Chapter 35: Home Care Test Bank

Multiple Choice

1. At what point during the patient’s admission to the hospital should discharge planning begin?

a. On admission b. Once the patient gets situated in a private or semiprivate room c. Once the patient stabilizes d. When the patient stabilizes and after all resources have been evaluated

ANS: A

When patients arrive at a neonatal or pediatric intensive care facility, the unit is already planning for discharge to an alternative site of care.

REF: p. 659

2. What are the goals of discharge planning?

I. To reduce the number of hospitalizations

II. To have the patient resume activities of daily living

III. To reduce the number of emergency room visitsIV. To reduce the patient’s length of stay a. I and IV only b. I, II, and III only c. I, II, and IV only d. II, III, and IV only

ANS: D

The intent for discharge planning is to reduce the hospital stay, which minimizes medical costs and risk of additional infection.

REF: p. 659 a. The family and the physician b. The nurse and the family c. The physician and nurse d. The family and the health care team

3. Before the patient is discharged home, who needs to meet and assess the needs of both the child and family?

ANS: D

The entire discharge planning team should meet and assess the needs of both the child and family. Before discharge home, the child must be medically stable and receiving optimal ventilatory, nutritional, and developmental support. Assessment includes evaluation of the family's ability, availability, and commitment to care for their child as well as a psychosocial assessment for parenting risk factors that could potentially result in adverse outcomes.

Limitations, including language, physical, and cognitive, may delay discharge until appropriate support can be provided to the family to help overcome these barriers.

REF: p. 659 a. Physician b. Patient c. Durable medical equipment (DME) company d. Discharge planner

4. Who is responsible for deciding the type of oxygen delivery system that will be used in the home?

ANS: C

The three types of oxygen systems available for the home environment are liquid oxygen, oxygen concentrators, and compressed oxygen cylinders. Selection of the system is commonly the responsibility of the DME provider. Regardless of the type of oxygen system provided, it is essential that the DME provider be advised of the specific flow rate the child requires. This will determine which flowmeter to use with the system.

REF: p. 663 b. It requires a power source. c. It requires filling every 6 months. d. It vents regardless of whether the flow is on or off.

5. Which of the following is the most important disadvantage of a liquid oxygen system? a. It is very heavy.

ANS: D

A disadvantage to using this system is that the base unit requires regular refilling by the DME provider. Frequency depends on both the oxygen flow rate and the size of the reservoir and can be as often as once a week to every other month. Another disadvantage to the liquid oxygen system is that it vents continually to prevent pressure from building within the reservoir, resulting in a loss of oxygen regardless of whether the flow is on or off.

REF: p. 663 a. It provides an unlimited supply of oxygen. b. It does not require a power source. c. It does not require gas analysis. d. It is ideal for transport situations.

6. What are the advantages of an oxygen concentrator?

ANS: A

Most concentrators provide greater than 90% oxygen. On some concentrators the flowmeters can be changed to provide low flow rates (see Figure 35-3 in the textbook) whereas others have dual flowmeters to accommodate the varied needs of the patient (see Figure 35-4 in the textbook). The DME provider needs to evaluate each concentrator's specifications before use with pediatric patients to ensure it can be used with low flows. When using concentrators, oxygen cylinders are provided for the patient to use for transport and for backup in the case of an electrical power outage. As long as there is an electrical source, an oxygen concentrator provides an unlimited supply of oxygen and does not need to be refilled.

REF: p. 663 a. Because patients generally cannot afford liquid oxygen b. Because compressed gas cylinders are being made smaller and lighter c. Because they are being made safer and people can smoke near them d. Because the grade of oxygen in compressed gas cylinders is higher than in liquid systems

7. Why are compressed gas cylinders of oxygen becoming more commonplace for patient transport in the home care setting?

ANS: B

Portable cylinders are available in a variety of sizes and are identified by letter designations. At one time the E cylinder was the smallest available in portable cylinders, making liquid oxygen the number one choice for pediatric patients. Today, however, compressed gas cylinders are gaining in popularity thanks to the availability of smaller cylinders with custom carrying cases and regulators that allow flows as low at 1/32 Lpm.

REF: p. 664 a. It facilitates billing the patient for services. b. It helps monitor oxygen use. c. It enables differentiating among different types of apnea. d. It helps decide the next laboratory evaluation.

8. What is the utility of downloading information from an apnea monitor?

ANS: C

The information obtained from a download can be used to distinguish the type of apnea, decide the type of medical treatment needed, and determine compliance and when to discontinue the monitor.

REF: p. 665

9. Which of the following infants may benefit from using an apnea monitor at home?

I. Infants who were born preterm

II. Infants who have experienced a life-threatening event

III. Infants who have been diagnosed with gastroesophageal reflux diseaseIV. Infants who have experienced an apneic episode for any reason in the hospital a. II and III only b. I, II, and IV only c. I, III, and IV only d. II, III, and IV only

ANS: A

An apnea monitor may be considered medically necessary for infants who:

• Have apnea of prematurity

• Are receiving caffeine or theophylline for treatment of apnea or bradycardia

• Have experienced an apparent life-threatening event

• Have pertussis with positive cultures

• Are diagnosed with gastroesophageal reflux disease accompanied by apnea, bradycardia, or oxygen desaturation

• Have neurologic or metabolic disorders affecting respiratory control

• Have chronic lung disease and require noninvasive or invasive ventilatory support

• Have two siblings who died of sudden infant death syndrome

REF: p. 665

10. What considerations need to be taken into account when applying external positive endexpiratory pressure (PEEP) to a home ventilator?

