CNML practice questions, sized like the five domains

Under the CMS Hospital Readmissions Reduction Program, what is the maximum Medicare payment reduction a hospital can face?

1. 1 percent of base operating payments.
   1 percent was the cap in the program's first year (FY2013); the cap rose to 3 percent from FY2015.
2. 25 percent of base operating payments.
   25 percent is far beyond any CMS quality-program adjustment and has no basis in the program.
3. 3 percent of base operating payments.
   Under the CMS Hospital Readmissions Reduction Program, the maximum payment reduction is 3 percent of a hospital's base operating DRG payments.
4. 10 percent of base operating payments.
   10 percent overstates the penalty; it confuses the readmissions program with much larger revenue risks.

Six months after the unit adopted a sepsis guideline, the nurse manager wants to know whether it has been integrated into practice and is improving care. Which evaluation approach is MOST appropriate?

1. Track bundle adherence as a process measure alongside sepsis mortality
   Pairing a process measure (bundle adherence) with an outcome measure (mortality) shows both whether the guideline is used and whether care is improving.
2. Audit bundle adherence alone as the measure of how well the guideline is used
   Adherence alone shows use but not whether patients are better off, so it cannot answer whether care improved.
3. Track sepsis mortality alone as the single measure of the guideline's success
   Mortality alone cannot show whether the guideline is being used, so a change in outcome cannot be linked to it.
4. Survey clinicians on how useful they find the new sepsis guideline
   Clinician opinion measures acceptability, not integration into practice or patient outcomes.

A pressure injury prevention program was launched on the unit six months ago. Which finding MOST validly demonstrates that the program is working?

1. A rise in documented skin assessments completed within 24 hours of admission
   More timely skin assessments show the process is being done, but a process gain alone does not prove fewer injuries.
2. Fewer pressure injuries this quarter than in the single previous quarter
   Comparing one quarter with a single previous quarter cannot separate a real effect from normal variation.
3. An increase in the number of pressure injuries reported through incident reports
   More reported pressure injuries may reflect better reporting or worse outcomes; it does not show the program is working.
4. A sustained decline in HAPI rates on a run chart while the risk mix stays stable
   A sustained decline on a run chart while the risk mix stays stable shows a real change in the outcome rather than chance variation or a healthier population.

A staffing agency representative asks the nurse manager to sign a revised rate agreement today so that agency nurses can start next week. Hospital policy does not give the manager authority to sign contracts. The nurse manager should:

1. sign it after adding a handwritten note that limits the length of the term.
   A handwritten limitation does not cure the lack of authority and may create a confusing, unenforceable contract.
2. route the agreement to the office authorized to review and sign contracts.
   Without signature authority, the manager routes the agreement to the office authorized to review and sign contracts, which protects the hospital from binding terms nobody vetted.
3. sign the agreement because the unit urgently needs the extra staff.
   Urgent need does not create signature authority; signing anyway can bind the hospital to unreviewed terms.
4. let the agency nurses start before any written agreement is signed.
   Letting agency nurses work with no signed agreement leaves rates, liability and credentialing undefined.

Nurses insist that 'good nurses never leave the floor for breaks,' and many skip meals even when coverage is available. The nurse manager recognizes that this deeply held belief shapes behavior. In Senge's learning organization, the belief is an example of:

1. personal mastery.
   Personal mastery is an individual's commitment to lifelong learning and growth.
2. a shared vision.
   A shared vision is a picture of the future the group commits to, not an unexamined assumption about breaks.
3. team learning.
   Team learning is a group's ability to think and learn together through dialogue.
4. a mental model.
   In Senge's learning organization, a deeply held belief that shapes how people act is a mental model.

An interview panel rejects a qualified RN candidate because 'she just doesn't feel like one of us,' without citing any job-related evidence. To reduce bias in future decisions, the nurse manager should direct the panel to:

1. rely on each panel member's instinct about how well she fits in.
   Relying on instinct about fit is how affinity bias operates, so it would repeat the problem.
2. judge candidates on job criteria and what they add to the team.
   Judging candidates on job-related criteria and on what they would add to the team counters affinity bias in hiring.
3. give the final choice to the most senior panelist.
   Handing the choice to the most senior panelist concentrates one person's bias instead of reducing it.
4. hire only candidates who match the current team.
   Hiring only candidates who match the current team institutionalizes bias and narrows the team's perspectives.

After one dramatic fall that injured a patient last week, the nurse manager wants to shift all staff education to falls, although unit data show pressure injuries are a far more frequent harm. This reasoning reflects:

1. anchoring bias.
   Anchoring bias is relying too heavily on the first information received, not on a memorable recent event.
2. confirmation bias.
   Confirmation bias is seeking evidence that supports an existing belief; the manager is reacting to a single dramatic event.
3. availability bias.
   Overweighting one vivid, recent fall while ignoring data on more frequent harm is availability bias.
4. the halo effect.
   The halo effect is letting one positive impression color overall judgment of a person.

Nurses complain that respiratory therapists arrive late for scheduled treatments, and therapists say nurses page them for nonurgent tasks. The nurse manager meets with the respiratory therapy manager. Which approach will MOST likely resolve the conflict?

