Review the repeated heart-failure transitions and determine the strongest case-management response before the next discharge.
Trend
Choose your responses, then check the answer.
Explanation
The pattern reflects unresolved transition barriers rather than a single education failure. Safe discharge planning begins early and incorporates the client's goals, preferences, caregiver availability, functional ability, medication access, transportation, food resources, equipment, and follow-up. The nurse should coordinate pharmacy, social work, nutrition, primary care, home health, and payer or community resources, then use teach-back and closed-loop confirmation that medications, appointments, transportation, a scale, and escalation contacts are actually available. A pamphlet or repeated instruction without solving access barriers does not create an executable plan.
Correct Answer The client needs a coordinated, patient-centered transition plan that resolves identified social and logistical barriers before discharge.
Why It Fits Each readmission follows a different unresolved barrier involving medicines, transportation, equipment, food, or understanding.
Clinical Picture Calling the behavior nonadherence hides correctable system and access failures that case management should address.
Memory Link A discharge plan is not complete until the client can carry it out.
NCLEX Rule Involve the client and support people, identify transition risks, coordinate required services, and confirm that follow-up resources are operational.
Why the Alternatives Fail Repeating generic teaching, scheduling without transportation, or waiting until discharge day leaves the causal barriers unchanged.
Sources
1CMS Condition of Participation - Discharge Planning
2AHRQ Re-Engineered Discharge Toolkit
3NCSBN 2026 NCLEX-RN Test Plan
Medical unitAn older adult with heart failure lives alone and has had repeated short-interval admissions. The case manager reviews what happened after each transition rather than labeling the client as nonadherent.
Case management — Coordinated assessment and organization of services needed to meet a client's health and transition goals.
Care transition — Movement between care settings that requires accurate information, accessible services, and clear accountability.
Closed-loop confirmation — Verification that a communicated plan was received, understood, and completed or assigned to an accountable person.