Chapter 1 Critical Care Nursing Practice Promoting Excellence-Caring, Collaboration Evidence Questions

Chapter 1 Critical Care Nursing Practice: Promoting Excellence-Caring, Collaboration Evidence Questions and Correct Answers 1. A nurse is the only one in the ICU who has not achieved certification in critical care nursing. She often will ask her fellow nurses what to do in caring for a patient because she doubts the accuracy of her knowledge and her intuition. She loves her work but wishes she could do it with a greater level of competence. What is the most important effect that obtaining certification would likely have on the nurses practice? A) Recognition by peers B) Increase in salary and rank C) More flexibility in seeking employment D) Increased confidence in making decisions - Correct Answers: D) Increased confidence in making decisions Certification is associated with positive outcomes for the nurse. Certified critical care nurses indicated increased competence with 20 skills. 6 Certification of nurses was associated with overall workplace empowerment. Not only do patients and nurses benefit from certification, but so too does the organization. Certification allows the employer to know that the nurses working for them have the knowledge and expertise to promote optimal patient outcomes. Nurses who become certified have demonstrated their commitment to quality since they have taken the time to become certified in a specialty area of practice. Certified nurses show their employers that they are taking responsibility for their own professional development, which may give them a competitive edge when seeking promotion or new career opportunities. Certified nurses reported lower intent to leave their current positions.6,11 Additionally, vacancy and turnover rates were shown to be inversely associated with certification. 2. A hospital interviews two different candidates for a position in the ICU. Both candidates have around 10 years of experience working in the ICU. Both have excellent interpersonal skills and highly positive references. One, however, has certification in critical care nursing. Which of the following is the most compelling and accurate reason for the hospital to hire the candidate with certification? A) The certified nurse will have more knowledge and expertise. B) The certified nurse will behave more ethically. C) The certified nurse will be more caring toward patients. D) The certified nurse will work more collaboratively with other nurses. - Correct Answers: A) The certified nurse will have more knowledge and expertise. Certification is associated with positive outcomes for the nurse. Certified critical care nurses indicated increased competence with 20 skills. 6 Certification of nurses was associated with overall workplace empowerment. Not only do patients and nurses benefit from certification, but so too does the organization. Certification allows the employer to know that the nurses working for them have the knowledge and expertise to promote optimal patient outcomes. Nurses who become certified have demonstrated their commitment to quality since they have taken the time to become certified in a specialty area of practice. Certified nurses show their employers that they are taking responsibility for their own professional development, which may give them a competitive edge when seeking promotion or new career opportunities. Certified nurses reported lower intent to leave their current positions.6,11 Additionally, vacancy and turnover rates were shown to be inversely associated with certification. 3. A nurse is caring for an elderly man recently admitted to the ICU following a stroke. She assesses his cognitive function using a new cognitive assessment test she learned about in a recent article in a nursing journal. She then brings a cup of water and a straw to the patient because she observes that his lips are dry. Later, she has the patient sit in a wheelchair and takes him to have some blood tests performed. He objects at first, saying that he can walk on his own, but the nurse explains that it is hospital policy to use the wheelchair. That evening, she recognizes signs of an imminent stroke in the patient and immediately pages the physician. Which action taken by the nurse is the best example of evidence-based practice? A) Giving the patient a cup of water B) Transferring the patient in a wheelchair C) Using the cognitive assessment test D) Recognizing signs of imminent stroke and paging the physician - Correct Answers: C) Using the cognitive assessment test EBP takes what is known and uses it to guide patient care to achieve the best possible outcomes. In the translation of knowledge into clinical practice, it is essential for the critical care nurse to consider the strength or level of the evidence: EBP is "a way of providing health care that is guided by a thoughtful integration of the best available scientific knowledge with clinical expertise. This approach allows the practitioner to critically assess research data, clinical guidelines, and other information resources to identify correctly the clinical problem, apply the most high-quality intervention, and reevaluate the outcome for future improvement."13 EBP is essential to help optimize patient outcomes in today's dynamic health care environment. In the United States, the National Academy of Medicine, the American Nurses Credentialing Center, and The Joint Commission acknowledge EBP as a crucial step in improving health care quality 4. A nurse is on a committee that is trying to reduce the occurrence of hospital-acquired infections in the ICU. Her role is to