Final Exam Flashcards
A new graduate is asked to serve on the hospital’s quality improvement (QI) committee.
The nurse understands that the first step in quality improvement is to:
a. Collect data to determine whether standards are being met.
b. Implement a plan to correct the problem.
c. Identify the standard.
d. Determine whether the findings warrant correction.
ANS: C
Identifying standards most important to the user of health care services is the first step in a
six-step process for quality improvement.
A nurse manager wants to decrease the number of medication errors that occur in her
department. The manager arranges a meeting with the staff to discuss the issue. The
manager conveys a philosophy of total quality management (QM) by:
a. Explaining to the staff that disciplinary action will be taken in cases of additional
errors.
b. Recommending that a multidisciplinary team assess the root cause of errors in
medication.
c. Suggesting that the pharmacy department explore its role in the problem.
d. Changing the unit policy to allow a certain number of medication errors per year
without penalty.
ANS: B
QM emphasizes improving the system, rather than focusing on staff errors. If errors occur,
reeducation of staff is emphasized, rather than imposition of punitive measures such as
disciplinary action or blaming
With the rise of workplace violence in the emergency department, the nurse manager
decides that she should work with the risk manager in violence prevention. The nurse
manager should:
a. Request all staff to accept new risk management practices.
b. Hold staff accountable for safe practices.
c. Document inappropriate behaviour.
d. Hire more police security
ANS: B
Active involvement of staff in risk management activities is key to prevention of adverse
events. Accountability for safety can be one aspect of performance evaluations.
Hospital ABCD is a Magnet hospital. This designation has been applied to Hospital ABCD
because it:
a. Facilitates active staff participation in decision-making related to quality nursing
care.
b. Has implemented a graduate nurse orientation program.
c. Espouses commitment to excellence in patient care.
d. Is establishing career ladders for nurses.
ANS: A
Magnet hospitals are particularly successful in implementing excellence in patient care
through use of standards, evidence, and participatory decision-making in quality
improvement. Organizations that cannot pursue Magnet status can implement strategies
such as career ladders.
An example of an effective patient outcome statement is:
a. “Eighty percent of all patients admitted to the emergency department will be seen
by a nurse practitioner within 3 hours of presentation in the emergency
department.”
b. “Patients with cardiac diagnoses will be referred to cardiac rehabilitation
programs.”
c. “The hospital will reduce costs by 3% through the annual budget process.”
d. “Quality is a desired element in patient transactions.”
ANS: A
Statements about patient outcomes must include measurable, specific, and patient-centred
information.
Patient perceptions are useful in:
a. Determining disciplinary actions in QI.
b. Establishing the competitive advantage of QI decisions.
c. Establishing priorities among possible changes to care identified in QI.
d. Establishing blame for poor-quality care.
ANS: C
Quality and patient dissatisfaction are useful indicators of the areas that are of greatest
concern to patients, and of what matters to nurses and organizations. Patient perceptions
guide areas of inquiry; however, they do not establish which disciplinary decisions would be
made.
Your institution has identified a recent rise in postsurgical infection rates. As part of your QI
analysis, you are interested in determining how your infection rates compare with those of
institutions of similar size and patient demographics. Such a determination is known as:
a. Quality assurance.
b. Sentinel data.
c. Benchmarking.
d. Statistical analysis
ANS: C
Benchmarking is a widespread search to identify the best performance against which to
measure practices and processes.
The QI process begins with:
a. identifying implications for practice.
b. identifying the aim.
c. team assembly.
d. sustaining the improvements.
ANS: B
The QI process begins with the selection of a clinical activity or issue for exploration and
improvement—what is the goal or aim of the improvement? Theoretically, any and all
aspects of clinical care could be improved through the QI process. However, the aim of QI
efforts should be concentrated on changes to patient care or systems that will have the
greatest effect.
A nurse manager was orienting new staff members with regard to computerized charting. To
understand computerized charting, staff members must understand informatics. Which of
the following are the core concepts in informatics?
a. Hardware, software, competency, and printers.
b. Data, information, knowledge, and wisdom.
c. Decision making, data gathering, data analysis, and reporting.
d. Wireless technology, voice recognition, and handheld devices.
ANS: B
Informatics is the application of technology to all fields of nursing to facilitate and extend
nurses’ decision-making abilities and to support nurses in the use, storage, and linkage of
clinical information in providing effective and efficient patient care. Nursing informatics,
like all nursing communication, is founded on the concepts of data, information, knowledge,
and, more recently acknowledged, wisdom.
The nursing manager of a surgical unit has been asked by administration to evaluate patient
outcomes after cardiac catheterization. Using data about patient outcomes after cardiac
catheterization for the past 6 months so as to modify practice is an example of:
a. Gathering information.
b. Cost-effective care.
c. Meeting standards.
d. Evidence-informed practice.
ANS: D
Evidence-informed practice is a systematic approach to clinical decision-making; to provide
the most consistent and best possible care to patients in this scenario, evidence is being used
to optimize care for patients after cardiac catheterization.
A home health nurse has been assigned to cover a 500-km2 area of remote Alberta. Mrs.
Banister has just been discharged home and will need daily contacts for the next week.
Because it is not possible to visit Mrs. Banister in person every day and see all the other
patients, the nurse gives her a laptop computer with Internet meeting software installed.
Each morning, both dial in at an agreed-upon time and discuss her progress. The home
health nurse assesses whether the patient needs to be seen that day. This type of technology
is called:
a. Distance learning.
b. Knowledge software.
c. Telecommunications.
d. Biomedical technology.
ANS: C
Telecommunications facilitate clinical oversight and provision of health care at a distance
via telephone, remote monitoring, and the Internet.
Nurses need to know how to operate a computer, compare data across time, and look for
patterns in patient responses to treatments. These are examples of which of the following?
a. Canadian Nursing Informatics Association standards.
b. Information systems.
c. Informatics competencies.
d. Requirements for nursing licensure
ANS: C
Nurses must utilize hospital database management, decision support, and expert system
programs to access information and analyze data from disparate sources for use in planning
for patient care processes and systems.
