Effective communication

Coordinating Care Communication. Effective communication is a key component of fostering teamwork and coordinating care. To provide safe, effective care, everyone involved in a patient’s care should understand the patient’s condition and his or her needs. Unfortunately many issues result from a breakdown in communication. Miscommunication often occurs during transitions of care. One structured model used to improve communication is the SBAR (Situation-Background-Assessment-Recommenda­tion) technique (Table 1-6). This technique provides a way to talk about a patient’s condition among members of the health care team in a predictable, structured manner. Other ways to enhance communication during transitions include performing surgical time-outs, using a standard change-of-shift process, and conducting interprofessional rounds to identify risks and develop a plan for delivering care. Table 1-6 Guidelines for Communicating Using SBAR Purpose: SBAR is a model for effective transfer of information by providing a standardized structure for concise factual communications from nurse-to-nurse, nurse-to-physician, or nurse-to–other health professionals.Steps to Use: Before speaking with a physician or other health care professional about a patient problem, assess the patient yourself, read the most recent physician progress and nursing notes, and have the patient’s chart available. S Situation • What is the situation you want to discuss? What is happening at the present time? • Identify self, unit. State: I am calling about: patient, room number. • Briefly state the problem: what it is, when it happened or started, and how severe it is. State: I have just assessed the patient and I am concerned about: identify why you are concerned. B Background • What is the background or circumstances leading up to the situation? State pertinent background information related to the situation that may include • Admitting diagnosis and date of admission • List of current medications, allergies, IV fluids • Most recent vital signs • Date and time of any laboratory testing and results of previous tests for comparison • Synopsis of treatment to date • Code status A Assessment • What do you think the problem is? What is your assessment of the situation? State what you think the problem is: • Changes from prior assessments • Patient condition unstable or worsening R Recommendation/Request • What should we do to correct the problem? What is your recommendation or request? State your request. • Specific treatments • Tests needed • Patient needs to be seen now image Source: Institute for Health Care Improvement: SBAR technique for communication: a situational briefing model. Retrieved from ihi.org Clinical Pathways. Clinical pathways (critical paths, patient care protocols, care maps) are interprofessional care plans that specify care and desired outcomes during a specific time period for patients with a particular diagnosis or health condition. Think of a clinical pathway as a road map the patient and health care team should follow. As the patient progresses along the road, the patient should receive specific care and accomplish specific goals. If a patient’s progress differs from the planned path, a variance has occurred. A negative variance occurs when specific goals are not met. The nurse usually identifies when a negative variance is present and works with the interprofessional team to create a plan to address the issue.16 The exact content and format of clinical pathways vary among agencies and settings. Each agency usually develops its own pathways based on evidence-based practice guidelines. Com­mon components include assessment guidelines, laboratory and diagnostic testing, medications, activity, diet, and teaching. In 11acute care, clinical pathways often describe which patient care components are required at specific times for each day of hospitalization. The case types selected for this type of pathway are usually those that are high volume or high risk and predictable, such as myocardial infarction and surgical procedures (e.g., joint replacements, cholecystectomies, cataract surgery). Delegation and Assignment. As a registered nurse (RN), you will delegate nursing care and supervise others who are qualified to deliver care. Delegation is transferring authority to a competent individual for completing selected nursing tasks in a selected situation.20 The delegation and assignment of nursing activities is a process that, when used appropriately, can result in safe, effective, and efficient patient care. Delegating can allow you more time to focus on complex patient care needs. Delegating care and supervising others will be one of your fundamental roles as a professional nurse. Delegation typically involves tasks and procedures that licensed practical/vocational nurses (LPNs/LVNs) and unlicensed assistive personnel (UAP) perform. Nursing interventions that require independent nursing knowledge, skill, or judgment (e.g., initial assessment, determining nursing diagnoses, patient teaching, evaluating care) are your responsibility and cannot be delegated. State boards of nursing and agency policies identify activities that you can delegate to LPNs/LVNs and UAP. You need to use professional judgment to determine appropriate activities to delegate based on the patient’s needs, the LPN/LVN’s and UAP’s education