conduct research to find which interventions have been shown to be most effective in reducing these infections. She consults many different sources and finds conflicting information. Which of the following sources should she consider the most authoritative? A) AACN expert panel report B) A meta-analysis of randomized controlled trials in the American Journal of Nursing C) A systematic review of qualitative studies in the Journal of Advanced Nursing D) A single randomized controlled trial in the American Journal of Critical Care - Correct Answers: B) A meta-analysis of randomized controlled trials in the American Journal of Nursing *The highest level of evidence, Level I, includes experimental studies, randomized controlled trials, and systematic reviews of randomized controlled trials, with or without meta-analysis. In EBP, the lowest level of evidence is Level V, which is based on experiential and non-research evidence. This level includes literature reviews, quality improvement studies, program and financial evaluations, case reports, and opinions of experts based on experiential evidence. Level IV evidence is based on the opinion of respected authorities and/or nationally recognized expert committees/consensus panels based on scientific evidence. Included in this level are clinical practice guidelines and consensus panel reports. Evidence classified as Level III includes nonexperimental studies, systematic reviews of a combination of randomized controlled trials, quasi-experimental and nonexperimental studies, or nonexperimental studies with or without meta-analysis. Evidence from qualitative studies and systematic reviews, with or without meta-analysis, also is classified as Level III. Evidence classified as Level II comes from quasi-experimental studies and systematic reviews of a combination of randomized controlled trials and quasi-experimental or quasi-experimental only with or without meta-analysis. 5. A nurse who has been recently hired to manage the nursing staff of the ICU is concerned at the lack of evidence-based practice she sees among the staff. Which of the following would be the best step for her to take to promote incorporating evidence into clinical practice? A) Only hire nurses certified in critical care nursing. B) Leave copies of several different nursing journals in the nurses lounge. C) Demonstrate to the staff the best nursing-related search terms to use in Google or Yahoo! D) Introduce the staff to the PubMed search engine and assign them topics to research on it. - Correct Answers: D) Introduce the staff to the PubMed search engine and assign them topics to research on it. 6. A physician visits a patient in the ICU while the nurse is out. The patient complains that the pain medication is not effective and that he would like to receive an increased dose. The physician has the nurse paged and consults with him in the hallway regarding the patients request for stronger pain medication. The nurse explains that patient was started on a morphine drip only 20 minutes ago and that the drug has not had time to take effect yet. The physician agrees and tells the patient to give it just a bit more time. Which component of a healthy work environment is most evident in this scenario? A) Skilled communication B) Appropriate staffing C) True collaboration D) Meaningful recognition - Correct Answers: C) True collaboration True collaboration occurs when "the unique knowledge and abilities of every professional are respected to achieve safe quality care for patients. Without the synchronous, ongoing collaborative work of health care professionals from multiple disciplines, patient and family needs cannot be optimally satisfied within the complexities of today's health care system."19 It takes time and trust to build a collaborative team. When true collaboration is achieved, the unique contributions of each member of the team are acknowledged and respected, leading to the provision of optimal care for patients. Formal processes and structures are needed to foster true collaboration built on skilled communication and joint decision making. Conflict is an inevitable part of teamwork and human relationships. Therefore, structures and processes need to be in place to support skilled communication, true collaboration, and joint decision making. Professional development activities for the interprofessional team will help improve working relationships, thus leading to true collaboration that optimizes patient care 7. A nurse in the ICU is responding to a patient who has just gone into cardiac arrest. A moment later, the nurse is notified that another patient has just gone into anaphylactic shock due to a drug allergy. She is conflicted as to what to do, as she is the only nurse available at the moment to tend to both patients. Which component of a healthy work environment is lacking in this scenario? A) Effective decision making B) Appropriate staffing C) Authentic leadership D) Meaningful recognition - Correct Answers: B) Appropriate staffing For appropriate staffing, one must consider the knowledge, skills, and abilities—collectively referred to as competencies—of staff assigned in relation to the individualized, holistic needs of the patient and family. When the needs of patients and families are matched with the competencies of the assigned nurse, optimal outcomes may be achieved. However, the beneficial impact of appropriate staffing in which the needs of the patients are in line with the competencies and experience of the nurse can only be effective if done within an HWE.19 8. An ICU nurse has provided excellent care for a 6-year-old girl