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Difficulty: MediumReduction of Risk Potential

A practical nurse (PN) is caring for a client who has a nasogastric (NG) tube connected to low continuous suction. The client's morning comprehensive metabolic panel reveals a serum potassium level of 2.8 mEq/L. The client's current vital signs are: blood pressure 98/58 mm Hg, heart rate 114 beats/min, and respiratory rate 18 breaths/min. The client is scheduled to receive an oral dose of digoxin in 30 minutes. Which action is the priority for the PN?

  1. Withhold the scheduled digoxin and immediately report the potassium level and vital signs to the registered nurse.Answer
  2. B
    Administer the digoxin as scheduled, because the client's heart rate is safely above the parameter of 60 beats/min.
  3. C
    Accept the registered nurse's verbal delegation to administer a prescribed intravenous potassium chloride bolus.
  4. D
    Continue to monitor the client, assuming the mild hypotension and tachycardia are expected findings during nasogastric decompression.

Answer

The priority action is to withhold the scheduled digoxin and immediately report the critical laboratory findings and vital signs to the registered nurse.
The correct answer identifies that a serum potassium level of 2.8 mEq/L is critically low (hypokalemia). Because hypokalemia significantly increases the risk of digoxin toxicity, administering the medication could provoke life-threatening cardiac dysrhythmias. The client's borderline hypotension and tachycardia further indicate physiological compromise. The safest and most appropriate action for the practical nurse is to withhold the dose and immediately notify the registered nurse for further intervention.

Step-by-Step Solution

1
Analyze the laboratory values.
The serum potassium level is 2.8 mEq/L, which indicates severe hypokalemia (normal is 3.5 to 5.0 mEq/L).
Nasogastric suction removes potassium-rich gastric fluids, leading to depletion.
2
Evaluate the clinical risks associated with the medications.
The client is scheduled to receive digoxin. Hypokalemia drastically increases the risk of digoxin toxicity.
Digoxin toxicity can precipitate life-threatening cardiac dysrhythmias, especially when potassium is low.
3
Assess the vital signs.
The blood pressure (98/58 mm Hg) and heart rate (114 beats/min) are abnormal.
These borderline vital signs indicate early cardiovascular compromise, hypovolemia, or developing dysrhythmia.
4
Determine the safest nursing action within the PN scope of practice.
The PN must withhold the digoxin and immediately escalate the situation.
Administering the medication could cause harm, and the client requires immediate RN and provider intervention for electrolyte replacement and stabilization.

Key Concept

Reduction of Risk Potential: Recognizing critical laboratory values (hypokalemia) and preventing medication complications (digoxin toxicity).
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Topics

Reduction of Risk Potential

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