and training, and extent of supervision required. The most common delegated nursing actions occur during the implementation phase of the nursing process. For example, the nurse can delegate measuring oral intake and urine output to UAP, but the RN uses nursing judgment to decide if the intake and output are adequate. The general guideline for LPN/LVN practice is that they can function independently in a stable, routine situation. However, they must work under the direct supervision of a professional nurse in acute, unstable situations when a patient’s condition can rapidly change. In most states, LPNs/LVNs may administer medications, perform sterile procedures, and provide a wide variety of interventions planned by the RN. The procedure itself is not the issue in determining what can be delegated. Rather, the stability of the patient determines whether it is appropriate for an RN to delegate a procedure to an LPN/LVN. For example, the LPN/LVN can change a dressing on an abdominal surgical wound, but the RN should perform the initial dressing change and wound assessment. UAPs hold many titles, including nurse aides, orderlies, nursing assistants, patient care assistants, or technicians. The activities UAPs perform typically include obtaining routine vital signs on stable patients, feeding and assisting patients at mealtimes, ambulating stable patients, and helping patients with bathing and hygiene. Delegation can also occur among professional nurses. For example, if one RN has accountability for an outcome and asks another RN to perform a specific intervention related to that outcome, that is delegation. This type of delegation typically occurs when one RN leaves the unit/work area for a meal break. Assignment is different from delegation in that assignment is the work each staff member is to accomplish during a given work period.20 Staff members can only be assigned activities that are within their scope of practice. Therefore the term assign is used when you direct a person to do something that he or she is authorized to do. For example, you can assign an LPN/LVN to administer medications to a patient, because this is within the LPN/LVN’s scope of practice. You cannot assign an LPN/LVN to a patient who needs an admission assessment, because an RN must perform the initial patient assessment. Whether you delegate or are working with staff to whom you assign tasks, you are responsible for the patient’s total care during your work period. You need to determine what patient care tasks must be accomplished during the given time period, identify who will accomplish them, and prioritize the order in which the tasks must be completed. You are responsible for supervising UAP or LPNs/LVNs. Clearly communicate what tasks must be done and provide necessary guidance. Since you are accountable for ensuring that delegated tasks are completed in a competent manner, evaluate the care given, follow-up as needed, and make sure no care was missed. Delegation is a skill that is learned and you must practice to be proficient in managing patient care. You need to use critical thinking and professional judgment to ensure that the Five Rights of Nursing Delegation are implemented (Table 1-7). To 12assist you, information on delegation is presented in teamwork and collaboration boxes and questions in case studies at the end of the management chapters. Table 1-7 Five Rights of Delegation The Five Rights of Delegation The registered nurse uses critical thinking and professional judgment to be sure that the delegation or assignment is: 1. The right task 2. Under the right circumstances 3. To the right person 4. With the right directions and communication 5. Under the right supervision and evaluationRights of DelegationDescriptionQuestions to AskRight TaskOne that can be delegated for a specific patient Is it appropriate to delegate based on legal and agency factors? Has the person been trained and evaluated in performing the task? Is the person able and willing to do this specific task?Right Circum­stancesAppropriate patient setting, available resources, and considering relevant factors, including patient stability What are the patient’s needs right now? Is staffing such that the circumstances support delegation strategies?Right PersonRight person is delegating the right task to the right person to be performed on right person Is the prospective delegatee a willing and able employee? Are the patient needs a “fit” with the delegatee?Right Directions and Communi­cationClear, concise description of task, including its objective, limits, and expectations Have you clearly communicated the task? With directions, limits, and expected outcomes? Does the delegatee know what and when to report? Does the delegatee understand what needs to be done?Right Supervision and EvaluationAppropriate monitoring, evaluation, intervention, and feedback Do you know how and when you will interact about patient care with the delegatee? How often will you need to provide direct observation? Will you be able to give feedback to the staff member if needed? image Source: Delegation Joint Statement NCSBN-ANA. Retrieved from ncsbn.org Safety As the complexity of health care environments increases, patient safety is affected. It is estimated that between 210,000 and 440,000 patients each year suffer some type of harm that contributes to their death because of preventable