Chapter 16

Question 1

The provision of guidance, direction, evaluation, and follow-up by a licensed nurse for tasks provided by an NAP (nursing assistive personnel) is:

a. delegation. c. authority.
b. accountability. d. supervision.

Answer 1

D: According to the ANA (1997, p. 20), supervision is “the active process of directing, guiding, and influencing the outcome of an individual’s performance of an activity.” The supervisory nurse provides clear direction and information to staff concerning what tasks are to be accomplished, for what patients, at what time, and how the tasks are to be done. SUPERVISION

Question 2

Three types of supervision identified by Hansten and Washburn (2004) are:

a. unsupervised, supervised, and periodic inspection.
b. unsupervised, initial direction, and assessment.
c. continuous supervision, periodic inspection, and initial assessment.
d. initial direction, unsupervised, and continuous supervision.

Answer 2

D: Hansten and Washburn’s levels of supervision are 1) unsupervised, 2) initial direction and periodic supervision, and 3) continuous supervision. They are based upon the type of task delegated, education, competency, experience, and working relationship of all of the people to be involved. SUPERVISION

Question 3

As an RN, you recognize that delegation involves which of the following?

a. Assigning your staff to tasks that need to be completed
b. Transferring responsibility for the performance of a task from one individual to another while retaining accountability for the outcome
c. Identifying the appropriate individual to give care and demonstrate accountability for that care
d. Transferring accountability for the provision of care to the individual assigned to give the care

Answer 3

B: As an RN, you would recognize that delegation involves the transfer of responsibility for the performance of a task from one individual to another while retaining accountability for the outcome. When making assignments, you would identify the appropriate staff members to complete specific tasks. While the staff members are responsible for their assigned tasks, you as the RN always retains accountability. DELEGATION

Question 4

As the nurse manager of the unit, it is important for you to consider which of the following when making patient assignments?

a. Staff education levels, skill sets, cultural traditions, willingness to be a team player
b. Staff education levels, scope of practice, experience, and patient acuity
c. Staff skill sets, education levels, timeliness, and patient acuity
d. Patient acuity, staff experience, education, and ethnicity

Answer 4

B: When making patient care assignments, you must consider staff education levels, scope of practice, experience, and patient acuity. An assignment is a distribution of work that each staff member is to accomplish during a given time period according to their scope of practice. An NAP should not be assigned to irrigate a colostomy or do a dressing change of a stage II decubitus ulcer even if the NAP is very experienced. Willingness to be a team player and skill level are important, but they should not be the sole factors when making assignments. ASSIGNMENT

Question 5

Delegation is important for which reason?

a. It is a means to organize the patient care needs according to acuity, desired outcomes, and staff levels.
b. It provides a way to assign difficult patients to uncooperative nurses.
c. It enables new nurses to gain experience with difficult patients by themselves.
d. It is a means to organize the patient care needs according to acuity, desired outcomes, and staff levels, and it provides a way to assign difficult patients to uncooperative nurses.

Answer 5

A: While delegation, as defined by the ANA, is “the transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome,” the RN can use this skill to organize how the staff is utilized to meet the patient care needs for the shift. When delegating tasks to nursing personnel, the RN should take into consideration the patient’s condition (acuity), staff skills and experience, complexity of the task assigned, staff workload, desired outcomes, and the amount of supervision needed to achieve the desired outcomes for the shift. NURSE MANAGER RESPONSIBILITIES

Question 6

As an RN, you maintain accountability for overall patient care on the unit. The obligation of the NAPs to correctly perform their assigned duties is the NAP’s:

a. accountability. c. assignment.
b. delegation. d. responsibility.

Answer 6

D: The act of being responsible (responsibility) for one’s actions includes reliability, dependability, the obligation to accomplish work once the assignment has been accepted, and the desire to perform at an acceptable level in accordance with one’s educational level and experience. ACCOUNTABILITY AND RESPONSIBILITY

Question 7

According to the ANA (2005), delegation is:

a. the transfer of responsibility for the performance of an activity from one individual to another without transfer of the accountability for the outcome.
b. a legal and management concept and process that involves assessment, planning, action, intervention, and evaluation.
c. trust, empowerment, responsibility, and authority to perform the task.
d. the responsibility for the completion of tasks is given to others as a means of saving time, energy, and leader blame.

