Deck 2: Interprofessional Collaboration and Care Coordination

Question 1

In preparing a patient for transfer from the hospital to a rehabilitation facility after joint replacement surgery, which action does the nurse implement to manage the patient's transition of care?
1)Reviewing newly prescribed medications with the patient and the family
2)Notifying the insurance carrier of the patient's discharge
3)Teaching about clinical manifestations of infection
4)Initiating transition planning the day of discharge

Answer 1

3

Question 2

The home care nurse is planning care for a patient with diabetes mellitus who requires an extensive dressing change twice a day, assistance with activities of daily living (ADLs), and comprehensive education. Which role is the nurse assuming by coordinating the care this patient requires?
1)Collaborator
2)Case manager
3)Health educator
4)Health promoter

Answer 2

2

Question 3

The nurse provides discharge teaching for a patient who is being discharged after receiving intravenous antibiotics for pneumonia. Which statement by the nurse demonstrates effective use of the teach-back method?
1)"Do you understand the information I have presented?"
2)"Please show me how you would clean the site before infusing the medication."
3)"You need to have another set of serum cultures before discharge."
4)"Please complete this short quiz about your discharge instructions."

Answer 3

2

Question 4

Which should be the focus of an educational session for nurses and other members of the interdisciplinary team when addressing high rates of patient readmission to the health system?
1)Medication errors
2)Coordination of care
3)Adverse clinical events
4)Roles of each member providing care

Question 5

A patient with type 1 diabetes mellitus has developed an open sore on the shin, is having trouble meeting daily goals for exercising, and is scheduled for discharge in a couple of days. When planning for this patient's continued care, who will the nurse notify to coordinate the patient's needs after discharge?
1)Pharmacist
2)Case manager
3)Physical therapist
4)Occupational therapist

Question 6

The nurse is managing care for a patient who recently had a stroke and has difficulty swallowing and is concerned about potential aspiration. Which member of the healthcare team can best assess this patient's swallowing ability?
1)Occupational therapist
2)Dietician
3)Social worker
4)Speech pathologist

Question 7

The nurse case manager has been extensively involved with a shooting victim and members of the patient's family in coordinating care of providers from many disciplines as the patient progressed from the emergency department (ED) to the intensive care unit (ICU), and then onto the medical-surgical unit. After 3 weeks of hospitalization, the case manager is helping to prepare the patient for discharge to a rehabilitation center. Which outcomes have been documented in the literature as benefits of such collaboration? Select all that apply.
1)Improved patient outcomes
2)Decreased duplication of healthcare services
3)Increased overall cost of healthcare services
4)Decreased patient morbidity and mortality
5)Decreased level of job satisfaction

Question 8

The nurse provides care to a patient who is newly diagnosed with type 2 diabetes mellitus. Which interprofessional care team member is most important for the nurse to include when planning care related to the patient's blood glucose levels and nutritional and energy needs?
1)Registered dietitian/nutritionist (RD)
2)Home care coordinator
3)Speech-language pathologist (SLP)
4)Physical therapist

Question 9

The case manager interviews a hospitalized patient who requires inpatient rehabilitation before being discharged home after hip replacement surgery. The case manager works with the hospital nursing staff, the rehabilitation center, the patient's family members, and other care providers to assist with a successful transition. Which is the primary goal of the care management model described here?
1)To provide greater peace of mind for the patient and his or her family members
2)To track a patient's progress to ensure that appropriate care is provided until discharge
3)To manage concerns that are related to the patient's medical care and treatment regimen only
4)To provide a continuum of clinical services in order to help contain costs and improve patient outcomes

Question 10

The nurse prepares to present information for patients during multidisciplinary rounds (MDR). Which does the nurse plan to include when presenting information on assigned patients?
1)The medical plan for the current shift
2)A comprehensive overview of the patient's clinical situation
3)General actions that need to be completed before the patient's discharge
4)Results from a risk screen indicating potential post-acute care needs

Question 11

The nurse is discussing follow-up care with a patient who is being discharged. The patient and family cross their arms and state angrily that the team's suggestions are not acceptable. Which response by the nurse is MOST appropriate?
1)"We only want what's best for you."
2)"We will leave you alone to discuss your options."
3)"Perhaps you did not understand the recommendations."
4)"Let's discuss other options that might work well for you and your family."

Question 12

In providing an educational program to new graduate nurses, which statement by one of the participants indicates the need for further teaching related to the Five Rights of Delegation?
1)"If the UAP has completed training, I can assign any task to them."
2)"I need to follow up on a patient when the UAP reports a change in the patient's condition."
3)"It is the UAP's responsibility to ask questions if unsure of the task to be completed."
4)"I am ultimately responsible for ensuring that all delegated tasks are completed."

