Exhibits
The practical nurse (PN) calls the healthcare provider to notify them that the heart rate is too low to administer the digoxin.
Place the nurse statements in Situation, Background, Assessment, Recommendation (SBAR) format. Each column must have at only one answer selected.
I am holding the digoxin because the client's heart rate is too low.
The client is a 59-year-old male with hypertension and heart failure. He is currently taking furosemide and digoxin.
Do you want to recheck the digoxin level to see if there is toxicity? I will monitor the client's heart rate, blood pressure, and perfusion with a continuous monitor until his heart rate returns to normal.
Heart rate is 48 beats/minute, blood pressure is 109/76 mm Hg.
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"D"},"D":{"answers":"A"}}
SBAR Format:
Situation:
I am holding the digoxin because the client's heart rate is too low.
Background:
The client is a 59-year-old male with hypertension and heart failure. He is currently taking furosemide and digoxin.
Assessment:
Heart rate is 48 beats/minute, blood pressure is 109/76 mm Hg.
Recommendation:
Do you want to recheck the digoxin level to see if there is toxicity? I will monitor the client's heart rate, blood pressure, and perfusion with a continuous monitor until his heart rate returns to normal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Synergistic actions: Synergistic effects occur when two drugs enhance each other’s action, but they are not the primary concern after one week of stable medication use. While important to monitor, they are less critical than cumulative effects in older adults who have slower drug metabolism.
B. Cumulative effects: Cumulative effects are the most important to assess in an older adult because aging decreases liver and kidney function, slowing drug metabolism and excretion. This can lead to drug buildup in the body, increasing the risk of toxicity even when medications have been taken as prescribed.
C. Idiosyncratic responses: Idiosyncratic reactions are unpredictable and not dose-dependent. They are important but tend to occur early in therapy rather than after a week of consistent medication use, making them less of a focus at this stage.
D. Antagonistic reactions: Antagonistic reactions, where drugs block each other's effects, are possible but would generally present early during therapy. After a week of stable use without new drugs added, cumulative buildup remains the greater priority for safe ongoing care.
Correct Answer is D
Explanation
A. Apply lotion to sacrum: Applying lotion may help with general skin hydration but does not directly address pressure relief, which is the primary intervention needed to prevent worsening of a stage one pressure injury.
B. Use wet-to-dry dressings daily: Wet-to-dry dressings are used for wounds with necrotic tissue that need debridement. A stage one pressure injury involves intact skin without an open wound, so such dressings are not appropriate.
C. Elevate head of bed 30 degrees: Elevating the head of the bed slightly can reduce aspiration risk but also increases pressure on the sacrum if maintained for long periods. Position changes are more critical to relieve sacral pressure.
D. Change positions every 2 hours: Repositioning every two hours is essential to relieve pressure on the sacrum and promote circulation. This practice helps prevent progression of the pressure injury and is a cornerstone of effective pressure ulcer prevention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.