medical errors.21 A number of organizations are addressing this issue by providing safety goals for health care organizations and identifying safety competencies for health professionals. By implementing various procedures and systems to improve health care delivery to meet safety goals, health care systems are working to attain a culture of safety that minimizes the risk of harm to the patient. Serious Reportable Events The National Quality Forum (NQF) uses the term serious reportable event (SRE), also called a “never” event, to describe adverse events that are serious, largely preventable, and of concern to the public and health care providers.22 These events include such things as a patient acquiring a stage III or greater pressure ulcer while hospitalized and death or disability from a fall or hypoglycemia. To reduce the occurrence of these events, the NQF provides a list of effective Safe Practices that should be used in health care settings to improve the safety of care. You are implementing NQF practices when you perform a time-out prior to a surgical procedure, complete accurate medication records, and implement interventions to prevent catheter-associated urinary tract infections, pressure ulcers, and falls. National Patient Safety Goals The Joint Commission (TJC), the accrediting agency for health care organizations, gathers and reports data on serious errors they call sentinel events. A sentinel event is a patient safety event not related to the patient’s illness or underlying condition that reaches a patient and results in death, permanent harm, or severe temporary harm.23 Events are “sentinel” because they signal the need for immediate investigation and response. Many sentinel events are also serious reportable events. If the patient undergoes a wrong-site or wrong-procedure surgery, experiences an assault in the health care setting or receives an incompatible blood product, the occurrence is both a sentinel event, reportable to TJC, and a serious reportable event, reportable to NQF. To address specific patient safety concerns, TJC issues National Patient Safety Goals (NPSGs).23 NPSGs promote patient safety by providing evidence-based solutions to common safety problems. The 2016 NPSGs are listed in Table 1-8. Table 1-8 National Patient Safety Goals Safety GoalExamples Goal 1: Identify patients correctly. • Use at least two ways to identify patients (e.g., have them state full name and date of birth). • Give the correct patient the correct blood with every blood transfusion.Goal 2: Improve communication among the health care team. • Quickly get critical test results to the right staff person.Goal 3: Use medications safely. • Label all medicines that are not already labeled. Discard any found unlabeled. • Use appropriate precautions with patients who take anticoagulants. • Find out what medications each patient is taking. Make certain that it is safe for the patient to take any new medicines with his or her current medicines. • Give a list of the patient’s medicines to the patient and his or her caregiver before they go home. Explain the list.Goal 6: Use clinical alarm systems safely. • Respond to alarms in a timely manner. • Do not turn alarms off.Goal 7: Prevent health care–associated infections. • Use soap, water, and hand sanitizer before and after every patient contact. • Use evidence-based practices to prevent infections related to central lines, indwelling urinary catheters, and multidrug-resistant organisms.Goal 15: Identify the safety risks inherent in the agency’s patient population. • Assess patients at risk for suicide. • Assess any risks for patients who are getting home oxygen therapy, such as fires.Universal Protocol (UP) Preprocedure verification Mark procedure site Performance of time-out • Conduct a time-out before the start of any invasive or surgical procedure. • Confirm correct patient, procedure, and site. image Adapted from The Joint Commission (TJC): 2016 National patient safety goals, Oakbrook Terrace, Ill. Retrieved from jointcommission.org The latest safety goal, focusing on improving the safety of clinical alarm systems, will greatly affect nursing. Patient monitoring systems provide important information. Alarms that work well improve patient safety and care by telling you when a patient requires your attention. However, so many alarms can go off that alarm fatigue occurs, and nurses can become desensitized to the sounds. By better managing alarms, alarm fatigue will be reduced and patient safety improved. Because you have the greatest amount of interaction with patients, you play a key role in promoting safety. Many describe nurses as the patient’s last line of defense. Every nurse has the responsibility to ensure the patient receives care in a manner that prevents errors and promotes patient safety. Throughout this book, safety alerts highlighting patient care issues and NPSGs will assist you in learning to apply safety principles. Quality Improvement Quality care is related to safety: the higher the culture of safety, the better the quality of care. Health care systems focused on 13quality outcomes use practice standards and protocols based on best evidence while considering the patient’s unique preferences and needs. Your role is to coordinate the complex aspects of patient care, including the care delivered by others, and identify and correct issues associated