consider which of the following?
Average nonproductive hours
Incivility is a disruptive behavior or communication that creates a negative environment and interferes with quality patient care and safety. The manager can implement steps that help to alleviate uncivil behavior on a unit. Which of the following would not be an appropriate first step?
Terminating staff member
When progressive discipline is used, the steps are followed progressively only for repeated infractions of the same rule. On some occasions, rules that are broken are so serious that the employee is:
Terminated after the first infraction
The chief nursing officer reviews the policy about “progressive discipline process.” The progressive discipline process includes which of the following? The manager:
Should terminate the employee if the problem persists
A nurse manager understands that the second step in handling an employee with a disciplinary problem is to document the incident. Which of the following is best for documentation of personnel problems?
Notes made immediately after an incident that include a description of the incident, actions taken, plans, and follow-up
A nurse manager understands that the typical first step in handling an employee with a disciplinary problem is a:
Reminder of employment standards.
In keeping with guidelines of the organization, the nurse manager documents staff problems. Documentation of disciplinary problems should:
Include a plan to correct them and to prevent future occurrences.
The unit manager on 4E is concerned about the performance of Jean, a staff nurse. She is not involved directly with Jean, so she has not been able to determine whether the problem is one of motivation, ability, or both. If Jean lacks ability, which of the following strategies might the head nurse use?
Document all problem areas and then discuss with Jean.
The nursing director calls a meeting with one of the new unit managers. She is very concerned about a report of substance abuse on the manager’s unit, and she reviews the procedures involved in dealing with chemically dependent staff. Which of the following statements would not be included in the discussion? “As a manager, you:
Should realize that the nurse is a professional embarrassment and should be kept out of sight of other staff.”
Nurse Stacey is a self-admitted drug addict and has been a heavy abuser of codeine. Stacey and the unit manager decide that changes have to occur. Stacey enrolls in an addiction program, and the manager has her transferred to a drug-free area. What other strategies might be appropriate?
The manager could assist in monitoring Stacey’s progress.
Nurses generally experience difficulty in identifying behaviors and actions that could signal chemical dependency in a co-worker. Which of the following is not a behavioral change that occurs with chemical dependency?
Changes in educational involvement and pursuit
The nurse manager places a staff member on probation because of reports of chemical dependency. The nurse manager should be aware that which of the following statements is true regarding chemical dependency?
The chemically impaired nurse affects the entire healthcare organization.
Clinical incompetence is one of the more serious problems facing a nurse manager. Joyce, the nurse manager, is not aware of the problems of Sarah, a novice nurse. After she investigates, it is obvious that Sarah’s peers are covering for her. Which of the following might Joyce include in her meeting with the nurses? (Select all that apply.)
a.
“It is a nurse’s professional responsibility to maintain quality control.”
b.
“All instances of clinical incompetence are to be reported.”
c.
“It is not considered being disloyal when one nurse reports another for poor care.”
d.
“Patient care is the number one concern. Meeting standards is mandatory and necessary.”
Ellen is a novice nurse on your unit. Even though she has come to you highly recommended, as her supervisor, you have noticed some knowledge and skill deficiencies. These deficiencies have been noticed by her peers as well. Which of the following is likely to be the greatest asset to Ellen in improving her performance?
Making arrangements for practice time for her in the hospital’s skills lab
The chief nursing officer understands that clinical incompetence is best prevented by a:
Formalized competency program with established standards for practice.
The unit manager discusses absenteeism with the unit clerk. She indicates that it is a serious problem on the unit. Which of the following points would they have likely discussed? (Select all that apply.)
Care will suffer and standards will be lowered.
Susan, a new graduate, is upset that so many staff have been absent lately from the unit. She declares to you that all absenteeism could be eliminated with proper management. Your response is based on understanding that:
Not all absenteeism is voluntary.
Nathan has been on the cardiac unit for 6 months and has found it difficult to adjust to the expectations of his team. Which of the following behaviors would most likely signal that Nathan is intending to resign from his position on the unit?
Increased absenteeism over the past month
The nurse manager knows that the most serious effect that absenteeism has on the nursing unit is that:
Unacceptable patient care may result
You are a member of a team assigned to care for 15 general medical/surgical clients. You have all worked well together in the past in this same type of care. If you are assigned to coordinate this team’s work, your best strategy, based on the Hersey and Blanchard model, would be to:
Provide minimal direction and let them come to you with questions. Correct
The nurse manager is setting up the room assignments for the unit. She has one critical patient on the unit, who is going to require more care than the others. Before delegating a task, a nurse manager should:
Assess the amount of guidance and support needed in a particular situation
The night nurse understands that certain factors need to be considered before delegating tasks to others. These factors include the:
Complexity of the task and the potential for harm
The unit manager is working in a large metropolitan facility and is told that two UNPs are to be assigned to work with her. Delegation begins with:
Matching tasks with qualified persons
The day shift nurse asks an LPN/LVN to complete a component of care for a client. The day shift nurse is _____ care.
Assigning
You are working in a home health service and have three unlicensed nursing personnel (UNPs) assigned to your team. You have worked with two of them for 2 years; the third is new. The two experienced UNPs have patients with complex illnesses for whom they provide basic care. The third member of the team has been assigned to patients with less complex illnesses. Your best approach to supervising their care is to:
Meet the new staff member at the first patient care site and call the others with questions to determine whether anything is unusual
With delegation, responsibility and accountability remain with the:.
Professional who delegates
Which of the following exemplifies accountability? Karen, the nurse manager on 5E:
Outlines her rationale for reduction of RN coverage on nights to the Nursing Practice Committee after serious patient injury
Which of the following indicates safe delegation?
A unit manager agrees to release a staff from her unit to Unit B. The staff member she agrees to release is experienced on Unit B and is agreeable to the change. The unit manager’s unit is fully staffed and patients are stable
Which of the following would be most in line with Hersey and Blanchard’s concepts?
The team of caregivers on day shift is familiar with their roles and with the patients. The nurse manager decides to work on the unit budget in her office
In delegating to a UNP in a home health setting, which of the following represents the most appropriate delegation communication?
“Mrs. S. needs help to get into and out of her bathtub. Her bath will need to be completed by 10:00. When you are helping her to dry, please check between her toes and toenails, and phone me by 10:30 if you notice nail discoloration or redness.”
An RN colleague, who is a long-standing and collaborative member of your team, is performing a complex and novel dressing for the first time for the patient to whom she has been assigned. Which of the following would be the most appropriate communication with her?
“Here is what you need for the dressing, and I will show you what needs to be done.”
You ask Evelyn, a new UNP, to check what is left in Mrs. N.’s inhaler when Evelyn makes visits to Mrs. N., and also to check whether Mrs. N. is receiving any positive effect from the medication. Evelyn reports for 3 weeks that Mrs. N. is using the inhaler, and that there is enough medication left in the device. The day of her last visit to Mrs. N., Mrs. N. is admitted to the hospital in severe respiratory distress. When she is admitted, she tells the physician that she has not been using the inhaler for 4 weeks. This incident is an example of:
Failure to follow through
