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Soru

Zorluk: OrtaPharmacological Therapies

An 80-year-old client with a history of heart failure is prescribed a daily oral dose of digoxin. The morning laboratory results indicate a serum potassium level of 3.1 mEq/L (3.1 mmol/L). Upon assessment, the practical nurse (PN) notes the client is experiencing new-onset acute confusion and nausea. Which action should the PN take?

  1. Withhold the medication and immediately report the clinical findings to the registered nurse (RN).Cevap
  2. B
    Administer the medication and document the confusion as an expected manifestation of the aging process.
  3. C
    Administer a prescribed intravenous (IV) push antiemetic to treat the client's nausea.
  4. D
    Verify the client's identity using their room number before administering the digoxin.

Cevap

The correct action is to withhold the medication and immediately report the clinical findings to the registered nurse (RN).
The correct action prioritizes client safety by recognizing the high risk for digoxin toxicity. A potassium level of 3.1 mEq/L indicates hypokalemia, which increases the myocardium's sensitivity to digoxin. Combined with the clinical signs of nausea and new-onset confusion, the practical nurse (PN) must safely withhold the drug and escalate the findings to the registered nurse (RN) for further medical evaluation.

Adım Adım Çözüm

1
Analyze the client's laboratory values.
The serum potassium level is 3.1 mEq/L, which indicates hypokalemia (normal is 3.5 to 5.0 mEq/L).
Hypokalemia significantly increases the myocardium's sensitivity to digoxin, raising the risk for toxicity.
2
Evaluate the client's clinical presentation in the context of the laboratory results.
The client has new-onset acute confusion and nausea.
Gastrointestinal symptoms (nausea) and neurologic changes (confusion) are classic signs of digoxin toxicity, especially in older adults.
3
Determine the appropriate practical nurse (PN) action based on scope of practice and safety protocols.
The PN must recognize the high risk for toxicity, safely withhold the scheduled digoxin dose, and notify the supervising RN.
Administering the medication could cause severe harm. Modifying the treatment plan or providing advanced assessment requires RN or provider intervention.

Anahtar Kavram

Digoxin toxicity recognition, electrolyte imbalances, and the practical nurse's role in withholding medication and escalating critical findings.
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Pharmacological Therapies

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