1
NCLEX RN Exam Bank: Coordination of Care &
Patient Transition Planning
Table of Contents
Subtopic 1: Interdisciplinary Team Collaboration in Patient Transitions ............................. 2
Subtopic 2: Safe Discharge Planning and Continuity of Care .......................................... 10
Subtopic 3: Care Transitions Between Acute and Long-Term Settings .............................. 17
Subtopic 4: Patient Education and Self-Management in Transition Planning .................... 26
Subtopic 6: Nurse Case Management and Continuity of Care ......................................... 34
, 2
Subtopic 1: Interdisciplinary Team Collaboration in Patient
Transitions
Question 1
A nurse is coordinating discharge planning for a patient with a new colostomy. Which of the
following interdisciplinary team members should be consulted to ensure the patient’s
successful transition home?
A. Wound and ostomy care nurse
B. Dietitian
C. Speech therapist
D. Respiratory therapist
Correct Answer: A. Wound and ostomy care nurse
Rationale: A wound and ostomy care nurse specializes in managing and educating patients
with colostomies, which is essential for a smooth home transition and prevention of
complications.
Question 2
Which of the following best represents effective communication in interdisciplinary care
planning?
A. Documenting patient care in the chart
B. Conducting daily bedside rounds with all team members
C. Updating family members on the plan
D. Calling the primary provider once daily
Correct Answer: B. Conducting daily bedside rounds with all team members
Rationale: Daily interdisciplinary rounds enhance communication and ensure that the
patient’s care plan is cohesive and understood by all involved.
Question 3
, 3
During interdisciplinary rounds, the nurse should prioritize reporting:
A. All lab values
B. Patient’s current pain level and response to treatment
C. The number of visitors the patient has had
D. Nurse’s personal impression of patient progress
Correct Answer: B. Patient’s current pain level and response to treatment
Rationale: The pain level and response to interventions are clinically relevant and influence
care planning across disciplines.
Question 4
A patient recovering from a stroke needs physical, occupational, and speech therapy. What
is the nurse’s primary role during interdisciplinary coordination?
A. Perform all therapy activities with the patient
B. Communicate therapy goals to the care team
C. Schedule therapy sessions
D. Document only nursing interventions
Correct Answer: B. Communicate therapy goals to the care team
Rationale: The nurse acts as a liaison, ensuring that patient-centered goals are shared and
understood across all disciplines.
Question 5
A nurse is coordinating care for a patient being discharged to a rehabilitation facility. Which
information is most important to include in the transition report?
A. Insurance provider details
B. Current medications and recent changes
C. Date of hospital admission
D. Nurse’s opinion of family support
, 4
Correct Answer: B. Current medications and recent changes
Rationale: Medication reconciliation is critical to ensure safety and continuity of care
during transitions.
Question 6
Which statement by a nurse demonstrates an understanding of the role of a case
manager?
A. “They only handle insurance approvals.”
B. “They are responsible for medication administration.”
C. “They coordinate patient care across multiple settings.”
D. “They supervise nursing staff.”
Correct Answer: C. “They coordinate patient care across multiple settings.”
Rationale: Case managers facilitate transitions of care, ensuring patients receive
necessary services after discharge.
Question 7
In preparing for discharge, which professional is most appropriate to evaluate home safety
for an elderly patient with impaired mobility?
A. Social worker
B. Occupational therapist
C. Physical therapist
D. Speech-language pathologist
Correct Answer: B. Occupational therapist
Rationale: Occupational therapists assess and modify the home environment to promote
safety and independence.
Question 8
NCLEX RN Exam Bank: Coordination of Care &
Patient Transition Planning
Table of Contents
Subtopic 1: Interdisciplinary Team Collaboration in Patient Transitions ............................. 2
Subtopic 2: Safe Discharge Planning and Continuity of Care .......................................... 10
Subtopic 3: Care Transitions Between Acute and Long-Term Settings .............................. 17
Subtopic 4: Patient Education and Self-Management in Transition Planning .................... 26
Subtopic 6: Nurse Case Management and Continuity of Care ......................................... 34
, 2
Subtopic 1: Interdisciplinary Team Collaboration in Patient
Transitions
Question 1
A nurse is coordinating discharge planning for a patient with a new colostomy. Which of the
following interdisciplinary team members should be consulted to ensure the patient’s
successful transition home?
A. Wound and ostomy care nurse
B. Dietitian
C. Speech therapist
D. Respiratory therapist
Correct Answer: A. Wound and ostomy care nurse
Rationale: A wound and ostomy care nurse specializes in managing and educating patients
with colostomies, which is essential for a smooth home transition and prevention of
complications.
Question 2
Which of the following best represents effective communication in interdisciplinary care
planning?
A. Documenting patient care in the chart
B. Conducting daily bedside rounds with all team members
C. Updating family members on the plan
D. Calling the primary provider once daily
Correct Answer: B. Conducting daily bedside rounds with all team members
Rationale: Daily interdisciplinary rounds enhance communication and ensure that the
patient’s care plan is cohesive and understood by all involved.
Question 3
, 3
During interdisciplinary rounds, the nurse should prioritize reporting:
A. All lab values
B. Patient’s current pain level and response to treatment
C. The number of visitors the patient has had
D. Nurse’s personal impression of patient progress
Correct Answer: B. Patient’s current pain level and response to treatment
Rationale: The pain level and response to interventions are clinically relevant and influence
care planning across disciplines.
Question 4
A patient recovering from a stroke needs physical, occupational, and speech therapy. What
is the nurse’s primary role during interdisciplinary coordination?
A. Perform all therapy activities with the patient
B. Communicate therapy goals to the care team
C. Schedule therapy sessions
D. Document only nursing interventions
Correct Answer: B. Communicate therapy goals to the care team
Rationale: The nurse acts as a liaison, ensuring that patient-centered goals are shared and
understood across all disciplines.
Question 5
A nurse is coordinating care for a patient being discharged to a rehabilitation facility. Which
information is most important to include in the transition report?
A. Insurance provider details
B. Current medications and recent changes
C. Date of hospital admission
D. Nurse’s opinion of family support
, 4
Correct Answer: B. Current medications and recent changes
Rationale: Medication reconciliation is critical to ensure safety and continuity of care
during transitions.
Question 6
Which statement by a nurse demonstrates an understanding of the role of a case
manager?
A. “They only handle insurance approvals.”
B. “They are responsible for medication administration.”
C. “They coordinate patient care across multiple settings.”
D. “They supervise nursing staff.”
Correct Answer: C. “They coordinate patient care across multiple settings.”
Rationale: Case managers facilitate transitions of care, ensuring patients receive
necessary services after discharge.
Question 7
In preparing for discharge, which professional is most appropriate to evaluate home safety
for an elderly patient with impaired mobility?
A. Social worker
B. Occupational therapist
C. Physical therapist
D. Speech-language pathologist
Correct Answer: B. Occupational therapist
Rationale: Occupational therapists assess and modify the home environment to promote
safety and independence.
Question 8