Leslie, a UNP, transfers a patient while using improper technique. The patient is injured, and as a result, a suit is launched in which both Sarah, the delegator, and Leslie, the delegatee, are named. Sarah is named in the suit because she:
Retains accountability for the outcomes of care for the patient
One means of ensuring that nurses floated to other patient care areas in healthcare organizations are qualified to work in those areas is:
Cross-educating staff members to other areas of the institution.
You volunteer at a free community clinic. A 13-year-old girl claims to have been diagnosed with SLE and presents with chlamydia. The team leader at the clinic advises that:
Treatment is provided as long as consent is voluntary and information about treatment is provided
After a car/pedestrian accident, a pedestrian client is brought to the emergency dept. The client is alert and oriented but complains of dyspnea. Oxygen saturation levels vary from 88% to 90%. Oxygen is applied at 2 liters per nasal cannula with no improvement in SpO2. Oxygen per mask is initiated at 40% with little improvement. Radiograph films reveal no obvious injury or fractures. Suddenly the client loses consciousness, has a respiratory arrest, and subsequently dies. During the respiratory arrest resuscitation, it is determined that a nurse failed to open the valve to the oxygen tank and the client had not been receiving oxygen. What is the key ethical principle involved in this situation
Nonmaleficence
To reduce the incidence of falls in a skilled nursing unit, the nurse manager contacts the risk manager. The aim of risk management is to identify potential hazards through a process that attempts
Eliminate these risks before anyone else is harmed.
The ANA Code of Ethics for Nurses articulates all of the following roles of professional associations and association members except:
associations and their members are responsible for ongoing education and collegial networking
The prospective payment system is based on:
DRG’s
The rise of prospective payment systems (PPS) can be largely attributed to which of the following
Healthcare costs
Which health focus is related to a Healthy People 2010 outcome for promoting healthy and safe communities?
Violence
A client refuses a simple procedure that you believe is in the client’s best interest. The two ethical principles that are directly in conflict in such a situation are:
a. Fidelity and justice.
b. Veracity and fidelity.
c. Autonomy and beneficence.
d. Paternalism and respect for others.
ANS: C
Autonomy refers to the freedom to make a choice (e.g., refuse a procedure), and beneficence to doing good (performing a procedure that will benefit the patient).
A colleague asks you to give her your password access so that she can view her partner’s healthcare record. This request violates the patient’s right to:
a. Privacy.
b. Confidentiality.
c. Undue authorization of treatment.
d. Protection against slander.
ANS: A
Privacy refers to the right to protection against unreasonable and unwarranted interference with the patient’s solitude, which extends, in the medical context, to protection against public disclosure of private facts about the patient to the public.
With regard to nursing practice, nurse managers are held responsible for (select all that apply):
a. Practicing within legal guidelines established under state law and nurse practice acts.
b. Ensuring that nursing staff under their supervision are currently licensed to practice.
c. Referring all errors in nursing judgment to state discipline boards.
d. Ensuring that physicians are properly licensed to provide care on patient care units.
ANS: A, B
Nurses are responsible for knowing and practicing under state law and nurse practice acts. Managers are responsible for monitoring staff practice and ensuring that staff hold current, valid licensure.
To effectively delegate in a team nursing environment, the RN team leader must be familiar with the legal and organizational roles of each group of personnel and must:
a. Be able to effectively communicate with patients.
b. Build relationships with physicians.
c. Be able to adapt to daily changes in staffing.
d. Adapt in communicating information to her supervisor.
ANS: C
A particular challenge in team nursing is that staff mixes and staff may change daily because of individual schedules and shortages.
Nurse managers role
Benchmarking, budget, scheduling, staffing process
Martin, the unit manager, receives complaints from community agencies that patients who have been discharged from his unit seem to lack understanding about their disorder and immediate strategies for managing elements of their care. Martin checks the patient teaching sheets and notes that the sheets are initialed by staff. He calls the agencies and indicates that teaching has been done. Martin’s follow-up to complaints from the community is:
a. Appropriate and indicates that he has assumed accountability for the actions of his staff.
b. Indicative that he does not clearly understand the concept of accountability.
c. Indicative of strong support for his staff and their autonomy.
d. Important in clarifying the difference between his accountability and that of the community in patient care.
ANS: B
Accountability refers to the achievement of desired outcomes. If community agencies are noticing that limited or no change in patient behavior has occurred despite teaching on the unit, then the staff has not achieved accountability, and he is not holding his unit responsible for the outcomes. Martin is also demonstrating lack of accountability.
Potential outcomes of Martin’s actions (Question 16) include (select all that apply):
a. Poor morale on the unit.
b. Corruption of community relationships.
c. Corruption of patient-staff relationships.
d. Unmet patient outcomes for quality care.
ANS: A, B, C, D
Kupperschmidt (2004) points out that when accountability is not accepted, then relationships suffer, professional practice is diminished, and self-esteem suffers.
The chief nursing officer understands that clinical incompetence is best prevented by a:
a. Flexible protocol for evaluating competency skills.
b. Standardized clinical skills checklist.
c. Newly established peer review process.
d. Formalized competency program with established standards for practice.
ANS: D
The competency program with established standards of practice outlines what the nurse must do to achieve desired competencies in her current position. Competency assessment and goal-setting should help the nurse identify how to excel and which competencies the nurse wants to achieve in the future.
Clinical incompetence is one of the more serious problems facing a nurse manager. Joyce, the nurse manager, is not aware of the problems of Sarah, a novice nurse. After she investigates, it is obvious that Sarah’s peers are covering for her. Which of the following might Joyce include in her meeting with the nurses? (Select all that apply.)
a. “It is a nurse’s professional responsibility to maintain quality control.”
b. “All instances of clinical incompetence are to be reported.”
c. “It is not considered being disloyal when one nurse reports another for poor care.”
d. “Patient care is the number one concern. Meeting standards is mandatory and necessary.”
ANS: A, B, C, D
The nurse leader must remind employees that professional responsibility is to maintain quality care, and thus they are obligated to report instances of clinical incompetence, even when it means reporting a co-worker. Ignoring safety violations or poor practice is unprofessional and jeopardizes patient care.
An example of a care activity that would likely not be delegated by an RN to a UNP is (select all that apply):
a. Teaching self-catheterization to a patient with paraplegia who has limited English.
b. Basic care for a patient with a head injury who is rapidly deteriorating.
c. One-to-one observation with a suicidal patient.
d. Assessment of patients being admitted through the Emergency Department.
e. Basic hygienic care for a patient who is post MI and stable.
ANS: A, B, D
Functions such as assessment, diagnosis, planning, and evaluation cannot be delegated. In addition, stability, critical thinking, time, and safety are factors that are considered in assessing whether or not to delegate care to a UNP. Teaching self-catheterization to a patient with limited English requires critical thinking; basic care for a patient who is rapidly deteriorating exemplifies concern with stability; and assessment of patients through Emergency is related to the factor of time. An exception to safety and stability in which patients may be delegated to UNPs is when patients are placed on suicide precautions.
Time management is very essential for the nurse manager. Which of the following is not a good time-management technique?
a. Decide what not to do.
b. Learn to say “No.”
c. Learn to delegate.
d. Break down your workload into large manageable tasks.
ANS: D
To manage time successfully, it is important to break down your workload into smaller, manageable tasks. Developing PERT and Gantt charts will aid in dealing with larger, complex projects. Both charts can be used to outline how an individual will approach a large project.
The nurse is caring for a client in the ICU. Which task would be most appropriate for the nurse to delegate to a UAP?

