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Leadership Review

Skills of the Nurse Manager

Communication Organization Delegation Supervision Critical thinking

Characteristics of the Nurse Manager

Authority Accountability Responsibility Leadership Commitment to Quality

* Questions often included examples of nursing interventions which DO or DO NOT demonstrate these skills and characteristics.

Classic Leadership Styles

Democratic: Assertive Authoritarian: Aggressive Laissez-Faire: passive

Communication Skills (Being Assertive)

Clearly defined goals and expectations Verbal/Non-verbal messages congruent Critical to the directing phase of management Assertive communication starts with I need rather than you must.


The nurse manager can provide an environment that will promote motivation:

Positive feedback Respect Seeking input

* Motivation comes from within an individual.

Organizational Skills

People Time Supplies/resources


State Nurses act gives authority to RNs to delegate.

Process by which responsibility and authority are transferred to another individual

Responsibility: the obligation to complete a task Authority: the right to act or command the action of others Accountability: the ability and willingness to assume responsibility for actions and related consequences

The nurse transfers responsibility and authority to others.but retains Accountability. Use the 5 rights to determine delegation

5 Rights of Delegation

Right Right Right Right Right

task circumstance person direction/communication supervision

Supervision Skills


Clear, concise directions Expected outcome Time Frame Limitations Verification of assignment


Check in frequently Communication lines Achievement of outcomes


Communication evaluation findings to the LPN or UAP and other appropriate personnel Determine if teaching/guidance is needed

Critical Thinking Skills (Use the Nursing Process)

Assessment: What are the needs/issues? Analysis: What is the highest priority? Planning:

What outcomes/goals must be accomplished? What are the available resources? (staff, team members, time, equipment, space etc.)


Communicating expectations Is documentation complete?


Where the desired outcomes achieved? Was safe, effective care provided?

Any activity requiring nursing judgment CANNOT be delegated Delegating to the right person requires that the nurse be aware of the qualifications of the delegate. (training, skills, education and demonstrated/documented competence)

RN is Accountable for:
Direction, Evaluation and Follow-up for LPNs Graduate nurses Inexperienced nurses Student nurses UAPs


Assessed first Significant change in condition Most critically ill Safety and infection control are high priority when determining room assignments

Implements basic nursing process after the RN has evaluated client and determined plan of care


Inspect Document Administer what medications? Obtain Skills


Assist with ADLs Document intake/output Telling Assisting Ambulating Bed making

Lewins Change Theory

Unfreezing: Initiation of change Moving: Motivation/moving toward the change Refreezing: Implementation of a change

Skills of Change Agents

Problem-solving Decision making Interpersonal

* Change causes anxiety. The change agent must also show respect, value opinions, and build trust.

Collaborative Healthcare Teams


2. 3.

Shared goals, commitment and accountability Open and clear communication Respect for the expertise of all team members

Critical Pathways

Interdisciplinary plan of care For diagnoses and care that can be standardized A guide to track client progress Does NOT replace individualized care Positive or negative variance

Case Management

Coordination of care provided by an interdisciplinary team Manages resources effectively Use critical pathways to organize care

Quality Assurance

CQI: Continuous Quality Improvement TQM: Total Quality Management

both are organized approaches to the improvement of: Outcome achievements Quality of care provided

Legal Aspects of Nursing

Nurse Practice Act: Governs the nurses responsibility in making assignments.

Educational preparation Experience Knowledge

Negligence and Malpractice (Unintentional Tort)

Negligence: Performing an act that a reasonable and responsible person would not do. (Would a reasonable and professional nurse under the same circumstance act in the same manner?) Malpractice: professional misconduct, or unreasonable lack of skill in carrying out professional duties.

4 Elements are necessary to prove Negligence or Malpractice

1. Duty: Obligation to use due care. (What a reasonable and responsible nurse would do). Failure to care for or protect others against reasonable risks.

