NURS 5461/ NURS5461 Quiz 2
Adult Gerontology Management Across the Continuum of Care
Guide
UTA (Latest 2026/2027 Update)
100% Verified Questions & Answers | Grade A |
Q1: According to CMS guidelines, discharge planning should begin:
A. On the day of discharge.
B. At the time of admission. [CORRECT]
C. 24 hours prior to discharge.
D. When the patient requests it.
Correct Answer: B
Rationale: The CMS Discharge Planning Condition of Participation requires that the discharge
planning process begin immediately upon admission to the hospital to ensure a safe and timely
transition.
Board Pearl: Discharge planning is a process, not an event; start at admission.
Q2: An 82-year-old patient with HFpEF requires rehabilitation after a 5-day hospital stay for
exacerbation. The patient has Medicare Part A. What is the requirement for the patient to qualify
for Medicare-covered Skilled Nursing Facility (SNF) care?
A. The patient must have been hospitalized for at least 3 consecutive midnights. [CORRECT]
B. The patient must have prior authorization from the PCP.
B. The patient must require only custodial care.
C. The patient must be admitted to the SNF within 30 days of discharge.
Correct Answer: A
,Rationale: Medicare Part A covers SNF stays only if the patient has a qualifying hospital
inpatient stay of at least 3 consecutive midnights (not counting the day of discharge) and requires
skilled nursing or rehab services.
Board Pearl: No 3-Midnight Stay = No Medicare SNF Coverage (usually).
Q3: Which of the following is the most critical step to prevent adverse drug events during a
transition from hospital to home?
A. Providing the patient with a printed list of appointments.
B. Medication reconciliation. [CORRECT]
C. Referring the patient to home health for vitals.
D. Ensuring the patient has transportation.
Correct Answer: B
Rationale: Medication reconciliation—comparing the patient's current medication orders to what
they were taking previously—is the single most important intervention to prevent continuity
errors and adverse drug events.
Board Pearl: Reconcile, Reconcile, Reconcile—Stop med errors at the door.
Q4: A frail 78-year-old patient is being considered for Home Health services. To qualify for
Medicare-covered home health, the patient must be:
A. Homebound. [CORRECT]
B. Able to drive themselves to appointments.
C. In need of part-time intermittent skilled care.
D. Both A and C. [CORRECT]
Correct Answer: D
Rationale: Medicare home health eligibility requires the patient to be homebound (leaving home
requires considerable and taxing effort) and need skilled nursing or therapy services on an
intermittent basis.
Board Pearl: Home Health = Homebound + Skilled Need.
.
, Q5: Which strategy is most effective in reducing 30-day all-cause readmissions for patients with
Heart Failure?
A. Discharging with a prescription only.
B. Scheduled follow-up appointment within 7 days post-discharge. [CORRECT]
C. Providing a generic diet handout.
D. Telling the patient to call if they feel bad.
Correct Answer: B
Rationale: Early follow-up (within 7 days) allows for clinical assessment, medication titration,
and reinforcement of self-management, significantly reducing readmission risk.
Board Pearl: The 7-Day Follow-Up Rule prevents the "Revolve Door" of admission.
Q6: An 85-year-old patient is no longer able to live independently due to mobility issues but does
not require 24-hour nursing care. Which setting is the most appropriate transition?
A. Long-Term Acute Care (LTAC).
B. Assisted Living Facility. [CORRECT]
C. Inpatient Rehabilitation Facility (IRF).
D. Acute Care Hospital.
Correct Answer: B
Rationale: Assisted Living is designed for individuals who need help with ADLs/IADLs but do
not require the skilled medical or nursing care provided by a SNF or LTAC.
Board Pearl: Needs help with life (ADLs) but not nursing? Assisted Living.
Q7: The Transitional Care Model (TCM) emphasizes the role of the APRN in:
A. Providing direct bedside care indefinitely.
B. Conducting home visits and phone calls to bridge the gap between hospital and home.
[CORRECT]
C. Filing insurance claims.
D. Performing housekeeping duties.
Correct Answer: B
.