1. Instruct the UAP to empty the client’s chest tube.
2. Request the UAP to double check a unit of blood that is being hung
3. Change the surgical dressing on the client with a Syme amputation.
4. Ask the UAP to transfer the client from the ICU to the medical unit.

Correct answer: 4
1. The drainage is the client’s chest tube system is not emptied. The drainage chamber should be marked for output, but not emptied
2. An RN must double check a unit of blood prior to infusing the blood; therefor this task cannot be delegated
3. The surgical dressing for a Syme amputation must be changed by a surgeon or the nurse; this task cannot be delegated .
4. The UAP could transfer the client from the ICU because the client is stable and is being transferred to the medical unit.
The nurse is caring for clients on a psychiatric pediatric unit. Which action is reportable to the state board of nursing? The nurse :

1. leaves for lunch and does not return to complete the shift.
2. fails to check the ID band when administering medications.
3. Has had three documented medication errors in the last 3 months
4. Has admitted to having an affair with another staff member.

Correct answer: 1
1. Abandonment is a reportable offense to the state board of nursing in every state. Reportable offenses could result in stipulations made to the nurse’s license.
2. this is failure to follow the 5 rights of medication administration, but it is not a reportable offense.
3. Multiple medications errors are a management issue, not a reportable offense.
4. Not a reportable offense.
A staff nurse is facing a dilemma between upholding personal care standards and meeting organizational goals. The nurse manager understands that the best way to assist staff members in resolving ethical dilemmas effectively is to:
A. avoid applying any pressure to compromise personal values.
B. change their work assignment until the dilemma is resolved.
C. continually remind staff of consequences related to ignoring organizational goals.
D. refer indecisive staff members for additional training.
A. Avoid applying any pressure to compromise personal values

An important way in which those in health care facilities and their managers can assist nursing professionals in resolving ethical dilemmas effectively is by neither explicitly nor implicitly pressuring them to go against their own ethical values (Cooper et al., 2003).

