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Exhibits

The nurse calls the healthcare provider (HCP) to notify them that the digoxin level is above therapeutic range.

Place the nurse statements in Situation, Background, Assessment, Recommendation (SBAR) format. Each column must have only one response selected.

Do you want to recheck the digoxin level again tomorrow morning to see if we can restart it? I will keep the client on the monitor to assess for changes in heart rate.

The results came back for the digoxin level. It is currently 2.2 ng/mL (2.8 nmol/L). The client's heart rate was 79 beats/minute. She is alert. There are no signs and symptoms of decreased perfusion at this time.

I am holding the digoxin because the client's digoxin level is too high.

The client is a 61- year-old female with heart failure. She started digoxin 3 days ago.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"D"},"D":{"answers":"A"}}

Rationale:

Assessment: This describes the findings relevant to the current situation, such as the elevated digoxin level (2.2 ng/mL), the client’s heart rate (79 beats/minute), and the absence of symptoms such as decreased perfusion, indicating that the client is stable for now.
Background: Provides necessary patient details, such as age, diagnosis (heart failure), and the fact that the client has been on digoxin for three days, so the nurse provides a brief clinical history relevant to the current issue.
Recommendation: The nurse suggests rechecking the digoxin level the next day to assess if it has returned to the therapeutic range. Suggests an action to the healthcare provider (recheck digoxin level tomorrow) and indicates that the nurse will monitor the client closely for any changes.
Situation: The nurse is holding the digoxin due to the elevated level, which exceeds the therapeutic range. This introduces the immediate reason for the call, explaining the context of the patient's condition and recent treatment.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Determine how long the client has been lying prone: Prone positioning is used post-amputation to prevent hip flexion contractures. However, prolonged periods in this position can cause discomfort or complications. Knowing the duration helps evaluate if it’s appropriate to reposition or maintain it for therapeutic reasons.

B. Measure the client's vital signs: Vital signs are important in the postoperative period, but this task can be completed after addressing the client’s immediate request and assessing the potential impact of their current positioning on healing and comfort.

C. Inspect the dressing on the stump: Inspecting the stump is crucial for monitoring for infection or bleeding. However, unless there is a concern based on symptoms or reports from the client, it should follow assessment of position and comfort needs.

D. Assist the client in turning to a position of comfort: Turning the client without assessing how long they have been prone could interfere with therapeutic positioning aimed at preventing complications like hip contractures, especially in early postoperative care.

A. The woman is timid and speaks softly when asked about the accident. B. spiral fracture on the woman's arm and wrist. C. The woman is hyperventilating and appears to be in pain. D. Fresh bruises on the woman's shoulder and chest.

Correct Answer is B

Explanation

A. The woman is timid and speaks softly when asked about the accident: Timid behavior may suggest fear or anxiety, but it's nonspecific and may be due to trauma or emotional distress, not necessarily abuse.

B. Spiral fracture on the woman's arm and wrist: Spiral fractures occur from twisting injuries and are often associated with non-accidental trauma, especially when the injury doesn't match the reported mechanism.

C. The woman is hyperventilating and appears to be in pain: Hyperventilation and visible pain may indicate anxiety or physical injury, but they are expected after trauma and not unique to domestic violence.

D. Fresh bruises on the woman's shoulder and chest: Bruising is a possible sign of abuse, but bruises alone can result from a car accident. The type and location must be assessed in context.

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Exhibits The nurse calls the healthcare provider (HCP) to notify them that the digoxin level is above therapeutic range. Place the nurse statements in Situation, Background, Assessment, Recommendation (SBAR) format. Each column must have only one response selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A woman and her live-in significant other come in the emergency department following a motor vehicle collision. Which finding should alert the nurse to assess for the possibility of domestic violence?

Correct Answer is B

Explanation

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Exhibits

The nurse calls the healthcare provider (HCP) to notify them that the digoxin level is above therapeutic range.

Place the nurse statements in Situation, Background, Assessment, Recommendation (SBAR) format. Each column must have only one response selected.