Causes and risk factors
Causes and risk factors ( 7 Questions)
A nurse is reviewing the medication administration record of a client who is receiving digoxin, a cardiac glycoside. The nurse notes that the client's apical pulse is 58 beats per minute. Which of the following actions should the nurse take?
Administering the medication as prescribed or holding the medication and notifying the provider are not appropriate actions for the nurse to take without further assessment of the client's condition.
Digoxin can lower the heart rate, but it can also improve cardiac output and contractility in clients with heart failure. Therefore, the nurse should not withhold the medication based on one vital sign measurement alone.
Checking the client's blood pressure and oxygen saturation is an appropriate action for the nurse to take when the client's apical pulse is below 60 beats per minute, which is the lower limit of normal. This is because a low pulse rate can indicate bradycardia, which can affect the client's hemodynamic status and tissue perfusion.
Repeating the apical pulse measurement after 5 minutes is not an appropriate action for the nurse to take when the client's apical pulse is below 60 beats per minute, as it delays further assessment and intervention.
Checking the client's blood pressure and oxygen saturation is an appropriate action for the nurse to take when the client's apical pulse is below 60 beats per minute, which is the lower limit of normal. This is because a low pulse rate can indicate bradycardia, which can affect the client's hemodynamic status and tissue perfusion.
A and B are incorrect. Administering the medication as prescribed or holding the medication and notifying the provider are not appropriate actions for the nurse to take without further assessment of the client's condition. Digoxin can lower the heart rate, but it can also improve cardiac output and contractility in clients with heart failure. Therefore, the nurse should not withhold the medication based on one vital sign measurement alone.
D is incorrect. Repeating the apical pulse measurement after 5 minutes is not an appropriate action for the nurse to take when the client's apical pulse is below 60 beats per minute, as it delays further assessment and intervention.