During a routine morning assessment, a client receiving pharmacological therapy for heart … — NCLEX-PN

During a routine morning assessment, a client receiving pharmacological therapy for heart failure states, "I feel sick to my stomach, and all the lights have a strange yellow glow around them." The client's medication profile includes daily oral digoxin and furosemide. A review of today's laboratory results reveals a serum digoxin level of $2.8\text{ ng/mL}$ . Which action should the practical nurse implement?

A
Administer the scheduled digoxin dose as prescribed, recognizing that the serum level is within the expected therapeutic range.
B
Bypass the medication barcode scan to quickly administer an as-needed antiemetic to relieve the client's nausea.
Withhold the upcoming dose of digoxin and immediately notify the registered nurse of the clinical findings.Answer
D
Accept a delegated task from the registered nurse to administer an intravenous push medication to manage potential dysrhythmias.

Answer

The correct action is to withhold the upcoming dose of digoxin and immediately notify the registered nurse of the clinical findings.

The client is exhibiting both subjective symptoms (nausea, visual halos) and objective data (a serum digoxin level of

2.8\text{ ng/mL}

) that clearly indicate severe digoxin toxicity. The normal therapeutic range is

0.8

2.0\text{ ng/mL}

. Safe nursing practice dictates that the practical nurse must hold the offending medication to prevent further toxicity and immediately alert the supervising registered nurse or healthcare provider to initiate corrective treatment.

Step-by-Step Solution

Evaluate the subjective clinical manifestations reported by the client.

The client reports nausea and seeing yellow halos around lights.

Gastrointestinal distress and visual disturbances are classic early signs of digoxin toxicity.

Analyze the objective laboratory data provided in the electronic health record.

The serum digoxin level is

2.8\text{ ng/mL}

Comparing the client's level against the normal therapeutic range (

0.8

2.0\text{ ng/mL}

) confirms that the level is toxic.

Determine the safest and most appropriate nursing intervention within the PN scope of practice.

The medication administration must be halted and the supervising nurse notified.

Preventing further harm by holding the toxic medication and escalating critical labs ensures patient safety and adheres to the chain of command.

Key Concept

Digoxin Toxicity Recognition and Management

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