Coordination of Care 1 — Questions and Answers
Question 1: A nurse is preparing to discharge a client who was hospitalized for heart failure. Which action best supports continuity of care?
- Provide written discharge instructions only and ask the client to call if questions arise
- Arrange follow-up appointments, communicate with the home health agency, and use teach-back to confirm understanding (Correct answer)
- Tell the client the cardiologist will contact them within a week
- Document the discharge in the chart and notify the charge nurse
Correct answer: Arrange follow-up appointments, communicate with the home health agency, and use teach-back to confirm understanding
Effective care coordination at discharge includes arranging post-discharge follow-up, communicating the care plan to receiving providers, and verifying client understanding through teach-back. This reduces readmission rates and ensures seamless transitions.
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?
- Contact each department separately over the course of the shift
- Ask the family to schedule the consultations to save time
- Initiate an interdisciplinary care conference to coordinate simultaneous planning (Correct answer)
- Wait for the physician to order all consults before taking action
Correct answer: Initiate an interdisciplinary care conference to coordinate simultaneous planning
An interdisciplinary care conference brings together all team members (wound care, PT, dietitian, physician, nursing) to coordinate an integrated care plan. This prevents fragmented care, reduces duplicated effort, and ensures goals are client-centered.
Question 3: A nurse is handing off care using the SBAR communication tool. Which element is included under the 'Recommendation' component?
- The client's current vital signs and lab values
- A concise summary of the clinical background and history
- What the nurse believes needs to happen and the requested action (Correct answer)
- An objective description of the client's current condition
Correct answer: What the nurse believes needs to happen and the requested action
In SBAR (Situation, Background, Assessment, Recommendation), the Recommendation component contains what the nurse is requesting — such as a medication order, diagnostic test, or transfer. It is the action-oriented conclusion of the communication.
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:
- An acute rehabilitation facility for 6 weeks before returning home
- Home health services including physical therapy and skilled nursing visits (Correct answer)
- A psychiatric social worker to assess for depression
- The hospital dietary department for meal planning instructions
Correct answer: Home health services including physical therapy and skilled nursing visits
A client with limited mobility who lives alone after hip replacement requires home health services to ensure safe recovery. Home physical therapy improves mobility and fall prevention, while skilled nursing visits monitor wound healing and medication adherence.
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?
- Add the medication to the MAR based on the client's verbal report
- Perform medication reconciliation by contacting the transferring provider to verify the complete list (Correct answer)
- Hold all medications until the family can bring the original bottles
- Administer a standard dose based on the client's weight and diagnosis
Correct answer: Perform medication reconciliation by contacting the transferring provider to verify the complete list
Medication reconciliation at transitions of care is a critical safety process. The nurse must verify the complete and accurate medication list with the previous provider before administering anything. Administering unverified medications can cause serious harm.
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:
- Address each issue independently on separate days to avoid overwhelming the team
- Document the concerns and wait for the physician's next scheduled visit
- Initiate a multidisciplinary team meeting to address barriers to the care plan (Correct answer)
- Ask the family to contact the hospital's patient advocate directly
Correct answer: Initiate a multidisciplinary team meeting to address barriers to the care plan
When multiple barriers affect a client's care plan simultaneously, a multidisciplinary team meeting is the most efficient and coordinated response. It allows the team to problem-solve collaboratively and align goals with the client and family.
Coordination of Care 1
A nurse is preparing to discharge a client who was hospitalized for heart failure.
Which action best supports continuity of care?