As a nurse manager representative on a team to select a clinical information system, you
would be particularly concerned if the favoured system has which of the following
characteristics?
a. It involves screen displays that are best configured for nonclinical users.
b. It requires an upgrade to servers in the facility.
c. It requires staff orientation and training during implementation of the software.
d. It minimizes the amount of data entry necessary.
ANS: A
An ideal hospital information system should include as much instrumentation as possible to
minimize data entry. As a clinical end-user, you would expect orientation and training on
how the screen display can be configured so as to suit the purposes and preferences of users
in clinical areas.
The nurse manager schedules evaluations of staff members by using a newly developed
performance appraisal tool. The development of a performance appraisal tool should include:
a. The organizational mission and philosophy and the position requirements.
b. A generalized overview of the duties of a position.
c. A skills checklist and accreditation requirements.
d. An ordinal scale that ranks all employees.
ANS: A
Performance appraisal tools and processes should reflect the organizational mission and
philosophy, and also position requirements.
Joshua, a new graduate, reviews the employee evaluation for his new position. The first
section requires that he list his own specific objectives to be accomplished. This is an example
of:
a. The traditional rating scale.
b. Learning goals or management by objectives.
c. A forced distribution scale.
d. A behaviourally anchored rating scale (BARS)
ANS: B
In management by objectives, the employer and the employee jointly establish clear and
measurable objectives for the next performance period.
Joshua notes that the next section of the evaluation tool is specific to the organizational
philosophy and has a four-point ordinal scale that describes performance from “always meets
expectations” to “does not meet expectations.” This type of evaluation is most commonly
known as:
a. A BARS.
b. Management by objectives/learning goals.
c. The forced distribution scale.
d. A traditional rating scale.
ANS: D
Traditional rating scales are commonly used in evaluation and reflect generalizations rather
than specific behaviours.
On your unit, despite efforts to build a strong sense of team, conflict between some of the staff
is ongoing. Nonetheless, you want to proceed with developing a systematic and effective
performance appraisal system. Which of the following approaches would be most appropriate
for you to implement?
a. Peer review.
b. A combination of tools.
c. Anecdotal notes.
d. Rating scale.
ANS: B
A combination of tools is probably superior to any one method in any situation. Peer review
would not be recommended alone or in combination because it is not useful in an environment
characterized by a high degree of mistrust or conflict
Which of the following is a strategy that clinical nurse educators can use to ensure
understanding and retention of information in newly hired staff nurses?
a. Provide written information of all orientation topics.
b. Evaluate whether there is fit between learner and organizational values.
c. Develop a range of strategies that cover a variety of learning styles.
d. Organize group sessions for orientation to increase cost effectiveness.
ANS: C
Preceptors teach newly hired nurses in the clinical setting. Clinical nurse educators can assist
in developing strategies that cover a variety of learning styles of new employees. This allows
the preceptor to ensure uptake and retention of information in the newly hired staff member.
Which of the following might best conclude an interview?
a. “Thank you for your interest. Someone will be in touch with you soon.”
b. “Before you go, we will make sure that we have your contact information. Thank
you for coming.”
c. “I will be in contact with all candidates by telephone by next Friday. It has been a
pleasure to meet you.”
d. “We have several excellent candidates so I am not sure about the outcome of the
interview, but I will let you know. Thank you for coming.”
ANS: C
An employment interview should always conclude with information as to how and when
follow-up to the interview will occur.
In addressing the primary challenge in recruitment of new staff, which of the following
interview questions might be asked?
a. “Could you review your resume for us, highlighting your certifications and
experience?”
b. “If we were to ask your references, what would they list as your strengths?
Weaknesses?”
c. “We have a number of older adult patients on this unit. If you noticed another staff
member addressing one of these patients impatiently, how would you respond?”
d. “Tell us about your work and academic experiences and qualifications.”
ANS: C
The primary challenge in the recruitment of new staff is finding candidates who can function
well within your work culture. Asking behaviour-related questions in the interview allows you
to assess how a candidate may function in real-life situations and to assess whether this
behaviour is compatible with the culture on the unit.
The biggest challenge in the recruitment of staff is:
a. Finding well-qualified candidates who can function well within a particular work
culture.
b. Recruiting individuals with the appropriate qualifications and experience.
c. Screening out candidates who are unable to function well within a team.
d. Determining whether candidates have had previous negative experiences in a work
environment.
ANS: A
Choosing the right individual is the challenge for managers and involves finding qualified
candidates who will work well within the culture.
Anecdotal notes:
a. Should be completed only when there are performance concerns.
b. Can be used to support and justify fairness in termination discussions.
c. Are unnecessary if the evaluation instrument is thorough.
d. Need to be completed at the end of a performance period.
ANS: B
Anecdotal notes should be kept consistently throughout the evaluation period and should
reflect both favourable and unfavourable behaviours if they are to provide an accurate
assessment of performance. Anecdotal notes provide documentation to support scale ratings
and narrative evaluation summaries.
An outpatient clinic advertised for registered nurse positions. Before authorizing a position
opening, the nurse manager should:
a. Review the position description and performance expectations for the opening.
b. Place an advertisement in the local newspaper and on the telephone job line.
c. Review all current applications on file.
d. Look for employees within the system who might best fill the position.
ANS: A
The position description provides the basis for this position within the organization and
communicates expectations for the role.
Yasmine is a likable and popular staff member. Despite occasional complaints from patients
about inappropriate comments and rough handling of patients, Yasmine continues to receive
positive performance appraisals. This is an example of:
a. A halo effect.
b. Rare conflict.
c. Role ambiguity.
d. Evaluator bias.
ANS: A
A halo effect occurs when the performance rating is based on a characteristic of the individual
that actually has nothing to do with the work traits being considered. Managers may give
higher ratings to individuals they like (halo effect) and lower ratings to individuals they do not
like (negative halo effect).