On admission, the patient was found to have a blood glucose level of 218. The RN knows that except in emergency situations, it is hospital policy to obtain physician’s orders before administering any medication. Because the on-call physician did not return the page, the nurse administered insulin according to the common sliding scale. Four hours later, the patient was found nonresponsive in her bed and later died. According to the autopsy, the patient died from heart failure. Her postmortem blood glucose level was 22. Because of the nurse’s actions, the admitting hospital may be found to be:
A. a judicial risk.
B. an ostensible authority.
C. indemnified.
D. vicariously liable.
D. Vicariously Liable

If a nurse negligently injured a client during the course of and within the scope of employment, not only would the nurse be directly liable for damages, but also the health care organization would be vicariously liable.

To establish legal liability on the grounds of malpractice, the injured party must prove which of the following (select all that apply)?
A. A duty of care was owed to the injured party.
B. An agreement was made to assume another party’s liability.
C. There was a breach of duty.
D. Causation was present.
E. Actual harm or damages were suffered by the plaintiff.
A. A duty of care was owed to the injured party
C. There was a breach of dute.
D. Causation was present
E. Actual harm or damages were suffered by the plaintiff.

These four elements are required to establish legal liability on the grounds of malpractice.

Transferring the authority to perform a selected nursing task in a selected situation to a competent individual is:
A. authorization.
B. delegation.
C. empowerment.
D. supervision.
B. Delegation

The National Council of State Boards of Nursing (1995) defines delegation as transferring the authority to perform a selected nursing task in a selected situation to a competent individual.

The provision of guidance or direction, evaluation, and follow-up by the licensed nurse for accomplishment of a nursing task delegated to unlicensed assistive personnel (UAP) is:
A. authorization.
B. delegation.
C. observation.
D. supervision.
D. Supervision

Supervision is the provision of guidance or direction, evaluation, and follow-up by the licensed nurse for accomplishment of a nursing task delegated to UAP (National Council of State Boards of Nursing, 1995).

The five rights of delegation are right task, right circumstance, right person, right direction and communication, and right:
A. interaction.
B. outcome.
C. supervision.
D. time.
C. Supervision

Right supervision is the fifth right of delegation as outlined by the National Council of State Boards of Nursing (1995).

Evaluation of the effect of nurse staffing on quality patient, financial, and organizational outcomes is known as:
A. patient acuity.
B. staffing effectiveness.
C. nurse-to-patient ratio.
D. nursing workload.
B. Staffing Effectiveness

Staffing effectiveness is the evaluation of the effect of nurse staffing on quality patient, financial, and organizational outcomes.

The Joint Commission’s (TJC’s) staffing regulation states:
A. staffing ratios are recommended in perinatal and critical care areas.
B. Incorrect Response nurse managers may determine the nurse-to-patient ratio as long as the patient’s needs are being met.
C. hospitals must also provide the right number of competent staff members to meet the patients’ needs.
D. hospitals may limit the number of admissions to ensure there are an adequate number of staff members to meet patient needs.
C. hospitals must also provide the right number of competent staff members to meet the patients’ needs.

TJC noted the following (2006): The goal of the human resources function is to ensure that the hospital determines the qualifications and competencies for staff positions based on its mission; populations; and care, treatment, and services. Hospitals must also provide the right number of competent staff members to meet the patients’ needs. (p. HR-1)

An approach for decreasing nursing RN skill mix was implemented in a “one size fits all” approach across organizations in the 1990s. These changes in skill mix led to:
A. decreases in RN workload.
B. increased nursing satisfaction.
C. decreased patient satisfaction.
D. decreased patient safety concerns.
C. Decreased Patient Satisfaction

The approach for decreasing nursing RN skill mix was implemented in a “one size fits all” approach across organizations and often lacked evaluation of the skill mix change and other changes on the quality of care and nurse job satisfaction and retention (Eck, 1999; Norrish & Rundall, 2001). This was most apparent in California where a leaner RN skill mix was tried by Kaiser Permanente Northern California in the early 1990s. Skill mix was reduced from 55% RNs to 30% RNs in 1995 (Robertson & Samuelson, 1996). The changes in skill mix led to widespread real and perceived increases in RN workload, patient safety concerns, and nurse and consumer complaints.

The workload standard commonly used in nursing when calculating staffing patterns is:
A. patient days.
B. patient acuity system.
C. average length of stay.
D. nursing care hours per patient day.
D. Nursing care hours per patient day

The amount of work performed by a unit is referred to as its workload, and workload volume is measured in terms of units of service. The workload standard commonly used is nursing care hours per patient day, although the validity of this measure is disputed.

A successful enterprise risk management (ERM) program will (select all that apply):
A. identify risks.
B. improve quality.
C. prevent damage.
D. control occurrences.
E. control legal liability.
A. Identifies Risks
C. Prevent Damage
D. Control Occurrences
E. Control Legal Liability
Authentic respect for others requiring time, presence, engagement, and intention to seek common ground is called _____.
Civility

Civility is authentic respect for others requiring time, presence, engagement, and intention to seek common ground

The manager of a rural, thriving, nurse-managed clinic is considering purchasing equipment to furnish two additional examination rooms. The resource he must consider is the _____ budget.
A. capital
B. expense
C. operating
D. product line
A. Capital

The capital budget is the plan for the purchase of major equipment or assets.