1. Jointly define which requests are urgent and how each will be communicated.
   Having the two managers jointly define what counts as urgent and how requests will be communicated addresses both groups' complaints and builds a shared process.
2. Ask each department to document the other's failures for one month.
   Documenting each other's failures escalates blame and builds evidence for a fight rather than a solution.
3. Have nurses give the treatments themselves when therapists are late.
   Having nurses give respiratory treatments works around the conflict and may exceed role expectations without fixing the request process.
4. Let the staff work it out, since the conflict is among the frontline staff members.
   Leaving frontline staff to sort it out ignores the managers' responsibility for the process that causes the conflict.

The unit will change from 8-hour to 12-hour shifts in three months. Some staff support the change and others strongly oppose it. To communicate the change, the nurse manager should:

1. announce it one week before the change to limit the time for resistance.
   Announcing it a week ahead to cut off resistance breeds distrust and leaves staff no time to plan their lives.
2. share it first with supporters so that they can persuade the other staff.
   Telling supporters first creates an in-group and lets opponents hear it secondhand, which deepens division.
3. email the new schedule template and ask staff to adjust their own plans.
   An emailed template with no rationale or discussion treats a major change as a clerical update.
4. announce it early with the rationale and hold sessions to hear concerns.
   Announcing the change early with its rationale and holding sessions to hear concerns gives staff time to adjust and a voice in how it is implemented.

Nurses on a medical unit created a private social media group to arrange shift swaps. A nurse posted a complaint in the group about a patient's family, naming the patient and the room number. A staff member shows the post to the nurse manager. The nurse manager should:

1. ask the nurse to delete the patient's name but leave the rest of the post.
   Deleting only the name still leaves the room number and details that can identify the patient.
2. take no action, because the group is private and used outside work hours.
   A private group and off-duty posting do not remove the duty to protect patient information.
3. have the post removed and report it under the hospital's privacy policy.
   Naming a patient and room number in a social media post is a privacy breach even in a private group, so the post must come down and be reported under the privacy policy.
4. ban all staff discussion of work topics on any social media platform.
   A blanket ban on discussing work topics online is overbroad; the problem is the disclosure, not all discussion.

A unit has had four managers in two years, and staff are skeptical of the new nurse manager's promises. Which behavior will MOST effectively build trust?

1. Following through on commitments and reporting back on progress.
   On a unit that has heard many promises, consistently following through on commitments and reporting back on progress is what rebuilds trust.
2. Promising that she will stay with the unit for at least five years.
   Promising to stay five years is a commitment she cannot guarantee, and staff have no reason to believe it.
3. Describing her leadership philosophy at the first staff meeting.
   Describing a leadership philosophy is more words, which this skeptical staff has heard from previous managers.
4. Making several quick changes to show that things will be different.
   Quick changes made to show difference risk repeating the instability staff already distrust.

Patients on the unit whose preferred language is Spanish receive discharge instructions printed in English, which an interpreter reads aloud. Several patients return confused about their medications. Which change BEST gives staff the tools for linguistically appropriate care?

1. Print the instructions through a free online translator without review
   Unreviewed machine translation can introduce dangerous medication errors.
2. Give translated written instructions along with interpreted teaching
   Translated written instructions combined with interpreted teaching give patients accurate information they can understand and refer back to at home.
3. Add more detail to the English instructions so that they are complete
   More detail in English does not help patients who cannot read English.
4. Ask a bilingual relative to rewrite the English instructions at home
   Relying on a relative to translate risks errors and breaches the patient's right to qualified language services.

The chief nursing officer asks the nurse manager to reduce next year's labor budget by 10%, about 4 FTEs. The unit has 5 vacant budgeted positions and a stable census. What should the nurse manager do FIRST?

1. Review vacant positions and workload data before considering layoffs.
   Reviewing vacant budgeted positions and workload data first may meet much of the target without layoffs and shows where reductions are safest.
2. Eliminate all of the unlicensed assistive personnel positions on the unit.
   Eliminating all assistive staff positions shifts their work to RNs and is a drastic step taken without analysis.
3. Tell staff now that layoffs are coming.
   Announcing layoffs before any analysis creates panic and may drive away staff the unit needs to keep.
4. Cut an equal number of hours from every shift on the unit.
   Equal cuts on every shift ignore differences in workload and acuity and may leave the busiest shifts unsafe.

Capital funds this year will cover only one of the unit's requests. Which request should the nurse manager rank FIRST?

1. Adding workstations on wheels to reduce waiting at shift change
   Workstations on wheels would improve efficiency at shift change, yet efficiency gains come after a failed safety device.
2. Upgrading the patient television system to improve satisfaction scores
   A television upgrade may help satisfaction scores, but comfort never outranks equipment needed to save lives.
3. Replacing defibrillators that failed biomedical safety inspection
   Defibrillators that failed a safety inspection are a direct patient-safety and regulatory risk, so replacing them ranks ahead of every comfort or efficiency request.
4. Renovating the staff lounge to support recruitment and retention
   A lounge renovation may help retention, but it does not compete with a known safety hazard for scarce capital.

A new chief nursing officer has joined the hospital, and the nurse manager wants to build an effective working relationship. Which approach will BEST accomplish this?

1. Avoid raising any problems until the relationship is well established.
   Holding back all problems withholds information the CNO needs and erodes trust when the problems surface later.
2. Wait for the CNO to schedule a meeting before initiating any contact.
   Waiting passively for the CNO to make contact misses the chance to build the relationship early.
3. Present a list of the unit's unmet needs at the first meeting.
   Opening with a list of unmet needs frames the relationship around demands before any shared understanding exists.
4. Learn the CNO's priorities and show how the unit's work supports them.
   Learning the new CNO's priorities and showing how the unit's work supports them builds a relationship based on shared goals, the core of managing up.