I. The ventilator circuit must be able to accommodate the weight of the PEEP valve.

II. The PEEP valve must be able to function at any angle.

III. Thoracostomy tubes need to be available to treat a pneumothorax.

IV. The exhalation ports must be free from obstructions.a. II and IV only b. I, II, and III only c. I, II, and IV only d. II, III, and IV only

ANS: C

Another factor to be considered when selecting a home ventilator concerns the compatibility of the circuit and the positive end-expiratory pressure (PEEP) valve. PEEP is often accomplished by using an external PEEP valve, which can be heavy and may also have exhalation ports that can be easily blocked. The combination of the PEEP valve and circuit must have minimal exhaled resistance. The PEEP valve must also be able to function at any angle; this precludes gravity and water columns for home use.

REF: p. 672 a. It is easy to analyze the inspired fraction of oxygen (FiO2). b. No humidification is necessary. c. It provides a variety of ventilation modes. d. A variety of power sources can be used.

11. What is a major advantage of using a portable ventilator?

ANS: D

A major advantage of a portable ventilator is the ability to use a variety of power sources, including house current, an internal battery for short periods, and an external battery for extended periods. Some portable ventilators can operate from a car battery by connecting to the cigarette lighter.

REF: p. 672

12. Which of the following backup equipment needs to be provided for a home-ventilated infant who (1) lacks the ability to breathe spontaneously for at least 4 successive hours, (2) lives 2 hours away by automobile from medical assistance, and (3) requires mechanical ventilation for mobility? a. Point-of-care blood gas analyzer b. Second oxygen concentrator c. Additional source of oxygen d. Additional ventilator and ventilator circuits

ANS: D

A second ventilator, or backup ventilator, should be provided in the home for the child who (1) cannot maintain spontaneous ventilation for at least 4 consecutive hours, (2) lives in an area where a replacement ventilator cannot be provided within 2 hours, or (3) requires mechanical ventilation during mobility. An emergency backup ventilator must be available in the event of a ventilator malfunction. Without a backup ventilator in the home, the home care company must assume the responsibility for providing immediate service. It is also best to have extra ventilator circuits and a spare temperature probe in the home.

REF: p. 673

13. Which of the following circumstances constitute obstacles to discharging a child who requires home mechanical ventilation?

I. Lack of family access to public transportation

II. Large number of siblings

III. Delays in approval for home care fundingIV. Unsuitable home environment a. I and II only b. II and III only c. III and IV only d. II, III, and IV only

ANS: C

In spite of the most valiant attempts at organization, communication, and planning within the discharge process, obstacles to discharge will still occur. The major barriers for chronically ventilated children include failure to obtain qualified nursing staff, delays in approval for home care funding, an unsuitable home environment, complex family issues, and arrangements for out-of-home placement.

REF: p. 673 a. The process continues because eventually the funding will materialize. b. Only the essential components of the discharge plan are initially implanted. c. The discharge process is delayed until the caregivers receive education to perform additional services. d. The discharge is delayed indefinitely.

14. What is the outcome when delays in funding for the home care services occur?

ANS: D

Funding delays are often the greatest hurdle to getting the child home. Without reimbursement, home equipment cannot be obtained. The greatest difficulty arises when little or no reimbursement is available for the ventilator. Community resources, such as nursing, speech therapy, physical therapy, and occupational therapy, are also unattainable without funding. Without reimbursement, discharge is delayed indefinitely.

REF: p. 673 a. It helps the family become more familiar with providing health care at home. b. It provides the family with the opportunity to earn more income to facilitate the discharge process. c. It affords the family more time to recruit additional health care providers to be used in the home. d. It often results in a negative change in the family dynamics.

15. What effect does an extended hospital stay tend to have on the discharge planning process for a child expected to receive mechanical ventilation at home?

ANS: D

Family issues are all too often the most difficult barriers to overcome. The longer the hospital stay, the more likely that family dynamics will change. Strained finances, guilt, fatigue, worry, and emotional distress are all issues faced by most families of ventilator-assisted children. However, issues such as divorce, which often results in loss of one of the primary caregivers, and drug abuse and mental illness, are the types of issues that tend to cause the longest delays.

REF: p. 674 a. The ventilator setting must be stable for at least 3 weeks. b. Arterial blood gas measurements must be stable and within normal limits. c. The patient’s FiO2 must be 0.80 or less. d. If PEEP is used, it must be no more than 10 cm H2O.

16. Before a ventilator-dependent child can be discharged home, which of the following criteria must be met?

ANS: B

Before a ventilator-dependent child can be discharged home, the following criteria must be met: Ventilator settings must be stable for at least 1 week. The oxygen concentration must be less than 40%, and blood gas measurements must be stable and within normal limits. The home environment must be acceptable, and the home equipment available either at the hospital or at the child’s home.

