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","C","D"]
Explanation
A. Medications are limited to managing pain: While pain management is a key component of hospice care, medications are not limited only to pain management. Hospice care also addresses other symptoms like shortness of breath, nausea, and anxiety to improve comfort.
B. Care can be provided in the home: Hospice care can indeed be provided in the home, allowing the client to remain in a familiar environment while receiving palliative care. This is a central aspect of hospice services.
C. Care focuses on quality of life at the end of life: Hospice care prioritizes comfort and quality of life, providing emotional, spiritual, and physical support for both the client and family at the end of life.
D. Curative measures are optional: In hospice care, curative treatments are typically discontinued because the focus shifts to palliative care aimed at comfort and symptom relief rather than attempting to cure the illness.
E. Family is responsible for care decisions: While families are involved in decisions, hospice care involves collaboration with the healthcare team, and decisions are made based on the patient's wishes and comfort, not solely by the family.
Correct Answer is B
Explanation
A. Show the UAP how to use a transfer belt to safely move the client: A transfer belt is useful for clients who can bear some weight and follow instructions. Since the client is confused and cannot bear weight, using a transfer belt is unsafe and increases the risk of injury.
B. Work with the UAP to use a mechanical lift and sling for the transfer: A mechanical lift provides the safest method for transferring a confused, non-weight-bearing client. It minimizes the risk of injury to both the client and staff while ensuring the transfer is done safely and correctly.
C. Instruct the UAP to use a pivot technique when moving the client: Pivot techniques require the client to bear weight and follow simple directions, neither of which is appropriate given the client's confusion and inability to bear weight.
D. Notify the charge nurse that the client cannot be transferred: While updating the charge nurse may eventually be needed, the immediate action is to modify the transfer method to ensure the client's needs are safely met using appropriate equipment.
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