Question 13

A school-age patient is admitted to the pediatric intensive care unit (PICU), unconscious and with multiple traumatic injuries, after a skateboard accident that included a closed head injury. Many health professionals are involved in the patient's care and the scene is chaotic. The parents are extremely anxious and want to know what is happening. The case manager asks for an interdisciplinary team meeting to speak with the patient's parents. Which is the rationale for this meeting?
1)To allow for each specialty to independently describe their roles in the patient's care
2)To share information for care planning and to prevent priority conflicts, redundancy, and omissions in care
3)To allow the primary healthcare provider to take the lead in the decision making regarding the patient's care
4)To prevent the parents from trying to change the goals of care

Question 14

In providing a change-of-shift report to the oncoming nurse, which is the main objective for ensuring effective communication during a patient hand-off?
1)Avoiding lawsuits
2)Promoting patient safety
3)Facilitating quality improvement
4)Ensuring documentation is complete

Question 15

Which initiatives were instrumental to the United States addressing healthcare that is coordinated, safe, and focused on the patient's unique needs across all setting care settings? Select all that apply.
1)Project RED (Re-engineered Discharge)
2)To Err Is Human: Building a Safer Health Care System
3)Crossing the Quality Chasm: A New Health System for the 21st Century
4)Transforming Care at the Bedside Project
5)Project BOOST (Better Outcomes for Older Adults through Safe Transitions)

Question 16

The nurse managers in a community hospital have been charged with reviewing job descriptions of unlicensed assistive personnel (UAPs) and have questions about the delegation of certain patient care activities to UAPs by nurses. To whom would committee members direct their questions to obtain definitive answers about the parameters of nurse delegation to UAPs?
1)The State Board of Nursing
2)The American Nurses Association
3)The hospital's Chief Nursing Officer
4)The hospital's Chief Executive Officer

Question 17

The nurse is caring for a patient who is reporting pain of 8 out of 10 on a 1 to 10 numerical pain scale. The nurse administers the prescribed pain medication. When the nurse reevaluates the patient 1 hour later, the patient is still reporting pain of 8 out of 10. Which action by the nurse is appropriate at this time?
1)Wait for the healthcare provider to make rounds to report the problem.
2)Report to the healthcare provider by telephone.
3)Increase the dosage of the medication.
4)Include in the nursing report that the medication is ineffective.

Question 18

The nurse correlates which of the following as one of the primary driving factors to the identified need for improved transitional care services in today's healthcare system?
1)Shortage of primary care healthcare providers
2)Increase in the numbers of patients readmitted within 30 days of discharge
3)Decrease in the numbers of acute care beds
4)Shortage of registered nurses employed in hospitals

Question 19

Which is a basic principle of the Patient Protection and Affordable Care Act of 2010 that the nurse should include in a teaching session for members of the healthcare team?
1)Limiting choices of healthcare providers to control costs
2)Lowering the cost of care by decreasing readmissions
3)Mandating insurance charges to increase hospital revenues
4)Extending length of stays in acute care facilities

Question 20

The nurse is preparing a patient for discharge who will be requiring physical therapy (PT) for rehabilitation after a total knee replacement. After reading the healthcare provider's order for PT, which would be the nurse's initial action?
1)Teach the family the exercises needed for the patient.
2)Call home health and schedule a therapist to visit the home for therapy.
3)Set up appointments according to the order with the hospital PT department.
4)Discuss the various types of settings for therapy and have the patient choose the venue.

Question 21

The post-discharge call nurse provides care to a patient after discharge. Which actions does the nurse implement when assuming this role? Select all that apply.
1)Calling the patient within 12 hours after discharge
2)Connecting the patient to home care based on current needs
3)Identifying potential challenges the patient may be experiencing
4)Diagnosing new medical problems that necessitate the patient to seek further follow-up
5)Answering questions from the patient's caregiver, who was not present during discharge teaching

Question 22

When discussing the importance of interprofessional collaboration, which advantages should the nurse include? Select all that apply.
1)Improved team member satisfaction
2)Increased division among team members
3)Increased safety with medication administration
4)Enhanced communication among team members
5)Increased patient satisfaction with discharge transition process

Question 23

Which of the following statements by a patient indicates that teaching was effective about the role of the transition care nurse in the plan of care. Select all that apply.
1)"This nurse will visit me in my home for the next month."
2)"This nurse will call me every day to make sure that I take my medications."
3)"This nurse will visit be before I am discharged."
4)"This nurse will monitor my progress for the next year."
5)"This nurse will make follow-up phone calls during the second month that I am at home."

Question 24

The nurse recognizes which factors as important to a successful transitional care program? Select all that apply.
1)Patient-centered approach
2)Agency-centered approach
3)Outcomes focused
4)Disease management focused
5)Patient education focused

Question 25

The case manager assembles a team of healthcare professionals, including the patient's primary healthcare provider, physical therapist, and social worker, for the purpose of collaborative discharge planning and decision making. Which type of team did the case manager assemble? Select all that apply.
1)Management
2)Intradisciplinary
3)Interdisciplinary
4)Interprofessional
5)Primary nursing care