CNL Care Transitions & Discharge Planning

Question 1

Which of the following is the PRIMARY goal of a structured discharge planning process in the CNL role?

Accepted Answer

Ensuring continuity of care and preventing avoidable readmissions

Answer

Reducing hospital length of stay to lower costs

Answer

Completing required documentation before the patient leaves

Answer

Notifying insurance providers of the discharge date

Question 2

The CNL notices a patient has multiple chronic conditions, low health literacy, and limited social support. Which discharge strategy is MOST appropriate?

Accepted Answer

A teach-back session with caregivers plus a follow-up call within 48 hours

Answer

Standard written discharge instructions given at bedside

Answer

Referral to the social worker only

Answer

Early discharge to reduce infection exposure

Question 3

Which model specifically focuses on reducing rehospitalizations through nurse-led home visits and phone follow-up after discharge?

Accepted Answer

Care Transitions Intervention (CTI)

Answer

SBAR Model

Answer

Donabedian Model

Answer

Lean Six Sigma

Question 4

A patient being discharged after a hip replacement asks about weight-bearing restrictions. The CNL's BEST response is to:

Accepted Answer

Provide written instructions and use teach-back to confirm understanding

Answer

Refer all questions to the orthopedic surgeon's office

Answer

Tell the patient to look up the information online

Answer

Document that education was provided and move on

Question 5

Which federal program penalizes hospitals financially for excess readmissions within 30 days for certain conditions?

Accepted Answer

Hospital Readmissions Reduction Program (HRRP)

Answer

Medicare Advantage

Answer

Meaningful Use Program

Answer

Value-Based Insurance Design

Question 6

Which patient factor is the STRONGEST independent predictor of 30-day hospital readmission?

Accepted Answer

History of prior hospitalizations in the past 6 months

Answer

Patient age over 65

Answer

Female gender

Answer

Urban versus rural residence

Question 7

A CNL is coordinating discharge for a patient going to a skilled nursing facility (SNF). Which action is MOST critical before transfer?

Accepted Answer

Sending a complete, reconciled medication list and care summary to the receiving facility

Answer

Calling the SNF dietary department about food preferences

Answer

Informing the patient's employer about the discharge

Answer

Removing the IV access before transport