An external factor that affects violence in hospitals is the:
A. availability of handguns.
B. growing acceptance of drug use by health professionals.
C. inability of facilities to screen employees properly.
D. increasing number of patients with mental illness.
A. Availability of handguns

Violence in hospitals is caused by a combination of internal and external factors. External conditions include the availability of handguns.

When staff nurses ignore a patient’s verbal threats or acts of intimidation:
A. a greater number of patients return to the facility for care.
B. staff nurses report increased job satisfaction.
C. the patient receives exposure to a positive role model.
D. violence escalates.
D. Violence Escalates

The toleration of hostile or threatening behavior can result in escalation that results in physical harm (Hoag-Apel, 1999).

An important role of the human resources department in limiting workplace violence is:
A. allowing the local police force to control violence within the facility.
B. delegating the control of workplace violence to individual unit managers.
C. developing comprehensive violence prevention policies and procedures.
D. empowering each nurse to assess each situation and react accordingly.
C. Developing comprehensive violence prevention policies and procedures

Human resource management policies addressing hiring, discipline, counseling, training, threat assessment, threat management, and reporting are essential for the prevention and/or mitigation of violence from current or former workers in health care organizations.

A patient who is not fully informed about his or her health status is an example of a violation of which ethical principle?
A. Autonomy
B. Justice
C. Utilitarianism
D. Confidentiality
A. Autonomy

Autonomy refers to the client’s right of self-determination and freedom of decision making. A patient who is not fully informed is denied the freedom and access to make a decision.

A staff nurse has kept a time log to assist her in developing her time management skills. After a week, she reviews the log with her nurse manager and notices that there were several times that she was waiting for supplies and missing medications. The nurse manager suggests which of the following?
A. Notifying the pharmacy and central supply that there are delays in supply delivery
B. Gathering supplies and checking for the availability of medications so they can be ordered prior to starting care
C. Informing the prior shift that this is a problem
D. Completing an occurrence report so quality assurance will investigate the problem
B. Gathering supplies and checking for the availability of medications so they can be ordered prior to starting care

Changes in patient conditions and medical orders occur frequently, which require new or different equipment and medications to be added or changed. It is always best, particularly if it is known that there are discrepancies in this area, to check to see whether all needed supplies are available before initiating care.

Over lunch in the cafeteria, student nurses are sharing educational information about the patients for whom they are caring. This is a(n):
A. breach of beneficence.
B. example of maleficence.
C. potential assault and battery charge.
D. violation of the Health Insurance Portability and Accountability Act (HIPAA).
D. violation of Health Insurance Portability and Accountability Act (HIPAA).

HIPAA provisions have heightened awareness about and encouraged strategies to protect a patient’s privacy in health care transactions. This is an example of breach of confidentiality.

If a licensed practical/vocational nurse (LPN/LVN) provides discharge teaching, who is legally responsible?
A. Chief executive officer
B. Institution where the LPN/LVN works
C. Risk manager
D. UAP
B. Institution where the LPN/LVN works

The institution where the LPN/LVN works is liable for negligence or malpractice of the LPN/LVN or RN. Only the RN can provide discharge instruction.

The nurse has asked a nurse’s aide to greet a postoperative patient who has just arrived on the unit and to determine whether he is in stable condition. This act of delegation is an example of a nurse inappropriately delegating:
A. assessment of the patient.
B. evaluation of an intervention.
C. nursing judgment.
D. teaching to a delegate.
A. Assessment of the patient

The RN is responsible for assessment, evaluation, and nursing judgment and should not delegate these professional responsibilities.

The categories of standards pertain to standards of care and standards of professional performance. Standards of care deal with:
A. a competent level of care demonstrated by the nursing process
B. a process of care
C. behaviors/attitudes
D. guidelines of care
A. A competent level of care demonstrated by the nursing process

Standard of care deal with a competent level of care demonstrated by the nursing process

The phrase “the buck stops here” best describes which of the following terms?
A. Accountability
B. Authority
C. Responsibility
D. Trustworthiness
A. Accountability

Accountability refers to the liability for task performance. Accountability means being answerable and liable. The assignment of responsibility and the granting of authority create accountability.

A 17-year-old male has presented to the emergency department with appendicitis. He speaks English, but his mother speaks Spanish. The mother needs to sign a consent for emergency surgery, because the patient is a minor. Which of the following is the most appropriate method of obtaining consent?
A. No consent is needed because of the emergency nature of the surgery.
B. Have the patient sign the consent because he understands the explanation from the surgeon.
C. Have the patient’s sister explain the procedure in Spanish, but ask the mother to sign the Spanish consent form.
D. Obtain an interpreter to explain the procedure to the patient and mother in Spanish, and ask her to sign a Spanish consent form.
D. Obtain an interpreter to explain the procedure to the patient and mother in Spanish, and ask her to sign a Spanish consent form.

According to the Office of Minority Health (2007) in the USDHHS, the National Standards on Culturally and Linguistically Appropriate Services (CLAS) state that health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. Therefore, because the patient is a minor, the legal parent must understand the procedure in her native language.

The Code of Ethics serves the following purposes:
A. A succinct statement of the ethical obligations and duties of every individual who enters the profession
B. The profession’s nonnegotiable ethical standard
C. An expression of nursing’s own understanding of its commitment to society
D. All of the above
D. All of the above

The Code of Ethics is a succinct statement of ethical obligations and duties, the nonnegotiable ethical standard and nursing’s understanding of its commitment to society

Time management is an essential skill for nurse managers. This can be effectively managed through the creation of to-do lists and is an example of:
A. delegation.
B. motivation.
C. negotiation.
D. prioritization.
D. Prioritization
A nurse manager is evaluating the efficiency of a process on the nursing unit. The manager believes that the unit could be more efficient if one aspect of this process were delegated to unlicensed personnel. To establish whether the delegation of this duty would be legal, he should check with the:
A. ANA.
B. current federal defense attorney.
C. state nurse practice act.
D. policy and procedure manual of the unit.
C. State Nurse Practice Act

Nurse practice acts exist for each state and govern the legal practice of nursing, including standard of care, delegation, and supervision.

