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 A

Explanation

A. Elevate the head of bed 45 degrees is the correct action because it helps clear the airway and reduce vomiting.

B. Irrigating the nasogastric tube with water is not the most appropriate action in this scenario. While it may help clear any obstructions in the tube itself, it does not directly address the immediate concern of clearing the airway of vomitus to prevent aspiration.

C. While suctioning is an effective intervention for clearing the airway, if the client is in a choking situation, establishing a safe position (like elevating the head of the bed) is a priority before any suctioning is performed.

D. Reviewing the advance directive document is important for understanding the client's wishes regarding medical interventions, including resuscitation and life-sustaining treatments.

A. Advise the client that lifestyle changes often take several weeks to be effective. B. Determine the amount of weight the client has lost since increasing activity. C. Encourage the client to exercise every day to eliminate bedtime wakefulness. D. Ask the client to describe the exercise schedule that he has been following.

Correct Answer is D

Explanation

D. The most appropriate action for the nurse to take is to gather more information about the client's exercise schedule. This will help the nurse assess whether the client's exercise regimen may be contributing to or exacerbating the insomnia. Understanding the timing, intensity, and duration of the client's aerobic workouts can provide insights into potential factors affecting sleep patterns.

A. Advising the client that lifestyle changes often take several weeks to be effective is a valid point. However, it does not directly address the potential impact of exercise timing on sleep.

B. Determining the amount of weight the client has lost since increasing activity may provide useful information about the client's progress with weight loss but does not directly address the issue of difficulty falling asleep.

C. Encouraging the client to exercise every day to eliminate bedtime wakefulness is not necessarily appropriate, as excessive or late-night exercise may exacerbate rather than alleviate bedtime wakefulness in some individuals.

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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

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

Correct Answer is A

Explanation

A client tells the nurse about starting an aerobic workout program to lose weight and help with insomnia. The client states that it still takes over an hour to fall asleep at night. Which action should the nurse implement?

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.