A practical nurse is preparing to administer a scheduled morning dose of digoxin to an adult client. The bedside vital sign monitor displays a heart rate of 54 beats/minute. Arrange the following nursing actions in the correct sequence to reduce the client's risk of potential complications.
- 1Auscultate the apical pulse manually for one full minute.
- 2Withhold the scheduled dose of digoxin.
- 3Notify the registered nurse (RN) or healthcare provider.
- 4Document the vital signs and the withheld medication in the medical record.
Cevap
The correct sequence is to first verify the heart rate by auscultating the apical pulse manually, then withhold the digoxin, notify the RN or healthcare provider, and finally document the actions and findings.
When a practical nurse identifies a potentially abnormal vital sign reading from an automated device, the first priority is to assess the client and verify the finding manually. Once an apical pulse below 60 beats/minute is confirmed, the nurse must withhold the digoxin to reduce the risk of toxicity. Subsequently, the nurse escalates the finding by notifying the RN or provider. Finally, all assessments, interventions, and notifications must be thoroughly documented in the client's medical record.
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Anahtar Kavram
Prioritization and risk reduction for clients receiving cardiac glycosides with borderline vital signs
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