The nurse must anticipate risks




Breach of Duty: Failure to perform according to the standards of practice Injury/Damages: causes actual damage or injury to the client (physical or mental) Causation: A connection exists between the conduct and the injury

Hospital policies: provide a guide for nursing actions. They are NOT LAW, but courts generally rule against nurses who do not follow hospital guidelines. Incident reports: alert administration to possible liability claims and the need for further investigation. They DO NOT protect against legal action.

Assault: mental or physical threat, forcing without touching. (forcing a client to take medication..sneaking medication into food or drink. Forcing a client to take treatment. Battery: Touching with or without the intent to harm. (hitting or touching a client). If a competent adult refuses a treatment, and is forced, a battery has occurred.

Invasion of Privacy

False Imprisonment: confinement without authorization

Exposure of a Person: Exposure or discussion of a clients case. After death, the client has a right to be unobserved and protected.

Invasion of Privacy

Defamation: Divulgence of privileged information or communication (charts, conversations, or observations)


Willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property.

Presenting false credentials (nursing school, licensure) Describing no truths in treatments

Telling a client that the procedure will hurt, when indeed there is pain involved!

NOT reporting suspected child abuse is considered a crime

It is he nurses legal responsibility to report suspected child abuse.

Assisting or giving aid to a person in the commission of a crime makes that person equally as guilty of the crime.

Omitting an act where there is legal duty to perform is a crime.

Refusing to assist in the birth of a child if such refusal results in an injury to the child.

Nursing Practice Act and the Law

Civil Procedures: Methods used to protect the rights of psychiatric clients.

Voluntary Admission: client admits him/herself to an institution for treatment and retains civil rights.

Nursing Practice Act and the Law

Involuntary Admission: Someone other than the client applies for admission into an institution.

Emergency Admission: Any adult may apply for emergency detention of another. However, medical or judicial approval is needed to keep them more than 24 hours.

Legal and Civil Right of Patients

Right to: 1. Wear their own clothes, keep personal items, and a reasonable amount of cash 2. Have individual storage space for their own use 3. See visitors daily

Legal and Civil Right of Patients

Right to: 4. Have reasonable access to phone and opportunity to have private conversations by telephone 5. Right to receive and send (unopened) mail 6. Right to refuse shock treatments or lobotomy


Competency Hearing: Legal hearing that is held to determine a persons capability to make responsible decisions about self, dependents, or property.


Persons declared incompetent have the legal rights status of a minor, they cannot:

Vote Make contracts or wills Drive a car Sue or be sued Hold a professional license

A legal guardian is appointed by the court

Insanity: a legal term meaning the accused is not criminally responsible for the unlawful act committed because of mental illness




Inability to stand trial: not mentally capable of standing trial. He/She: Cannot understand the charge against him/her Must be sent to a psychiatric unit until legally determined competent for a trial Once the individual is mentally fit, he/she must stand trial and serve any sentence, is convicted

Patient Identification

Use at least 2 patient identifiers whenever taking blood samples, admin. meds, or admin. blood products. Patient room number MAY NOT be used as a form of identification.

Surgical Permit

Consent to operate, must be obtained prior to any surgical procedure, however minor it might be.

1. 2. 3.

Legally, the surgical permit must be: Written Obtained voluntarily Explained to the client (informed consent) must be obtained

Surgical Permit
Surgery Permits: 1. Must be witnessed by an authorized person such as a healthcare provider or a nurse.

2. Protect the client against unnecessary surgery and protect the healthcare provider/surgeon, hospital, and hospital staff against possible claims of unauthorized operations

Surgical Permit
3. Adults and emancipated minors may sign their own operative permits if they are mentally competent. 4. Permission to operate on a minor child or an incompetent adult or unconscious adult must be obtained from a responsible family member or legal guardian.

