The client who is to receive a scheduled dose of digoxin has an irregular apical pulse at 92 beats per minute and a serum potassium of 3.9 mEq/dL. Which nursing documentation reflects the most appropriate action.
Serum potassium level WNL Digoxin given for rapid apical pulse.
Digoxin withheld to prevent toxicity due to the low potassium level.
HCP informed of irregular HR and low serum potassium level.
Digoxin withheld because the client's apical HR is irregular.
The Correct Answer is A
A. Serum potassium level WNL Digoxin given for rapid apical pulse: The serum K⁺ of 3.9 mEq/L is within normal range and the apical rate of 92 bpm is >60, so per usual digoxin administration guidelines the nurse may give the medication and document that K is WNL and digoxin was administered. (If the rhythm is an unexpected irregularity, the nurse would still note it and monitor/notify per facility policy.)
B. Digoxin withheld to prevent toxicity due to the low potassium level: The potassium value is not low (3.9 mEq/L is within normal limits), so withholding for low K⁺ is not indicated.
C. HCP informed of irregular HR and low serum potassium level: While informing the HCP of an irregular pulse may be appropriate, the serum potassium is not low, so documenting “low potassium” would be inaccurate.
D. Digoxin withheld because the client's apical HR is irregular: Irregular rhythm alone (with rate >60 and no other contraindications) is not an automatic reason to withhold digoxin; the usual criterion is to withhold for low heart rate (commonly <60) or other signs of toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Serum sodium 140 mEq/L: Normal serum sodium (≈135–145 mEq/L); not an expected adverse effect of spironolactone.
B. Serum calcium 10.5 mg/dL: Mildly high calcium is not a characteristic adverse effect of spironolactone.
C. Serum potassium 5.2: Spironolactone is a potassium-sparing diuretic and commonly causes hyperkalemia (monitor K+ closely).
D. Serum chloride 99 mEq/L: Chloride ~99 mEq/L is within normal limits (≈98–106) and not specific to spironolactone toxicity.
Correct Answer is B
Explanation
A. Glipizide blocks glucose production in the liver: That is more the action of biguanides (metformin) affecting hepatic gluconeogenesis.
B. Glipizide stimulates the pancreas to release adequate insulin: Glipizide is a sulfonylurea that increases insulin release from pancreatic β-cells.
C. Glipizide promotes the breakdown of glycogen to glucose: That would raise blood glucose; glipizide does the opposite by increasing insulin.
D. Glipizide slows gastric emptying and decreases appetite: That is the mechanism of some GLP-1 agonists, not sulfonylureas.
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