Chapter 07: Evidence-Based Practice

1.Which organization is preparing future nurses to have the knowledge, skills, and attitudes (KSAs) of evidence-based practices necessary to continuously improve the quality and safety of the health care systems within which they work?

a.
The Joint Commission
b.
Quality and Safety Education for Nurses’ (QSEN)
c.
The National Database of Nursing Quality Improvement (NDNQI)
d.
The Agency for Health care Research and Quality (AHRQ)

ANS: B

Evidence-based practice is also one of the Quality and Safety Education for Nurses’ (QSEN) competencies, with the overall goal for the QSEN project being to meet the challenge of preparing future nurses to have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems within which they work (QSEN, 2012). The Joint Commission provides Patient Safety Goals. All magnet-designated hospitals maintain the National Database of Nursing Quality Improvement (NDNQI). The database has information on falls, pressure ulcer incidence, and nurse satisfaction. The AHRQ is a national agency that provides important sources of new scientific information that include standards and practice guidelines.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 91 OBJ: Discuss the QSEN competencies for evidence-based practice.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care

2.A registered nurse questioned the nurses on the neonatal intensive care unit about the practice of kangaroo care for neonates. The nurse had read literature supporting the practice, but the nurses that work on the neonatal unit stated that they had never done anything like that at their institution. The nurse continued to ask questions and began a literature review. Which behavior was the nurse demonstrating?

a.
Variables
b.
Peer review
c.
Evidence-based practice
d.
Process measurement

ANS: C

Evidence-based practices (EBP) guide nurses and other health care providers in making effective, timely, and appropriate clinical decisions. Nurses and other health care providers can no longer accept and practice the status quo. Greater attention must be given to why certain health care approaches are used, which ones work, and which ones do not. Hypotheses are predictions made about the relationship among study variables (e.g., characteristics or traits that vary among subjects). An example of a research question is: Does the use of chlorhexidine 2% compared with povidone-iodine reduce CLABSI in patients with CVCs? Within that question the author is studying the variables (independent) of chlorhexidine and povidone-iodine solutions as they affect the outcome (dependent variable) of CLABSI in patients. Peer review is the practice of nurses evaluating nurses. A peer-reviewed article is one submitted for publication and reviewed by a panel of experts familiar with the topic or subject matter of the article. When you implement a practice change, you sometimes want to monitor whether or not the process or protocol was implemented. This requires a process measurement. The nurse has not implemented kangaroo care (only reviewed literature), so there is no need for a process measurement.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 89-90 OBJ: Discuss ways to apply evidence in nursing practice.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

3.A registered nurse wants to review the latest information regarding prevention of a health care acquired infection. Where is the best place for the nurse to obtain this information?

a.
Online information
b.
Peer-reviewed nursing journal
c.
Latest edition of a nursing textbook
d.
Most recent edition of a popular magazine

ANS: C

The best scientific evidence comes from well-designed, systematically conducted research studies, usually found in peer-reviewed scientific journals. A good textbook incorporates current evidence into the practice guidelines and procedures it describes. However, a textbook relies on the scientific literature, and sometimes information on a particular topic is outdated by the time a book is published. Peer-reviewed material is better than online information or recent popular magazines.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 91 OBJ: Discuss the levels of evidence in the literature.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care

4.A 15-year-old patient was admitted to the hospital with a bowel obstruction. The patient underwent surgery and was experiencing postoperative pain. The nurse caring for the patient had recently read a research article in which a study had been done with neonatal (infant) patients and the use of therapeutic touch to assist with pain control. Which factor is mostimportant for the nurse to consider in this case when applying research to clinical practice?

a.
The patient’s gender
b.
The patient’s preference
c.
The patient’s allergies
d.
The patient’s roommate

ANS: B

Using clinical expertise and considering patients’ values and preferences ensures that a nurse will apply the available evidence to practice both safely and appropriately. Even when you use the best evidence available, application and outcomes differ based on your patients’ values, state of health, preferences, concerns, and/or expectations. Patient’s allergies, gender, and roommate are not important in this scenario as it does not affect therapeutic touch.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:91

OBJ:Explain how critiquing the scientific literature leads to best evidence for practice changes.TOP:Nursing Process: Assessment

MSC: NCLEX: Management of Care

5.A nurse is using evidence-based practice (EBP) to provide care. Which action should the nurse take first?

a.
Collect the most relevant and best evidence.
b.
Integrate evidence with one’s clinical expertise.
c.
Critically appraise the evidence gathered.
d.
Ask a clinical question.