Two medical units are being merged, and staff from the smaller unit say they are grieving the loss of their team and routines. The nurse manager's BEST initial action is to:

1. assign staff from both units to mixed teams so bonds form quickly.
   Forcing mixed teams right away pushes the new beginning before staff have dealt with the ending.
2. hold listening sessions to acknowledge what staff feel they are losing.
   Bridges' transition model starts with endings: acknowledging what staff feel they are losing helps them let go before they can engage with the merged unit.
3. set firm expectations that staff must adapt to the new unit's routines.
   Firm expectations to adapt ignore the transition people are going through and harden resistance.
4. remind staff that the merger will improve efficiency and career options.
   Reminding staff of the merger's benefits skips the grief they are expressing and can feel dismissive.

Staff nurses on the unit say they cannot make good decisions about supply use because they never see cost or budget data. According to Kanter's theory of structural empowerment, the nurse manager should increase staff access to:

1. opportunity for career growth.
   Opportunity for growth is another empowerment structure, but it does not answer the nurses' complaint about missing cost data.
2. support through supervisor feedback.
   Supervisor feedback falls under access to support, which is not the gap the nurses describe.
3. formal power through job titles.
   Formal power through job titles is not the structure that gives staff the financial data they lack.
4. information about unit finances.
   In Kanter's structural empowerment theory, access to information, such as cost and budget data, gives staff what they need to make good decisions.

The unit practice council has approved a staff nurse's redesign of patient whiteboards intended to improve patient understanding of the daily plan. The nurse manager should support implementation by:

1. piloting the design in one pod with defined measures before spreading it.
   Piloting the redesign in one pod with defined measures tests whether it improves patient understanding before spreading it, a sound way to support staff innovation.
2. waiting until the organization adopts a hospital-wide whiteboard standard.
   Waiting for a hospital-wide standard stalls an approved unit improvement indefinitely.
3. installing the new design in every room at once to show strong support.
   Installing it everywhere at once spreads an untested change and makes problems harder to fix.
4. asking the nurse who proposed it to implement the change on her own.
   Leaving the nurse to implement it alone withholds the support and resources a unit-level change needs.

Six months into a unit initiative to reduce central line infections, rates have dropped and the director suggests ending the project team. Several related practices, such as dressing audits, are still new. Using Kotter's model, the nurse manager should:

1. restart with a new sense of urgency across the unit.
   Restarting with urgency goes back to step one, although the change is already under way and working.
2. celebrate the success and then return the unit to routine work.
   Celebrating and returning to routine work removes attention before the new practices are part of the culture.
3. keep the team going and use the gains to extend the changes.
   Kotter warns against declaring victory too soon: the manager should keep the team going and use early gains to extend and anchor the new practices.
4. disband the team, because the target has now been met.
   Disbanding the team as soon as the target is met risks losing practices that are not yet embedded, the premature victory Kotter cautions against.

A competent adult patient with pneumonia insists on leaving before discharge. A nurse asks the nurse manager whether security can keep the patient on the unit until the physician arrives in two hours. The nurse manager should direct staff to:

1. keep the patient's clothing and belongings until discharge is done.
   Withholding clothing and belongings to prevent departure is another form of unlawful detention.
2. explain the risks, notify the provider, and not detain the patient.
   A competent adult may leave against advice, so staff explain the risks, notify the provider and let the patient go rather than detaining the patient.
3. have security block the exit until the physician sees the patient.
   Blocking the exit is false imprisonment of a competent patient.
4. apply soft restraints, since leaving early endangers the patient.
   Restraining a competent patient to prevent leaving is unlawful and violates the patient's autonomy.

At 1900, a charge nurse submits an assignment-despite-objection form stating that the night assignment is unsafe after two new high-acuity admissions. The nurse manager should:

1. review the acuity data and adjust staffing or escalate the gap.
   An assignment-despite-objection form signals a possible unsafe assignment now, so the manager reviews acuity and adjusts staffing or escalates the gap.
2. tell staff to reserve such forms for situations in which harm occurred.
   These forms exist to flag risk before harm occurs, so saving them for harm defeats their purpose.
3. remind the charge nurse that filing such forms may affect evaluations.
   Hinting that filing may affect evaluations is retaliation that discourages nurses from reporting safety concerns.
4. file the form for later review, since the shift is already staffed.
   Filing the form for later review ignores a concern about the coming night shift.

A nurse tells the nurse manager, well in advance, of a moral objection to participating in a procedure scheduled on the unit next week. The nurse manager should:

1. require the nurse to participate, since objections are not permitted.
   Nurses may decline to take part in some procedures on moral grounds when they give notice; flatly forbidding objections is incorrect.
2. report the nurse to human resources for refusing a work assignment today.
   Reporting the nurse to HR treats a properly raised objection as insubordination.
3. allow the nurse to walk away from the patient once the procedure begins.
   Walking away once the procedure has begun would abandon the patient; objections must be raised in advance.
4. arrange an alternate assignment so that patient care is not affected.
   With advance notice of a moral objection, the manager arranges an alternate assignment so patient care is not compromised and the nurse's conscience is respected.

The window for the hospital's unannounced Joint Commission survey has opened. The nurse manager wants staff ready to answer surveyors' questions during tracers. Which approach is MOST effective?

