A practical nurse (PN) reviews the morning laboratory results for a client with heart failure who is scheduled to receive a daily dose of digoxin. The client's serum potassium level is . During data collection, the client reports new-onset nausea and generalized weakness. Which action should the PN take first?
- AAdminister a prescribed PRN antiemetic to relieve the nausea before giving the digoxin.
- Withhold the digoxin dose and immediately report the findings to the registered nurse (RN).Cevap
- CAdminister the digoxin as prescribed and continue to monitor the client's vital signs.
- DAdjust the digoxin dose according to the current potassium level and administer.
Cevap
The PN must withhold the digoxin dose and immediately report the findings to the registered nurse (RN).
The correct answer is to withhold the medication and notify the RN. The client's potassium level is low (normal is 3.5 to 5.0 mEq/L), which strongly predisposes the client to digoxin toxicity. Combined with the clinical symptoms of nausea and weakness, these findings strongly suggest early toxicity. The safest action within the practical nurse's scope of practice is to hold the drug and escalate the data for further medical evaluation.
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Anahtar Kavram
Digoxin Toxicity and Hypokalemia