Surgical Permit

If HESI asks who should explain the procedure:

The ans: The Provider The nurses responsibility is to make sure it is signed and on the chart before the procedure, it is NOT the nurses responsibility to explain the procedure

The law does not require written consent to perform medical procedures. Client must be fully informed Can be treated with verbal consent If informed consent can not be obtained, emergency laws can be applied (if treatment means to save life or limb) Ex: unconscious patient arrives in ED

Verbal Consent

Describes in detail how and why verbal consent was obtained Placed in the clients record Witnessed and signed by 2 persons

Written or Verbal Consent

Alert, coherent, competent adults Parent or legal guardian Person having right to make decisions for the client

Consent of Minors

Minors 14 years of age and older must agree to treatment along with their parent of guardian Emancipated minors can consent for treatment themselves

Good Samaritan Act

Protects health practitioners against malpractice claims for care provided in emergency situations The nurse is required to perform in a reasonable and prudent manner


Phone orders: read-back Cannot alter orders in any way

What if ???????

He/she (RN) believes order is WRONG????

Inform the healthcare provider/physician Record the physician was informed Inform nursing supervisor Refuse to carry out the prescription

What if ????????

He/She (RN) believes the order is of

poor judgment?

Record provider was notified and questioned Carry out the order (nursing judgment cannot be substituted for medical judgment)

What If???????

The nurse is asked to perform a task of which they have not been educationally prepared for or that is out of their scope of practice?

Inform the provider that he/she does not have education or experience Refuse to carry out the prescription


Restraints of any kind can be considered false imprisonment without an order Freedom from restraints is a basic human right and is protected by law


Can only be applied

In an emergency For a limited time For the limited purpose of protecting the client from injury

Nursing Responsibilities (Restraints)

Nurse must notify the provider/physician immediately that the client has been restrained Document the facts regarding the rationale for restraining the client Use restraints after exhausting all reasonable alternatives


Apply restraints properly Check frequently to ensure no damage or injury to the client Remove restraints as soon as possible


Ensures patient privacy/confidentiality

Which client(s) would be appropriate to assign a newly graduated RN, who has recently completed orientation? (Choose all that apply)

An anxious chronic pain client who frequently uses the call button A second day post-op who needs pain medication prior to dressing changes A client with HIV who reports a HA and abdominal and pleuritic chest pain A client being discharged with a surgically implanted catheter

You are caring for a patient with esophageal cancer. Which of the following can be delegated to the nursing assistant?
b. c. d.

Assist the patient with oral hygiene Observe the patients response to feedings Facilitate expression of grief or anxiety Initiate daily weights

In caring for a patient with oral cancer, which task would be appropriate to delegate to the LPN/LVN? (Select all that apply)


c. d.

Assist the patient to brush and floss Explain when flossing and brushing are contraindicated Give antacids and sucralfate suspension as ordered Recommend saliva substitutes

You are the charge nurse. Which client is most appropriate to assign to the step-down unit nurse pulled to the intensive care unit?
a. b. c.


A 68-year-old client with acute respiratory failure and respiratory acidosis A 72-year-old client with COPD and normal ABGs who is ventilator dependent A 56-year-old new admit with DKA on an insulin drip A 39-year-old client on a ventilator with narcotic overdose and respiratory alkalosis

Which of the following cancer patients could potentially be placed together as roommates?
a. b.



A patient with a neutrophil count of 1000/mm3 A patient who underwent debulking of a tumor to relieve pressure A patient receiving high-dose chemotherapy after a bone marrow harvest A patient who is post-op laminectomy for spinal compression

In caring for a patient with neutropenia, what tasks can be delegated to the CNA? (Choose all that apply)
a. b. c. d. e. f.

Take VS every 4 hours Report temp > 100.4 Assess for sore throat or cough Gather supplies to prepare the room for protective isolation Report superinfections, such as candidiasis Practice good handwashing technique.

The MD has written the following orders. The clients morning assessment reveals bounding peripheral pulses, a 2 lb weight gain, pitting edema, and moist crackles bilat. What would you do first?
a. b. c. d.

Initiate daily weights Maintain accurate intake and output Restrict fluids to 1000-1500 per day Adminster Furosemide 40mg

You are the charge nurse for the coronary care step-down unit. Which patient is best to assign to an RN who has floated for the day from the general medical-surgical floor?
a. b. c. d.