The validity of comments and ratings related to performance is enhanced by which of the
following:
a. Maintenance of anecdotal notes over the entire evaluation period.
b. Quantity of information gathered for appraisal purposes.
c. Agreement of the employee with the ratings and comments.
d. Whether other individuals have contributed to the observations.
ANS: A
Anecdotal notes compiled consistently over the entire rating period are a much more equitable
method of providing an accurate summary of the employee’s performance.
A nurse manager in the intensive care unit works with his staff to develop an appraisal
instrument that includes quantitative data and respects standards for a registered nurse
working on that unit. What type of appraisal is this?
a. Rating scale.
b. Collaboratively based appraisal system.
c. Narrative instrument.
d. BARS.
ANS: D
A BARS describes performance quantitatively and qualitatively, and when staff members are
involved in the development of these instruments, they are more likely to understand the
importance of evaluation for each criterion selected and to have an understanding of their
performance expectations.
The primary disadvantage of a BARS is that it is:
a. Situation specific.
b. Well understood by the staff.
c. Too generalized.
d. Expensive to develop.
ANS: D
BARS take a considerable amount of time to implement, and although they are specific to the
specialty of nursing and are potentially well accepted by staff, they are expensive to develop.
Marcia, a nurse manager, discusses her concerns about the hospital’s employee appraisal
system with her work group, noting that all it includes is one rating scale, which means
nothing unless the manager is effective in her job. Marcia’s concerns reflect which best
practices associated with performance appraisal?
a. Rating scales are too generalized to be considered valid or reliable.
b. The effectiveness of any appraisal system is tied directly to the skills and
communication abilities of the manager.
c. BARS are considered superior to simple rating scales in terms of performance
appraisal.
d. Rating scales need to be designed by users to be well accepted.
ANS: C
Rating scales are relatively easy to construct and easy to complete but usually consist of
generalizations and nonspecific behaviours, and the rating is relatively subjective in nature;
these characteristics do not reflect best evaluative practices. The effectiveness of any system is
tied directly to the skills and communication abilities of the person who is using it. However,
the system itself must be effective. BARS combine ratings with critical incidents (specific
examples that have occurred) or criterion references (examples usually based on standards of
practice or competency-based standards).
During a performance appraisal, Joanne, the nurse manager, indicates that Alysha has
difficulty mentoring students on the unit. Alysha responds that this is not her responsibility. In
responding to Alysha, Joanne needs to consider:
a. Alysha’s level of confidence.
b. Whether mentoring is included in the position description.
c. Whether mentoring is an essential component of the position description.
d. Whether mentoring can be accurately observed and measured.
ANS: B
Performance appraisal is tied to roles and responsibilities of the position, as outlined in the
position description. If roles and responsibilities are not included specifically, they cannot be
appraised.
The final section of a performance appraisal is a rating scale. This scale is very detailed and
relates to competency standards specific to surgical patients. The scale is a summary of
performance directly observed or documentation reviewed and is specific to patient care
situations in which the employee has been involved. This type of evaluation is most
commonly known as:
a. A traditional rating scale.
b. Management by objectives/learning goals.
c. A forced distribution scale.
d. A BARS.
ANS: D
A BARS contains both quantitative (rating scales) and qualitative data. It is specific to
situations and positions.
John’s performance was satisfactory during the first month, but after that time he was very
inconsistent in the provision of nursing care. One month before the end of the rating period,
he cared for a very wealthy and influential patient, who is a close friend of the clinical
manager. This patient donated new furniture for the staff lounge in John’s name to show
appreciation for his care. Joshua’s subsequent performance appraisal resulted in outstanding
ratings in all areas. This is an example of:
a. A performance rating based on justifiable evidence.
b. A bias related to recent events.
c. The effect of personality on the appraisal of performance.
d. The effective use of a BARS
ANS: B
To obtain and provide an accurate evaluation of performance over time, anecdotal notes need
to be maintained throughout the evaluation period. This process assists in avoiding bias
related to recent or sensational events that make a particularly strong impression.
As a manager, you are interested in developing behavioural questions for an interview. You
know that there is team conflict at times on your unit. Which of the following questions would
satisfy your interest in behavioural questions?
a. “Tell me about a time you were involved in a conflict related to a project. What
was your role in the conflict? In the resolution of the conflict?”
b. “If you were to employ one strategy for managing conflict, what would it be?”
c. “What is your preferred style of conflict resolution?”
d. “How effective are you in working in a group? In dealing with conflict?
ANS: A
Behaviour-related questions seek demonstrated examples of behaviour from the candidate’s
past experiences and concentrate on job-related functions and accomplishments.
Which of the following strategies might be effective in empowering staff?
a. Communication book in which new information on policies and processes is
communicated and mistakes are highlighted.
b. Monthly staff meetings during which a portion of the agenda is devoted to sharing
ideas and presentations on best practices for implementation on the unit.
c. Once-yearly summative evaluations based on what the manager likes best about
each individual.
d. Immediate discussion of errors in care and with involved staff with direction as to
how errors are to be prevented in the future.
ANS: B
Empowerment is a process in which people acknowledge the values and judgements of other
people and trust their decisions. It allows freedom for making decisions while retaining
accountability and provides an environment that is safe in which to explore.
The chief nursing officer establishes a shared governance model to help empower the nursing
staff, thus empowering the organization. Common characteristics of empowered organizations
are:
a. Shared values, high salaries, and a human focus.
b. Shared values, flexibility, and a human-capital focus.
c. Commitment to communication, high salaries, and flexibility for evaluations.
d. Creation of community and of effective stress management in the midst of
divergent goals.
ANS: B
Shared governance involves valuing the contributions of each member of the team, releasing
the need to control, and understanding that accountability rests with members of the team.
Nora, a new nurse manager, writes certain assumptions regarding the organization’s
objectives into her budget. Her supervisor tells her that the objectives implied in her
assumptions are not entirely consistent with the organization and that she needs to clarify
these objectives with her supervisor. Nora apologizes and says she had more latitude with the
budget where she previously worked. This is an example of:
a. Role complexity.
b. Role ambiguity.
c. Role conflict.
d. Time-dependent roles.