ANS: D

EBP is a systematic approach to determine the most current and relevant evidence on which to base patient care decisions. Melnyk and Fineout-Overholt recommend a six-step process for EBP: (1) Ask a clinical question; (2) Collect the most relevant and best evidence; (3) Critically review and evaluate/appraise the evidence gathered; (4) Combine/Integrate evidence with one’s clinical expertise and patient preferences and values in making a practice decision or change; (5) Evaluate the practice decision or change; (6) Communicate results of the change. Collecting the best evidence is step 2. Integrating evidence is step 4. Critically appraising the evidence is step 3.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 91 OBJ: Describe the steps of evidence-based practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

6.The nurse manager of a 30-bed medical surgical unit has noticed that the fall rate of postoperative patients has increased in the past 2 months. The nurse manager wants to address this situation using evidence-based practice. Which type of trigger did the nurse manager use?

a.
Literature-focused trigger
b.
Problem-focused trigger
c.
Knowledge-focused trigger
d.
Expectations-focused trigger

ANS: B

A problem-focused trigger is one you face while caring for patients or a trend you see on a nursing unit. A knowledge-focused trigger is a question that arises as a result of new information available on a topic, such as current information in literature. Titler et al. (2001) suggest using problem- and knowledge-focused triggers to think critically about clinical and operational nursing-unit issues. It does not include literature or an expectations trigger.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 91-92 OBJ: Describe the steps of evidence-based practice.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

7.A registered nurse who works for a surgical intensive care unit (ICU) has recently read several articles in professional nursing journals about the use of quiet time in the ICU to enhance patient outcomes. The nurse would like to apply the research findings to the unit. How did the nurse formulate the clinical question?

a.
Measurement-focused trigger
b.
Problem-focused trigger
c.
Knowledge-focused trigger
d.
Expectations-focused trigger

ANS: C

A knowledge-focused trigger is a question that arises as a result of new information available on the topic. For example, “What is the current evidence for the best way to educate patients with low health literacy?” A problem-focused trigger is one you face while caring for patients or a trend you see on a nursing unit. Titler et al. (2001) suggest using problem- and knowledge-focused triggers to think critically about clinical and operational nursing-unit issues. It does not include measurement or expectation focuses.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 91-92 OBJ: Describe the steps of evidence-based practice.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

8.A nurse’s manager has suggested that a nurse formulate a PICO question to clarify the topic before doing a literature review. When the nurse asks what the acronym PICO stands for, how should the nurse manager respond?

a.
Policy, information, comparison, outcome
b.
Patient, information, collection, outcome
c.
Patient, intervention, comparison, outcome
d.
Policy, intervention, communication, outcome

ANS: C

P: Patient population of interest. Identify patients by age, gender, ethnicity, disease, or health problem.

I: Intervention of interest. Which intervention do you want to use in practice (e.g., a treatment, diagnostic test, educational approach)?

C: Comparison of interest. What is the usual standard of care or current intervention that you now use in practice?

O: Outcome. What result do you wish to achieve or observe as a result of an intervention (e.g., change in patient behavior, physical finding, patient perception)?

Policy, information, comparison, collection, and communication are not included in PICO.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:92OBJ:Develop a PICO or PICOT question.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

9.A nurse working on a PICO question has found a large amount of literature available on the topic with multiple studies that have been published. Which type of study should have the bestevidence?

a.
Meta-analysis of randomized control trials
b.
Opinion of an expert committee
c.
One well-designed randomized control trial
d.
Systematic review of descriptive and qualitative studies

ANS: A

Systematic reviews or meta-analyses are state-of-the-science summaries from an individual researcher or panel of experts and are on the highest level of the hierarchy. These research summaries are the perfect answers to PICO(T) questions because the researchers have rigorously summarized all current evidence on the question. A single RCT is not as conclusive as a review of several RCTs on the same question. Opinion of an expert committee is on the lowest level of the hierarchy of evidence. Systematic review is above opinions but is below meta-analysis on the hierarchy of evidence.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 93-94 OBJ: Discuss the levels of evidence in the literature.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