Adult Gerontology Management Across the Continuum of Care
Guide
UTA (Latest 2026/2027 Update)
100% Verified Questions & Answers | Grade A |
Q1: According to CMS guidelines, discharge planning should begin:
A. On the day of discharge.
B. At the time of admission. [CORRECT]
C. 24 hours prior to discharge.
D. When the patient requests it.
Correct Answer: B
Rationale: The CMS Discharge Planning Condition of Participation requires that the discharge
planning process begin immediately upon admission to the hospital to ensure a safe and timely
transition.
Board Pearl: Discharge planning is a process, not an event; start at admission.
Q2: An 82-year-old patient with HFpEF requires rehabilitation after a 5-day hospital stay for
exacerbation. The patient has Medicare Part A. What is the requirement for the patient to qualify
for Medicare-covered Skilled Nursing Facility (SNF) care?
A. The patient must have been hospitalized for at least 3 consecutive midnights. [CORRECT]
B. The patient must have prior authorization from the PCP.
B. The patient must require only custodial care.
C. The patient must be admitted to the SNF within 30 days of discharge.
Correct Answer: A
,Rationale: Medicare Part A covers SNF stays only if the patient has a qualifying hospital
inpatient stay of at least 3 consecutive midnights (not counting the day of discharge) and requires
skilled nursing or rehab services.
Board Pearl: No 3-Midnight Stay = No Medicare SNF Coverage (usually).
Q3: Which of the following is the most critical step to prevent adverse drug events during a
transition from hospital to home?
A. Providing the patient with a printed list of appointments.
B. Medication reconciliation. [CORRECT]
C. Referring the patient to home health for vitals.
D. Ensuring the patient has transportation.
Correct Answer: B
Rationale: Medication reconciliation—comparing the patient's current medication orders to what
they were taking previously—is the single most important intervention to prevent continuity
errors and adverse drug events.
Board Pearl: Reconcile, Reconcile, Reconcile—Stop med errors at the door.
Q4: A frail 78-year-old patient is being considered for Home Health services. To qualify for
Medicare-covered home health, the patient must be:
A. Homebound. [CORRECT]
B. Able to drive themselves to appointments.
C. In need of part-time intermittent skilled care.
D. Both A and C. [CORRECT]
Correct Answer: D
Rationale: Medicare home health eligibility requires the patient to be homebound (leaving home
requires considerable and taxing effort) and need skilled nursing or therapy services on an
intermittent basis.
Board Pearl: Home Health = Homebound + Skilled Need.
.
, Q5: Which strategy is most effective in reducing 30-day all-cause readmissions for patients with
Heart Failure?
A. Discharging with a prescription only.
B. Scheduled follow-up appointment within 7 days post-discharge. [CORRECT]
C. Providing a generic diet handout.
D. Telling the patient to call if they feel bad.
Correct Answer: B
Rationale: Early follow-up (within 7 days) allows for clinical assessment, medication titration,
and reinforcement of self-management, significantly reducing readmission risk.
Board Pearl: The 7-Day Follow-Up Rule prevents the "Revolve Door" of admission.
Q6: An 85-year-old patient is no longer able to live independently due to mobility issues but does
not require 24-hour nursing care. Which setting is the most appropriate transition?
A. Long-Term Acute Care (LTAC).
B. Assisted Living Facility. [CORRECT]
C. Inpatient Rehabilitation Facility (IRF).
D. Acute Care Hospital.
Correct Answer: B
Rationale: Assisted Living is designed for individuals who need help with ADLs/IADLs but do
not require the skilled medical or nursing care provided by a SNF or LTAC.
Board Pearl: Needs help with life (ADLs) but not nursing? Assisted Living.
Q7: The Transitional Care Model (TCM) emphasizes the role of the APRN in:
A. Providing direct bedside care indefinitely.
B. Conducting home visits and phone calls to bridge the gap between hospital and home.
[CORRECT]
C. Filing insurance claims.
D. Performing housekeeping duties.
Correct Answer: B
.
