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Difficulty: MediumPharmacological Therapies

A practical nurse (PN) reviews the morning laboratory results for a client with heart failure who is scheduled to receive a daily dose of digoxin. The client's serum potassium level is 3.1 mEq/L3.1\text{ mEq/L}. During data collection, the client reports new-onset nausea and generalized weakness. Which action should the PN take first?

  1. A
    Administer a prescribed PRN antiemetic to relieve the nausea before giving the digoxin.
  2. Withhold the digoxin dose and immediately report the findings to the registered nurse (RN).Answer
  3. C
    Administer the digoxin as prescribed and continue to monitor the client's vital signs.
  4. D
    Adjust the digoxin dose according to the current potassium level and administer.

Answer

The PN must withhold the digoxin dose and immediately report the findings to the registered nurse (RN).
The correct answer is to withhold the medication and notify the RN. The client's potassium level is low (normal is 3.5 to 5.0 mEq/L), which strongly predisposes the client to digoxin toxicity. Combined with the clinical symptoms of nausea and weakness, these findings strongly suggest early toxicity. The safest action within the practical nurse's scope of practice is to hold the drug and escalate the data for further medical evaluation.

Step-by-Step Solution

1
Analyze the client's laboratory data.
The potassium level is 3.1 mEq/L, which indicates hypokalemia (normal is 3.5 to 5.0 mEq/L).
Identifying abnormal lab values is a crucial safety step before administering high-alert medications.
2
Correlate the lab findings and clinical symptoms with the scheduled medication.
Hypokalemia increases the risk for digoxin toxicity. Furthermore, nausea and generalized weakness are early clinical indicators of toxicity.
Recognizing the interaction between electrolyte imbalances and medication adverse effects is essential to prevent severe complications.
3
Determine the appropriate nursing action within the PN scope of practice.
The medication must be withheld and the critical findings escalated to the RN immediately.
The PN must ensure client safety by intervening when contraindications are present and reporting unstable conditions to the supervising RN.

Key Concept

Digoxin Toxicity and Hypokalemia
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Topics

Pharmacological Therapies

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