A nurse receives a verbal order for a client for digoxin. Which of the following entries should the nurse document in the client's medical record?

Phenytoin is a potent antiepilepticthat requires extreme caution during intravenous administration due to its high alkalinity and potential for precipitation. It is incompatible with most intravenous solutions and must be delivered through a large-bore catheter to prevent extravasationand tissue necrosis. Close cardiovascular monitoring is mandatory during infusion to detect potential arrhythmias or severe hypotension.

Rationale:

A.Injecting sterile water after administration is not the standard protocol; instead, the line must be flushed with 0.9% sodium chloride. Phenytoin is highly unstable and will precipitate if it comes into contact with many other fluids. Using 0.9% sodium chloride ensures the vein is cleared of the medication without causing the formation of dangerous micro-crystals in the IV tubing.

B.Administering phenytoin with 5% dextrose in water (D5W) is strictly contraindicated because the medication will immediately precipitate into a solid form. Phenytoin is only compatible with 0.9% sodium chloride, and any contact with glucose-containing solutions leads to crystallization. Such precipitates can cause emboli or severe vein irritation, compromising the safety of the intravenous access site.

C.Discarding the medication if it appears cloudy is a critical safety action because cloudiness indicates that the phenytoin has precipitated. Intravenous phenytoin should be a clear, colorless solution; any presence of crystals or opaqueness means the drug is no longer safe for infusion. Injecting a precipitated solution can cause catastrophic vascular damage or pulmonary embolism in the client.

D.Administering the medication at a rate of 100 mg/min is dangerously fast and exceeds the maximum recommended safety limit. To prevent severe hypotension and cardiac arrhythmias, the infusion rate must not exceed 50 mg/min for adults. Rapid administration can lead to cardiovascular collapse, making slow, controlled delivery and continuous heart rate monitoring an essential nursing priority.

An ST-elevation myocardial infarction(STEMI) occurs when a coronary artery is completely occluded, leading to transmural myocardial ischemiaand necrosis. This medical emergency is identified by specific ECG changes and elevated cardiac biomarkerslike Troponin I (> 0.03 ng/mL). Immediate pharmacologic intervention focuses on reperfusion, preventing further thrombus propagation, and reducing myocardial oxygen demand to preserve functional cardiac tissue.

Rationale:

A. Heparin is an anticoagulant indicated in the acute phase of a STEMI to prevent the formation and extension of fibrin clots. By accelerating the action of antithrombin 3, it neutralizes thrombin and factor Xa. This prevents further occlusion of the coronary artery while the patient awaits definitive reperfusion therapy like percutaneous coronary intervention.

B. Digoxin is a positive inotrope and negative chronotrope primarily used for chronic heart failure or atrial fibrillation with rapid ventricular response. In the setting of an acute STEMI, it is generally avoided because it increases myocardial oxygen consumptionby increasing contractility. Excessive oxygen demand during an active infarction can exacerbate myocardial injury and extend the area of necrosis.

C. Aspirin is a cornerstone of acute coronary syndrome management due to its immediate antiplatelet effects. It irreversibly inhibits cyclooxygenase-1, preventing the synthesis of thromboxane A2, which is a potent stimulator of platelet aggregation. Administering aspirin early significantly reduces mortality by limiting the size of the developing thrombus within the obstructed coronary vessel.

D. Morphine is the preferred analgesic for managing the crushing chest pain associated with myocardial infarction when nitrates are insufficient. Beyond pain relief, it provides beneficial hemodynamic effectsby reducing preload through venous dilation and decreasing systemic vascular resistance. These actions lower the myocardial workload and oxygen demand, while also alleviating the patient's anxiety and sympathetic surge.

E. Dopamine is a sympathomimetic amine used for hemodynamic support in cases of cardiogenic shock or clinically significant hypotension. The client's blood pressure is currently stable at 126/80 mm Hg, making a vasopressor or potent inotrope unnecessary and potentially harmful. Administering dopamine in a stable STEMI patient would unnecessarily increase heart rate and myocardial metabolic demand, worsening the ischemia.