1. An instruction to refer every surveyor question to the charge nurse.
   Referring every question to the charge nurse suggests staff do not know their own processes.
2. A list of standards posted in the break room for staff self-study.
   Posting standards for self-study is passive and does not prepare staff to explain their own practice.
3. Brief huddles in which staff practice explaining their daily work.
   Tracers ask staff to explain how they actually do their work, so huddles where staff practice describing daily care prepare them best.
4. A script of approved answers for staff to memorize before the survey.
   Memorized scripts sound rehearsed and fall apart when surveyors ask follow-up questions about real practice.

The nurse manager is asking staff to adopt a new fall-risk huddle. Which opening at the staff meeting is MOST likely to engage staff both emotionally and intellectually?

1. A brief story of a recent fall on the unit and then the unit's fall data.
   A short story of a real fall on the unit engages emotions, and following it with unit data engages reasoning, which is how influence works best.
2. A summary of the hospital's policy on fall-risk assessment and prevention.
   A policy summary informs without engaging staff emotionally or explaining why the huddle matters to them.
3. A statement that the new huddle will be mandatory beginning next week.
   Announcing a mandate relies on position power and engages neither emotion nor reasoning.
4. A reminder that fall rates are reported to accreditation and payer agencies.
   Pointing to external reporting appeals to compliance pressure rather than to patient impact.

An engagement survey shows that nurses on the unit feel their achievements go unrecognized and see few chances for growth. According to Herzberg's theory, which action BEST addresses these motivators?

1. increasing the evening and night shift differentials for all nurses
   Shift differentials are pay, a hygiene factor that may reduce dissatisfaction but does not motivate.
2. improving parking access for staff who work on the night shift
   Better parking is a working condition, so it may prevent complaints but does not address recognition or growth.
3. praising specific accomplishments and offering roles such as precepting
   Herzberg's motivators include recognition, responsibility and growth, so praising specific accomplishments and offering roles such as precepting target what staff say is missing.
4. renovating the staff lounge and adding new break-room equipment
   Lounge renovations improve working conditions, a hygiene factor rather than a motivator.

Participative decision making is MOST appropriate when:

1. a cardiac arrest requires immediate direction of the team.
   A cardiac arrest calls for immediate, directive leadership, not group deliberation.
2. a regulation leaves no discretion in how a rule is applied.
   When a regulation leaves no discretion, there is nothing for the group to decide.
3. the decision involves a confidential personnel matter about one nurse.
   A confidential personnel matter about one nurse cannot be opened to group discussion.
4. staff will carry out the decision and time allows their input.
   Participative decision making fits when staff will carry out the decision and there is time for input, because involvement improves both quality and commitment.

A patient with injuries in various stages of healing is always accompanied by a partner who answers questions on the patient's behalf. Staff suspect intimate partner violence. The nurse manager should ensure that staff:

1. screen the patient in private and offer advocacy and safety resources.
   Screening for intimate partner violence must happen privately, away from the partner, with advocacy and safety resources offered whatever the patient discloses.
2. confront the partner about the injuries before any discharge is arranged.
   Confronting the partner may escalate the risk to the patient and is not the staff's role.
3. ask about violence in front of the partner to observe both reactions.
   Asking in front of the partner can put the patient in danger and makes honest disclosure unlikely.
4. wait for the patient to raise concerns without being asked directly.
   Waiting for the patient to raise it misses a chance to help; routine private screening is recommended.

A patient who uses a wheelchair reports being unable to use the unit's bathroom or to be weighed on its standard scale. Which action by the nurse manager BEST demonstrates accountability for equitable care?

1. Transfer patients with disabilities to another unit with accessible rooms
   Transferring disabled patients elsewhere is segregation and avoids fixing the unit's own barriers.
2. Ask family members to help with toileting and weighing during visits
   Relying on family for toileting and weighing shifts the unit's responsibility onto relatives and compromises dignity.
3. Record estimated weights for patients who cannot use the scale
   Estimated weights are inaccurate and can cause dosing errors, so they accept the barrier rather than remove it.
4. Assess accessibility with patients and obtain accessible equipment
   Assessing accessibility with patients and obtaining accessible equipment removes the barrier and gives disabled patients care equal to others.

The nurse manager is revising unit patient education. Staff suggest a screening tool to identify patients with low health literacy so that only those patients receive simplified materials. Which approach reflects current health literacy guidance?

1. Give simplified materials only to patients who screen as low literacy
   Simplifying materials only for those who screen low misses many patients with limited literacy and can stigmatize those identified.
2. Offer detailed written materials to all, since more information helps
   More detailed written material often overwhelms patients and lowers understanding.
3. Use clear communication with every patient as a universal precaution
   Current guidance treats health literacy as a universal precaution: use clear, plain communication and teach-back with every patient, because literacy is hard to judge.
4. Judge each patient's literacy from education level and appearance
   Education level and appearance are unreliable predictors of health literacy and invite bias.

A respected senior nurse openly criticizes a planned change to the unit's staffing grid, and several colleagues echo her concerns. The nurse manager should:

1. ask her closest colleagues to persuade her to accept the change.
   Sending her peers to persuade her is indirect and avoids the manager's own conversation with the person whose concerns matter most.
2. invite her to help plan how the change will be put into practice.
   An influential resister often voices real concerns and carries referent power, so inviting her to help plan implementation surfaces problems early and can turn a critic into a champion.
3. refer her to human resources for undermining an approved decision.
   Treating open disagreement as misconduct for HR punishes voice and teaches staff to resist covertly instead.
4. exclude her from planning meetings to limit the spread of negativity.
   Shutting her out of planning confirms her fears, wastes her insight and usually deepens the resistance her colleagues already echo.