The Scope and Standards of Practice are:
A. A broad direction for the practice of nursing
B. A legal document
C. Authoritative statements about nursing practice
D. All of the above
D. All of the Above
When determining that delegation of an element of patient care needs to occur, the nurse delegates with a clear, concise description of the task, including its objectives, limits, and expectations. The nurse allows the delegate to clarify without fear of repercussion. Which of the following five rights of delegation is being demonstrated?
A. Right task
B. Right circumstance
C. Right person
D. Right direction/communication
E. Right supervision/evaluation
D. Right direction/ communication

The right direction/communication of delegated elements of care will be a clear, concise description of the task, including its objective, limits, and expectations. The nurse allows for clarification without the fear of repercussions.

Which of the following are examples of patient privacy or security breaches (select all that apply)?
A. Encrypted e-mail communications
B. Fax transmission sent to incorrect physician office
C. Prescription given to patient with wrong label attached
D. Case management coordinator obtaining information about a patient’s diagnosis
E. Discharge summary given to patient’s spouse
B. Fax Transmission sent to incorrect physicians office
C. Prescription given to patient with wrong label attached

Fax transmissions sent to the incorrect physician’s office or prescriptions given to a patient with the wrong label attached are examples of privacy or security breaches under HIPAA. Electronic transmissions should be end-user encrypted for data security.

An elderly client becomes confused after surgery. He is in a room farthest away from the nurse’s station. The client has been trying to get out of bed several times during the shift. The nurse documents this very well. The client falls out of bed and breaks his hip. Who can possibly be held negligent (select all that apply)?
A. Client’s wife
B. Nurse manager
C. Pharmacist
D. Staff RN
B. Nurse Manager
D. Staff RN

It is possible that the nurse and nurse manager could be held negligent. The nurse could be held negligent for not moving the patient closer to the nurse’s station, calling the physician or nurse practitioner for medications or change in medications, or obtaining an order for a vest restraint. The nurse manager may be held negligent because of 24-hour accountability for the care of patients on his or her unit and possible lack of supervision.

A nurse manager uses many sources of data when planning the unit’s workload for the year. Which of the following data must be considered in the planning?

a. Weekend requirements
b. Maximum work stretch for each employee
c. Trends in acuity on the unit
d. Hours of operation of the unit

ANS: C

Acuity levels are determined through classification systems, which determine the nursing resources required.

A nurse manager must also consider a number of internal variables that will affect staffing patterns. An internal variable to be considered is:

a. Organizational staffing policies.
b. Professional Nursing Association standards.
c. Consumer feedback and expectations.
d. State regulations and standards.

ANS: A

State licensing standards outline what a nurse can do. Internal policies determine what a nurse may do in a particular setting as well as the amount of flexibility that is allowed to manage times of high and low volumes, as well as changes in acuity. Organizational policies can put the nurse manager in a situation where patient safety cannot be maintained or financial obligations met.

A local hospital has formed a corporate partnership with a reputable HMO (health maintenance organization). The nurse manager has had to educate staff and personnel about the financial implications of this partnership. A health maintenance organization:

a. Provides more expensive care than other types of insurance plans.
b. Has a centralized administration that directs and compensates physician services.
c. Pays physicians on a fee-for-service basis.
d. Does not pay as much for acute care as other practice plans.

ANS: B

Managed care involves prospective pay for care received over a specified length of time or a prepaid payment period rather than a retrospective system that pays physicians for services actually rendered through fee-for-service. Health maintenance organizations are a form of managed care that is administered centrally.

To prepare staffing schedules, a nurse manager needs to calculate paid nonproductive time. When calculating paid nonproductive time, the nurse manager considers:

a. Vacation time, holiday time, and sick time.
b. Paid hours minus meeting time.
c. Paid hours minus worked hours.
d. Work time, educational time, and holiday time.

ANS: A

Nonproductive hours are hours of benefit time and include vacation, holiday, and personal or sick time.

The chief nursing office continues to seek ways to improve healthcare services to clients and to save the hospital money. However, with the federal guidelines of paying agencies based on capitation, the chief nursing office faces a challenge. Capitation provides incentives for healthcare providers to control costs by:

a. Requiring second opinions.
b. Providing fewer services to fewer clients.
c. Using fewer services per client.
d. Using high-technology treatments.

ANS: C

In a capitated environment, a single fee is paid for all services provided. To be financially viable under this reimbursement model, organizations would be interested in decreasing the volume of services used and increasing the volume of patients. High-technology treatments and second opinions may increase the number of services used.

A nurse is on a client care team with a practical nurse and a nursing assistant. The nurse has noted that the practical nurse has been taking long breaks and spending time on the phone. In addition, the nursing assistant has complained that the practical nurse delegates an unfair share of tasks, and the next shift has commented that the practical nurse frequently leaves tasks uncompleted. Which of the following statements should the nurse make to attempt to resolve this conflict?

a. “Several staff members have commented that you don’t do your fair share of the work.”
b. “If you don’t do your share of the work, I will have to inform the nurse manager.”
c. “I need to talk to you about unit expectations regarding delegating and completing tasks.”
d. “You have been very inconsiderate of others by not completing your share of the work.”