with poor quality and unsafe care. Quality improvement (QI) programs involve systematic actions that monitor, assess, and improve health care quality. QI is an interprofessional team effort that is required by accrediting agencies. As part of professional nursing practice, you need to be able to collect data using QI tools, implement interventions to improve quality of care, and monitor patient outcomes. Several public and private groups focusing on improving health care quality have developed standard QI measures. These performance measures assess how well the health care team cares for a patient with a certain condition or receives a specific treatment. They describe what data must be collected and monitored. Fig 1-5 shows an example of a QI system for adult patients with asthma. In this example, you would monitor patient medical records to determine if the rate of flu vaccine administration exceeds 90%. You would share the results with the interprofessional team and, if the identified proficiency was not met, work as a team to implement measures to correct the deficiency. image FIG. 1-5 Quality improvement system. (Adapted from Courtlandt CD, Noonan L, Leonard GF: Model for improvement—part 1: A framework for health care quality, Ped Clin North Am 56:757, 2009.) National Database of Nursing Quality Indicators The National Database of Nursing Quality Indicators (NDNQI) provides data on nursing-sensitive measures to evaluate the impact of nursing care on patient outcomes. Patient outcomes are nursing sensitive if they improve with a greater quantity or quality of nursing care. NDNQI outcomes are unique because they identify how nursing workforce factors, including nurse staffing and skill mix, directly influence patient outcomes. NDNQI data show the incidence of falls and health care–associated pressure ulcers and infections decreases with adequate staffing and increased nurse education and satisfaction with the work environment. Table 1-9 lists the current NDNQI. Table 1-9 National Database of Nursing Quality Indicators • Workforce factors • Nurse turnover • Nursing hours per patient day • RN surveys on job satisfaction and practice environment scale • RN education and certification • Skill mix: RNs, LPNs/LVNs, UAP • Hospital readmission rates • Pain assessment cycle • Peripheral IV infiltration rate • Physical restraint prevalence • Physical/sexual assault rate • Patient falls and falls with injury • Pressure ulcer incidence • Health care–associated infections (HAI) • Ventilator-associated pneumonia and events • Central line-associated bloodstream infection • Catheter-associated urinary tract infection Source: National Database of Nursing Quality Indicators. Retrieved from www.nursingquality.org. Informatics Nursing is an information-intense profession. Advances in informatics and technology have changed the way nurses plan, deliver, document, and evaluate care. All nurses, regardless of their setting or role, use informatics and technology every day in practice. Informatics has changed how you obtain and review diagnostic information, make clinical decisions, communicate with patients and health care team members, document, and provide care. Technology advances have increased the efficiency of nursing care, improving the work environment and the care nurses provide. Computers and mobile devices allow you to document at the time you deliver care and give you quick and easy access to information, including clinical decision-making tools, patient education materials, and references. Texting, video chat, and e-mail enhance communication among health care team 14members and help you deliver the right message to the right person at the right time. Technology plays a key role in providing safe, quality patient care. Medication administration applications improve patient safety by flagging potential errors, such as look-alike and sound-alike medications and adverse drug interactions, before they can occur. Computerized provider order entry (CPOE) systems can eliminate errors caused by misreading or misinterpreting handwritten orders. Sensor technology can decrease the number of falls in high-risk patients. Care reminder systems provide cues that decrease the amount of missed nursing care. Being able to use technology skills to communicate and access information is now an essential component of your professional nursing practice. You must be able to use word processing software, communicate by e-mail and book messaging, access appropriate information, and follow security and confidentiality rules. You need to demonstrate the skills to safely use patient care technologies and navigate electronic documentation systems. Protected health information (PHI) is highly sensitive. The Health Insurance Portability and Accountability Act (HIPAA) is part of federal legislation that addresses actions for how PHI is used and disclosed. With the increased use of informatics and technology come new concerns on how to comply with HIPAA regulations and maintain a patient’s privacy. New wireless technologies, increased use of e-mail and computer networking, and the ongoing threat of computer viruses increase the need for properly protecting a patient’s privacy. Ethical/Legal Dilemmas Social Networking: HIPAA Violation Situation You log into a closed group on a social networking site and read a posting from a fellow nursing