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) A nurse tells a client's health care surrogate that the client might require restraints if diversion activities are ineffective:

This scenario does not represent slander. While discussing the possibility of using restraints with a client's health care surrogate involves sensitive communication, it does not constitute slander. The nurse is providing information about potential interventions based on the client's needs and safety concerns, which is a part of the nursing role.

B) A nurse documents that a client was shouting and directly quotes the client's words:

This scenario involves accurate documentation of a client's behavior and does not constitute slander. Documenting a client's actions, such as shouting, with direct quotes from the client's words is essential for providing an accurate record of events and communication during the client's care.

C) A client overhears assistive personnel make a false statement about the assigned nurse and requests a different nurse:

This scenario represents slander. Slander involves making false statements that harm someone's reputation, and in this case, the assistive personnel's false statement about the assigned nurse could damage the nurse's professional reputation. The client's request for a different nurse indicates the potential negative impact of the false statement on the nurse's relationship with the client.

D) A staff member reports to the unit supervisor during a private meeting that a coworker is possibly impaired:

This scenario involves reporting a concern about a coworker's potential impairment, which is not an example of slander. Reporting concerns about impairment is a critical aspect of ensuring patient safety and maintaining professional standards in healthcare settings. However, such reports should be handled confidentially and with appropriate discretion.

A. Verify the medication name along with its intended purpose. B. Verbalize the letters "B-I-D" for the dosing instead of saying "twice per day." C. Transcribe the medication name using the trade me. D. Remind the provider to countersign the prescription in 72 hr.

Correct Answer is A

Explanation

A. Verify the medication name along with its intended purpose.

Rationale:

Verifying the medication name along with its intended purpose is crucial to ensure accuracy and patient safety. In this scenario, the nurse should confirm that the medication name "propranolol" matches the intended medication prescribed by the provider. Additionally, understanding the purpose of the medication ensures that the nurse can correctly communicate this information to the patient, reinforcing patient education and adherence to the prescribed treatment plan. Verifying the medication name and purpose helps prevent medication errors and promotes safe medication administration practices.

B. Verbalize the letters "B-I-D" for the dosing instead of saying "twice per day."

Verbalizing the letters "B-I-D" for the dosing frequency instead of saying "twice per day" is not the most appropriate action in this situation. While using medical abbreviations like "B-I-D" (which stands for "bis in die" or "twice a day") is common in healthcare settings, it's essential to ensure clear communication with all involved parties, including patients and providers. Using layman's terms like "twice per day" helps avoid confusion and promotes better understanding, reducing the risk of medication errors due to misinterpretation.

C. Transcribe the medication name using the trade name.

Transcribing the medication name using the trade name is not appropriate unless specifically instructed by the provider or if there is a specific reason to do so. In this scenario, the nurse should use the generic name "propranolol" when transcribing the medication to ensure consistency and accuracy in documentation and communication. Using trade names can lead to confusion, especially in environments where multiple brand names may exist for the same generic medication.

D. Remind the provider to countersign the prescription in 72 hr.

Reminding the provider to countersign the prescription in 72 hours is not relevant to the immediate task of verifying and reading back the prescription information. While ensuring proper documentation and authorization of prescriptions is important, it should not be addressed during the initial verification and communication process. This action can be addressed separately, following the completion of the prescription verification process.

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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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