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Which transition of care intervention would the community health nurse perform when a client is discharged from the hospital to home?
  1. Assisting the client with activities of daily living
  2. Administering medications in the home setting
  3. Performing medication reconciliation
  4. Transporting client to medical appointments
Which condition does the nurse recognize as increasing the risk of a poor outcome during a transition of care?
  1. A client being discharged from hospital to home
  2. A client with an identified social support system
  3. A client with limited health literacy
  4. A client with one provider
The home care nurse is performing medication reconciliation with a client during the first home visit following hospital discharge. Which statement by the client requires follow-up by the nurse?
  1. “I understand why the doctor has stopped some of my medications.”
  2. “I have not seen that blue pill before.”
  3. “I set alarms on my phone to remind me to take my medications.”
  4. “I use a daily pill box to set up my medications.”
The nurse, caring for a client who will be transferred from the hospital to a rehabilitation facility following a stroke, is using a care transition model to facilitate the transfer. Which explanation for the use of a care transition model will the nurse provide to the nursing student working the client?
  1. “Care transition models predict client outcomes during care transitions.”
  2. “Care transition models guide health care providers in the decision-making process.”
  3. “Care transition models support the coordination of care between health care settings.”
  4. “Care transition models focus on client education during care transitions.”
Which action will the nurse take when planning discharge for a client using the IDEAL Discharge Planning guide?
  1. Use accurate medical terms when educating the client and family about discharge instructions
  2. Engage clients and their families in the discharge planning process
  3. Ask the client if they have any questions to evaluate understanding of the discharge teaching
  4. Provide the client with a standardized discharge plan of care
Using the Transitional Care Model (TCM), which action would the nurse take when preparing an 81-year-old client with diabetes, hypertension, and heart failure for discharge home from the hospital following an exacerbation of heart failure?
  1. Provide the client with a standardized plan of care to follow
  2. Identify risk factors for readmission and develop an individualized discharge plan
  3. Refer the client to a discharge coach to encourage client self-management
  4. Contact the advanced practice nurse to coordinate the discharge from hospital to home
The community health nurse is facilitating transitional care for an older adult client between the hospital and home. Which action is a priority responsibility of the community health nurse in this transition of care?
  1. Providing direct client care in the home setting
  2. Educating clients about health promotion and prevention
  3. Coordinating care among health care providers
  4. Administering medication in the home
A nurse is concerned about the increasing rate of hospital readmissions in clients due to not filling or picking up prescriptions at the pharmacy after discharge from the hospital. Which intervention should the nurse recommend to the hospital leadership to improve adherence to the medication regimen after discharge?
  1. Calling prescriptions in to the client’s pharmacy at discharge
  2. Handing client prescriptions for home medications during discharge instruction
  3. Providing client with home medications at discharge
  4. Telling the client that medication adherence will reduce readmissions to the hospital
Which intervention by the community health nurse improves care for clients during the transition from behavioral health hospitalization to outpatient care?
  1. Ensuring effective communication among health care providers
  2. Reducing the number of providers involved in the client’s care
  3. Requiring medications to be taken under direct observation by a nurse
  4. Attending follow-up appointments with the client
Which health information system would the nurse utilize to promote self-management in a client with diabetes who has been having difficulty controlling blood glucose levels?
  1. Decision support systems
  2. Mobile health applications
  3. Care coordination platforms
  4. Electronic health records

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