Coordination of Care

Question 1

A nurse is preparing to discharge a client who was hospitalized for heart failure. Which action best supports continuity of care?

Accepted Answer

Arrange follow-up appointments, communicate with the home health agency, and use teach-back to confirm understanding

Answer

Provide written discharge instructions only and ask the client to call if questions arise

Answer

Tell the client the cardiologist will contact them within a week

Answer

Document the discharge in the chart and notify the charge nurse

Question 2

A nurse is caring for a client who needs a wound consult, physical therapy evaluation, and dietary assessment. What is the nurse's most effective approach?

Accepted Answer

Initiate an interdisciplinary care conference to coordinate simultaneous planning

Answer

Contact each department separately over the course of the shift

Answer

Ask the family to schedule the consultations to save time

Answer

Wait for the physician to order all consults before taking action

Question 3

A nurse is handing off care using the SBAR communication tool. Which element is included under the 'Recommendation' component?

Accepted Answer

What the nurse believes needs to happen and the requested action

Answer

The client's current vital signs and lab values

Answer

A concise summary of the clinical background and history

Answer

An objective description of the client's current condition

Question 4

A case manager is coordinating discharge for an elderly client who lives alone and has limited mobility after a hip replacement. The priority referral is to:

Accepted Answer

Home health services including physical therapy and skilled nursing visits

Answer

An acute rehabilitation facility for 6 weeks before returning home

Answer

A psychiatric social worker to assess for depression

Answer

The hospital dietary department for meal planning instructions

Question 5

During a care transition, the nurse realizes that a client's medication list from the transferring facility omits a daily blood thinner. What is the nurse's priority action?

Accepted Answer

Perform medication reconciliation by contacting the transferring provider to verify the complete list

Answer

Add the medication to the MAR based on the client's verbal report

Answer

Hold all medications until the family can bring the original bottles

Answer

Administer a standard dose based on the client's weight and diagnosis

Question 6

A nurse identifies that a client's pain is poorly controlled, the physical therapist has been unable to complete sessions, and the family has unresolved questions about hospice. The nurse's best next step is to:

Accepted Answer

Initiate a multidisciplinary team meeting to address barriers to the care plan

Answer

Address each issue independently on separate days to avoid overwhelming the team

Answer

Document the concerns and wait for the physician's next scheduled visit

Answer

Ask the family to contact the hospital's patient advocate directly