A practical nurse is reviewing morning laboratory results before administering scheduled o… — NCLEX-PN

A practical nurse is reviewing morning laboratory results before administering scheduled oral medications to a client with chronic kidney disease and atrial fibrillation.

Scheduled Medications	Dose
Calcitriol	$0.25\text{ mcg}$
Calcium acetate	$667\text{ mg}$
Sevelamer	$800\text{ mg}$
Digoxin	$0.125\text{ mg}$

Laboratory Test	Result
Serum calcium	$11.8\text{ mg/dL}$
Serum phosphorus	$6.2\text{ mg/dL}$
Serum potassium	$4.5\text{ mEq/L}$
Serum digoxin level	$1.1\text{ ng/mL}$

Which action should the practical nurse take?

Withhold the calcitriol, calcium acetate, and digoxin; administer the sevelamer; and notify the registered nurse.Answer
B
Administer the calcium acetate and sevelamer with breakfast, withhold the calcitriol, and report the findings during shift handoff.
C
Withhold all scheduled medications, independently initiate continuous cardiac monitoring, and immediately contact the health care provider.
D
Administer the calcitriol and digoxin after verifying the client's room number, withhold the sevelamer and calcium acetate, and notify the registered nurse.

Answer

Withhold the calcitriol, calcium acetate, and digoxin; administer the sevelamer; and notify the registered nurse.

The client's serum calcium is critically elevated (

11.8\text{ mg/dL}

). Calcitriol (active vitamin D) and calcium acetate must be withheld because they will further increase serum calcium. Furthermore, hypercalcemia significantly increases the risk of digoxin toxicity and fatal dysrhythmias, even when the serum digoxin level is within the normal therapeutic range. Therefore, digoxin must also be withheld. Sevelamer is a non-calcium-based phosphate binder that safely addresses the hyperphosphatemia (

6.2\text{ mg/dL}

) without worsening the hypercalcemia. The practical nurse must notify the registered nurse of these critical findings.

Step-by-Step Solution

Analyze the laboratory results against normal reference ranges.

Serum calcium (

11.8\text{ mg/dL}

) and phosphorus (

6.2\text{ mg/dL}

) are critically elevated. Potassium (

4.5\text{ mEq/L}

) and digoxin (

1.1\text{ ng/mL}

) are within normal limits.

Identifying abnormal physiological values is the first step in determining medication safety.

Evaluate the mechanism of action for the prescribed phosphate binders and vitamins.

Calcitriol increases calcium absorption, and calcium acetate adds calcium. Sevelamer lowers phosphorus without adding systemic calcium.

The client has hypercalcemia, so any medication that further increases calcium (calcitriol, calcium acetate) must be withheld.

Evaluate the digoxin order in the context of the client's electrolyte imbalances.

Digoxin must be withheld despite the normal serum level.

Hypercalcemia sensitizes the myocardium to digoxin, significantly increasing the risk of toxicity and fatal dysrhythmias.

Determine the appropriate practical nursing action based on scope of practice.

Administer only the sevelamer, withhold the unsafe medications, and immediately report the critical laboratory values to the supervising registered nurse.

This action protects the client from pharmacological harm and follows the correct chain of command.

Key Concept

Pharmacological management of chronic kidney disease and the critical interaction between hypercalcemia and digoxin toxicity.

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