Patient requiring discharge teaching about a coronary artery stent. Patient receiving IV furosemide to treat acute left ventricle failure Patient just transferred from the radiology dept. after a coronary angioplasty Patient just admitted with unstable angina and who has orders for a heparin infusion and aspirin.

a. b. c.


You are ambulating a cardiac surgery patient who has telemetry cardiac monitoring when another staff member tells you that the patient has developed superventricular tachycardia with a rate of 146 bpm. In which order will you take these actions? Call the patients physician Have the patient sit down Check the patients BP Administer 02 via nasal cannula

During the initial post-operative assessment of a patient who has just been transferred to the PACU after repair of a AAA, you obtain all of the following data. Which has the most immediate implications for the patients care?
a. b.


The arterial line indicates a blood pressure of 190/112 The monitor shows sinus rhythm with frequent PACs The patient does not respond to verbal stimuli The patients urine output is 100 mL of amber urine

A new RN is preparing to administer PRBCs to a client whose anemia was caused by blood loss after surgery. Which action by the new RN requires that you, as the charge nurse, intervene immediately?
a. b. c. d.

The new RN waits 20 minutes after obtaining the PRBCs before starting the infusion The new RN starts an IV access for the transfusion using a 22gauge catheter The new RN primes the infusion set with Lactated Ringers The new RN tells the client that the PRBCs can cause a serious reaction.



c. d.

A group of clients is assigned to an RN-LPN/LVN team. The LPN/LVN is most likely to be assigned to provide client care and administer meds to which of these clients? A client in renal failure who needs epoetin (Procrit) A client who needs Vancomycin with peaks and troughs A client who needs a last dose of chemotherapy A client who needs a blood transfusion

A client is admitted to the ER after a MVA. He does not remember the accident. He is awake and oriented to person only. He is confused regarding time, month and the city he lives in. Pupils are equal and reactive to direct light. He c/o of a severe HA and is becoming restless. What is your priority at this time?

Continue to stimulate the patient to keep him oriented

Restrain him to keep him safe from injury Perform neuro checks every 15 minutes Administer Demerol for pain and restlessness.




Which assignment would be appropriate for a L&D nurse who will be working for one shift on a Medical-Surgical floor?
b. c. d.


3-year-old with croup 30-year-old with malignant hypertension 40-year-old with unstable angina 50-year-old with congestive heart failure

After receiving shift report, which client would you assess first?

A 20-year-old with a possible acute myelogenous leukemia who has arrived on the medical unit. A 38-year-old with aplastic anemia who needs teaching about decreasing risks for infection. A 40-year-old with lymphedema who requests help putting on compression stockings before getting OOB.




A 60-year-old with non-Hodgkins lymphoma who is refusing the ordered chemotherapy.


c. d.

You are preparing to admit a patient with a seizure disorder. Which of the following actions would you delegate to the LPN/LVN? Document the admission assessment Set up 02 and suction equipment Place a padded tongue blade at the bedside Check the room to make sure it is clean

a. b. c.


After a patient has a seizure, what action can you delegate to the nursing assistant? Document the seizure Initiate neuro checks Restrain the patient Take the patients VS

A patient has been placed in fixed skeletal traction with a halo fixation device. When caring for this patient the nurse will delegate which of the following to the LPN/LVN? (Choose all that apply)

b. c.


Check the patients skin for pressure from the device Assess the patient neurological status Observe the halo insertion sites for signs of infection Clean the halo insertion sites with alcohol

After receiving the am. shift report, which of these clients will you see first?

A 23-year-old with a migraine who is complaining of severe nausea associated with retching


A 45-year-old who is scheduled for a craniotomy in 30 min. and needs preoperative teaching
A 59-year-old with Parkinsons who needs a swallowing assessment before breakfast A 63-year-old with multiple sclerosis who has an oral temp of 101.8 and flank pain