ANS: C
nurse is notified that a client has filed a complaint about care received on the nursing unit from one of the assistive personnel (AP). The nurse should understand that the delivery of quality care to a specific client is primarily the responsibility of the

a. staff member providing care.
b. the nurse manager for the unit.
c. admitting provider.
d. institution where care is provided.

ANS: A
When entering the postoperative care unit, the nurse manager notices that the temporary agency nurse has incorrectly entered the rate of infusion for the patient’s vasopressor medication and that the arterial line is indicating a blood pressure of 76/40. Discontinuing the intravenous infusion, the nurse manager’s next most appropriate action is to determine which of the following?

a. The nurse in charge of the unit
b. If there is an assigned resource nurse to serve as mentor for the temporary nurse
c. If there are standing orders for interventions for hypotension
d. If the temporary nurse has had an orientation to the unit

ANS: C

Patient safety is always the first concern, and attention must first center on ensuring the patient’s welfare. To prevent such an occurrence in the future, the nurse manager should next determine who is in charge of the unit. Questions to ask the charge nurse include asking about the temporary nurse’s qualifications and experiences caring for critical postoperative patients, if a resource nurse was assigned to the temporary nurse so that the temporary nurse had a mentor and could ask questions if needed. Finally, the nurse manager should ask about the orientation to the unit and whether the temporary nurse was informed about the types of intravenous pumps used in this facility, how to set the appropriate drip rate, and the necessary monitoring of patients who are receiving vasopressor agents.

An incident report of the incident described in Question 31 needs to be completed. The most appropriate wording to be included in the incident report is:

a. Patient was noted to have a low arterial blood pressure (76/40) and the vasopressor medication was discontinued.
b. Patient’s vasopressor medication was infusing at a higher rate than ordered and the medication was discontinued when the patient’s blood pressure dropped to 76/40.
c. Nurse MJ started the vasopressor medication; the patient subsequently was noted to have a blood pressure reading of 76/40, the medication was discontinued, and the physician notified.
d. Patient receiving vasopressor medication intravenously; blood pressure fell to 76/40 and intravenous infusion discontinued; physician notified and the patient given 500 mL of IV fluid over 15 minutes.

ANS: D

The most complete incident report note is Option D because it states what was happening, why an intervention was needed, and the follow-up care for the patient. Option A is also correct but is less desirable as there is no mention of what follow-up measures were done to ensure the patient’s welfare. Options B and C are incorrect; there should never be a mention or indication, however slight, of liability in the incident report, as it could later be used in a court of law to show liability against the healthcare providers and the institution.

You are the nurse manager for a busy intensive care unit (ICU). Two patients are awaiting admission to the ICU; one is a 42-year-old bank president admitted through the emergency center with a diagnosis of an acute myocardial infarction, and the other is an elderly woman who experienced a cardiac arrest on the general medical unit. After reviewing the charts of all the patients already in the ICU, you contact the physician about a patient who can safely be discharged to a general medical unit so that two beds will be available for the two people awaiting admission. The ethical principle that you have most closely applied is that of:

a. Respect for others
b. Beneficence
c. Justice
d. Fidelity

ANS: C

Justice concerns treating people equally and fairly. Both patients awaiting admission to the ICU are equally in need of the medical and nursing care available in this unit. The next best choice is respect for others, transcending culture differences, gender issues, racial concerns, and, in this instance, age differences. Though one of the patients is much younger and seemingly more affluent in the local society, both are deserving of the highest quality care. Beneficence could also be said to be applied in this instance; doing good by assuring that both patients are admitted to the unit. Fidelity is the least applicable principle in this instance as it pertains to keeping one promises and commitments and, given the facts of the scenario, there is no indication of any promise being made to either of the patients to be admitted.

The nurse manager on a skilled nursing unit notices that the number of patient falls in his unit has escalated over the past year, resulting in a fall rate that is below the target projected for this unit. The best evidence-based approach to reducing the number of falls is to:

a. Increase the number of total nursing hours on the unit.
b. Institute a safety restraint policy.
c. Purchase side rails that are easy to raise and lower.
d. Place patients at risk for falls close to the nursing station.

ANS: A

Research supports the idea that patient falls increase when there is insufficient staffing on a unit. While putting patients who are at risk for falls close to the nursing station is often appropriate, it is not the most effective strategy. Restraints are a poor nursing strategy for preventing falls, and although side rails may be helpful, they do not stop patients from falling when getting out of bed or in other situations.

Regulations in most states require that the number of patients a nurse should care for in a particular setting should be determined by a staffing plan developed by registered nurses, some of whom are direct patient caregivers. The rationale for this approach is: (Select all that apply.)

a. Multiple factors, such as patient acuity and nurse experience, influence the time required to adequately care for the patient. This requires nursing judgment to determine the standard.
b. Having nurses who provide direct care involved in developing a staffing plan will prevent cost from being the major influence on determining the number of staff required on a unit.
c. Mandated staffing ratios may prevent an adequate staffing pattern in some circumstances, when unusual resources are required for a particular patient.
d. Decisions by staffing committees made up of registered nurses are more likely to be accepted by the nursing staff.

