Following breakfast, a client receiving treatment for heart failure experiences multiple episodes of emesis and states, 'The lights in the room have strange yellow rings around them.' The client is scheduled to receive a daily dose of oral digoxin in 30 minutes. A review of today's laboratory panel reveals a serum digoxin level of 2.7 ng/mL. What is the most appropriate action for the practical nurse to take?
- ANote the abnormal laboratory value in the flow sheet and administer the medication as prescribed.
- Hold the scheduled medication and promptly communicate the clinical findings and laboratory value to the registered nurse.Cevap
- CPrepare and administer a prescribed intravenous push medication for nausea prior to giving the cardiac medication.
- DSkip the barcode verification step to rapidly provide the cardiac medication before further gastrointestinal distress occurs.
Cevap
The practical nurse should hold the scheduled medication and immediately report the findings to the registered nurse.
The client is exhibiting classic signs of digoxin toxicity, including gastrointestinal distress and visual changes (yellow halos). This is confirmed by the critical laboratory value of 2.7 ng/mL, which exceeds the normal therapeutic range of 0.8 to 2.0 ng/mL. The safest and most appropriate action within the practical nurse's scope of practice is to withhold the next scheduled dose and immediately report these assessment findings to the registered nurse to prevent further harm.
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Anahtar Kavram
Recognizing medication toxicity and safely applying the practical nurse scope of practice.