An adult client presents to the emergency department (ED) with nausea, vomiting, and mild confusion and reports having blurred vision. The cardiac telemetry monitor reveals atrial fibrillation (A-fib) with a controlled ventricular response (CVR). The client reports taking digoxin. Which intervention should the nurse implement?

Rationale:

• Infection: The client exhibits fever (101.2 °F), leukocytosis (WBC 20,000/mm³), neutrophilia (72%), and a recent surgical wound with redness, swelling, and tenderness, all indicative of a potential postoperative infection. Infection is the most immediate concern because it can rapidly progress to systemic inflammatory response syndrome (SIRS) or sepsis, particularly in older adults.

• Perfusion: The client has hypotension (BP 118/74 mm Hg), tachycardia (126 beats/min), weak distal pulses, and prolonged capillary refill (4 seconds), suggesting impaired tissue perfusion. Early recognition and monitoring of perfusion are critical to prevent organ dysfunction and shock. Nursing care will include fluid management, hemodynamic monitoring, and assessment of end-organ function to maintain adequate perfusion.

• Pain: While the client reports moderate pain (5/10), pain management is secondary to addressing infection and perfusion deficits. Pain control is important but does not take priority over life-threatening systemic issues.

• Oxygenation: Oxygen saturation is 94% on room air, slightly below normal but not immediately critical. Although monitoring oxygenation is part of routine care, it is not the primary focus compared with infection and perfusion concerns in this client.

• Ventilation: The client’s respiratory rate is mildly elevated (22 breaths/min), but there is no evidence of respiratory compromise such as hypoventilation or distress. Ventilation is not the primary concern at this time, as systemic infection and perfusion issues pose more immediate risk.

Rationale:
A. Complete a neurological assessment using the Glasgow Coma Scale: While assessing neurological status is important, the client’s symptoms of nausea, vomiting, confusion, and blurred vision are classic signs of digoxin toxicity. Lab evaluation takes priority to confirm toxicity and guide treatment.

B. Collect specimens for serum electrolytes and digoxin levels: Digoxin toxicity is influenced by drug levels and electrolyte imbalances (especially potassium, magnesium, and calcium). Obtaining these labs allows the provider to confirm toxicity and determine appropriate management.

C. Bring the crash cart to the bedside for immediate accessibility: While the client is at risk for arrhythmias due to digoxin toxicity, immediate verification of digoxin levels and electrolytes is the first step before initiating emergency treatment.

D. Obtain a prescription for digoxin immune fab IV: Digoxin-specific antibody therapy is reserved for severe toxicity with life-threatening arrhythmias or hyperkalemia. Administering it without confirmation and lab assessment would be premature.