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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. "Hyperglycemia often results in weight loss." While chronic uncontrolled hyperglycemia, particularly in Type 1 diabetes, can lead to weight loss due to the body breaking down fat and muscle for energy, this is less typical for the acute or early signs of hyperglycemia.
B. "Hyperglycemia often presents as increased thirst and urination." This is a classic symptom of hyperglycemia, polydipsia (increased thirst) and polyuria (increased urination), caused by the body attempting to eliminate excess glucose through urine.
C. "Hyperglycemia causes an increased sensation of being hungry." Hyperglycemia can cause an increased sensation of hunger (polyphagia), which occurs due to insulin resistance or the body’s inability to use glucose properly.
D. "Hyperglycemia causes a headache and flushed, dry skin." A common symptom of hyperglycemia is headache, and flushed, dry skin can occur due to dehydration from excessive urination.
E. "Hyperglycemia causes cool and clammy skin." Cool and clammy skin is more indicative of hypoglycemia (low blood sugar) rather than hyperglycemia. Hyperglycemia usually presents with warm, dry skin due to dehydration.
Correct Answer is C
Explanation
A. Dilated pupils, tachycardia, elevated blood pressure, elation: These symptoms are more typical of stimulant intoxication and do not indicate alcohol withdrawal. They are not consistent with the need for a detox protocol focused on alcohol or other depressants.
B. Excessive eating, constipation, headache: These symptoms are not associated with alcohol or drug intoxication or withdrawal. They do not suggest a need for detoxification medication protocols.
C. Nausea, vomiting, diaphoresis, anxiety, tremors: These are classic signs of alcohol withdrawal and suggest the need for detoxification. These symptoms require immediate intervention to manage withdrawal safely and avoid complications.
D. Mood lability, poor hand coordination, fever, drowsiness: These signs are more indicative of intoxication with substances like sedatives. While concerning, they do not point to alcohol withdrawal, which requires specific detox protocols.
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