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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.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Instruct the client to cough as the suction tip is removed: Coughing can help clear secretions, but this action is not the primary safety concern during suctioning. The priority is minimizing the risk of injury, infection, and contamination during the procedure

B. Instil 3 mL of 0.9% sodium chloride before suctioning: Instilling saline before suctioning is generally not recommended as it can lead to complications, such as increasing mucus production, which can make suctioning more difficult.

C. Wear protective goggles while performing the procedure: Suctioning a tracheostomy can involve secretions that may potentially splash, so it’s important to wear protective goggles, as well as other appropriate personal protective equipment, to ensure safety and prevent contamination.

D. Apply a water-soluble lubricant to the catheter: Applying lubricant to the catheter is not recommended. The suction catheter should be kept sterile and dry to avoid introducing any contaminants into the trachea or the airway.

A. Maintain the client on an NPO status. B. Determine if the client is over-hydrating to feel satiated. C. Administer daily vitamin supplements. D. Encourage positive self accolades for dietary adherence.

Correct Answer is A

Explanation

A. Maintain the client on an NPO status: After bariatric surgery, vomiting and the inability to tolerate food and liquids could indicate complications such as gastric outlet obstruction or stenosis. Maintaining NPO status allows the gastrointestinal system to rest while the cause of the symptoms is investigated and treated.

B. Determine if the client is over-hydrating to feel satiated: While over-hydration can cause discomfort, the immediate concern is the client's inability to tolerate food and liquids, which may suggest a more serious issue.

C. Administer daily vitamin supplements: While vitamin supplementation is essential after bariatric surgery to prevent deficiencies, it does not directly address the current issue of vomiting and inability to tolerate food and liquids.

D. Encourage positive self accolades for dietary adherence: Though reinforcing positive behavior is important in long-term weight loss management, it is not the priority at this moment. The immediate focus is addressing the client's symptoms and ensuring they are medically managed.

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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

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Correct Answer is C

Explanation

A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?

Correct Answer is A

Explanation

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

The nurse is speaking with the spouse of a client who has passed away unexpectedly. The spouse is very calm and says, "No, there must be a mistake." Which action should the nurse take?

Exhibits Drag from Word Choices to complete the sentence. According to the lab values, the client has dropdownrelated to dropdownordropdown.

Exhibits For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.

Exhibits The nurse considers the brief interaction with the client and the triage report. Which finding(s) should the nurse investigate further? Select all that apply.

Exhibits The nurse reviews the intake information prior to seeing the client. What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.

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.