The nurse manager is developing a business plan for a new outpatient diabetes education service. Which element establishes whether the service can be financially viable and should be completed before detailed staffing and budget plans?

1. A marketing campaign and promotional budget for launch
   A marketing campaign comes after viability is established; promoting a service with unknown demand puts the cart before the horse.
2. A market analysis projecting demand and patient volume
   A market analysis projecting demand and volume shows whether the service can attract enough patients to be viable, and those projections drive the staffing and budget plans.
3. A detailed staffing schedule with position descriptions
   A detailed staffing schedule depends on projected volume, so it cannot come first.
4. A five-year schedule for replacing the clinic's equipment
   An equipment replacement schedule is a later operational detail, not a test of financial viability.

A patient who has lost decision-making capacity has a durable power of attorney for health care that names a close friend as agent. The patient's adult daughter disagrees with the friend's decisions. The nurse manager advises staff that decisions should come from:

1. the ethics committee, since the family members disagree.
   An ethics committee can advise on the conflict, but it does not replace the legally designated agent.
2. the daughter, as the patient's legal next of kin.
   Next-of-kin status does not override a legally appointed health care agent.
3. the friend named as the patient's health care agent.
   A durable power of attorney for health care gives decision-making authority to the named agent, here the friend, ahead of next of kin.
4. the attending physician, until the family reaches agreement.
   The physician does not take over decisions because family members disagree with the agent.

While explaining how the hospital is governed, the nurse manager contrasts the role of the board with that of management. Which responsibility belongs to the board rather than to the executive team?

1. Selecting and evaluating the chief executive officer
   Selecting and evaluating the chief executive is a core governance duty of the board; management runs operations.
2. Hiring the nurse managers for each inpatient unit
   Hiring nurse managers is an executive and management function delegated within the organization.
3. Approving the unit's nurse staffing schedules each month
   Approving monthly staffing schedules is an operational task for unit and nursing leaders, not the board.
4. Setting daily bed assignments during a patient surge
   Daily bed assignments during a surge are front-line operations far below the board's governance role.

During a surge, a charge nurse periodically reviews each patient's condition, her team members' workload, the unit environment, and progress toward the shift's goals. Which TeamSTEPPS situation-monitoring tool is she using?

1. CUS
   CUS is an escalation phrase ("I'm concerned, uncomfortable, this is a safety issue"), not a monitoring framework.
2. DESC
   DESC is a script for resolving conflict, not for monitoring the situation.
3. SBAR
   SBAR structures a communication about a patient, not a review of the team, environment and progress.
4. STEP
   STEP stands for Status of the patient, Team members, Environment and Progress toward the goal, the TeamSTEPPS situation-monitoring tool the charge nurse is using.

During a massive transfusion, the unit's only nurse trained on the rapid infuser was off the floor, and the team lost several minutes waiting for that nurse to return. Which action BEST strengthens the unit's ability to recover from the next unexpected event?

1. Cross-train several nurses on each critical device and role
   Cross-training spreads a critical skill across several people, so the unit keeps working when any one of them is absent; that spare capacity is what lets a team recover quickly.
2. Keep the trained nurse on the floor during high-risk cases
   Keeping one nurse on the floor still leaves the unit dependent on a single person, who may be busy, sick or on leave when the next event comes.
3. Post step-by-step device instructions beside the rapid infuser
   Written instructions help a nurse who already knows the device, but learning it from a sheet in the middle of an emergency is too slow to replace hands-on skill.
4. File an incident report and review it at the next staff meeting
   An incident report records what went wrong and supports learning, but it adds no one who can run the device next time.

The unit has one budgeted education position. The nurse manager can use it for a sepsis-recognition program or for a new-graduate residency coordinator, but not both. The value of the program not chosen represents the:

1. sunk cost of the decision.
   A sunk cost is money already spent that cannot be recovered; nothing has been spent here yet.
2. opportunity cost of the decision.
   The value of the program not chosen is the opportunity cost: the benefit given up when a limited resource goes to the alternative.
3. variable cost of the decision.
   A variable cost changes with volume, which has nothing to do with choosing between two uses of one position.
4. fixed overhead cost of the decision.
   Fixed overhead is an indirect cost that does not change with volume; it does not describe a forgone alternative.

The nurse manager has a strong candidate and wants to hire an additional full-time RN, but the unit has no vacant budgeted positions. The nurse manager should:

1. split an existing part-time position into two roles without approval.
   Splitting a position without approval still bypasses position control and changes the budgeted staffing plan.
2. make the offer and ask finance to adjust the approved budget later on.
   Making the offer before approval commits the hospital to a cost leaders have not authorized.
3. request approval for a new position through the position control process.
   Adding a full-time RN beyond the budgeted FTEs requires approval of a new position through position control, however strong the candidate.
4. hire the nurse now and cover the extra cost with savings in the supply budget.
   Covering a new salary with supply savings is an unauthorized budget transfer and treats a one-time saving as a recurring offset.

The nurse manager is setting next year's patient-experience goal for the unit. Which approach BEST reflects evidence-based goal setting?