ANS: B
Role ambiguity in the workplace creates an environment for misunderstanding and hinders
effective communication. Without clear expectations of performance, missteps in performance
can occur.
A survey of staff satisfaction is conducted. The results indicate that staff members are
satisfied, are loyal to the organization, and believe that they have reasonable control in their
individual responsibilities. The findings best exemplify:
a. Clarity in roles and valuing of contributions.
b. Satisfaction but not empowerment.
c. Effective coaching of new staff.
d. Role attachment.
ANS: A
Satisfaction is linked to clear role expectations and a feeling that contributions are valued.
You have hired Bumika as a new staff member on your unit. Although she is an experienced
intensive care unit nurse, this is her first educator role. A month into her new position she
confides that she feels really incompetent in her new position and bursts into tears. Your
response is based on application of your understanding of:
a. Role acquisition.
b. Role conflict.
c. Role complexity.
d. Performance appraisal.
ANS: A
Acquisition of a role is time dependent and involves application of life experiences to each
role and interpretation of the role within a person’s own value system. As roles become more
complex, an individual may take longer to assimilate the components of each role.
An environment that fosters misunderstanding and that hinders effective communication leads
to:
a. Role conflict.
b. Role ambiguity.
c. Role clarity.
d. Role certainty.
ANS: B
Employees must have role clarity or clear role expectations and perceive that their
contributions are valued. Role conflict is where employees know what is expected of them,
but they are either unable or unwilling to meet those expectations due to differences in
personal values and/or behavior fit. Role certainty is present when the nurse is confident in the
work and satisfied with personal performance.
Nurse Managers are increasingly being held accountable for nurse retention. Which of the
following actions should a nurse manager focus on to retain nurses? (Select all that apply.)
a. Support and encourage employees.
b. Clarify the organization’s mission.
c. Be unclear about expectations.
d. Select the right person for the right position.
ANS: A, B, D
Retention is based on understanding the role, being the right person for the specific role,
understanding the organization’s mission and expectations, and knowing that support and
encouragement are part of the unit’s culture. Being unclear about expectations for the role
places the employee at a disadvantage and leads to a lack of job satisfaction and leaving for a
more appropriate and supportive environment.
In staff development which of the following would support retention of nurses? (Select all
that apply.)
a. Residency-type programs for new graduates.
b. Preceptorship program.
c. Nonexistent ongoing staff development plan.
d. Orientation to the role and the organization.
ANS: A, B, D
Residency programs usually of a year duration are recognized as a method of easing new
graduates transition from school to clinical practice. Having a preceptor for up to 12 weeks is
also a transition support. A thorough orientation program eases the new nurse into the
organization and assists in understanding the expectations and norms of the organization.
Nurses expect ongoing staff development throughout their careers and not having support in
this area leads to a retention issue
Coaching is an approach that retains nurses. Which of the following are coaching behaviours?
(Select all that apply.)
a. Is costly.
b. A learned process.
c. Promotes optimal performance.
d. Is a personal approach.
ANS: B, C, D
Coaching is a process in which a manager helps others learn, think critically, and grow
through communications about performance. This coaching process is a personal approach in
which the manager and the employee interact on a frequent and regular basis with the ultimate
outcome that the employee performs at an optimal level. Coaching is not financially costly as
it occurs mostly during working hours, and is mutually beneficial to both employee and
manager.
During the performance appraisal session, what should the manager do? (Select all that
apply.)
a. Maintain a relaxed and professional manner.
b. Inquire about the employee’s personal life and how it is affecting performance.
c. Allow the employee to express opinions orally and in writing.
d. Plan to give specific examples only for poor performance.
ANS: A, C
During a performance appraisal, it is important to provide examples of both strong and
problematic performance and to provide opportunities to express opinions. The supervisor
needs to maintain a relaxed professional manner.
The clinic nurse has just accessed a patient’s chart on the computer. The resident comes
over and asks her to stay logged on because he needs to add a note to that patient’s chart.
What should she say?
a. “No problem. Just log me off when you’re done.”
b. “I’ll put the note in for you. What do you want to say?”
c. “Just make sure that you sign your note because it’s under my password.”
d. “I’m sorry, but you will have to enter the information using your own password.”
ANS: D
Passwords must be protected to guard against unauthorized access to patient information
and intrusion of privacy.
The chief nursing officer understands that to be able to compare data across patient
populations and sites, it is important that nurses use:
a. Similar settings.
b. Information systems.
c. Knowledge systems.
d. Consistent nursing languages.
ANS: D
Consistent nursing language, such as the uniform minimum health data set and the nursing
minimum data set (NMDS), enables comparison of data across patient populations and sites
and aids in the retrieval of meaningful comparison data from an information system.
Leaders in nursing must advocate for information and knowledge systems that support
nursing practice. How is this best accomplished?
a. Participating in organizational information technology committees.
b. Submitting written requests for needed information systems.
c. Requesting budgetary funds needed for systems.
d. Sending staff nurses to conferences that discuss cutting-edge technologies.
ANS: A
The nurse manager must recognize the utility of nursing involvement in the planning,
design, choice, and implementation of information systems in the practice environment.
You are in the process of designing a patient education program that will provide education
and monitoring for patients with hypertension. To support your planning, you obtain and
present patient data from which of the following?
a. A clinical database.
b. Biomedical technologies.
c. Email.
d. Internet sources.
ANS: A
Clinical databases are collections of elements organized and structured for the processing,
organization, and presentation of data for interpretation as information, which in this
particular instance includes outpatient data.
As the head nurse involved in determining which patient surveillance systems to acquire for
your unit, one of your aims is to avoid adverse events through the implementation of
appropriate technology. What does this particular aim recognize?
a. Human error is significant in contributing to adverse events.
b. Documentation of patient data is often illegible and therefore misinterpreted.
c. Data systems provide backup documentation with adverse events that staff cannot
provide.
d. Physiologic monitoring systems enable detection of early changes before an
adverse event occurs
ANS: D
Data about adverse events suggests that a majority of physiologic abnormalities are not
detected early enough and may be present hours before an adverse event actually occurs.
