NURS 4065 Patient-Centered Care Coordination
Exam Overview Questions Bank and Correct
Answers Guaranteed Pass Latest Version 2025
with Rationales
NURS 4065 (often listed as NURS FPX 4065 in flexible-path or online formats, such
as at Capella University) is a nursing course focused on preparing students to
deliver holistic, patient-centered care through effective coordination across
healthcare settings. The course emphasizes interprofessional collaboration,
ethical considerations, cultural competence, and evidence-based strategies to
improve patient outcomes during care transitions. It aligns closely with the
American Association of Colleges of Nursing (AACN) Essentials and Quality and
Safety Education for Nurses (QSEN) competencies, particularly in Domain 2:
Person-Centered Care.
**Sample Practice Questions** (with brief explanations):
1. **What is the primary goal of care coordination per AHRQ?**
*Answer*: To organize activities and share information among providers for
safer, higher-quality care. *Explanation*: This ensures seamless transitions,
reducing errors—core to QSEN Safety.
2. **A patient with diabetes refuses insulin due to cultural beliefs. How do you
apply patient-centered care?**
*Answer*: Elicit values, explore alternatives (e.g., oral meds or education), and
collaborate with a cultural liaison. *Explanation*: Aligns with QSEN Patient-
Centered Care by respecting preferences while promoting self-management.
3. **Describe how informatics supports care coordination in a team setting.**
, *Answer*: EHRs enable real-time data sharing for shared decision-making, e.g.,
alerting teams to medication interactions. *Explanation*: Ties to QSEN
Informatics and Teamwork.
### Continuing from Sample Practice Question 3
(Describe how informatics supports care coordination in a team setting)
**Full Model Answer (exam-ready response)**
Informatics is a foundational QSEN competency that directly enhances care
coordination by improving communication, reducing errors, and supporting
evidence-based decision-making across the interprofessional team. Key examples
include:
- **Electronic Health Records (EHRs)**: Provide a single, real-time source of
truth. For instance, when a diabetic patient is admitted, the nurse, physician,
pharmacist, dietitian, and case manager can simultaneously view lab results (e.g.,
A1C 9.8%), current medications, and social determinants (lives alone, no
transportation). This prevents fragmented care and duplicate orders.
- **Clinical Decision Support (CDS) tools**: Embedded alerts notify the team of
potential issues (e.g., “Patient at high risk for readmission—initiate teach-back
and schedule home health”). CDS also flags drug–drug interactions or gaps in
preventive care.
- **Secure messaging and care coordination platforms** (e.g., Epic Care
Everywhere, TigerConnect, or CarePort): Allow rapid consults. A hospital case
manager can message the skilled nursing facility (SNF) social worker directly to
confirm bed availability and send the reconciled medication list before discharge.
- **Patient registries and population health tools**: Identify high-risk patients
(e.g., all patients with CHF and ≥2 admissions in 6 months) so the ambulatory care
coordinator can proactively schedule follow-up visits, telehealth check-ins, or
pharmacist-led medication reconciliation.
,- **Telehealth and remote patient monitoring (RPM)**: Devices (Bluetooth
glucometers, BP cuffs, weight scales) transmit data to the EHR, triggering alerts if
parameters worsen. The primary care nurse coordinator can intervene early,
preventing ED visits.
In practice, informatics transforms care coordination from reactive and siloed to
proactive and team-based, directly supporting safer transitions and better
outcomes.
### Sample Practice Questions 4–10 (with concise answers)
4. **A 78-year-old patient is being discharged after a hip fracture. List four
essential elements that must be included in a patient-centered discharge plan.**
Answer:
- Medication reconciliation and teach-back
- Scheduled follow-up appointments (PCP, PT, surgeon)
- Home safety evaluation and durable medical equipment (walker, commode)
- Red flags education (“Call 911 if…”) with easy-to-read materials at ≤6th-grade
level
5. **True or False: Care coordination is primarily the responsibility of the case
manager or social worker.**
Answer: False. Care coordination is a shared responsibility of the entire
interprofessional team, with the registered nurse often serving as the central
coordinator.
, 6. **A patient with limited English proficiency (LEP) is readmitted for
hyperglycemia. Using the teach-back method, how would you confirm
understanding of insulin administration?**
Answer: After demonstration, ask open-ended questions: “When you get home,
how will you draw up your insulin?” or “In your own words, what will you do if
your blood sugar is over 300?” Correct any misunderstandings without shaming.
7. **Identify two ethical principles at risk when coordinating care for an
undocumented immigrant with end-stage renal disease who cannot afford
dialysis.**
Answer: Justice (fair distribution of resources) and non-maleficence (avoiding
harm by denying life-sustaining treatment). Advocacy may involve connecting to
charity care programs or safety-net clinics.
8. **How does the Transitional Care Model (TCM) by Mary Naylor differ from
traditional discharge planning?**
Answer: TCM uses advanced practice nurses (Transitional Care Nurses) who
follow high-risk older adults from hospital to home for 1–3 months, performing
in-home visits, accompanying to follow-up appointments, and coordinating with
the primary care provider—shown to reduce readmissions by ~50%.
9. **A patient states, “I don’t want my children involved in my care decisions.”
How should the nurse respond while still promoting coordination?**
Answer: Respect autonomy: Document the patient’s preference, confirm the
designated surrogate (if any), and coordinate care directly with the patient using
preferred communication methods (large-print materials, phone calls, patient
portal).