Answer 7

A: According to the ANA (2005), the act of delegation involves the transfer of responsibility for the performance of actions while the accountability for the outcomes remains with the delegator; it does not shift to the person performing the task. The nurse retains the accountability for the delegation. Delegation is a legal and management concept and process involving the four-step process of assessment, planning, intervention, and evaluation. Action, while important and a means of accomplishing the task goals, is not a part of this four-step process. DELEGATION

Question 8

A nursing instructor evaluates whether the students know the five rights of delegation. The students would be correct if they responded that these rights are which of the following?

a. Right task, right circumstance, right route, right communication, and right person
b. Right task, right circumstance, right person, right communication, and right supervision
c. Right communication, right person, right task, right time, and right evaluation
d. Right time, right task, right person, right communication, and right supervision

Answer 8

B: The five rights of delegation have to do with identifying and providing the correct (right) task, in the correct (right) circumstance, to the correct (right) person, with the correct (right) direction/communication, and under the correct (right) supervision and evaluation. TABLE 16-2 THE FIVE RIGHTS OF DELEGATION

Question 9

The act of being responsible for the actions or inactions of yourself and of others in nursing is:

a. accountability. c. assignment.
b. authority. d. delegation.

Answer 9

A: Accountability is being responsible for the actions or inactions of oneself and of others. Authority refers to a right to delegate based upon the state’s Nurse Practice Act and nursing management. Assignment refers to the duties (i.e., patients) assigned to individuals generally on a daily basis. Delegation is the transferring of the authority to perform a selected nursing task in a selected situation to a competent individual. ACCOUNTABILITY AND RESPONSIBILITY

Question 10

A new graduate RN assigns a NAP to provide basic ADL (activities of daily living) to several patients on her unit. The NAP obtains vital signs and helps to bathe and feed the patients assigned. The nurse is:

a. accountable only for the actions done by herself.
b. accountable for all her own actions and those of the NAP.
c. accountable only for the basic ADL provided by the NAP.
d. not accountable for anything the NAP does outside of the NAP’s scope of practice.

Answer 10

B: Through the act of delegation, the nurse is accountable for the actions or inactions of the assigned NAP. The NAP is always responsible for completing the tasks assigned, but accountability stays with the RN. NURSING ASSISTIVE PERSONNEL (NAP)

Question 11

A nursing instructor evaluates whether the nursing students know the steps in the NCSBN decision-making tree. Which response by a student would indicate that further teaching is needed?

a. Assessment, planning, and communication
b. Intervention and delegation
c. Surveillance and supervision
d. Evaluation and feedback

Answer 11

B: Further teaching would be needed if a student included intervention and delegation as one of the steps. The NCSBN decision-making tree consists of assessment and planning, communication, surveillance and supervision, and evaluation and feedback. While intervention and delegation are important decision-making factors, they are not as vital as these other components because they relate to delegation to nursing assistive personnel. NCSBN DECISION TREE-DELEGATING TO NURSING ASSISTIVE PERSONNEL

Question 12

Poole, Davidhizar, and Giger (1995) have noted several cultural phenomena to be considered when working with culturally diverse staff. Which of the following would be included?

a. Communication, space, social organization, time, environmental control, biological variations, cultural expectations, and traditional barriers
b. Space, social organization, biological variations, communication, environmental factors, and cultural norms
c. Biological variations, traditional barriers, time, environmental control, space, communication, and social organization
d. Social organization, time, space, environmental control, biological variations, and communication

Answer 12

D: Six cultural phenomena suggested by Poole, Davidhizar, and Giger that should also be considered when delegating to a culturally diverse nursing staff are social organization, time, space, environmental control (locus of control), biological variations, and communication. All of these factors can impact how staff organize and perform their tasks. While traditional barriers, cultural expectations, and norms are also important factors to be considered when working with culturally diverse staff and patients, they are not described by Poole et al. as being as critical as those mentioned above. TRANSCULTURAL DELEGATION

Question 13

The degree to which people perceive they have power over their environment is:

a. control c. fate and luck.
b. transcultural delegation. d. environmental control.