Physiologic monitoring aids in early detection of such changes.
As a nurse manager in a multisite facility, you are comparing the effectiveness of prompted
voiding training programs for staff by examining the effect of prompted voiding on the
frequency of incontinence in patients. To do this, you access an NMDS, which allows you
to:
a. Retrieve standardized information regarding patient care and trends.
b. Access medical diagnoses and pharmacologic interventions.
c. Learn sociodemographic and population-based trends.
d. Find information on public funding and private health insurance revenues.
ANS: A
Although there continues to be inconsistency in nursing language, the NMDS defines
essential nursing data to be collected for all patients that enable comparison of patient data,
description of patient care, determination of trends, stimulation of nursing research, and
provision of nursing data to influence decision-making
When assessing the appropriateness of adopting personal digital assistants (PDAs) for a
nursing unit, you need to consider which of the following advantages?
a. Lower cost in relation to personal computers.
b. Small display screen.
c. Font size.
d. Speed of operation.
ANS: A
PDAs offer a lower-cost method of documentation and communication than do personal
computers, and also easy portability. Disadvantages of PDAs include small screen size,
suboptimal readability, and slowness in situations when speed is most needed.
A nurse manager is excited by the possible use of speech recognition (SR) systems for
documentation of patient care, especially during crisis situations when staff members need
to focus on performing rapid assessments and implementation of procedures. She learns,
however, that SR systems would be impractical at this point for this. What characteristic
would lead to this conclusion?
a. SR systems are not available outside pilot projects.
b. The type of speech required for voice recognition is unlikely in a pressured
situation.
c. The hands-free function has not been perfected in SR technology.
d. Wireless communications are prone to unreliability in transmission
ANS: B
Speech recognition systems rely on staccato-like speech, pauses between words, and
programming for each user, any and all of which would be rare in a pressured crisis
situation. SR is being used primarily for therapeutic purposes and in situations in which data
entry is stable
For a nurse manager, one challenge is to orient new staff to the agency’s policies and
procedures, and also to provide training across various shifts. Which of the following would
be a cost-effective and effective learning strategy?
a. Development of new learning modules and software to support document retrieval.
b. Email distribution to staff home email addresses regarding important policies.
c. Preparation of digital video disks (DVDs) that can be viewed on computers at the
nursing station during “down times.”
d. Linking policies and procedures to the network for access when required at the
point of care.
ANS: D
The most accessible and cost-effective approach would be use of what is already available
in the work environment. Development of new software is often expensive; DVDs are
visually appealing but less nimble in enabling staff to find answers quickly at the point of
care.
What is the most critical factor in ensuring nurses’ comfort and knowledge in the use of
technology in health care regardless of age, education level, or area of practice?
a. Confidence in using technology.
b. Adequacy and substance of professional development.
c. Repeated training sessions.
d. Peer and leader support
ANS: B
Confidence in using technology was found to be the result of the adequacy of professional
development in the (Wang, Nagle, Li, et al., 2004) study. Regardless of age, education level,
and area of practice, peer and leader support appropriate professional development was
critical to success.
Peggy, a nurse leader on a busy medical surgical unit, is concerned that the rapid expansion
in use of EHRs and clinical decision support systems may lead to leaked patient information
and breach of confidentiality. She decides to form a nurse led committee to address these
concerns. Which of the following must be addressed to prevent breach of confidentiality?
(Select all that apply.)
a. Assign a password that uniquely identifies a user to the system by name and title.
b. Ensure nurse confidentiality through ongoing discussion.
c. Ensure nurses understand privacy legislation that applies to them, and their work
setting.
d. Monitor individual nurses.
ANS: A, B, C
Password must have a unique signature assigned to a nurse that is traceable to
documentation and care the nurse provides. Having staff nurses involved in this process
provides maximum input on the issue and keeps the information at the critical level to
ensure confidentiality. Understanding privacy legislation and work policies provides a
framework for ethical standards. Monitoring individual nurses is unlikely as the unique
individual identifiers will highlight a problem if an anomaly is detected.
Nurses rely on technology to lessen the number of adverse events that are well documented,
yet are challenged in keeping the unique therapeutic relationship between nurse and patient
with increasing use of technology. What approaches can be used to ensure the therapeutic
relationship is preserved (Select all that apply.)
a. Involving patients in decisions about their own care.
b. Actively listening while conducting electronic charting.
c. Showing patients what is being documented.
d. Repeatedly monitoring equipment while documenting
ANS: A, B, C
Therapeutic relationships can be enhanced through the use of technology and patient safety
increased when nurses engage the patient in their care and incorporate technology and
patient engagement when documenting and recording data from medical devices. Keeping
the patient at the centre of care avoids the likelihood of losing the therapeutic connection
between nurse and patient.
As a nurse manager, you want to institute point-of-care devices on your unit. The rationale
that you provide to support the point-of-care devices includes which of the following?
(Select all that apply.)
a. Reduction in incidents of medication error.
b. Immediate documentation of care.
c. Improving discharge planning.
d. Increasing confusion with nursing workflow.
ANS: A, B, C
Point-of-care devices that allow documentation of assessment, care, and teaching at the
patient’s bedside reduce the gap in time between care and documentation, thereby reducing
error, increasing accuracy, and improving communication of care, discharge planning, and
teaching, in addition to fitting better with nursing workflow.
The chief executive officer asks the nurse manager of the telemetry unit to justify the
disproportionately high number of registered nurses on the telemetry unit. The nurse
manager explains that nursing research has validated which statement about a low
nurse-to-patient ratio?
a. “It promotes teamwork among health care providers.”
b. “It increases adverse events.”
c. “It improves outcomes.”
d. “It contributes to duplication of services.”
