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 []
Explanation
- Hyponatremia: The client's sodium level of 130 mEq/L is below the normal range (136–145 mEq/L), indicating hyponatremia. Symptoms like weakness, brain fog, and dehydration are typical signs. Immediate correction is necessary to prevent complications such as seizures or coma.
- Metabolic Alkalosis: Metabolic alkalosis is unlikely here, as vomiting typically leads to a loss of acid, not an increase. The client's symptoms and lab results suggest hyponatremia rather than alkalosis, which doesn’t match the clinical presentation.
- Hyperkalemia: The potassium level of 3.4 mEq/L is slightly below the normal range, not elevated. Hyperkalemia, which causes muscle weakness and arrhythmias, is not supported by the client's lab values, making it an unlikely diagnosis.
- Hypovolemia: While the client may be experiencing hypovolemia due to fluid loss, the primary concern is hyponatremia. The signs of dehydration (poor skin turgor, dry mucous membranes) are secondary to the electrolyte imbalance, not the primary issue.
- Infuse a bolus of IV fluids: Given the client’s dehydration and low sodium level, infusing a bolus of IV fluids, especially those containing sodium, is essential. This helps correct fluid loss and addresses the hyponatremia, improving hydration status and electrolyte balance.
- Request prescription for antiemetic: Controlling the client’s vomiting with an antiemetic is necessary to prevent further fluid and electrolyte loss. This will allow for better fluid retention and reduce the risk of exacerbating hyponatremia and dehydration.
- Monitor lab values every six hours: Regular lab tests every six hours allow for monitoring the client’s sodium and potassium levels, as well as assessing the effectiveness of the fluid resuscitation. This will ensure the condition is progressing and adjustments can be made if needed.
- Neurological status: Hyponatremia can cause neurological symptoms, including confusion and lethargy. Monitoring the client’s neurological status is crucial to assess the severity of the condition and detect any worsening of symptoms that may indicate more severe imbalances.
- Oral intake: Although oral intake is important, the client is likely unable to tolerate enough fluids due to vomiting. IV fluid administration is the immediate solution for rehydration, with oral intake becoming more relevant once vomiting is controlled.
- Electrocardiogram: Monitoring the ECG is critical to detect arrhythmias, which can result from electrolyte imbalances like hyponatremia. Sodium and potassium disturbances can affect heart rhythms, so regular ECG monitoring helps identify any cardiac complications.
- Oxygen saturation: While important, oxygen saturation is not the primary concern here. The immediate need is to correct fluid and electrolyte imbalances. Oxygen levels should still be monitored, but they are secondary to managing the hyponatremia and dehydration.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
- 1. 21 to 24%: The client’s fat intake for the three days totals approximately 69 grams of fat (24g + 22g + 23g), which, when multiplied by 9 calories per gram, equals about 621 calories from fat. Given the total caloric intake of 3,200–3,310 calories per day, fat constitutes approximately 21% to 24% of the total caloric intake, which is within the recommended range for a balanced diet.
- 2. has an appropriate fat intake for calories: The fat intake of 21% to 24% of total calories aligns with the general dietary recommendation, which is for 20% to 35% of total calories to come from fat. Therefore, the client’s fat intake is appropriate and does not require any adjustments.
- 1. 26 to 28%: This percentage would be too high for the client’s daily fat intake. To reach 26% to 28% of calories from fat, the client would need to consume more grams of fat. Based on the actual fat intake (69g), this range is not appropriate.
- 1. 14 to 19%: A fat intake of 14% to 19% would be considered lower than the recommended range, and would suggest the client is consuming too little fat for a balanced diet. Given the actual fat intake, this percentage is not accurate.
- 2. should increase his fat intake: Given that the client’s fat intake is already within the recommended 20%–35% range, there's no need for the client to increase his fat intake. Therefore, this option is not appropriate.
- 2. should reduce his fat intake: Reducing the client’s fat intake is not necessary, as the fat intake falls within the recommended range. A reduction in fat would lower the total percentage of calories from fat below the suggested 20%–35% range, which could be harmful for overall nutrition.
- 2. should decrease his caloric intake: There’s no indication that the client is consuming an excessive amount of calories based on the information provided. His calorie intake seems appropriate for his needs. Decreasing caloric intake isn't necessary, especially when his fat intake is within the normal range.
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