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.”

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

A. Wait 30 min and return to measure the oral temperature:

Waiting 30 minutes may not be necessary. It's more practical to take immediate steps to address potential factors affecting the reading.

B. Provide the client a sip of warm water, wait 5 min, and measure the temperature:

This can be a reasonable and practical approach to stimulate blood flow in the oral cavity and achieve a more accurate oral temperature reading.

C. Document that the nurse was unable to measure the client’s temperature:

Before documenting an inability to measure the temperature, the nurse should attempt appropriate interventions, such as warming the oral cavity or using an alternate route

D. Determine if the client has eaten or drank within the last 15 minutes:

Eating or drinking something cold shortly before taking an oral temperature can result in a lower reading. Checking for recent intake is important to ensure the accuracy of the measurement.

E. Use an alternate route (i.e., axillary, rectal) to take the client’s temperature:

If the oral temperature reading remains difficult to obtain or is not reliable, using an alternate route may be necessary. However, this depends on the client's condition, the reason for the temperature measurement, and the healthcare facility's protocols.

A. Develop a plan of care for the client B. Provide a schedule of visiting hours to the client’s family C. Teach the client about his diagnosis D. Document the client’s code status

Correct Answer is D

Explanation

A. Develop a plan of care for the client:

Developing a plan of care is essential, but it should be informed by the client's current condition, diagnosis, and code status. Documenting the code status is a foundational step.

B. Provide a schedule of visiting hours to the client’s family:

While facilitating family involvement is important, it is not the top priority during the initial admission assessment. Ensuring the client's safety and understanding their code status takes precedence.

C. Teach the client about his diagnosis:

Patient education is important, but in a critical situation, the priority is to assess and document key information, including the code status. Education can follow once the immediate priorities are addressed.

D. Document the client’s code status

When conducting the initial admission assessment for a critical client, the priority action is to document the client's code status. Code status refers to the set of directives given by the client or their legal representative regarding the use of cardiopulmonary resuscitation (CPR) and other life-sustaining measures in the event of a cardiac or respiratory arrest.

Understanding and documenting the client's code status is crucial for informing the healthcare team about the client's preferences for resuscitation efforts. This information guides the team in providing care that aligns with the client's wishes and values.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is measuring a client’s oral temperature. The thermometer reads 33 C (91.4F). Which of the following actions should the nurse take? (Select all that apply)

Correct Answer is ["B","D","E"]

Explanation

A nurse is completing the initial admission assessment and history for a critical client. Which of the following is the priority action for the nurse to take?

Correct Answer is D

Explanation

While taking an adult patient’s pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next?

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The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment, what finding would the nurse expect?

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A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

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