A practical nurse is caring for an adult client with heart failure who is scheduled to receive a morning dose of oral digoxin. During the pre-administration assessment, the client's apical pulse is beats/min, and the client reports feeling nauseous and seeing yellow halos around the lights in the room. Which of the following actions should the practical nurse take first?
- Withhold the dose of digoxin and immediately notify the registered nurse.Answer
- BAdminister the scheduled dose of the medication and document the client's heart rate.
- CAdminister half of the prescribed dose and reassess the client's apical pulse in one hour.
- DAssess the client's blood pressure and administer the dose if the systolic reading is normal.
Answer
Withhold the dose of digoxin and immediately notify the registered nurse.
The client is exhibiting classical clinical signs of digoxin toxicity, which include gastrointestinal distress (nausea) and visual disturbances (yellow halos). Furthermore, the client's apical pulse is below the standard adult parameter of 60 beats/min. The safest and most appropriate action within the practical nurse scope of practice is to withhold the medication and escalate these critical findings to the registered nurse for further evaluation.
Step-by-Step Solution
Key Concept
Digoxin toxicity recognition and safe medication administration parameters.