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?
A.
Administer the medication as prescribed.
B.
Hold the medication and notify the provider.
C.
Check the client’s blood pressure and oxygen saturation.
D.
Repeat the apical pulse measurement after 5 minutes.
The Correct Answer is C
When a client is receiving digoxin and the apical pulse is 58 beats per minute, the appropriate action is:
B. Hold the medication and notify the provider.
Explanation:
- Digoxin is a cardiac glycoside that can slow the heart rate. It is important to monitor the client’s apical pulse before administering the medication. The usual guideline is to withhold digoxin if the apical pulse is below 60 beats per minute in adults (or 70 beats per minute in children), as a lower pulse rate can indicate digoxin toxicity or an adverse effect.
- A. Administer the medication as prescribed. This would be inappropriate if the apical pulse is below the recommended threshold, as it could lead to further complications.
- C. Check the client’s blood pressure and oxygen saturation. While important for overall assessment, this does not address the immediate concern related to the low pulse rate.
- D. Repeat the apical pulse measurement after 5 minutes. Repeating the measurement may not be necessary if the pulse is clearly below the threshold for administering digoxin; instead, the medication should be held, and the provider should be notified for further guidance.