1. Base the goal on comments from the three most vocal staff members.
   Basing the goal on a few vocal staff members uses anecdote instead of evidence.
2. Set the target at 100% top-box scores to show high expectations of staff.
   A 100% top-box target is unrealistic and discourages staff rather than motivating them.
3. Adopt last year's goal unchanged, since the target was nearly met anyway.
   Reusing last year's goal because it was nearly met ignores current data and offers no stretch.
4. Combine HCAHPS trends, complaint themes and benchmarks to set the target.
   Combining HCAHPS trends, complaint themes and external benchmarks produces a target grounded in data that is both ambitious and achievable.

A usually reliable nurse has been late and distracted since a recent divorce. There are no signs of impairment or patient harm. The nurse manager should:

1. ask detailed questions about the divorce to judge how much it affects the nurse's work.
   Probing about the divorce intrudes on the nurse's privacy; the manager's focus is performance, and the EAP handles personal issues.
2. start formal discipline for lateness without discussing the reason for it.
   Starting formal discipline without discussion skips the conversation that could resolve a first-time problem in a reliable nurse.
3. discuss the performance change and offer a referral to the employee assistance program.
   The manager addresses the change in performance and offers an EAP referral, which supports the nurse while keeping expectations clear and the personal details private.
4. overlook the lateness until the nurse's personal situation has had time to settle.
   Overlooking the lateness lets the problem grow and is unfair to colleagues who cover the late arrivals.

The nurse manager is preparing next year's supply budget. Which approach BEST involves staff in the process?

1. Build the budget alone, since most staff lack formal financial training.
   Building the budget alone excludes the people who use the supplies and know where the waste is.
2. Share the final budget with staff only after it has been approved.
   Sharing the budget only after approval informs staff but gives them no part in shaping it.
3. Let staff set the supply budget without reference to usage data.
   Handing the whole budget to staff abandons the manager's own accountability for it, swinging from exclusion to abdication.
4. Ask the unit practice council to review usage data and suggest savings.
   Asking the unit practice council to review usage data and suggest savings involves staff in budgeting with the information they need to contribute.

The nurse manager is implementing the Age-Friendly Health Systems framework on a unit that serves many older adults. Which set of elements should guide care?

1. What Matters, Medication, Mentation and Mobility
   The Age-Friendly Health Systems framework is built on the 4Ms: What Matters, Medication, Mentation and Mobility.
2. Autonomy, Beneficence, Justice and Nonmaleficence
   Autonomy, beneficence, justice and nonmaleficence are ethical principles, not the Age-Friendly framework.
3. Medication, Memory, Mood and Maintenance of Safety
   Memory and mood are folded into Mentation, and the set leaves out What Matters, the element that anchors the framework.
4. Mobility, Nutrition, Hydration and Skin Integrity
   Mobility, nutrition, hydration and skin integrity are basic care needs, and the framework's 4Ms leave out three of them.

Unit data show that COPD readmissions cluster in two ZIP codes with poor air quality and few primary care clinics. Which action by the nurse manager BEST applies a population health approach?

1. Wait for the hospital's next community needs assessment before acting
   Waiting for the next needs assessment delays action on a pattern the unit's own data already show.
2. Partner with local health centers to follow these patients after discharge
   When readmissions cluster in neighborhoods with poor air and few clinics, partnering with community clinics on follow-up addresses the shared upstream causes, a population health approach.
3. Increase inpatient COPD teaching for every patient on the whole unit
   More inpatient teaching for every patient is an individual-level fix that ignores the neighborhood conditions driving readmissions.
4. Report the readmissions as a problem of individual patient nonadherence
   Labeling the readmissions as nonadherence blames patients for social and environmental conditions.

The nurse manager wants each nurse to check her own fitness for duty, such as fatigue, stress, or illness, at the start of every shift. Which TeamSTEPPS tool supports this self-assessment?

1. CUS escalation
   CUS is an escalation phrase for safety concerns, not a personal readiness check.
2. SBAR briefing
   SBAR structures communication about a patient's situation, not one's own fitness for work.
3. I'M SAFE checklist
   I'M SAFE (Illness, Medication, Stress, Alcohol and drugs, Fatigue, Eating and elimination) is the TeamSTEPPS checklist for a personal fitness-for-duty self-check.
4. Two-challenge rule
   The two-challenge rule is for voicing a safety concern about someone else's action, not for self-assessment.

During a conversation about missed documentation, a nurse says, "So you think I'm a bad nurse." Which response by the nurse manager is an example of the Crucial Conversations skill of contrasting?

1. "Let's not make this personal; the notes simply have to be completed."
   Telling the nurse not to make it personal dismisses the feeling instead of correcting the misunderstanding about intent.
2. "I don't think you're a poor nurse; I do want the charting caught up."
   Contrasting pairs a statement of what the manager does not mean with a statement of the real goal, which corrects the misread intent and keeps the talk on the missed notes.
3. "What makes you feel that I think you are a poor nurse on this unit?"
   Asking about the feeling probes the emotion but does not clarify what the manager does and does not mean.
4. "You're a valued nurse, and I appreciate all the hard work you do here."
   Praise alone reassures but never restates the actual purpose, so the documentation problem drops out of the conversation.

A newly promoted charge nurse tells the nurse manager she feels torn between staying close to her former peers and enforcing break rules with them. She has not raised the issue with anyone else. This is BEST described as which type of conflict?

1. Interpersonal conflict
   Interpersonal conflict is between two or more people, but she has not raised the issue with her former peers.
2. Organizational conflict
   Organizational conflict arises from structures, policies or competition for resources across the organization.
3. Intergroup conflict
   Intergroup conflict occurs between groups, such as two units or professions.
4. Intrapersonal conflict
   Feeling torn between two roles inside oneself, here friend and enforcer of rules, is intrapersonal conflict; no one else is yet involved.