student. The posting describes in detail the complex care the student provided to an older patient in a local hospital the previous day. The student comments on how stressful the day was and asks for advice on how to deal with similar patients in the future. Ethical/Legal Points for Consideration • Protecting and maintaining patient privacy and confidentiality are basic obligations defined in the Code of Ethics for Nurses, which nurses and nursing students should uphold.1 • As outlined in the Health Insurance Portability and Accountability Act (HIPAA), a patient’s private health information is any information that relates to the person’s past, present, or future physical or mental health. This includes not only specific details such as a patient’s name or picture but also information that gives enough details that someone may be able to identify that person. • You may unintentionally breach privacy or confidentiality by posting patient information (diagnosis, condition, or situation) on a social networking site. Using privacy settings or being in a closed group does not guarantee the secrecy of posted information. Others can copy and share any post without your knowledge. • Potential consequences for improperly using social networking vary based on the situation. These may include (1) disciplinary action by the state board of nursing, (2) being disciplined, suspended, or fired by an employer, (3) dismissal from a nursing program, and (4) civil and/or criminal charges. • A student nurse who experienced a stressful day and is looking for advice and support from peers (e.g., “Today my patient died. I wanted to cry.”) could share the experience by clearly limiting the posts to the student’s personal perspective and not sharing any identifying information. This is one area in which it is safest to err on the side of caution to avoid the appearance of impropriety. Discussion Questions 1. How would you deal with the situation involving the fellow nursing student or a nursing colleague? 2. How would you handle a situation in which you observed a staff member who violated HIPAA? Reference 1. Code of Ethics for Nurses. [Retrieved from] nursingworld.org As a nurse, you have an obligation to ensure the privacy of your patient’s health information. To do so, you need to understand your agency’s policies regarding the use of technology. You need to know the rules regarding accessing patient records and releasing PHI, what to do if information is accidentally or intentionally released, and how to protect any passwords you use. If you are using social networking, you must be careful not to place any individually identifiable PHI online. Throughout this book, Informatics in Practice boxes offer suggestions on how to use informatics in your practice. Electronic Health Records The largest use of informatics is electronic health records (EHRs), also called electronic medical records. An EHR is a computerized record of patient information. It is shared among all health care team members involved in a patient’s care and moves with the patient—to other providers and across care settings. The ideal EHR provides a single place for team members to review and update a patient’s health record, document care given, and enter patient care orders, including medications, procedures, diets, and diagnostic and laboratory tests (Fig. 1-6). The EHR should contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, and test results.24 image FIG. 1-6 Members of the interprofessional team review a patient’s electronic health record. (From Arnold EC, Boggs KU: Interpersonal relationships, St Louis, 2011, Mosby.) With the ACA, an increase in EHR use is under way. EHRs have the potential to reduce medical errors associated with traditional paper records and improve clinical decision making, patient safety, and quality of care. Unfortunately, several obstacles remain in the way of fully implementing EHRs. Systems are expensive and technologically complex, requiring a number of resources to implement and maintain. In addition, communication is still lacking among computer systems and software 15applications in use. Finally, patients must be assured of their privacy and that information is only accessed by those with a right to know. Evidence-Based Practice Evidence-based practice (EBP) is a problem-solving approach to clinical decision making. Using the best available evidence (e.g., research findings, QI data), combined with your expertise and the patient’s unique circumstances and preferences, leads to better clinical decisions and improved patient outcomes. EBP closes the gap between research and practice, providing more reliable and predictable care than that based on tradition, opinion, and trial and error. EBP does not mean that you have to conduct a research study. Instead, EBP depends on you to take an active role in using the best available evidence when delivering care. You need to have an ongoing curiosity about what are the best nursing practices and routinely ask questions about your patient’s care. Recognize when you need more information. When you base your practice on valid evidence, you are solving problems and supporting best patient outcomes. Steps of EBP Process The EBP process has six steps (Table 1-10). Table 1-10 Steps of Evidence-Based Practice (EBP) Process 1. Ask the clinical question using the PICOT format: Patients/population Intervention Comparison or comparison group Outcome(s) Time (as applicable) 2. Search for the best evidence based on the clinical question. 