A nurse is preparing to administer IV digoxin to an elderly client in heart failure. Which nursing action takes priority?
a. Ask the client if he/she has ever had digoxin before.
b. Assess the client's pulse rate and hold the medication if it is less than 60 beats/min.
c. Prepare the client for any side effects of the medication.
d. Provide instruction to the client on the medication's expected effects.
B
Digoxin's actions include slowing the heart rate to allow more effective filling. However, with its narrow therapeutic range, toxicity is common. One manifestation of toxicity is bradycardia. Nearly all health care institutions have policies that require nurses to check the client's pulse rate before administering digoxin and to hold the dose and notify the physician if the pulse rate is less than 60 beats/min. While all options are appropriate nursing interventions, option b takes priority.
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