Saunders Comprehensive Review for the NCLEX-RN® Examination EIGHTH EDITION: CHAPTER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning ; With Practice Q&A.

Priority Concepts Leadership; Health Care Organizations I. Health Care Delivery Systems A. Managed care 1. Managed care is a broad term used to describe strategies used in the health care delivery system that reduc ...

Priority Concepts Leadership; Health Care Organizations I. Health Care Delivery Systems A. Managed care 1. Managed care is a broad term used to describe strategies used in the health care delivery system that reduce the costs of health care. 2. Client care is outcome driven and is managed by a case management process. 3. Managed care emphasizes the promotion of health, client education and responsible self-care, early identification of disease, and the use of health care resources. B. Case management 1. Case management is a health care delivery strategy that supports managed care; it uses an interprofessional health care delivery approach that provides comprehensive client care throughout the client’s illness, using available resources to promote high-quality and cost-effective care. 2. Case management includes assessment and development of a plan of care, coordination of all services, referral, and follow-up. 3. Critical pathways are used, and variation analysis is conducted. 4. The core functions of case management are assessment, treatment planning, linking, advocacy, and monitoring. 188 Case management involves consultation and collaboration with an interprofessional health care team. C. Case manager 1. A case manager is a professional nurse who assumes responsibility for coordinating the client’s care at admission and after discharge. 2. The case manager establishes a plan of care with the client, coordinates any interprofessional consultations and referrals, and facilitates discharge. 3. A case manager is knowledgeable in various types of health insurance, which allows them to assist clients in navigating health care options covered by insurance. D. Health Insurance 1. There are state and federal insurance plans. 2. An aim of the Affordable Care Act is to reduce the amount of uncompensated care the average U.S. family pays for by requiring everyone to have health insurance or pay a tax penalty. Its goals are to expand access to health insurance, reduce costs, and protect clients against arbitrary actions by insurance companies. 3. There are many insurance companies that provide state marketplace insurance; some include Aetna, Blue Cross Blue Shield, Cigna, Humana, Kaiser, United, and TriCare/Humana. 4. Types of insurance plans include health maintenance organizations (HMOs), preferred provider organizations (PPOs), exclusive provider organizations (EPOs), point-of-service (POS) plans, high-deductible health plans (HDHPs), and health savings accounts (HSAs); these offer varying options in terms of insurance coverage and out-of-pocket costs and premiums. 5. Medicare is a federal health insurance program for persons aged 65 or older, certain younger people with disabilities, and people with end-stage renal disease (ESRD) requiring dialysis or renal transplant. Certain premiums are attached to each part. a. Part A: covers hospital stays, skilled nursing facility stays, hospice care, and some home health care b. Part B: helps pay for some services not covered by Part A. Medicare usually covers 80% for approved services; Theories of Leadership and Management Charismatic: Based on personal beliefs and characteristics of influence Quantum: Based on the concepts of chaos theory; maintaining a balance between tension and order prevents an unstable environment and promotes creativity Effective Leader and Manager Behaviors and Qualities Behaviors Treats followers as unique individuals Functions of Management Planning: Determining objectives and identifying methods that lead to achievement of objectives Types of Power Reward: Ability to provide incentives Coercive: Ability to punish Referent: Based on attraction, loyalty, and respect Expert: Based on having an expert knowledge foundation and skill level Legitimate: Based on a position in society Personal: Derived from a high degree of self-confidence Informational: When one person provides explanations why another should behave in a certain way Reasons for Resisting Change Conformity One goes along with others to avoid conflict. Dissimilar Beliefs and Values Differences can impede positive change. 214 Habit Routine, set behaviors are often hard to change. Secondary Gains Benefits or payoff are present, so there is no incentive to change. Threats to Satisfying Basic Needs Change may be perceived as a threat to self-esteem, security, or survival. Fear One fears failure or has fear of the unknown Process for Medication Reconciliation 1. Obtain a list of current medications from the client. Discharge Teaching ▪ How to administer prescribed medications ▪ Side and adverse effects of medications that need to be reported to the primary health care provider (PHCP) Principles and Guidelines of Delegating ▪ Delegate the right task to the right delegatee. Be familiar with the experience of the delegatees, their scopes of practice, their job descriptions, agency policy and procedures, and the state nurse practice act. Guidelines for Prioritizing ▪ The nurse and the client mutually rank the client’s needs in order of importance based on the client’s preferences and expectations, safety, and physical and psychological needs; what the client sees as his or her priority needs may be different from what the nurse sees as the priority needs. Types of Disasters 217 Human-Made Disasters Dam failures resulting in flooding Hazardous substance accidents such as pollution, chemical spills, or toxic gas leaks Natural Disasters Avalanches Blizzards Communicable disease epidemics Federal Emergency Management Agency (FEMA) Levels of Disaster Level I Disaster Emergency Plans and Supplies ▪ Plan a meeting place for family members. ▪ Identify where to go if an evacuation is necessary. Emergency Department Triage Emergent (Red): Priority 1 (Highest) This classification is assigned to clients who have life-threatening injuries and need immediate attention and continuous evaluation but have a high probability for survival when stabilized. Urgent (Yellow): Priority 2 This classification is assigned to clients who require treatment and whose injuries have complications that are not life-threatening, provided that they are treated within 30 minutes to 2 hours; these clients require continuous evaluation every 30 to 60 minutes thereafter. Practice Questions 29. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1. A postoperative client preparing for discharge with a new medication 2. A client requiring daily dressing changes of a recent surgical incision 3. A client scheduled for a chest x-ray after insertion of a nasogastric tube 4. A client with asthma who requested a breathing treatment during the previous shift 220 30. The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? 1. A client complaining of muscle aches, a headache, and history of seizures 2. A client who twisted her ankle when rollerblading and is requesting medication for pain 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce 31. A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1. Each staff member is assigned a specific task for a group of clients. 2. A staff member is assigned to determine the client’s needs at home and begin discharge planning. 3. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an assistive personnel (AP). 4. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients. 32. The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1. A client who is ambulatory demonstrating steady gait 2. A postoperative client who has just received an opioid pain medication 3. A client scheduled for physical therapy for the first crutchwalking session 4. A client with a white blood cell count of 14,000 mm3 (14 × 109/L) and a temperature of 38.4° C 33. The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client’s room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1. Finish the bed bath and then administer the pain medication to the other client. 2. Ask the AP to find out when the last pain medication was given to the client. 3. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. 34. The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) 221 is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP? 1. Ignore the resistance. 2. Exert coercion on the AP. 3. Provide a positive reward system for the AP. 4. Confront the AP to encourage verbalization of feelings regarding the change. 35. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? 1. A client requiring a colostomy irrigation 2. A client receiving continuous tube feedings 3. A client who requires urine specimen collections 4. A client with difficulty swallowing food and fluids 36. The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. 1. Open doors to client rooms. 2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed. 5. Relocate ambulatory clients from the hallways back into their rooms. 37. The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? 1. A client who requires a bed bath 2. An older client requiring frequent ambulation 3. A client who requires hourly vital sign measurements 4. A client requiring abdominal wound irrigations and dressing changes every 3 hours 38. The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. 1. The acuity level of the clients 2. Specific requests from the staff 3. The clustering of the rooms on the unit 4. The number of anticipated client discharges 5. Client needs and workers’ needs and abilities 222