A new nurse has just admitted a patient to the Step-down Unit. She has recognized several education and implementation pieces that need to be set in place before the patient is discharged.
Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?
“I will begin upon the client’s admission to the facility.”
“I will begin once the client’s insurance company approves discharge coverage.”
“I will begin 48 hr before the client’s discharge.”
“I will begin once the client’s discharge order is written.”
The Correct Answer is A
A. “I will begin upon the client’s admission to the facility.”
Effective discharge planning should start upon the client's admission to the facility. It is an ongoing process that involves assessing the patient's needs, planning for post-discharge care, and ensuring a smooth transition from the hospital to the next level of care. Early initiation of discharge planning allows the healthcare team to address any potential barriers, educate the patient and their family, and coordinate necessary resources for a successful transition.
B. “I will begin once the client’s insurance company approves discharge coverage.”
Waiting for insurance approval may delay the discharge planning process and hinder the timely coordination of resources needed for post-discharge care.
C. “I will begin 48 hr before the client’s discharge.”
Waiting until 48 hours before discharge may not allow sufficient time to address all aspects of the discharge plan, potentially leading to rushed or incomplete preparations.
D. “I will begin once the client’s discharge order is written.”
Waiting for the discharge order may delay the start of the planning process, and effective discharge planning should be initiated earlier to ensure comprehensive and patient-centered care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Adequacy of circulation:
This assessment is the highest priority for a client who has undergone a procedure to bypass arteries in the right leg. Monitoring for signs of adequate blood flow, such as color, temperature, capillary refill, and pulses in the operated leg, is critical to identify and address any circulation issues early.
B. Patency of airway:
While maintaining a patent airway is always a priority in postoperative care, it is not the immediate concern in a client who has just undergone a leg bypass procedure. Airway management is essential, but assessing circulation in the operated limb takes precedence.
C. Movement of lower leg:
Assessing movement of the lower leg is important for detecting signs of impaired motor function or complications. However, it is secondary to assessing the adequacy of circulation, which is critical for preventing ischemia and other circulatory issues.
D. Neurovascular status of the left leg:
While monitoring the neurovascular status of the left leg is a valid aspect of the overall assessment, the priority in the immediate postoperative period is to assess the surgical site (right leg) to ensure that blood flow is adequate and that there are no immediate complications.

Correct Answer is ["A","D","E"]
Explanation
A. Client reports feeling dizzy when sitting up from a supine position.
Dizziness or lightheadedness when moving from a lying down to a sitting or standing position can be indicative of orthostatic hypotension.
B. Client reports feeling palpitations when rising from a supine to a standing position.
Palpitations (feeling of rapid or irregular heartbeat) can be associated with orthostatic changes and may indicate the heart's compensatory response to low blood pressure.
C. Erythema is present on the bilateral lower extremities.
Erythema (redness of the skin) is not typically associated with orthostatic hypotension. This symptom is more likely related to skin conditions or other causes.
D. The client has a temperature of 100.4 F.
Fever (elevated body temperature) is not a direct symptom of orthostatic hypotension. Orthostatic hypotension is primarily related to changes in blood pressure upon assuming an upright position.
E. The client states, “I feel lightheaded when sitting up.”
Lightheadedness upon sitting up or standing is a common symptom of orthostatic hypotension.
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