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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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Avoid forcing apart the teeth: Placing objects in the client’s mouth or trying to pry open the teeth can cause injury. It is important to let the seizure pass without interfering with the jaw or mouth.

B. Loosen clothing around the neck: Loosening tight clothing reduces the risk of airway obstruction or restricted breathing during a seizure. This is a correct and helpful intervention.

C. Position the head from injury: Protecting the client’s head with a soft object prevents trauma during convulsions. This is a recommended and safe practice during seizures.

D. Secure the limbs to the body: Restraining or holding down limbs can cause musculoskeletal injuries and increase agitation. Seizure safety protocols emphasize allowing movement without physical restraint.

A. Chicken, yams, pinto beans and pecans. B. Steak and baked potato with butter and cheese topping. C. Canned ham and green beans. D. Pasta with fish and an orange.

Correct Answer is D

Explanation

A. Chicken, yams, pinto beans, and pecans: This meal is not ideal for a client with CKD because pinto beans and pecans are high in potassium and phosphorus, which can be problematic for clients with CKD. Yams are also high in potassium.

B. Steak and baked potato with butter and cheese topping: Steak is high in protein and phosphorus, which can overload the kidneys. Baked potato, especially with cheese, can be high in potassium, which should be monitored in CKD.

C. Canned ham and green beans: Canned ham is often high in sodium, which is not recommended for clients with CKD, as it can exacerbate fluid retention and high blood pressure. Green beans are a good choice, but the sodium content in the ham is a concern.

D. Pasta with fish and an orange: Pasta is low in potassium and phosphorus, and fish provides a good source of protein that is generally easier on the kidneys compared to red meat. This meal is lower in sodium, phosphorus, and potassium, making it a better choice for CKD.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client's family member about seizure precautions. Which action described by the family member indicates the need for additional teaching?

Correct Answer is D

Explanation

The nurse is caring for a client with chronic kidney disease (CKD). Which meal selection should the nurse recommend to the client?

Correct Answer is D

Explanation

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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.