For a unit renovation project, the nurse manager's team estimates one task at 4 weeks (optimistic), 6 weeks (most likely) and 14 weeks (pessimistic). Using the PERT formula, what is the expected duration of the task?

1. 7 weeks
   PERT expected time = (optimistic + 4 × most likely + pessimistic) ÷ 6 = (4 + 24 + 14) ÷ 6 = 7 weeks.
2. 14 weeks
   14 weeks is the pessimistic estimate alone, the worst case rather than the expected duration.
3. 6 weeks
   6 weeks is simply the most likely estimate, ignoring the weighting with the optimistic and pessimistic values.
4. 8 weeks
   8 weeks is the plain average of the three estimates, (4 + 6 + 14) ÷ 3, without the PERT weighting.

To learn the true cost of the unit's new discharge lounge process, finance traces the nursing time, transport and supplies consumed at each step of the process and assigns costs accordingly. This costing approach is:

1. ratio of cost to charges.
   The ratio of cost to charges estimates cost from billed charges, a rough method, not activity tracing.
2. activity-based costing.
   Activity-based costing traces resources such as nursing time, transport and supplies to the activities that consume them, giving a truer cost of a process.
3. standard costing.
   Standard costing compares actual costs with predetermined standards rather than measuring activities.
4. step-down cost allocation.
   Step-down allocation spreads support department costs to revenue departments in sequence; it does not trace activities.

The nurse manager of a hospital-based infusion center explains to staff how Medicare pays for the center's visits. These hospital services are paid under:

1. the inpatient prospective payment system using MS-DRGs.
   MS-DRGs pay inpatient stays under the inpatient prospective payment system, not hospital outpatient visits.
2. a fixed capitation payment per member each month.
   Capitation pays a fixed amount per member per month under some managed care contracts; it is not how traditional Medicare pays hospital outpatient care.
3. retrospective cost-based reimbursement for each visit.
   Retrospective cost-based reimbursement was largely replaced by prospective payment and does not apply to most hospital outpatient services.
4. the outpatient prospective payment system using APC groups.
   Medicare pays hospital outpatient services, such as a hospital-based infusion center, under the outpatient prospective payment system, which groups services into ambulatory payment classifications (APCs).

The emergency department reports that patients board for hours because the nurse manager's unit discharges most patients after 3 p.m. The MOST effective systems approach is to:

1. tell staff to discharge patients before noon regardless of readiness.
   Discharging before noon regardless of readiness puts patients at risk to meet a target.
2. ask the ED to hold patients until beds are clean and fully staffed.
   Asking the ED to hold patients pushes the problem back onto the ED instead of fixing flow.
3. set a shared goal for discharge timing with the ED and case management.
   Late discharges and ED boarding are linked parts of one patient-flow system, so a shared discharge-timing goal with the ED and case management addresses the root cause.
4. report the ED's boarding problem to the chief nursing officer.
   Reporting the ED's boarding problem upward ignores the unit's own role in causing it.

A new early-mobility practice has worked well on one pod, but many nurses on other pods remain hesitant. Which strategy MOST effectively encourages the early majority to adopt it?

1. waiting for the hesitant nurses to request the practice
   Waiting for hesitant nurses to ask stalls diffusion, since the early majority looks for evidence from peers before acting.
2. sharing visible results and peer stories from the pilot pod
   Rogers' diffusion theory shows that observability, seeing peers' visible results, persuades the early majority to adopt a practice.
3. offering a gift card to each nurse who uses the practice
   Gift cards are an external reward that does not show the practice works and can undermine intrinsic motivation.
4. requiring all pods to adopt the practice by the end of the month
   Mandating adoption by a deadline may force compliance but does not build the conviction the early majority needs.

The nurse manager wants to move the unit's scheduled morning medication pass from 0900 to 1000 to reduce conflict with physician rounds. Before implementing the change, the nurse manager should:

1. consult pharmacy and other affected departments about downstream effects.
   A medication-time change affects pharmacy delivery schedules and other departments, so systems thinking calls for consulting them about downstream effects first.
2. ask the unit's physicians to approve the new medication pass time.
   Physician approval alone ignores pharmacy and other departments that the change affects.
3. survey the unit's nurses and adopt the time preferred by the majority.
   A majority vote of unit nurses considers only one group and misses effects outside the unit.
4. implement the new time on the unit first and then adjust if problems are reported.
   Implementing first and fixing problems later risks missed doses before the downstream effects are known.

The hospital ends a long-standing but unwritten practice that let nurses self-select holiday shifts. Staff describe feeling betrayed, although no policy or employment term was violated. This reaction reflects a breach of the:

1. psychological contract.
   A psychological contract is the set of unwritten expectations between employees and employer; ending a long-standing informal practice breaches it even when no written term is broken.
2. professional practice model.
   A professional practice model describes how nurses practice and are governed, not the informal expectations about holiday shifts.
3. organizational mission.
   The organizational mission states the hospital's purpose; staff feeling betrayed by a scheduling change is not a mission breach.
4. written employment contract.
   The written employment contract was not violated, as the stem states, so this option confuses formal and informal obligations.