3. Critically appraise and synthesize the evidence. 4. Implement the evidence in practice. 5. Evaluate the practice decision or change. 6. Share the outcomes of the decision or change. Step 1. Step 1 is asking a clinical question in the PICOT format. Developing the clinical question is the most important step in the EBP process.25 A good clinical question sets the context for integrating evidence, clinical judgment, and patient preferences. In addition, the question guides the literature search for the best evidence to influence practice. An example of a clinical question in PICOT format is, “In adult abdominal surgery patients (P = patients/population) is splinting with an elasticized abdominal binder (I = intervention) or a pillow (C = comparison) more effective in reducing pain associated with ambulation (O = outcome) on the first postoperative day (T = time period)?” A properly stated clinical question may not have all components of PICOT. Some only include four components. The (T) timing or (C) comparison components are not appropriate for every question. The (C) component of PICOT may include a comparison with a specific intervention, the usual standard of care, or no intervention at all. Step 2. Step 2 is searching for the best evidence that applies to the clinical question. Technology provides you with ready access to data. You can easily search a number of online resources and collect large amounts of clinical information and evidence. It is important to evaluate all data sources for their credibility and reliability. Not all evidence is equal. Figure 1-7 presents the hierarchy of evidence. As you go down the pyramid, the strength of the evidence becomes weaker. Systematic reviews and evidence-based clinical practice guidelines save time and effort in the EBP process. However, they are available for only a limited number of clinical topics and may not suit all types of clinical questions. When insufficient research exists to guide practice, recommendations from expert panels and authority figures may be the best evidence available. image FIG. 1-7 Hierarchy of evidence. (Modified from Guyatt G, Rennie D: User’s guide to the medical literature, Chicago, 2002, American Medical Association; Harris RP, et al: Current methods of the U.S. Prevention Services Task Force: a review of the process. Am J Prevent Med 20:21, 2001; Melnyk BM, Fineout-Overholt E: Evidence-based practice in nursing and healthcare: a guide to best practice, ed 3, Philadelphia, 2014, Lippincott Williams & Wilkins.) Step 3. Step 3 is critically appraising and synthesizing evidence found in the search. A successful critical appraisal process focuses on three essential questions: (1) What are the results? (2) Are the results reliable and valid? and (3) Will the results help me in caring for my patients? You must determine the 16strength of the evidence and synthesize the findings related to the clinical question to conclude what is the best practice. For example, you find strong evidence supporting effective­ness of elasticized binders and pillows in reducing pain associated with ambulation. However, the binder appears to be more effective if the patient is obese or has had prior abdominal surgery. Step 4. Step 4 involves implementing the evidence in practice. The decision to implement change is made by combining the evidence, clinical judgment, and the preferences and values of patients and caregivers. You may be part of an interprofessional team charged with implementing a practice change or applying evidence in a specific patient care situation. This may include developing clinical practice guidelines; policies and procedures; or new assessment, teaching, or documentation tools. For example, you may be part of a team implementing a new postoperative protocol focused on using elasticized abdominal binders with patients who are obese or had prior abdominal surgery. Step 5. Step 5 is evaluating the outcome in the clinical setting. After implementing the practice change for a specific period, you should monitor outcomes to determine whether the change has improved patient outcomes. Accrediting bodies require documentation of outcome measures to show that the organization is using evidence to improve patient care.25 Step 6. Step 6 is sharing the results of the EBP change. If you do not share the outcomes of EBP, then other health care providers and patients cannot benefit from what you learned from your experience. Information is shared locally using unit- or hospital-based newsletters and posters and regionally and nationally through journal publications and presentations at conferences. Implementing EBP To implement EBP, you must develop the skills to be able to seek and incorporate into practice scientific evidence that supports best patient outcomes. Throughout this book, two different types of EBP boxes are used to show how EBP is used in nursing practice. The Translating Research into Practice boxes provide initial answers to specific clinical questions. These boxes contain the clinical question, critical appraisal of the supportive evidence, implications for nursing practice, and the source of the evidence. Applying the Evidence boxes provide an opportunity for you to practice your critical thinking skills in applying EBP to patient scenarios. To assist you in identifying the use of evidence incorporated throughout this book, an asterisk (*) is used in the reference list at the end of each chapter to indicate evidence-based information for clinical practice. Bridge to NCLEX Examination The number of the question corresponds to the same-numbered outcome at the beginning of the chapter. 