ANS: C
Findings related to staffing and patient outcomes suggest that patient outcomes are
improved with a low ratio of nurses to patients and especially with a low ratio of registered
nurses to patients.
The nurse educator of the pediatric unit determines that vital signs are frequently not being
documented when children return from surgery. According to QI, to correct the problem the
educator, in consultation with the patient care manager, would initially do which of the
following?
a. Talk to the staff individually to determine why this is occurring.
b. Call a meeting of all staff to discuss this issue.
c. Have a group of staff nurses review the established standards of care for
postoperative patients.
d. Document which staff members are not recording vital signs, and write them up.
ANS: B
Leaders must identify safety shortcomings and must locate resources at patient care levels to
identify and reduce risks. One method of doing this is to invite all staff into a discussion
related to solutions to an identified concern. This approach encourages teamwork.
A nurse is explaining the pediatric unit’s QI program to a newly employed nurse. Which of
the following would the senior nurse include as the primary purpose of QI programs?
a. Evaluation of staff members’ performances.
b. Determination of the appropriateness of standards.
c. Improvement in patient outcomes.
d. Preparation for accreditation of the organization by The Joint Commission.
ANS: C
The primary purpose of QI is improvement of patient outcomes. Quality improvement refers
to an ongoing process of innovation, prevention of error, and staff development that is used
by institutions that adopt the QM philosophy
Before beginning a continuous QI project, a nurse should determine the minimal safety level
of care by referring to which of the following?
a. The procedure manual.
b. Nursing care standards.
c. The litigation rate of unsafe practice.
d. Job descriptions of the organization.
ANS: B
Standards establish the minimal safety level of care. Within health care systems, QI
combines the assessment of structure, process, and outcome standards. Policies should be
reviewed frequently and updated so that they reflect best practice standards and do not
become barriers to innovation.
The nurse gives an inaccurate dose of medication to a patient. After assessment of the
patient, the nurse completes an incident report. The nurse notifies the nursing supervisor of
the medication error and calls the physician to report the occurrence. The nurse who
administered the inaccurate medication understands that:
a. The error will result in suspension.
b. An incident report is optional for an event that does not result in injury.
c. The error will be documented in her personnel file.
d. Risk management programs are not designed to assign blame.
ANS: D
QM emphasizes improving the system, rather than focusing on staff errors. If errors occur,
reeducation of staff is emphasized rather than imposition of punitive measures such as
disciplinary action or blaming.
The nurse manager is concerned about the negative ratings that her unit has received on
patient satisfaction surveys. The first step in addressing this issue from the point of view of
quality improvement is which of the following?
a. Assemble a team.
b. Establish a benchmark.
c. Identify a clinical activity for review.
d. Establish outcomes.
ANS: C
In theory, any and all aspects of clinical activity could be improved through the QI process.
However, QI efforts should be concentrated on changes to patient care that will have the
greatest effect.
The nurse manager is performing a root-cause analysis related to medication administration
errors with insulin. A root-cause analysis is very similar to the QI process except that a
root-cause analysis is:
a. Retrospective.
b. Prospective.
c. Legislated for completion with all near-miss events.
d. Conducted by only one person.
ANS: A
A root-cause analysis is very similar to the QI process described in this chapter except that
the root-cause analysis is a retrospective review of an incident to identify the sequence of
events with the goal of identifying the root causes of the incident and may lead to the
development of specific risk-reduction strategies.
In determining the relationship between injury-producing falls and proposed preventive
measures as part of the QI process, a QI team might turn to which of the following for
confirmatory evidence?
a. Best Practice Guidelines (BPGs).
b. North American Nursing Diagnosis Association (NANDA).
c. National Quality Institute.
d. Agency for Healthcare Research and Quality
ANS: A
The Registered Nurses’ Association of Ontario launched the Nursing Best Practice
Guidelines (BPGs) program. To date, the program team has developed and disseminated 50
guidelines covering clinical topics in five broad areas: gerontology, primary health care,
home health care, mental health care, and emergency care.
As a nurse manager, you know that the satisfaction of patients is critical in making QI
decisions. You propose to circulate a questionnaire to discharged patients, asking about their
experiences on your unit. Your supervisor cautions you to also consider other sources of
data for decisions because:
a. The return rate on patient questionnaires is frequently low.
b. Patients are rarely reliable sources about their own hospital experiences.
c. Hospital experiences are frequently obscured by pain, analgesics, and other factors
affecting awareness.
d. Patients are reliable sources about their own experiences, but are limited in their
ability to gauge clinical competence of staff.
ANS: D
Patients are reliable and motivated sources of their own experience but often do not have
sufficient knowledge of clinical procedures to provide feedback about clinical competence.
A nursing unit is interested in refining its self-medication processes. In beginning this
process, the team is interested in how frequently errors occur with different patients. To
assist with visualizing this question, which organizational tool is most appropriate?
a. Histogram.
b. Flowchart.
c. Fishbone diagram.
d. Pareto chart.
ANS: A
Histograms are bar graphs that are useful in outlining and identifying frequency.
The outcome statement “Patients will experience a 10% reduction in urinary tract infections
as a result of enhanced staff training related to catheterization and prompted voiding” is:
a. Physician sensitive and nonmeasurable.
b. Measurable and nursing sensitive.
c. Precise, measurable, and physician sensitive.
d. Patient care centred and nonmeasurable
ANS: B
Nursing-sensitive outcomes are outcomes that are affected by nursing activity and are
precise, measurable, and patient centred.
At Hospital Ajax, staff members are reluctant to admit to medication errors because of
previous litigation and a culture that seeks to assign blame. This culture demonstrates:
a. QM principles that emphasize customer safety.
b. a deep concern with improvement of quality and processes.
c. effective employee orientation and development in relation to QM.
d. goals that are inconsistent with QM.
ANS: D
The aim of QM is improvement, not the assignment of blame.
Which of the following is not a principle of high reliability organizations?
a. Sensitivity to operations.
b. Preoccupation with failure.
c. Commitment to resiliency.
d. Reluctance to simplify.
e. Indeference to expertise.