Instead of reviewing a charge nurse's past mistakes, the nurse manager asks her to name one leadership behavior to improve and then offers two future-focused suggestions. This technique is called:

1. an improvement plan.
   An improvement plan is a formal corrective document with goals and timelines, not a brief coaching technique.
2. feedforward coaching.
   Feedforward asks for one behavior to improve and offers suggestions for the future instead of dwelling on past mistakes.
3. the feedback sandwich.
   The feedback sandwich wraps criticism of past performance between praise, the opposite of looking forward.
4. multirater feedback.
   Multirater (360-degree) feedback gathers ratings from several sources, which is not what happened in this one-on-one exchange.

Some nurses want to skip the required independent double check for insulin infusions during busy shifts, and a heated debate has started. Which conflict-management mode should the nurse manager use?

1. Compromising, by allowing the double check to be skipped on night shifts
   Compromising trades away part of a safety practice, which is not negotiable even on night shifts.
2. Accommodating, by allowing each nurse to decide during busy periods
   Accommodating staff by letting each nurse decide abandons a required safety check.
3. Competing, by requiring the double check while explaining the safety reason
   When a safety rule such as an independent double check is at stake, competing is appropriate: the manager holds the line and explains the safety reason.
4. Collaborating, by having the whole staff vote on whether to keep the double check
   Putting a safety requirement to a staff vote mislabels collaboration and treats patient safety as a matter of preference.

The Thomas-Kilmann Conflict Mode Instrument classifies conflict-handling modes along which two dimensions?

1. Urgency and importance of the issue
   Urgency and importance describe how to prioritize tasks, not how people handle conflict.
2. Formal authority and informal influence
   Formal authority and informal influence are sources of power, not the instrument's dimensions.
3. Task focus and relationship focus
   Task and relationship focus are dimensions of leadership-style models, a common mix-up with Thomas-Kilmann.
4. Assertiveness and cooperativeness
   The Thomas-Kilmann instrument places the five conflict modes on two dimensions: assertiveness (concern for one's own goals) and cooperativeness (concern for the other's).

Night-shift nurses say they learn about unit changes last and never get to give input, because all staff meetings are held at 1400. What should the nurse manager do?

1. Ask day-shift nurses to pass along meeting information to the night shift
   Relying on day staff to relay information is secondhand and still gives night staff no voice.
2. Email the meeting minutes to night staff after decisions are made
   Minutes sent after decisions inform night staff too late for them to contribute.
3. Require night-shift nurses to attend the 1400 meetings on their days off
   Requiring attendance on days off is unfair and unsustainable, and it treats a scheduling barrier as the staff's problem.
4. Rotate meeting times and offer recorded sessions with a way to give input
   Rotating meeting times and offering recordings with a way to give input lets night staff hear changes and shape them, not just learn about them later.

A 12-member task force on discharge delays has made little progress. Each member has a written assignment, but several contribute little because they assume others will do the work. This problem is BEST described as:

1. group polarization.
   Group polarization is a group drifting toward a more extreme position after discussion, not reduced individual effort.
2. social loafing.
   Social loafing is the tendency to put in less effort in a group because individual contributions feel less visible or necessary.
3. role ambiguity.
   Role ambiguity means unclear expectations, but each member here has a written assignment.
4. role conflict.
   Role conflict arises from incompatible demands on one person, which is not what holds this task force back.

An RN delegated vital signs for a postoperative patient to a nursing assistant. The patient has since become hypotensive and restless. Applying the NCSBN/ANA delegation guidelines, the nurse manager coaches the RN that:

1. the RN may delegate the assessment if the assistant has done it before.
   Assessment and clinical judgment cannot be delegated, regardless of how often the assistant has helped before.
2. vital signs can stay delegated if the assistant repeats them every hour.
   Hourly vital signs by the assistant do not replace the RN's assessment of an unstable patient.
3. the right circumstance no longer exists and the RN must reassess the patient.
   When the patient becomes hypotensive and restless, the right circumstance for delegation no longer exists, and the RN must reassess the patient personally.
4. the assistant becomes accountable for the patient once the task is fully accepted.
   Accepting a task makes the assistant responsible for performing it, but accountability for the patient stays with the delegating RN.

During a tense unit redesign, the nurse manager steps back from daily firefighting to observe patterns in how staff, physicians, and patients are reacting over several weeks. In adaptive leadership, this practice is called:

1. management by walking around.
   Management by walking around is informal visibility on the unit, the opposite of stepping back to observe from a distance.
2. getting on the balcony.
   In adaptive leadership, getting on the balcony means stepping back from the action to see patterns in how people are responding.
3. management by exception.
   Management by exception is a transactional practice of intervening only when standards are not met.
4. regulating the distress.
   Regulating the distress means keeping the pressure of change in a productive range, not observing patterns.

A state law sets a maximum of five patients per RN on medical-surgical units. Tonight two patients on the unit need frequent drip titration and close observation. In reviewing the charge nurse's assignments, the nurse manager should apply the law by:

1. treating five as a ceiling and lowering loads where acuity requires.
   A ratio law sets the most patients one RN may have at any time; it is a ceiling, so when acuity is high the manager lowers loads below the maximum.
2. giving every RN exactly five patients as the standard load.
   Treating the maximum as the standard load ignores acuity, the most common misreading of ratio laws.
3. allowing a sixth patient if the charge nurse documents the surge.
   Documenting the surge does not authorize exceeding a legal maximum; the gap must be filled with staff or escalated.
4. averaging the limit across the shift, letting some RNs take six patients.
   Ratios apply to each nurse at all times, so averaging them across a shift and letting some RNs exceed the limit violates the law.