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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
Rationale for Correct Choices:
- The nurse assesses the client. The client reports he was able to sleep through the night:
Being able to sleep through the night suggests that the client’s pain is adequately managed, indicating progress in terms of pain control post-surgery or trauma care. - The left arm is warm to touch: The warmth of the left arm indicates that circulation has improved from initially cool to touch. This is a positive sign, as it suggests that there are no significant vascular complications following the fracture or trauma.
- The client's left shoulder and collarbone are symmetric: Symmetry of the shoulder and collarbone suggests that there is no new displacement or injury to the bones post-trauma or surgery. This is a good sign indicating that the fracture is properly stabilized.
Rationale for Incorrect Choices:
- The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers: The numbness, tingling, and inability to move his fingers may indicate nerve involvement, which could be a sign of complications such as nerve compression or injury due to the fracture.
- The client reports mild nausea and has no desire to eat breakfast: Mild nausea is expected after anesthesia or pain medications, but continued lack of appetite or worsening nausea may signal complications, such as a delayed reaction to anesthesia or a side effect from medication, which should be monitored.
- There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage: While some blood may be expected post-surgery or after trauma, a blood stain of this size should be evaluated for any indication of active bleeding or complications such as hematoma formation. It may not be expected if the bleeding had been controlled.
Correct Answer is []
Explanation
Rationale for Correct Choices:
- Myocardial infarct (MI): The client presents with chest pain described as pressure and tightness, which worsens over time. The ECG shows ST depression, a common sign of ischemia. This combined with the risk factors and vital signs support myocardial infarction.
- Prepare client for possible percutaneous coronary intervention: If a myocardial infarction is suspected, preparing the client for PCI is critical. PCI is used to treat blockages in the coronary arteries, which is essential for restoring blood flow and minimizing myocardial damage.
- Educate on nitroglycerin administration: Nitroglycerin helps alleviate chest pain by relaxing coronary arteries, reducing heart workload, and improving blood flow. It is used in MI management to relieve symptoms and reduce ischemia.
- Electrocardiogram (ECG): Continuous ECG monitoring is essential to assess the progression of any arrhythmias or ischemic changes, which are common during an MI. It allows real-time identification of worsening conditions.
- Chest pain: Monitoring chest pain closely helps evaluate the effectiveness of treatment and determine whether ischemia persists or resolves. Pain relief indicates that interventions are successful.
Rationale for Incorrect Choices:
- Atrial fibrillation: While atrial fibrillation can cause chest discomfort, the patient’s clinical presentation, including ECG findings and risk factors, is more consistent with an MI. Atrial fibrillation usually presents with irregular heartbeats rather than persistent chest pressure.
- Congestive heart failure: The current presentation, including chest pain, ECG changes, and pain unrelieved by rest, points to a myocardial infarction rather than congestive heart failure. There are no signs of fluid overload or symptoms associated with heart failure in this scenario.
- New onset angina: While the client may experience angina, the unrelieved chest pain lasting for over 30 minutes and the severity of the symptoms suggest a myocardial infarction rather than just new onset angina, which typically resolves with rest.
- Begin chest compressions: Chest compressions are necessary only in cases of cardiac arrest. While this client is experiencing chest pain and signs of an MI, there is no indication of cardiac arrest, so chest compressions are not appropriate at this point.
- Consult physical therapy: Physical therapy is not immediately needed for the acute management of myocardial infarction. The priority is stabilizing the patient's cardiac status and addressing the ischemia, not physical rehabilitation.
- Conduct a nutritional history: While a nutritional history is important for long-term heart disease management, it is not an immediate concern during an acute MI episode. The focus should be on stabilizing the patient and addressing the immediate cardiovascular issues.
- Lung sounds: Lung sounds are not directly relevant to this patient's current condition. While they may be important for detecting complications like pulmonary edema, they are not a priority when assessing for an acute MI.
- Pedal pulses: Pedal pulses can be useful in assessing peripheral circulation but are not a priority in the management of MI unless signs of shock or poor circulation are noted.
- Intake and output: While monitoring intake and output is important for fluid balance, it is not the immediate focus for managing this patient’s acute MI. The focus should be on cardiac parameters and symptom relief, such as monitoring chest pain and ECG changes.
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