ANS: E
The fifth and final principle of HROs is deference to expertise. Those who have the most
knowledge about the situation are encouraged to speak up, voice concerns and share ideas.
Preoccupation with failure, the first principle, relates to the relentless focus of organizations
on safety concerns in the work environment. The second principle, reluctance to simplify,
focuses on the need for staff to look beyond the obvious and avoid jumping to potential
quick fix solutions. Sensitivity to operations, the third principle, outlines the importance of
situational awareness related to how systems and processes are working in the organization
so that potential risks to safety can be identified and actioned. The fourth principle,
commitment to resiliency, focuses on the ability of individuals and teams to address
problems, implement solutions and bounce back from errors.
The ability to compare data across health care sectors or organizations, such as hospital
acquired infection or hand hygiene rates may be hindered by?
a. Reluctance to share information.
b. Fear of reduced funding.
c. Fear of reduced reputation.
d. Differences in terminology.
ANS: D
Information technology plays a vital role in QI by increasing the efficiency of data entry and
analysis. A consistent information system that trends high-risk procedures and systematic
errors would provide a useful database regarding outcomes of care and resource allocation.
Efforts are underway to develop standardized indicators of performance so that true
comparisons can be made across health care settings, provinces, and territories.
Examples of sentinel events include (Select all that apply.)
a. Forceps left in an abdominal cavity.
b. Patient fall, with injury.
c. Short staffing.
d. Administration of morphine overdose.
e. Death of patient related to postpartum hemorrhage
ANS: A, B, D, E
Sentinel events are serious, unexpected occurrences leading to death or to physical or
psychological harm.
The most important approach that a nurse manager can take with an emotionally troubled
employee is to:
a. Act as a therapist for the employee.
b. Adjust the standard of care to assist the employee.
c. Assist the employee in obtaining professional help.
d. Adjust the employee’s work schedule to decrease stress.
ANS: C
Emotional difficulties are usually beyond the scope of skills that a nurse manager would
normally employ. A referral needs to be made to a professional who is specifically prepared to
deal with this kind of difficulty.
The nurse manager knows that the most serious effect that absenteeism has on the nursing unit
is that:
a. Using replacement personnel with new ideas may be beneficial.
b. Salary costs are lower because personnel are fewer, and outcome is favourable.
c. Absence on the part of the rest of the staff is decreased.
d. Unacceptable patient care may result
ANS: D
Reduced staffing adversely affects patient care. Employee morale suffers, care standards may
be lowered, and additional stress is placed on working staff.
In keeping with guidelines of the organization, the nurse manager documents staff problems.
Documentation of disciplinary problems should:
a. Include a plan to correct them and to prevent future occurrences.
b. State a detailed history of past problems that are related to the current one.
c. Be written at the convenience of the manager.
d. Accumulate until the evaluation period begins
ANS: A
In documenting staff problems, it is important to indicate specifically what rules were broken
or violated, consequences if behaviour is not altered, employee’s explanation of the incidents,
and the plan of action to achieve and to reach new goals. Accurate and factual documentation
and follow-up actions are key elements in the successful management of all personnel issues.
Before terminating an employee, a nurse manger must:
a. Be an expert in all legal aspects of employment termination and discipline
practices.
b. Know the organization’s specific policies for addressing disciplinary problems and
employment termination.
c. Function as a counsellor for problem employees.
d. Do everything to assist and protect the employee by adjusting standards and
policies.
ANS: B
It is important to know the policies of the organization to address disciplinary issues fairly and
equitably, and also to know the model that is employed to address employee problems.
A nurse manager understands that the typical first step in handling an employee with a
disciplinary problem is to:
a. Provide a verbal reprimand.
b. Prepare a written reprimand.
c. Counsel the employee regarding the problem.
d. Give the employee the day off without pay.
ANS: C
The progressive model of discipline advocates that the first step of the disciplinary process is
to counsel the employee regarding the problem. The second step is a reprimand of the
employee (first verbally, then in writing). The non-punitive discipline model advocates
reminding the employee of the employment policies and procedures of the agency.
The chief nursing officer understands that clinical incompetence is best prevented by which of
the following?
a. A flexible protocol for evaluating competency skills.
b. A standardized clinical skills checklist.
c. A newly established peer review process.
d. A 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 learn how to excel and identify which competencies the nurse
wants to achieve in the future.
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?
a. Use of the performance appraisal on an annual basis.
b. Notes made immediately after an incident that include a description of the incident,
actions taken, plans, and follow-up.
c. A tally sheet of medication errors and other specific problems that will be used at
annual review.
d. Copies of reports, placed in the employee’s file, of all unusual occurrences
involving the employee.
ANS: B
In documenting staff problems, it is important to indicate specifically what rules were broken
or violated, consequences if behaviour is not altered, employee’s explanation of the incidents,
and the plan of action to reach new goals.
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?
a. The chemically dependent employee usually hides any changes in behaviour.
b. When confronted with the issue, the affected employee is usually relieved to have
someone to talk to about the problem.
c. The chemically impaired nurse affects the entire health care organization.
d. Hospital policy, state laws, and nurse practice acts address procedures for the
chemically dependent employee in the most general terms.
ANS: C
A chemically impaired nurse jeopardizes patient care through impaired skills and judgement.
She or he also compromises teamwork and continuity as peers attempt to cover deficiencies in
work performance for their impaired team member.
The chief nursing officer reviews the policy about “progressive discipline process.” The
progressive discipline process includes which of the following?
a. The manager is a counsellor and friend to the employee.
b. The manager should reprimand and suspend the employee as a last resort.
c. The manager should rehire the employee after a reasonable length of time.
d. The manager should terminate the employee if the problem persists.