10.A registered nurse is concerned about the patients’ perceptions and feelings about the quality of life that they experience after a diagnosis of liver cancer. Which is the most appropriate type of research study the nurse should use to gather information about this situation?

a.
Quantitative study
b.
Randomized trial
c.
Qualitative study
d.
Case controlled study

ANS: C

Qualitative research offers analysis of interviews, observations, and/or surveys to measure people’s perceptions, feelings, or views of phenomena about which little is known. Randomized trial has participants divided into groups to test for the same outcome to determine if there is a difference in the effect of a treatment or intervention compared with a standard of care. A case control study compares patients who have a disease or outcome of interest with patients who do not have the disease or outcome. The researcher looks back to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and disease. If quantitative data such as physical measurements and scores on surveys are collected, statistical results from the study are explained. Quantitative data do not focus on perceptions and feelings.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:94

OBJ:Explain how critiquing the scientific literature leads to best evidence for practice changes.TOP:Nursing Process: Assessment

MSC: NCLEX: Management of Care

11.A nurse works for a facility in which the facility sends information to The National Data Base for Nursing Quality Improvement (NDNQI) regarding patient falls, pressure ulcer incidence, and nursing satisfaction. The nurse works at which facility?

a.
The Joint Commission
b.
A magnet-designated hospital
c.
The Centers for Disease Control and Prevention
d.
The American Association of Critical Care Nurses

ANS: B

All magnet-designated hospitals maintain the National Database of Nursing Quality Improvement (NDNQI). The database includes information from Magnet hospitals on falls, pressure ulcer incidence, and nurse satisfaction. The Joint Commission produces patient safety goals. The Centers for Disease Control and Prevention help produce guidelines for clinical practice. American Association of Critical Care Nurses provides standards and practice guidelines for critical care nurses.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:92

OBJ: Explain the relationship among nursing research, evidence-based practice, and quality improvement. TOP: Nursing Process: Evaluation

MSC: NCLEX: Management of Care

12.A student nurse is looking for research articles that can be used to complete a research paper. Where can the nursing student look to quickly find out if an article is research or clinically based?

a.
p value
b.
Abstract
c.
Analysis
d.
Literature review

ANS: B

An abstract is a brief summary of the article that quickly shows whether the article is research or clinically based. An abstract summarizes the purpose of the study or clinical review, the major themes or findings, and the implications for nursing practice. A good author offers a detailed background of previous studies and the level of evidence or clinical information that exists about the topic of the article, which is called the literature review. Analysis is the section that explains how the data collected in a study are analyzed. The p value (usually set at 0.05) is a probability level that tells you whether the difference between two groups was likely related to the intervention or if it was simply a difference by chance.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:95

OBJ:Explain how critiquing the scientific literature leads to best evidence for practice changes.TOP:Nursing Process: Assessment

MSC: NCLEX: Management of Care

13.A nurse working in an acute care setting wanted to determine the most accurate way to take patients temperatures. The nurse noticed that the tympanic thermometers used by the unit were often not accurate. The nurse found that the literature showed tympanic thermometers were not the most accurate method of obtaining a temperature. The nurse wants to change the nursing practice of the unit. What is the nurse’s most logical next step?

a.
Discuss the findings with a patient to gain support.
b.
Tell the aides to stop taking temperatures.
c.
Share the findings with the nursing policy and procedure committee.
d.
Write an editorial in the public newspaper to bring the community into the process.