Answer 13

D: How people perceive that they can control or have power over their environment is called environmental control. Two types of this perceived control are internal locus of control, where the person relies upon his own inner (internal) resources to handle stimuli from the environment, and external locus of control, which is when a person relies more upon external forces such as luck and chance for control over what is experienced from the environment. TABLE 16-8 CULTURAL PHENOMENA

Question 14

Your supervisor compliments you on your ongoing ability to integrate and apply the knowledge, skills, judgment, and personal attitudes required to practice safely and ethically. The supervisor is commenting on which of your qualities?

a. Authority c. Responsibility
b. Competence d. Right

Answer 14

B: The supervisor is complimenting you on your competence as an RN. Competence is the ongoing ability of a nurse to integrate and apply the knowledge, skills, judgment, and personal attitudes required to practice safely and ethically in a designated role and setting (Canadian Nurses Association, 2004). COMPETENCE

Question 15

The nurse manager would assign patient care that requires problem solving and innovation to which of the following staff members?

a. RN c. NAP
b. LPN/LVN d. Physician

Answer 15

A: A patient care assignment that requires problem solving and innovation should be given to an RN. These assignments require the RN to use critical thinking and specific knowledge and skills. Also, the nurse manager would not be assigning patient care of any type to the physician. RESPONSIBILITIES OF HEALTH TEAM MEMBERS

Question 16

A 64-year-old Italian cardiac patient in the telemetry unit post-CABG, is very demanding and expects his needs to be met immediately—if not sooner. He refuses to have female staff care for him. It is the end of shift, and he appears to be stable in normal sinus rhythm. He has removed his telemetry electrodes, is sitting up on the side of the bed, has thrown an empty tissue box across the room, and seems to be trying to get up and walk. He is now coughing loudly and is demanding his pain medication in a loud, booming voice that carries across the unit. The type of care that he requires now is:

a. direct patient care. c. teamwork.
b. indirect patient care. d. transcultural care.

Answer 16

A: This patient, while a postoperative cardiac patient, appears to be stable; however, he is agitated. He needs direct patient care from a nurse to assess his current state regarding agitation, to replace his electrodes, and to assist in easing his fears and need for control (demands). While teamwork would be great in this situation, it is not essential until the cause for his agitation has been determined, or unless he is a large man and assistance is required to get him back into bed. Indirect care, such as replacing his empty tissue box, would be beneficial, but it is not of top priority. DIRECT AND INDIRECT PATIENT CARE ACTIVITIES

Question 17

The use of interpersonal decision making, psychomotor skills, and application of the knowledge expected in the role of a licensed health care professional in the context of public health welfare and safety is an example of:

a. responsibility. c. delegation.
b. supervision. d. competence.

Answer 17

D: According to the NCSBN (1996), competence is defined as “the ability of the nurse to apply knowledge and interpersonal decision making, and psychomotor skills expected for the practice of public health safety and welfare.” It concerns the ethical and safe practice in a designated role and specific setting according to state laws and regulations. COMPETENCE

Question 18

You are developing the assignment for today. You are considering potential for harm, complexity of the task, amount of problem solving and innovation required, unpredictability of outcome, and level of patient interaction. Your analysis of these components will assist you with which of the following?

a. Supervising c. Directing
b. Delegating d. Staffing

Answer 18

B: The AACN (2004) reminds us that the potential for consequences and likely effects must be considered when delegating patient care. The five factors above should be contemplated before delegating care. While supervision also takes into account these important factors, they are not prerequisites before supervision can take place. RESPONSIBILITIES OF HEALTH TEAM MEMBERS

Question 19

Areas in which nursing assistive personnel (NAP) need training and skill development are:

a. critical thinking, decision making, communication skills, and basic care procedures.
b. basic care procedures, decision making, communication, and reliable thinking.
c. communication, basic care procedures, critical thinking, and teamwork.
d. basic care procedures, reliable thinking, communication, and teamwork.

Answer 19

A: Parkman (1996) suggested areas in which NAP require training and skill development are basic care procedures, communication skills, decision-making skills, and critical thinking skills. While being reliable in one’s thinking (thought processes) and teamwork are two other valuable areas in which personnel can gain skills, they are not essential for viable practice. ACCOUNTABILITY AND RESPONSIBILITY

Question 20

Which of the following is the legal authority for nursing practice and action according to each state?

a. The Joint Commission c. Nurse Practice Act
b. State boards of nursing d. NCLEX

Answer 20

C: While state boards of nursing operate under the Nurse Practice Act, they themselves are not the legal authority of such. The Joint Commission provides guidelines and standards for safe nursing practice according to evidence-based practice guidelines, and they do have the capacity to accredit health subscribed care facilities although they are not the legal authority for nurse practice. NCLEX is not the legal authority for nursing actions. NEW GRADUATE RESPONSIBILITY

