During morning rounds, a client's laboratory report indicates a serum potassium level of 3… — NCLEX-PN

During morning rounds, a client's laboratory report indicates a serum potassium level of $3.1\text{ mEq/L}$ . The client's vital signs include a blood pressure of $118/76\text{ mmHg}$ and an apical pulse of $56\text{ beats/min}$ . The medication administration record shows a scheduled dose of oral digoxin $0.25\text{ mg}$ . Based on these findings, which of the following actions is most appropriate for the practical nurse to perform?

A
Proceed with administering the medication after verifying the client's identity using their bed assignment.
B
Initiate an intravenous push of potassium chloride prior to giving the oral medication.
Withhold the medication and immediately report the clinical findings to the registered nurse.Answer
D
Administer the medication as prescribed because the serum potassium level is within the expected therapeutic range.

Answer

Withhold the medication and immediately report the clinical findings to the registered nurse.

The client is exhibiting bradycardia (an apical pulse less than

60\text{ beats/min}

) and hypokalemia (a serum potassium level less than

3.5\text{ mEq/L}

). Both conditions are contraindications or high-risk factors for administering digoxin, as low potassium significantly increases the risk of digoxin toxicity. The appropriate action within the practical nurse scope of practice is to withhold the medication and escalate these critical findings to the registered nurse or healthcare provider.

Step-by-Step Solution

Evaluate the client's vital signs and laboratory values against established normal parameters.

The apical pulse of

56\text{ beats/min}

is below the normal threshold (

60\text{ beats/min}

) for digoxin administration, and the potassium level of

3.1\text{ mEq/L}

indicates hypokalemia.

Safe medication administration requires ensuring that the client's current physiological status does not contraindicate the ordered pharmacological therapy.

Determine the relationship between the abnormal clinical findings and the scheduled medication.

Hypokalemia significantly increases the risk of digoxin toxicity, making the administration of the medication unsafe in the presence of a low heart rate.

Understanding drug-laboratory interactions is essential to prevent severe adverse pharmacological events.

Identify the correct nursing intervention within the practical nurse's scope of practice.

The medication must be withheld and the abnormal clinical findings promptly reported to the registered nurse for further medical evaluation.

Practical nurses must escalate critical abnormal findings and withhold potentially harmful medications to ensure client safety.

Key Concept

Pharmacological therapies require the practical nurse to evaluate pertinent laboratory values and vital signs prior to administration, withholding the medication and notifying the registered nurse when findings suggest a heightened risk for adverse effects or toxicity.

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