1. An example of a nursing activity that best reflects the American Nurses Association’s definition of nursing is a. treating dysrhythmias that occur in a patient in the coronary care unit. b. diagnosing a patient with a feeding tube as being at risk for aspiration. c. establishing protocols for treating patients in the emergency department. d. providing antianxiety drugs for a patient who has disturbed sleep patterns. 2. A nurse working on the medical-surgical unit at an urban hospital would like to become certified in medical-surgical nursing. The nurse knows that this process would most likely require a. a bachelor’s degree in nursing. b. formal education in advanced nursing practice. c. experience for a specific period in medical-surgical nursing. d. membership in a medical-surgical nursing specialty organiza­tion. 3. A nurse is providing care to a patient after right hip surgery. Within a pay-for-performance system, a critical role of the nurse is to a. ensure that care is provided using a minimal amount of supplies. b. discharge the patient at completion of the number of approved days of care. c. implement measures to decrease the risk of the patient acquiring an infection. d. assess the patient’s ability to pay for health care services at the time of admission. 4. The nurse is assigned to care for a newly admitted patient. Number in order the steps for using the nursing process to prioritize care. (Number 1 is the first step, and number 5 is the last step.) ___ Evaluate whether the plan was effective. ___ Identify any health problems. ___ Collect patient information. ___ Carry out the plan. ___ Determine a plan of action. 5. The linkages among NANDA-I nursing diagnoses, NOC patient outcomes, and NIC nursing interventions can be used to a. evaluate patient outcomes. b. provide guides for planning care. c. predict the results of nursing care. d. shorten written care plans for individual patients. 6. The nurse is caring for a diabetic patient in the ambulatory surgical unit who has undergone debridement of an infected toe. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Check the patient’s vital signs. b. Monitor the patient’s pain level. c. Assess the patient’s IV catheter site. d. Evaluate the patient’s tibial and pedal pulses. 7. The nurse’s role in addressing the National Patient Safety Goals established by The Joint Commission includes (select all that apply) a. answering monitoring alarms in a timely manner. b. using side rails and alarm systems as necessary to prevent patient falls. c. obtaining a complete, accurate list of the patient’s medications on admission. d. memorizing and implementing all the rules published by The Joint Commission. e. encouraging patients to be actively involved in and question their own health care. 17 8. Advantages of using informatics in health care delivery are (select all that apply) a. reduced need for nurses in acute care. b. increased patient anonymity and confidentiality. c. the ability to achieve and maintain high standards of care. d. access to standard plans of care for many health problems. e. improved communication of the patient’s health status to the health care team. 9. When using evidence-based practice, the nurse a. must use clinical practice guidelines developed by national health agencies. b. should use findings from randomized controlled trials to plan care for all patient problems. c. uses clinical decision making and judgment to determine what evidence is appropriate for a specific clinical situation. d. statistically analyzes the relationship of nursing interventions to patient outcomes to establish evidence for the most appropriate patient interventions. 1. b, 2. c, 3. c, 4. 5, 2, 1, 4, 3, 5. b, 6. a, 7. a, b, c, 8. c, d, e, 9. c. For rationales to these answers and even more NCLEX review questions, visit evolve.elsevier.com/Lewis/medsurg References 1. American Nurses Association. Nursing: a social policy statement. ed 3. The Association.: Washington DC; 2010 [(Classic)]. 2. Nightingale F. Notes on nursing: what it is and what it is not. (facsimile edition). Lippincott.: Philadelphia; 1946 [(Classic)]. 3. Henderson V. The nature of nursing. Macmillan.: New York; 1966 [(Classic)]. 4. Roy S, Andrews H. The Roy adaptation model. ed 2. Appleton & Lange.: Stamford, Conn; 1999 [(Classic)]. 5. American Association of Colleges of Nursing. Essentials of baccalaureate education for professional nursing practice. [Retrieved from] www.aacn.nche.edu. 6. American Nurses Credentialing Center. Certification. [Retrieved from] nursecredentialing.org (Jeff 10-17) Jeff, Sharon Lewis & Shannon Ruff Dirksen & Margaret Heitkemper & Linda Bucher & Mariann M. Harding &. Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume, 10th Edition. Mosby, 102016. VitalBook file. The citation provided is a guideline. Please check each citation for accuracy before use. pLEASE rEAD THIS. THIS PAPER IS DUE 09/29/2017. AT 8PM MINNESOTA TIME. CAN PUT IT BECAUSE THE SITE WILL NOT LET ME.