Patient Data History and Physical

The nurse calls the provider to notify them that the digoxin level is above therapeutic range. Place the nurse statements in Situation, Background, Assessment, Recommendation (SBAR) format.

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

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

Do you want to recheck the digoxin level again tomorrow morning to see if we can restart it?

Answer and Explanation

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

The medical history of the client provides a background of the current issue of concern The nurse describes the current situation that has prompted her to contact the healthcare provider

A recommendation provides a proposal of plan of care to allow the healthcare provider to either agree, disagree or add more insight

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Correct Answer is B

Explanation

A. When identifying goals to be included in a client's plan of care, the nurse should compare the client's manifestations (signs and symptoms) with the defining criteria of related nursing problems or diagnoses. This involves assessing the client's current health status, identifying specific problems or areas of concern, and determining desired outcomes or goals for improvement.

B. Reviewing the priority nursing problems already included in the plan of care helps the nurse understand the client's current status and ongoing care needs. However, this may leave out other client needs not stated as priority

C. While listing immediate nursing actions is important for addressing urgent care needs, it does not directly address the process of identifying goals for the client's plan of care.

D. Ensuring that prescribed treatments have been initiated is an important aspect of client care, but it pertains more to implementation rather than goal identification.

A. Bowel incontinence. B. Impaired bed mobility. C. Caregiver role strain. D. Fluid volume deficit.

Correct Answer is D

Explanation

D. Addressing fluid volume deficit promptly is essential to prevent complications such as hypovolemic shock and renal dysfunction.

A. Bowel incontinence, especially in a client with celiac disease experiencing diarrhea, can lead to skin breakdown, discomfort, and embarrassment. However, it may not be the highest priority if the client's safety and physiological needs are not compromised.

B. Impaired bed mobility after knee replacement surgery can impact the client's recovery, comfort, and risk of complications such as deep vein thrombosis (DVT). However, if the client's condition allows for safe positioning and mobility within bed, this problem may not be the highest priority compared to more immediate concerns.

C. Caregiver role strain is a valid concern, especially if the primary caregiver is experiencing difficulty managing the client's needs. However, the priority is typically focused on addressing the client's immediate physiological needs before addressing caregiver concerns.

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Patient Data History and Physical The nurse calls the provider to notify them that the digoxin level is above therapeutic range. Place the nurse statements in Situation, Background, Assessment, Recommendation (SBAR) format.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When identifying the goals to be included in a client's plan of care, the nurse should take which action?

Correct Answer is B

Explanation

The home health nurse identifies several nursing problems for a client with celiac disease, who had knee replacement surgery 2 weeks ago. The client is experiencing diarrhea and the primary caregiver is the client's spouse. In planning care, which nursing problem has the highest priority?

Correct Answer is D

Explanation

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Patient Data History and Physical

The nurse calls the provider to notify them that the digoxin level is above therapeutic range. Place the nurse statements in Situation, Background, Assessment, Recommendation (SBAR) format.