who had been admitted to the ICU for a head injury. The nurse was attentive not only to the needs of the patient but also went out of her way to care for the needs of the girls family. According to research, which of the following forms of recognition would the nurse value the most? A) A card from the girls family B) A plaque from the ICU physicians naming her as Nurse of the Year C) A letter of commendation from the hospitals administration D) A bouquet of flowers from her supervisor - Correct Answers: A) A card from the girls family *Handwritten notes from a supervisor, peer, or patient are a meaningful way for nurses to be recognized. When a leader takes time out of a busy day to recognize an employee on the spot in real time, nurses found this gesture to be especially meaningful. There seems to be widespread agreement that to retain nursing staff during a critical shortage, in addition to monetary rewards when possible, expression of appreciation by recognition for excellent performance should be a key part of the strategy. Meaningful recognition has been linked to burnout reduction, higher job satisfaction, greater job commitment, and more. There is an intrinsic value associated with recognition, unlike compensation and traditional incentives. 9. A patient in the ICU has recently been diagnosed with diabetes mellitus. Before being discharged, this patient will require detailed instructions on how to manage her diet, how to self-inject insulin, and how to handle future diabetic emergencies. Which nurse competency is most needed in this situation? A) Clinical judgment B) Advocacy and moral agency C) Caring practices D) Facilitation of learning - Correct Answers: C) Facilitation of learning *Patient and family education is a fundamental nursing competency.1 It is an ongoing and impactful nursing intervention that fits into every nurse-patient interaction.2 The overall goal of educating the patient and family (including significant others) is to improve health while also encouraging patients and families to care for themselves with confidence.3 Patients and families have a need to understand the current illness, the plan of care, requirements for discharge from the hospital, and directions for continued care. It is not unusual for a patient to be transferred to a step-down unit or directly discharged to home from an intensive care unit (ICU), placing an even greater responsibility for care on the patient and family. The ICU nurse not only manages the physical instabilities and emotional needs of the patient with a critical illness but also prepares the patient and family for discharge from the hospital. The amount of patient education required during critical illness is enormous and cannot be overstated. 10. An elderly patient is admitted to the ICU with stage IV lung cancer, diabetes mellitus, and congestive heart failure. The health care team assembled to care for her is large and diverse, including an oncologist, a pulmonologist, an endocrinologist, a cardiologist, and others. The patient is not expected to survive more than a few weeks, and her husband is overwhelmed with stress and grief. Which nurse competency or competencies are most needed in this situation? Select all that apply. A) Clinical judgment B) Caring practices C) Collaboration D) Response to diversity - Correct Answers: B) Caring practices C) Collaboration When true collaboration is achieved, the unique contributions of each member of the team are acknowledged and respected, leading to the provision of optimal care for patients. Formal processes and structures are needed to foster true collaboration built on skilled communication and joint decision making. When true collaboration is achieved, the unique contributions of each member of the team are acknowledged and respected, leading to the provision of optimal care for patients. Formal processes and structures are needed to foster true collaboration built on skilled communication and joint decision making. 11. An Ethiopian man with AIDS has recently been admitted to the ICU with a case of pneumonia. The man is new to the U.S. and has no health insurance. He would likely be eligible for the states Medicaid coverage, but does not understand how to access this coverage. Which competency or competencies are most needed in this situation? Select all that apply. A) Clinical judgment B) Advocacy and moral agency C) Collaboration D) Systems thinking E) Response to diversity F) Clinical inquiry - Correct Answers: B) Advocacy and moral agency D) Systems thinking E) Response to diversity 12. A nurse decides to seek certification in critical care nursing. What is the most important benefit for the individual nurse in becoming certified in a specialty? A) It will result in a salary increase. B) It is required to work in critical care. C) It demonstrates the nurses personal expertise. D) It is mandated by employers. - Correct Answers: C) It demonstrates the nurses personal expertise. 