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    Hesi RN exit proctored examQuestion 84
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    Hesi RN exit proctored exam

    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.

    Explanation & Rationale

    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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