Coordination of Care 2 — Questions and Answers

Question 1: A nurse is caring for a client who needs wound care daily after discharge. Which referral is most appropriate?

Physical therapy
Home health nursing (Correct answer)
Occupational therapy
Palliative care

Correct answer: Home health nursing

Home health nursing provides skilled nursing services such as wound care, medication management, and ongoing assessment in the client's home environment following discharge from an acute care facility.

Coordination of care includes connecting clients with the appropriate resources and services to ensure continuity after hospital discharge. When a client requires ongoing skilled wound care — such as irrigation, packing, assessment of healing, or wound VAC management — home health nursing is the appropriate referral because registered nurses can provide these skilled services at home. Home health nurses perform regular visits, assess wound healing progress, adjust wound care protocols, educate the client and family, and communicate with the primary care provider or wound care specialist. They can also identify signs of wound infection or complications early. Physical therapy addresses mobility, strength, and rehabilitation. Occupational therapy focuses on activities of daily living and adaptive equipment. Palliative care is appropriate for clients with serious illness focused on symptom management and quality of life — not wound care specifically. The discharge planning process should begin early in the hospital admission. The nurse collaborates with the case manager and social worker to identify client needs, arrange community resources, and ensure a smooth transition to home or another care level. The client and family should receive education on wound care, signs of infection, when to call the provider, and how to access home health services.

Question 2: A nurse receives a telephone order from a physician during an emergency. After taking the verbal order, which step is most important?

Implement the order immediately without delay
Read back the order to the physician for confirmation (Correct answer)
Document the order and have another nurse co-sign
Notify the charge nurse of the verbal order received

Correct answer: Read back the order to the physician for confirmation

Reading back the verbal/telephone order to the prescriber is the critical safety step that confirms accuracy before the nurse implements any intervention, reducing the risk of medication or treatment errors.

Verbal and telephone orders carry a high risk for miscommunication errors due to ambient noise, similar-sounding drug names (sound-alike drugs), and unclear pronunciation of numbers. The read-back process is a Joint Commission-required safety practice designed to catch errors before they harm patients. After receiving a verbal or telephone order, the nurse writes it down completely (including drug name, dose, route, frequency, and indication) and then reads it back verbatim to the prescriber. The prescriber confirms accuracy or corrects any discrepancies. Only after confirmed readback should the nurse implement the order. The nurse then documents the order in the medical record, noting it as a telephone order (TO) or verbal order (VO), and includes the prescriber's name, the date and time, and the nurse's signature. The prescriber is required to countersign the order within the timeframe specified by facility policy (typically 24-48 hours). In emergencies, action may need to be taken simultaneously with documentation, but the read-back should still occur before implementing if even a few seconds are available. This process applies to all verbal orders, not just medications — it also applies to lab results, diagnostic test changes, and treatment modifications.

Question 3: A nurse is preparing to transfer a client from the medical-surgical unit to the ICU due to deteriorating condition. Which action is most important to facilitate a safe transfer?

Ensure all personal belongings are packed and sent with the client
Provide a verbal and written handoff report to the receiving nurse (Correct answer)
Notify the client's family before the transfer occurs
Request that the physician accompany the client to the ICU

Correct answer: Provide a verbal and written handoff report to the receiving nurse

A thorough verbal and written handoff report (SBAR) is the most critical element of a safe client transfer, ensuring the receiving nurse has accurate and complete information about the client's condition, treatments, and current status.

Patient handoffs — the transfer of responsibility and care from one provider to another — are high-risk periods for errors and adverse events. Research shows that a significant percentage of medical errors in hospitals occur during handoffs. A structured handoff using SBAR (Situation, Background, Assessment, Recommendation) ensures that critical information is communicated clearly and completely. The handoff should include: the client's current condition and reason for transfer, relevant medical history, current medications including recent IV medications, active orders, IV access and infusions, pending labs or diagnostics, allergies, code status, and any immediate concerns. The receiving nurse should have the opportunity to ask questions. While notifying the family is important for emotional support and communication, it does not take priority over clinical handoff information for patient safety. Personal belongings and physician escort are logistical considerations, not primary safety mechanisms. Documentation must reflect the transfer including time, mode of transport, receiving unit and nurse, and client's status at time of transfer. If the client is unstable, a respiratory therapist, physician, or additional nursing support may accompany the client during transport, along with monitoring equipment and emergency medications.

Question 4: A nurse is working with an unlicensed assistive personnel (UAP). Which task is appropriate for the nurse to delegate to the UAP?