ANS: A, B, C, D
In reviewing staffing patterns on a unit, the nurse manager finds that in the last 2-week pay period, one of the nurses has worked seven 12-hour shifts. Two of these shifts were 7 AM to 7 PM; the remainder were 7 PM to 7 AM. The nurse manager should have an individual discussion with the nurse to:

a. Let her know how much her work is appreciated in a time when there is a shortage of staff.
b. Ask her to share her work schedule, since other staff may complain about a lack of opportunity to work overtime.
c. Review the research regarding the relationship between patient errors and fatigued nurses.
d. Put her on “warning” for putting patients’ safety at risk.

ANS: C

Beginning evidence is emerging that working more than 12 hours and rotating shifts can lead to errors that compromise patient safety.

Which of the following is the most appropriate assignment involving asking a nurse to “float” to another unit?

a. A nurse 9 months post licensure working on an orthopedic unit is asked to float to a cardiac step-down unit.
b. An experienced psych nurse is asked to work on a palliative care unit.
c. A nurse who has worked in the CCU for 2 years is asked to work on a cardiac step-down unit.
d. An experienced nurse working on a medical-surgical unit is asked to work in a medical-surgical ICU.

ANS: C

The nurse who has worked in the CCU will have had the necessary competencies validated for this assignment.

How can a leader deal fairly with employees who fail to meet established standards of care?

a. First, determine if the employee issue is a will or skill issue.
b. Conduct a chart review that reflects the care issue.
c. Ask questions of the employee that can reflect the employee’s knowledge base.

ANS: C

It is appropriate to obtain more information and questions regarding the employee’s knowledge base of both the standards of care and the evidence. Policies and procedures help add to this information so that the leader can make the best assessment possible. The leader could also use scenarios.

Upon entering a patient’s room, the Emergency Department nurse observes a visitor attempting to choke the patient. The visitor appears agitated and is screaming at the patient. The patient is gasping and looks cyanotic. What should the nurse do first?

a. Attempt to remove the visitor from the room.
b. Attempt to reason with the visitor and calm him or her down.
c. Assess the patient for injuries.
d. Call security for help.

ANS: D

The nurse should not attempt to intervene in this situation with a clearly agitated and aggressive visitor. In this situation, the safety of the nurse is the primary concern. Assistance is needed to first control the situation, remove the aggressor, and then assess the patient and provide appropriate care.

The nurse has received her assignment for the day and notices that her peer has a much lighter assignment in both number and acuity of patients. This is not the first time the nurse has noticed this inequity in assignments. She also has seen her peer and the charge nurse go to lunch together and knows that they spend time outside of work socializing. The nurse feels that this constant inequity in assignment is not fair. What is the best course of action for the nurse to address this problem?

a. Avoid the issue and say nothing but remain angry about the situation.
b. Confront the charge nurse about the inequity in the assignment.
c. Approach the peer and ask to switch assignments.
d. Share concerns with the charge nurse and find a mutually acceptable compromise for the situation.

ANS: D

Avoiding the situation creates feelings of powerlessness and frustration that can lead to the nurse feeling that she may not want to work in this environment, or may cause lack of focus that could result in patient safety concerns. Confrontation creates a power struggle and may escalate bad feelings for both parties. It may also affect the ongoing relationship between the charge nurse and the bedside nurse. Attempting to switch assignments without the charge nurse’s involvement is unacceptable. The best solution to the problem is to initiate a dialogue with the charge nurse. This may shed light on the rationale behind the assignment and allows the charge nurse to acknowledge the nurse’s concerns and negotiate an acceptable solution. It also allows the charge nurse to work on developing a better team environment.

A newly hired nurse has observed bullying behaviors on her new unit that include gossip, demeaning, criticizing, and intimidation. She also feels other nurses are avoiding her or giving her the silent treatment. The unit manger does little to address these behaviors. The consequences of this toxic culture include all of the following EXCEPT:

a. Loss of productivity and potential for high staff turnover
b. Potential for patient safety errors that may increase the cost of care
c. An increase in teamwork and communication
d. Increase in anxiety, low self-esteem, and sleep disorders among the staff

ANS: C

Bullying behaviors negatively impact teamwork and communication and can contribute to all of the other issues listed.

Ms. Viola questioned if her staffing ratios demand the use of high-level delegation strategies. What “delegation right” is she assessing?

a. Task
b. Circumstances
c. Person
d. Communication/Direction

ANS: B

Ms. Viola is assessing the circumstances (environment) on the unit to determine if she needs to use high-level delegation strategies to provide high-quality patient care.

The ability to transfer selected nursing activities in a given situation to a competent individual is known as:

a. Supervision.
b. Accountability.
c. Responsibility.
d. Legal authority.

ANS: D

Legal authority is the ability to transfer selected nursing activities in a given situation to a competent individual. Responsibility is the reliability, dependability, and obligation to accomplish work. Accountability determines if the actions taken were appropriate and provides a detailed explanation of what occurred. Supervision is the oversight of delegated work.

In the delegation process, all of the following factors need to be assessed EXCEPT:

a. Patient’s condition.
b. Complexity of the task to be performed.
c. Medical insurance of the patient.
d. Predictability of outcomes

ANS: C

In the delegation process, the three major factors that need to be assessed are the patient’s condition, complexity of the task to be performed, and the predictability of outcomes. The patient’s medical insurance is not a factor in the delegation process.

Delegation, a multifaceted decision-making process, is implemented for all of the following reasons EXCEPT to:

a. Improve the work performance of staff.
b. Decrease the registered nurses’ accountability.
c. Achieve nursing goals.
d. Improve patient care outcomes.

ANS: B

Delegation is a multifaceted decision-making process implemented to improve the work performance of staff, improve nursing care, and achieve nursing goals. The registered nurses maintain accountability for delegation decisions.