13. The American Association of Critical-Care Nurses (AACN) sponsors certification in critical care nursing for several critical care subspecialties. What is the most important benefit of such certification for the profession of nursing? A) Provides positive publicity for nursing B) Validates nurses expert knowledge and practice C) Mandated by government regulations D) Demonstrates basic knowledge in the field B) Validates nurses expert knowledge and practice - Correct Answers: 14. A nurse has achieved certification in critical care nursing. What is the most important effect that this certification will have on the nurses practice? A) Recognition by peers B) Increase in salary and rank C) More flexibility in seeking employment D) Increased confidence in critical thinking D) Increased confidence in critical thinking - Correct Answers: 15. The nurse cites evidence-based practice as a rationale for a patient care decision. What is the best description of evidence-based practice? A) Decisions based on expert legal testimony B) Use of best available research data C) Evolution of nursing practice over time D) Individual optimization of patient outcomes B) Use of best available research data - Correct Answers: 16. The nurse caring for a critically ill patient implements several components of care. What component is an example of the use of evidence-based practice? A) Use of a protocol for admission of a patient to the unit B) Application of an insulin sliding scale method from research C) Checking the patients armband before giving a medication D) Limiting visits to immediate family only for 2 hours a day B) Application of an insulin sliding scale method from research - Correct Answers: 17. The nurse wishes to increase the use of evidence-based practice in the critical care unit where he works. What is a significant barrier to the implementation of evidence-based practice? A) Use of computerized records by the hospital B) Health Information Privacy and Portability Act (HIPPA) C) Lack of knowledge about literature searches D) Strong collaborative relationships in the work setting C) Lack of knowledge about literature searches - Correct Answers: Barriers to implementation include lack of knowledge of the research process, attitude toward implementing EBP, lack of resources and training, time constraints and mismanagement, lack of motivation, inadequate staffing, cost, and lack of teamwork and organizational support 18. The nurse has identified an increase in medication errors in the critical care unit over the past several months. What aspect of medication procedures should be evaluated first? A) Adherence to procedures by nursing staff B) Clarity of interdisciplinary communication C) Number of new employees on the unit D) Changes in administration procedures - Correct Answers: B) Clarity of interdisciplinary communication An interdisciplinary approach in which all health care workers are giving the same information consistently is ideal. A clear and unified communication process is important to minimize confusion and distress among patients, families, and the health care team. Critical care nurses should explore their understandings and beliefs about prognosis, goals, and the plan of care and share these understandings with other health care providers to develop a unified message before discussing these issues with the family 19. A critical care unit has decided to implement several measures designed to improve intradisciplinary and interdisciplinary collaboration. In addition to an expected improvement in patient outcomes, what is the most important effect that should result from these measures? A) Identification of incompetent practitioners B) Improvement in manners on the unit C) Increased staff retention D) Less discussion in front of patients and families - Correct Answers: C) Increased staff retention 20. A nurse wishes to practice using the Synergy Model developed by the American Association of Critical-Care Nurses (AACN). What nursing behavior best supports use of this model? A) Attending mandatory hospital-wide in-service programs B) Self-directed study of best practice for the patients she cares for C) Gathering demographic data on the patients admitted to the unit D) Participating in a research study as a data collector - Correct Answers: B) Self-directed study of best practice for the patients she cares for 21. As part of the Synergy Model, the nurse has identified a patient characteristic of resiliency. What patient behavior demonstrates resiliency? A) Dysfunctional grieving behaviors after receiving bad news B) Developing a list of questions for the physician C) Denial of any possible negative outcomes for a procedure D) Assigning blame to others for undesired outcomes of illness - Correct Answers: B) Developing a list of questions for the physician 22. A patient is admitted to the critical care unit after receiving a mechanical heart implantation. In making a nursing assignment, the charge nurse best demonstrates application of the Synergy Model by assigning which nurse to care for this patient? A) A newly hired new graduate nurse, for the experience B) A nurse with a patient in the next room, for proximity C) The most senior nurse on the unit, for political reasons D) The nurse with most experience with this device, for expertise - Correct Answers: D) The nurse with most experience with this device, for expertise 23. A Muslim patient has been admitted to the critical care unit with complications after childbirth. Based on the Synergy Model, which nurse would be the most inappropriate to assign to care for this patient? A) New graduate female nurse B) Most experienced female nurse C) New graduate male nurse D) Female nurse with postpartum experience - Correct Answers: C) New graduate male nurse 24. Todays critical care nursing environment is constantly changing. What nursing behavior best illustrates awareness of current events affecting critical care nursing? A) Participating in the hospitals efforts to recruit new nurses B) Volunteering to serve on a disaster response planning committee C) Adhering to content taught in basic nursing program D) Attending hospital-mandated in-services without other education - Correct Answers: B) Volunteering to serve on a disaster response planning committee