ANS: C

A key feature of a practice environment that supports the use of best evidence is requiring clinical practice policies and procedures to be evidence based. Many organizations involve staff nurses and research-prepared advanced practice nurses in reviewing scientific articles relevant to policies and procedures and then making appropriate revisions. Policies and procedures are important tools for supporting hospital-based nurses in using evidence in their everyday practice and promoting positive patient outcomes. Discussing results with the patient will not get the procedure changed. Telling the aides to stop taking the temperatures is dangerous. Writing an editorial in the public newspaper is inappropriate to effect change on the unit. First follow policies and procedures of the agency in which one works.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 97 OBJ: Identify ways to sustain knowledge in evidence-based practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

14.After a practice change has taken place in an organization because of a nurse following evidence-based practice in a task force, which final step should the nurse take?

a.
Evaluate
b.
Encourage
c.
Engage
d.
Execute

ANS: A

After applying evidence in practice, the next step is to evaluate the effect. Newhouse and White (2011) recommend that to be successful in changing practice within an organization, it is essential to Engage, Educate, Execute, and Evaluate. Engage and execute have already occurred because the change has taken place. Encourage is not a step in the evidence-based process.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 96-97 OBJ: Identify ways to sustain knowledge in evidence-based practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

15.The nursing unit staff has used evidence-based practice to implement a practice change. What is the next step in the process the nursing staff should implement?

a.
Review literature.
b.
Engage companies.
c.
Measure outcomes.
d.
Ask a clinical question.

ANS: C

After implementing the change, the practice decision or change should be evaluated by using outcome or process measurements. Remember the “O” in your PICO(T) question. It represents the outcomes you choose to measure as you integrate the evidence. These outcomes tell you how well the evidence-based intervention works. Reviewing literature and asking a clinical question occurred before the change. Companies are not a part of this process.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 91 | 97 OBJ: Describe the steps of evidence-based practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

16.At a health care organization, patients are turned every 2 hours to help prevent pressure ulcers. Because of this nursing intervention, patients exhibit far fewer pressure ulcers than the national average. Which term should the nurse use to describe this finding?

a.
Sentinel event
b.
Qualitative research
c.
Manuscript narrative
d.
Nursing-sensitive outcome

ANS: D

A nursing-sensitive outcome focuses on how patients and their health care problems are affected by nursing interventions (ONS, 2012). Nursing-sensitive outcomes look at the effects of interventions within the scope of nursing practice. Sometimes a problem is presented to a committee in the form of a sentinel event, an unexpected occurrence involving death or serious physical or psychological injury of a patient. Qualitative research is analysis of interviews, observations, and/or surveys to measure people’s perceptions, feelings, or views of phenomena about which little is known. Manuscript narrative is the “middle section” or narrative of a manuscript that differs according to the type of evidence-based article it is.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:98

OBJ: Discuss ways to measure outcomes for an evidence-based practice change.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

17.The quality improvement or performance improvement (QI/PI) process should begin at which level of nursing?

a.
Staff nurse
b.
Nurse manager
c.
Nurse administrator
d.
Advanced practice registered nurse

ANS: A

The QI/PI process begins at the staff level, where all disciplines become involved in identifying quality problems. Although all those listed can do QI/PI, the process begins at the staff level.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:100

OBJ: Explain the relationship among nursing research, evidence-based practice, and quality improvement. TOP: Nursing Process: Assessment

MSC: NCLEX: Management of Care

MULTIPLE RESPONSE

1.The nurse is investigating an area of practice in which no research evidence is available. What types of non-research information should the nurse consider? (Select all that apply.)

a.
Performance improvement and risk management data
b.
International, national and local standards of care
c.
Study with pre- and post-test design
d.
Benchmarking
e.
Retrospective or concurrent chart reviews

ANS: A, B, D, E

Other sources of information from non-research evidence include: performance improvement and risk management data, international, national and local standards of care, infection control data, benchmarking, clinicians’ expertise, and retrospective or concurrent chart reviews. Study with a pre- and post-test design is a research study. The question asked for non-research information.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 91 OBJ: Discuss the levels of evidence in the literature.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

2.A nurse is describing types of performance improvement models. Which information should the nurse include? (Select all that apply.)

a.
Six Sigma
b.
Balanced scorecard
c.
Plan-Do-Study-Act
d.
Root cause analysis
e.
Human subjects committee

ANS: A, B, C, D

Performance improvement models include Six Sigma, balanced scorecard, Plan-Do-Study-Act, and root cause analysis. Research studies must be approved by an institutional review board (IRB), also called a human subjects committee, which is not involved with performance improvement models but with research.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:101

OBJ: Discuss the relationship between evidence-based practice and the improvement of the safety and quality of nursing practice. TOP: Nursing Process: Implementation

MSC: NCLEX: Management of Care