A nurse is assisting with the discharge of a client from acute care to home health care. Which of the following components of the medical record should the nurse provide to the home health agency?

Vital signs flow sheet

Nursing admission assessment

Current medications

Nurses' notes

Answer and Explanation

The Correct Answer is C

A) Vital signs flow sheet:

While vital signs are essential for assessing the client's health status, the home health agency typically focuses on the client's ongoing care needs rather than retrospective data such as vital sign trends.

B) Nursing admission assessment:

The nursing admission assessment provides valuable information about the client's initial condition upon admission to the acute care facility. However, the home health agency primarily requires information relevant to the client's current health status and ongoing care needs.

C) Current medications:

Providing the home health agency with a list of the client's current medications is essential for continuity of care. It allows the home health agency to ensure that the client receives the appropriate medications and dosages after discharge. This information helps prevent medication errors, adverse drug interactions, and omissions in the client's care plan. Additionally, the home health agency can use the medication list to reconcile medications and update the client's medication regimen as needed.

D) Nurses' notes:

While nurses' notes contain valuable information about the client's care during their stay in the acute care facility, they may not be immediately relevant to the home health agency's provision of care in the community setting. The focus of the home health agency is typically on the client's current status and needs rather than historical documentation.

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Correct Answer is C

Explanation

A) Determine which clients need priority medical treatment: This task requires clinical judgment and assessment skills beyond the scope of practice for assistive personnel. Nurses are responsible for assessing clients' needs during emergencies and determining priority for medical treatment based on the severity of their conditions.

B) Answer questions from area residents who have health concerns: While it's important to provide information and support to those affected by the tornado, answering questions about health concerns requires knowledge and expertise in healthcare that is typically within the nurse's scope of practice. Nurses should address inquiries and provide education to ensure the well-being of the community.

C) Perform CPR for a client who is not breathing: This task can be delegated to assistive personnel if they are trained and competent in CPR. In emergencies such as cardiac arrest, prompt initiation of CPR can be life-saving. However, it's crucial to ensure that the assistive personnel are properly trained and certified in CPR before delegating this task.

D) Complete distal capillary refill checks for a client who has an open leg wound: While assessing capillary refill is an important aspect of wound care, performing this task for a client with an open leg wound requires specialized knowledge and skills in wound assessment and management. It falls within the scope of nursing practice and should not be delegated to assistive personnel.

A. Reinforcing teaching with a client about stool specimen collection B. Collecting a urine specimen from a client who is experiencing dysuria C. Taking the vital signs of a client who is experiencing acute angina D. Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure

Correct Answer is B

Explanation

A) Reinforcing teaching with a client about stool specimen collection:

This task involves providing education to the client, which requires nursing knowledge and judgment. It is not appropriate to delegate to assistive personnel, as they may not have the necessary training or expertise to provide accurate and comprehensive teaching.

B) Collecting a urine specimen from a client who is experiencing dysuria:

Collecting a urine specimen from a client who is experiencing dysuria is an appropriate task to delegate to assistive personnel. This task involves following a standard procedure for specimen collection and does not require specialized nursing judgment or assessment skills.

C) Taking the vital signs of a client who is experiencing acute angina:

Assessing vital signs, especially in a client experiencing acute angina, requires nursing judgment and the ability to recognize and respond to changes in the client's condition. This task should not be delegated to assistive personnel, as they may not have the training to recognize signs of deterioration or respond appropriately.

D) Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure:

Providing information over the phone regarding NPO (nothing by mouth) status involves assessing the client's specific situation, understanding the procedure's requirements, and potentially making clinical decisions based on the client's condition. This task requires nursing judgment and should not be delegated to assistive personnel.

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A nurse is assisting with the discharge of a client from acute care to home health care. Which of the following components of the medical record should the nurse provide to the home health agency?

Nursing Test Bank

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