ANS: D
In some situations, despite best efforts of the manager/leader, the employee’s issue or
disruptive behaviour may continue. In such cases, there is sometimes no choice but to
terminate the employee
A nurse manager must be familiar with the agency’s policies regarding employment
termination. Termination procedures include which of the following?
a. Following specific procedures at other organizations.
b. Having an attorney present at the termination meeting.
c. Having adequate written documentation to support the action.
d. Having a friend present during the termination meeting.
ANS: C
All steps should be followed, including having full, appropriate, detailed documentation and
following the procedures of the organization.
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 behaviours are most likely to signal that
Nathan is intending to resign from his position on the unit?
a. Increased absenteeism over the past month.
b. Increased attempts to discuss his concerns with his colleagues.
c. Testing of workplace guidelines.
d. Frequent defensiveness.
ANS: A
Many employees increase their absenteeism just before submitting their resignation. If the
health care worker is experiencing some form of role stress, it might be manifested through
absenteeism. Role strain may be reflected by: (1) withdrawal from interaction; (2) reduced
involvement with colleagues and the organization; (3) decreased commitment to the mission
and the team; and (4) job dissatisfaction. Testing of workplace guidelines and defensiveness
are associated with immaturity.
All of the following are grounds for immediate dismissal except:
a. Failing to pursue further medical help for a patient, after which the patient dies.
b. Selling narcotics obtained from the unit supply of narcotics.
c. Restraining a patient in bed for 7 hours, unsupervised, as punishment for hitting a
staff member.
d. Grabbing the unit manager and threatening further physical harm after a poor
performance appraisal.
ANS: A
Situations that may warrant immediate dismissal include theft, violence in the workplace, and
wilful abuse of the patient.
Nurses generally experience difficulty in identifying behaviours and actions that could signal
chemical dependency in a coworker. Which of the following is not a behavioural change that
occurs with chemical dependency?
a. Personality and behavioural changes.
b. Job performance changes.
c. Changes in educational involvement and pursuit.
d. Absenteeism.
ANS: C
When suspicions of chemical dependency are raised, a manager needs to be alert to
behavioural changes in the affected employee. These changes include mood swings, changes
in hygiene and appearance, heightened interest in the pain control of patients, increases in
absenteeism, and increases in tardiness.
Aurora, RN, is a self-admitted drug addict and has abused codeine heavily. Aurora and the
unit manager decide that changes have to occur. Aurora enrolls in an addiction program, and
the manager has her transferred to a drug-free area. What other strategies might be
appropriate?
a. The manager could refer Aurora to the human resources department.
b. The manager could assist in monitoring Aurora’s progress.
c. The manager could counsel Aurora if Aurora has formed a trusting relationship
with her.
d. Aurora needs to be asked not to involve her family in the recovery program
because this is a work-related situation.
ANS: B
Effective management mandates that the organization take an active role in helping employees
with chemical dependencies. It is important for the manager/nurse leader to be supportive,
caring, empathic, and encouraging with such an employee. Many organizations have
employee assistance programs, to which the manager should refer employees.
Incivility is a disruptive behaviour or communication that creates negativity in the
environment and interferes with quality of patient care and safety. The manager can
implement steps that help to alleviate uncivil behaviour on a unit. Which of the following
would not be an appropriate first step?
a. Suspending the staff member from work.
b. Providing written admonishment that is discussed and placed in the employee’s
file.
c. Providing verbal admonishment.
d. Terminating the staff member.
ANS: D
Dismissal does not enable the organization to attempt remediation of the behaviour and is not
consistent with first steps in progressive discipline.
In which order should the strategies below occur in progressive discipline?
a. Suspending the staff member from work.
b. Providing written admonishment that is discussed and placed in the employee’s file.
c. Providing verbal admonishment.
d. Terminating the staff member.
a. A, B, C, D
b. B, A, C, D
c. C, B, A, D
d. C, A, B, D
ANS: C
Studies have shown that following this sequence is a fair and effective strategy for discipline
and remediation.
When progressive discipline is used, the steps are followed progressively only for repeated
infractions of the same rule. On some occasions, the breaking of rules is so serious that the
employee is:
a. Transferred to another unit.
b. Suspended indefinitely.
c. Asked to attend a union grievance meeting.
d. Terminated after the first infraction
ANS: D
Situations that may warrant immediate dismissal include theft, violence in the workplace, and
wilful abuse of a patient.
You need to terminate Gregory, who has had a long-standing history of conflict with you and
the staff and who recently was charged with theft of patient belongings. You consult the
human resources department, and together you develop a plan, which includes:
a. A private meeting with Gregory, a human resources representative, and you to
deliver the news and deliver the employment termination notice and all other
documents that are related.
b. Planning an opportunity for Gregory to return and be recognized at a staff farewell.
c. Calling Gregory at home to tell him that he is fired and that his paperwork will be
sent to him at a future date.
d. Calling him into a meeting in your office on the ward, where assistance is
available, should he become upset or agitated.
ANS: A
Employment termination requires careful planning as to timing, privacy, safety, and how to
preserve the employee’s dignity and avoid humiliation. Choosing a private location where
colleagues are not present and organizing all documentation that is required to be given to
Gregory achieves these goals and prevents his having to come to the organization at a future
date.
The nurse manager notices that Tia, a staff nurse, has been absent 2 to 3 days per month for
the past 3 months. What is the manager’s best response?
a. “Why are you absent from shifts every month?”
b. “I am concerned that you have been absent 3 days this month.”
c. “Your attendance record is not very good. Do you want to talk about it?”
d. “I am changing your shift rotation as it is obvious that you are not able to
consistently implement your scheduled shifts.”
ANS: B
Nurse leaders must confront persistent absenteeism and discuss the situation directly with the
employee by verbalizing their concern, in this case, when they see that a staff nurse has been
absent 2 to 3 days per month in the past 3 months. The manager mentions examples of
observed behaviour and tells the employee how they makes the manager feel. Asking why the
staff member has been absent is not the best response. Although the manager may ask the
nurse if she wants to talk about it, the manager would not begin the statement with a
value-laden negative response. Changing the shift rotation is based on the assumption that
scheduling is the problem, and that assumption may not be correct.