Question 21

A nursing instructor evaluates the nursing students’ understanding of factors involved in new nurse graduates’ tendency to underdelegate. Which response by the students would indicate that further teaching is needed?

a. Fear of resentment from older personnel
b. Need for approval
c. Lack of understanding of clinical principles
d. Confusion regarding their scope of duties

Answer 21

C: Further teaching is needed if the students responded lack of understanding of clinical principles. All new graduates should have a firm understanding of basic clinical principles and be willing to ask for assistance for clarification of areas in which they are unsure. The new nurse graduates tendency to underdelegate is usually related to fear or resentment on the part of more experienced nurses, the need for approval or validation by completing all of their assigned duties without assistance, or they may be unsure of the scope of their duties or what they are allowed to do (such as ask for help). UNDERDELEGATION AND OVERDELEGATION

Question 22

A new graduate nurse asks the unit manager, “What type of tasks can I assign to the NAP?” The most appropriate response by the unit manager would include which of the following?

a. Assignments that you don’t have the time to complete
b. Patients who are stable and only require routine care
c. Assignments that require patient teaching
d. Any patient whose care will require you to spend too much time at the bedside

Answer 22

B: The most appropriate response would be to assign the NAP to patients who are stable and only require routine care. FIGURE 16-2 ELEMENTS TO CONSIDER WHEN DELEGATING

Question 23

You are making assignments for your staff. Today you have one RN, one LPN/LVN, and two NAPs working with you. Which patient should be assigned to the LPN/LVN?

a. Applying soft restraints to a patient at risk for falls
b. Providing tracheostomy care for a client who has had a trach for several months
c. Completing the admission assessment for a patient admitted with pneumonia
d. Measuring vital signs and I&Os for all patients

Answer 23

B: You should assign the tracheostomy care to the LPN/LVN. The NPAs can apply the restraints and measure vital signs and I&Os. The RN should complete the admission assessment. While the RN and LPN/LVN are capable of measuring vital signs and I&Os, you would assign these tasks to the NAPs since there are two of them. FIGURE 16-2 ELEMENTS TO CONSIDER WHEN DELEGATING

Question 24

You are completing the list of assignments for today. Working with you are another RN, two LPNs, and two NAPs. Which patient would you assign the RN?

a. Providing general care for a patient with Scarlet Fever
b. Providing general care to a patient with Congestive Heart Failure 3 days after admission
c. Providing general care to a patient admitted in Sickle Cell crisis
d. Providing diversional activities for a patient who is depressed

Answer 24

C: The RN should be assigned to the patient in Sickle Cell crisis because of the complexity and instability of the patient. Also, the outcome for the patient may be unpredictable. The LPN/LVN should be assigned to the patient with Congestive Heart Failure since the client is 3 days post-admission and probably stable. The NAPs can care for the patient with Scarlet Fever and provide diversional activities for the patient who is depressed. FIGURE 16-2 ELEMENTS TO CONSIDER WHEN DELEGATING

Question 25

The nurse manager has assigned a new graduate to provide care to a client who is in cervical traction. The new graduate states that she has never cared for this type of patient. What should the nurse manager do?

a. Tell the new graduate that she will be suspended if she refuses the assignment.
b. Refer the new graduate to the unit’s policy and procedure manual.
c. Contact the supervisor and request that the new graduate be assigned to another patient care unit.
d. Reassign the patient to a more experienced nurse.

Answer 25

D: When a new graduate nurse refuses an assignment because of lack of experience, the best course of action for the nurse manager is to reassign the patient to a more experienced nurse. The nurse manager recognizes that assignments should be based on staff education levels, scope of practice, experience, and patient acuity. ASSIGNMENT

Question 26

A nurse from the Obstetrics unit has been floated to your unit. In making assignments, which patient would you assign to this nurse?

a. A 25-year-old client diagnosed with severe hypertension
b. A 42-year-old male who is receiving peritoneal dialysis treatment
c. A 22-year-old female in sickle cell crisis
d. A 47-year-old male who is 1 day post-gallbladder surgery

Answer 26

A: The nurse should be assigned the 25-year-old client with severe hypertension. Hypertension is often seen on the Obstetrics unit; therefore, the OB nurse should be able to provide the appropriate care needed. Care for a client receiving peritoneal dialysis, one in a sickle cell crisis, or the client who has had gallbladder surgery may require additional experience that the float nurse does not have. ASSIGNMENT