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 D

Explanation

D. This area is commonly used for LMWH injections due to its high vascularity and absorption rate. Injecting at least 2 inches away from the umbilicus helps minimize the risk of injury to the umbilical vessels and ensures proper absorption of the medication.

A. Massaging the injection site is not recommended after administering LMWH because it can increase the risk of bruising, bleeding, or tissue damage.

B. LMWH injections are typically administered in the abdomen, with sites rotated within the same area. While rotating between the abdomen and gluteal areas may be appropriate for some medications, LMWH is generally administered in the abdomen only.

C. If you expel the air bubbles before injecting, you might inadvertently expel a small amount of insulin along with the air. This could result in receiving less insulin than intended.

A. Increase the lighting in the room. B. Obtain a new catheter. C. Clean the catheter with providone-iodine. D. Reposition the legs before reinsertion.

Correct Answer is B

Explanation

B. If the tip of the urinary catheter reemerges from the insertion site during insertion, it means that the catheter has become contaminated with microorganisms from the urethra or surrounding area. Continuing to insert the same catheter can introduce these microorganisms into the urinary tract, increasing the risk of urinary tract infection (UTI).

A. Increasing the lighting in the room allows for optimal visualization during the procedure, but it is not the priority action when the catheter has become contaminated.

C. Cleaning the catheter with providone-iodine is not sufficient to sterilize the catheter and eliminate the risk of introducing pathogens into the urinary tract.

D. Repositioning the legs before reinsertion does not address the contamination of the catheter and does not mitigate the risk of introducing pathogens into the urinary tract.

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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

The nurse is teaching the client to self-administer a dose of low-molecular-weight heparin (LMWH) SUBQ: Which instruction should the nurse include?

Correct Answer is D

Explanation

The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next?

Correct Answer is B

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.