10. **Match the tool to its primary purpose**:
Exam Overview Questions Bank and Correct
Answers Guaranteed Pass Latest Version 2025
with Rationales
NURS 4065 (often listed as NURS FPX 4065 in flexible-path or online formats, such
as at Capella University) is a nursing course focused on preparing students to
deliver holistic, patient-centered care through effective coordination across
healthcare settings. The course emphasizes interprofessional collaboration,
ethical considerations, cultural competence, and evidence-based strategies to
improve patient outcomes during care transitions. It aligns closely with the
American Association of Colleges of Nursing (AACN) Essentials and Quality and
Safety Education for Nurses (QSEN) competencies, particularly in Domain 2:
Person-Centered Care.
**Sample Practice Questions** (with brief explanations):
1. **What is the primary goal of care coordination per AHRQ?**
*Answer*: To organize activities and share information among providers for
safer, higher-quality care. *Explanation*: This ensures seamless transitions,
reducing errors—core to QSEN Safety.
2. **A patient with diabetes refuses insulin due to cultural beliefs. How do you
apply patient-centered care?**
*Answer*: Elicit values, explore alternatives (e.g., oral meds or education), and
collaborate with a cultural liaison. *Explanation*: Aligns with QSEN Patient-
Centered Care by respecting preferences while promoting self-management.
3. **Describe how informatics supports care coordination in a team setting.**
, *Answer*: EHRs enable real-time data sharing for shared decision-making, e.g.,
alerting teams to medication interactions. *Explanation*: Ties to QSEN
Informatics and Teamwork.
### Continuing from Sample Practice Question 3
(Describe how informatics supports care coordination in a team setting)
**Full Model Answer (exam-ready response)**
Informatics is a foundational QSEN competency that directly enhances care
coordination by improving communication, reducing errors, and supporting
evidence-based decision-making across the interprofessional team. Key examples
include:
- **Electronic Health Records (EHRs)**: Provide a single, real-time source of
truth. For instance, when a diabetic patient is admitted, the nurse, physician,
pharmacist, dietitian, and case manager can simultaneously view lab results (e.g.,
A1C 9.8%), current medications, and social determinants (lives alone, no
transportation). This prevents fragmented care and duplicate orders.
- **Clinical Decision Support (CDS) tools**: Embedded alerts notify the team of
potential issues (e.g., “Patient at high risk for readmission—initiate teach-back
and schedule home health”). CDS also flags drug–drug interactions or gaps in
preventive care.
- **Secure messaging and care coordination platforms** (e.g., Epic Care
Everywhere, TigerConnect, or CarePort): Allow rapid consults. A hospital case
manager can message the skilled nursing facility (SNF) social worker directly to
confirm bed availability and send the reconciled medication list before discharge.
- **Patient registries and population health tools**: Identify high-risk patients
(e.g., all patients with CHF and ≥2 admissions in 6 months) so the ambulatory care
coordinator can proactively schedule follow-up visits, telehealth check-ins, or
pharmacist-led medication reconciliation.
,- **Telehealth and remote patient monitoring (RPM)**: Devices (Bluetooth
glucometers, BP cuffs, weight scales) transmit data to the EHR, triggering alerts if
parameters worsen. The primary care nurse coordinator can intervene early,
preventing ED visits.
In practice, informatics transforms care coordination from reactive and siloed to
proactive and team-based, directly supporting safer transitions and better
outcomes.
### Sample Practice Questions 4–10 (with concise answers)
4. **A 78-year-old patient is being discharged after a hip fracture. List four
essential elements that must be included in a patient-centered discharge plan.**
Answer:
- Medication reconciliation and teach-back
- Scheduled follow-up appointments (PCP, PT, surgeon)
- Home safety evaluation and durable medical equipment (walker, commode)
- Red flags education (“Call 911 if…”) with easy-to-read materials at ≤6th-grade
level
5. **True or False: Care coordination is primarily the responsibility of the case
manager or social worker.**
Answer: False. Care coordination is a shared responsibility of the entire
interprofessional team, with the registered nurse often serving as the central
coordinator.
, 6. **A patient with limited English proficiency (LEP) is readmitted for
hyperglycemia. Using the teach-back method, how would you confirm
understanding of insulin administration?**
Answer: After demonstration, ask open-ended questions: “When you get home,
how will you draw up your insulin?” or “In your own words, what will you do if
your blood sugar is over 300?” Correct any misunderstandings without shaming.
7. **Identify two ethical principles at risk when coordinating care for an
undocumented immigrant with end-stage renal disease who cannot afford
dialysis.**
Answer: Justice (fair distribution of resources) and non-maleficence (avoiding
harm by denying life-sustaining treatment). Advocacy may involve connecting to
charity care programs or safety-net clinics.
8. **How does the Transitional Care Model (TCM) by Mary Naylor differ from
traditional discharge planning?**
Answer: TCM uses advanced practice nurses (Transitional Care Nurses) who
follow high-risk older adults from hospital to home for 1–3 months, performing
in-home visits, accompanying to follow-up appointments, and coordinating with
the primary care provider—shown to reduce readmissions by ~50%.
9. **A patient states, “I don’t want my children involved in my care decisions.”
How should the nurse respond while still promoting coordination?**
Answer: Respect autonomy: Document the patient’s preference, confirm the
designated surrogate (if any), and coordinate care directly with the patient using
preferred communication methods (large-print materials, phone calls, patient
portal).
10. **Match the tool to its primary purpose**:
