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NURB 290: Acute Transitional Care
Section 1: Foundations of Transitional Care & Coordination
1. Which statement best defines the primary goal of "Transitional Care"?
A) To reduce the hospital’s overhead costs.
B) To ensure the coordination and continuity of healthcare as patients transfer
between different locations or different levels of care.
C) To provide long-term care for patients with chronic disabilities.
D) To replace the role of the primary care physician.
Elaboration: Transitional care is a set of interventions designed to prevent "falling through
the cracks." It ensures that the care plan remains consistent and safe as a patient moves
from, for example, the ICU to a Med-Surg unit, or from the hospital to home.
2. Which role is most responsible for overseeing the patient’s entire journey through the
healthcare system to ensure all disciplines are aligned?
A) The Staff Nurse.
B) The Attending Physician.
C) The Case Manager/Care Coordinator.
D) The Physical Therapist.
Elaboration: Case managers focus on the big picture, managing resources, facilitating
discharge planning, and ensuring that the interprofessional team communicates effectively to
meet the patient’s transitional goals.
3. The "LACE" tool is frequently used in transitional care to:
A) Determine a patient’s level of pain.
B) Predict the risk of unplanned 30-day readmission or death after hospital discharge.
C) Measure the patient's ability to perform activities of daily living (ADLs).
D) Calculate the cost of surgical supplies.
Elaboration: LACE stands for Length of stay, Acuity of admission, Comorbidities, and
Emergency department visits. A high LACE score alerts the transition team that the patient
requires intensive follow-up and resources.
4. At which point should formal discharge planning begin for an acute care patient?
, A) When the patient is medically stable.
B) Immediately upon admission to the healthcare facility.
C) Twenty-four hours before the scheduled discharge.
D) After the family has been consulted.
Elaboration: Effective transitional care requires early identification of barriers. Starting at
admission allows the team time to arrange for home health, equipment, or placement in a
sub-acute facility.
5. A "Warm Handoff" is characterized by:
A) Sending a faxed summary to the receiving facility.
B) A face-to-face or synchronous verbal report where the patient and family are often
present and included in the discussion.
C) Leaving a voicemail for the oncoming nurse.
D) Giving the patient a printed list of their medications.
Elaboration: Warm handoffs increase safety by allowing for real-time clarification and
ensuring the patient feels supported during the move between providers.
Section 2: Discharge Planning & Readiness
6. A nurse is evaluating a patient for discharge readiness. Which finding is the most
critical physiological indicator that the patient is NOT ready for transition to home?
A) The patient reports a pain level of 3/10.
B) The patient has not had a bowel movement in 24 hours.
C) The patient’s oxygen saturation drops to 86% during minimal ambulation.
D) The patient is frustrated with the hospital food.
Elaboration: Physiological stability, particularly regarding the ABCs (Airway, Breathing,
Circulation), is the baseline requirement for discharge. Desaturation with exertion indicates a
high risk for respiratory failure at home.
7. A patient is being discharged to a Skilled Nursing Facility (SNF). Which document is the
most vital piece of information the nurse must provide to the receiving facility?
A) A copy of the patient’s insurance card.
B) The patient’s preferred diet.
, C) An updated, accurate medication reconciliation and the latest provider progress
note.
D) The patient’s personal belongings list.
Elaboration: Medication errors are the most common complication during transitions. An
accurate "Med Rec" ensures the SNF continues appropriate therapy without omissions or
duplications.
8. Which assessment tool is used specifically to measure a patient’s functional
independence and readiness for a rehabilitation facility?
A) Braden Scale.
B) Functional Independence Measure (FIM) or the Barthel Index.
C) Glasgow Coma Scale.
D) PHQ-9.
Elaboration: These tools evaluate the patient’s ability to perform ADLs (eating, bathing,
grooming, mobility). Rehab facilities require this data to determine the intensity of therapy
needed.
9. The "Teach-Back" method is essential in transitional care education because it:
A) Saves the nurse time.
B) Allows the nurse to verify the patient’s understanding by having them explain the
information in their own words.
C) Documents that the patient was given a pamphlet.
D) Is required by Medicare for billing.
Elaboration: Passive learning (reading or listening) is often ineffective. Teach-back is the gold
standard for ensuring the patient can safely manage their care (e.g., wound care or
medication) after discharge.
10. A patient living alone is being discharged after a total hip replacement. The transition
nurse identifies that the patient's bathroom is on the second floor. This is an example
of identifying:
A) A clinical comorbidity.
B) A social determinant of health and an environmental barrier to transition.
C) A lack of patient motivation.
D) An insurance coverage issue.
NURB 290: Acute Transitional Care
Section 1: Foundations of Transitional Care & Coordination
1. Which statement best defines the primary goal of "Transitional Care"?
A) To reduce the hospital’s overhead costs.
B) To ensure the coordination and continuity of healthcare as patients transfer
between different locations or different levels of care.
C) To provide long-term care for patients with chronic disabilities.
D) To replace the role of the primary care physician.
Elaboration: Transitional care is a set of interventions designed to prevent "falling through
the cracks." It ensures that the care plan remains consistent and safe as a patient moves
from, for example, the ICU to a Med-Surg unit, or from the hospital to home.
2. Which role is most responsible for overseeing the patient’s entire journey through the
healthcare system to ensure all disciplines are aligned?
A) The Staff Nurse.
B) The Attending Physician.
C) The Case Manager/Care Coordinator.
D) The Physical Therapist.
Elaboration: Case managers focus on the big picture, managing resources, facilitating
discharge planning, and ensuring that the interprofessional team communicates effectively to
meet the patient’s transitional goals.
3. The "LACE" tool is frequently used in transitional care to:
A) Determine a patient’s level of pain.
B) Predict the risk of unplanned 30-day readmission or death after hospital discharge.
C) Measure the patient's ability to perform activities of daily living (ADLs).
D) Calculate the cost of surgical supplies.
Elaboration: LACE stands for Length of stay, Acuity of admission, Comorbidities, and
Emergency department visits. A high LACE score alerts the transition team that the patient
requires intensive follow-up and resources.
4. At which point should formal discharge planning begin for an acute care patient?
, A) When the patient is medically stable.
B) Immediately upon admission to the healthcare facility.
C) Twenty-four hours before the scheduled discharge.
D) After the family has been consulted.
Elaboration: Effective transitional care requires early identification of barriers. Starting at
admission allows the team time to arrange for home health, equipment, or placement in a
sub-acute facility.
5. A "Warm Handoff" is characterized by:
A) Sending a faxed summary to the receiving facility.
B) A face-to-face or synchronous verbal report where the patient and family are often
present and included in the discussion.
C) Leaving a voicemail for the oncoming nurse.
D) Giving the patient a printed list of their medications.
Elaboration: Warm handoffs increase safety by allowing for real-time clarification and
ensuring the patient feels supported during the move between providers.
Section 2: Discharge Planning & Readiness
6. A nurse is evaluating a patient for discharge readiness. Which finding is the most
critical physiological indicator that the patient is NOT ready for transition to home?
A) The patient reports a pain level of 3/10.
B) The patient has not had a bowel movement in 24 hours.
C) The patient’s oxygen saturation drops to 86% during minimal ambulation.
D) The patient is frustrated with the hospital food.
Elaboration: Physiological stability, particularly regarding the ABCs (Airway, Breathing,
Circulation), is the baseline requirement for discharge. Desaturation with exertion indicates a
high risk for respiratory failure at home.
7. A patient is being discharged to a Skilled Nursing Facility (SNF). Which document is the
most vital piece of information the nurse must provide to the receiving facility?
A) A copy of the patient’s insurance card.
B) The patient’s preferred diet.
, C) An updated, accurate medication reconciliation and the latest provider progress
note.
D) The patient’s personal belongings list.
Elaboration: Medication errors are the most common complication during transitions. An
accurate "Med Rec" ensures the SNF continues appropriate therapy without omissions or
duplications.
8. Which assessment tool is used specifically to measure a patient’s functional
independence and readiness for a rehabilitation facility?
A) Braden Scale.
B) Functional Independence Measure (FIM) or the Barthel Index.
C) Glasgow Coma Scale.
D) PHQ-9.
Elaboration: These tools evaluate the patient’s ability to perform ADLs (eating, bathing,
grooming, mobility). Rehab facilities require this data to determine the intensity of therapy
needed.
9. The "Teach-Back" method is essential in transitional care education because it:
A) Saves the nurse time.
B) Allows the nurse to verify the patient’s understanding by having them explain the
information in their own words.
C) Documents that the patient was given a pamphlet.
D) Is required by Medicare for billing.
Elaboration: Passive learning (reading or listening) is often ineffective. Teach-back is the gold
standard for ensuring the patient can safely manage their care (e.g., wound care or
medication) after discharge.
10. A patient living alone is being discharged after a total hip replacement. The transition
nurse identifies that the patient's bathroom is on the second floor. This is an example
of identifying:
A) A clinical comorbidity.
B) A social determinant of health and an environmental barrier to transition.
C) A lack of patient motivation.
D) An insurance coverage issue.