REF: p. 674

Chapter 36: Quality and Safety Test Bank

Multiple Choice

1. Lack of skills and/or failure to follow or deviation from standard practices/procedures is known as: a. Sentinel event b. Six Sigma c. Negligence d. Health failure mode

ANS: C

Negligence (described as a lack of skills and/or failure to follow or deviation from standard practices/procedures) was determined to be the cause in 27.6% of adverse events.

REF: p. 681 a. Medication related b. Patient misidentification c. Error in the diagnosis d. Delayed diagnosis

2. What is the most common serious error observed in the NICU?

ANS: A

NICU data revealed 47% of errors were medication related, 11% involved patient misidentification, 7% involved delay or errors in diagnosis, and 14% involved errors in the administration or methods of using a treatment.

REF: p. 681 a. Increase the number of physicians b. Increase the number of nurses and allied health professionals c. Develop teams of caregivers for multidisciplinary communication d. Involve the family in the health care team

3. What has been described by the IOM as a necessary component of change needed to occur to improve patient safety?

ANS: C

Developing teams of caregivers for multidisciplinary communication was described early on by IOM as a necessary component of change that needed to occur to improve patient safety.

REF: p. 682

4. The wrong dose of albuterol is administered to the patient, but the patient does not have any adverse response. What is the name of this event? a. Near miss b. Precursor safety event c. Serious safety event d. Sentinel event

ANS: B

The second classification is a precursor safety event, an event that reaches the patient but results in minimal to no detectable harm. If that same dose error is not detected by the pharmacist or nurse and gets delivered to the patient but the patient does not have any adverse response, it is a precursor safety event.

REF: p. 683

5. A therapist is assisting the pulmonologist during a bronchoscopy. While the child’s oxygen saturation was reading above 90%, the patient had been apneic for approximately 1 minute and suffered a mild anoxic injury. What is the name of an event like this? a. Near miss b. Precursor safety event c. Serious safety event d. Sentinel event

ANS: D

The Joint Commission (TJC) also reviews errors, which are classified as sentinel events. The Joint Commission defines a sentinel event is “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.”

REF: p. 683

6. Which of the following processes enables organizations to continuously measure services, practices, costs, and products using best practices to improve care? a. Self-reporting b. Benchmarking c. Quality measure reporting d. Quarterly budget

ANS: B

Measures of quality and safety can track progress of improvement initiatives using reporting benchmarks. Benchmarking in health care is defined as the continual and collaborative discipline of measuring and comparing the results of key work processes with those who have what is considered best practices. This process enables organizations to continuously measure services, practices, costs, and products using best practices to improve care.

REF: p. 683

7. Prevention of safety events is critical in pediatric patients because, when a safety event occurs: a. Hospital stay is 10 times longer b. Hospital mortality may be as high as 18 times greater c. Hospital charges are 50 times higher d. Hospitals do not get reimbursed

ANS: B

More recent reviews of potential pediatric safety issues reveal the hospitalized child who experiences a safety event, as compared with those who did not, has a length of stay 2 to 6 times longer, hospital mortality 2 to 18 times greater, and hospital charges 2 to 20 times higher.

REF: p. 687 a. Errors in administration of medications b. Accidental extubations c. Pneumonia

8. What is the most common complication of hospital care that the therapist should be aware of?

d. Health care–associated infections

ANS: D

Health care–associated infections (HAI) are infections patients acquire while receiving treatment for another condition in some type of health care facility. Millions of infections with thousands of deaths occur annually, making HAIs the most common complication of hospital care.

REF: p. 687

9. Which of the following types of infections are considered HAIs?

I. Catheter-associated blood stream infections

II. Catheter-associated urinary tract infections

III. Ventilator-associated pneumoniasIV. Surgical site infections a. II and III only b. I, II, and IV only c. I, III, and IV only d. I, II, III, and IV

ANS: D

Financially, HAIs add $28 to $33 billion to health care costs. AHRQ researches barriers and challenges in preventing the most frequent and therefore most costly HAIs. These infections cause extended hospital stays and increased cost and risk of mortality. Types of infections include: blood stream infections (BSIs), catheter-associated urinary tract infections (CATIs), surgical site infections (SSIs), and ventilator-associated pneumonia (VAP), which together account for more than 80 percent of all HAIs.

REF: p. 687

10. Which of the following postsurgical respiratory issues are associated with reintubation or prolonged mechanical ventilation?

I. Lack of use of incentive spirometry

II. Oversedation

III. Exacerbation of underlying cardiovascular conditionIV. Exacerbation of underlying respiratory condition a. II and III only b. II, and IV only c. I, II, and IV only d. II, III, and IV only

ANS: D

Respiratory issues postsurgery are not uncommon; reintubation or prolonged mechanical ventilation may be necessary. Causes include: oversedation, exacerbation of underlying cardiovascular or respiratory conditions, and ventilator-associated pneumonia (AHRQ, 2011). Close attention should be paid to these risk factors.

REF: p. 688