Administering a prescribed enema to a client
Measuring and recording urinary output from a catheter (Correct answer)
Assessing a client's pain level before ambulation
Teaching a client how to use an incentive spirometer

Correct answer: Measuring and recording urinary output from a catheter

Measuring and recording urinary output from a catheter is a routine, non-complex task within the UAP's scope of practice. Assessment, teaching, and medication administration (such as enemas) require nursing judgment and cannot be delegated.

Delegation is the transfer of responsibility for performance of a task from one healthcare provider to another while the nurse retains accountability for the overall outcome. Safe delegation requires applying the five rights of delegation: right task, right circumstance, right person, right direction and communication, and right supervision. UAPs are trained to perform routine, non-complex tasks that do not require nursing judgment, assessment, or clinical decision-making. Measuring and recording urinary output is an objective measurement that the UAP can reliably perform and report to the nurse. Activities that cannot be delegated to UAPs include: nursing assessment (pain assessment, physical assessment), nursing interventions requiring clinical judgment, medication administration, teaching, care planning, and evaluation of client responses. Administering an enema, while technically a physical task, involves assessment of client response, contraindications, and potential complications — making it a nursing function. The nurse remains responsible for the overall care of delegated clients. After delegating, the nurse must provide clear instructions, set expectations for reporting, follow up on completion, and document outcomes. If the UAP reports an abnormal finding (e.g., no urine output for 4 hours), the nurse must respond with appropriate assessment and intervention.

Question 5: A nurse is reviewing a newly admitted client's medication list and notices a potential drug-drug interaction. Which action should the nurse take first?

Administer both medications and monitor the client closely
Hold both medications until the interaction is resolved
Contact the prescribing provider to discuss the interaction (Correct answer)
Consult the pharmacist and document findings in the chart

Correct answer: Contact the prescribing provider to discuss the interaction

The nurse's first action should be to contact the prescribing provider to report the potential interaction and obtain guidance. The provider is responsible for deciding how to manage the interaction, which may include modifying doses, changing timing, or substituting medications.

Medication reconciliation is a critical nursing responsibility, especially at care transitions such as admission. When a nurse identifies a potential drug-drug interaction, prompt communication with the prescribing provider is essential because the nurse does not have prescriptive authority and cannot independently modify medication orders. The nurse prepares for this communication using the SBAR format: Situation (the specific medications and identified interaction), Background (why each was prescribed, client's diagnosis and history), Assessment (clinical significance of the interaction — minor, moderate, or major), and Recommendation (requesting provider review and guidance on how to proceed). Pharmacists are invaluable resources for drug interaction information and should be consulted as well, but the prescriber must be notified because they hold prescriptive authority and must make the final clinical decision. The nurse should not hold medications unilaterally without a provider order unless there is an immediate safety risk. All findings, communications, and provider responses must be documented in the client's medical record. If the provider does not respond promptly and the interaction is serious, the nurse should escalate through the chain of command following facility policy.

Question 6: A nurse is preparing discharge instructions for a client going home on warfarin (Coumadin). Which topic is most important to include in the teaching plan?

The importance of maintaining a consistent dietary intake of vitamin K (Correct answer)
The need to take the medication with food to prevent nausea
Instructions to double the dose if a dose is missed
The requirement to take aspirin for breakthrough pain

Correct answer: The importance of maintaining a consistent dietary intake of vitamin K

Warfarin's anticoagulant effect is directly influenced by vitamin K intake. Clients must maintain consistent (not eliminate) vitamin K consumption to keep INR stable. Abrupt changes in dietary vitamin K can cause the INR to become dangerously high or low.

Warfarin (Coumadin) is a vitamin K antagonist anticoagulant commonly used for atrial fibrillation, mechanical heart valves, DVT, and pulmonary embolism. Its therapeutic effect is highly variable and influenced by dietary vitamin K intake, other medications, illness, and genetic factors. Vitamin K is found primarily in leafy green vegetables (spinach, kale, broccoli, Brussels sprouts). Consuming large amounts of vitamin K counteracts warfarin's anticoagulant effect, lowering the INR and increasing clotting risk. Conversely, drastically reducing vitamin K intake can raise the INR to dangerous levels, increasing bleeding risk. Client education should emphasize consistency — not elimination — of vitamin K-containing foods. The client should eat roughly the same amount of leafy greens each week rather than avoiding them entirely, which is unsustainable and leads to INR fluctuations when foods are eventually reintroduced. Other essential warfarin teaching includes: take the medication at the same time each day, report signs of bleeding (unusual bruising, blood in urine/stool, prolonged bleeding from cuts), attend all INR monitoring appointments, and notify all providers they are on warfarin. The client should never double a dose for a missed one and should avoid aspirin and NSAIDs (which increase bleeding risk) unless specifically prescribed.

Coordination of Care 2

A nurse is caring for a client who needs wound care daily after discharge.
Which referral is most appropriate?