Question

Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54 . The appropriate nursing intervention is to: A. Record the pulse rate and administer the medication B. Administer the medication and monitor the heart rate C. Withhold the medication and notify the doctor D. Withhold the medication until the heart rate increases

Short answer

Answer: The appropriate nursing intervention is to withhold the medication and notify the doctor, as the apical pulse rate is below the threshold of 60 beats per minute.

Step-by-step solution

Know the medication's function and possible side effects

Lanoxin (digoxin) is a medication used to treat certain heart conditions, such as heart failure and atrial fibrillation. One of its side effects is bradycardia (low heart rate).

Understand the normal and significant apical pulse rates

A normal adult resting heart rate falls between 60 and 100 beats per minute. In the case of Lanoxin administration, withholding the medication is usually considered if the heart rate drops below 60 beats per minute. This threshold may be different for special cases, such as athletes or elderly patients, as per doctor's instructions.

Compare the observed apical pulse rate with the known threshold

In this exercise, the nurse finds the apical pulse rate to be 54, which is below the general threshold of 60 beats per minute. Hence, this indicates that there might be a risk of bradycardia due to the medication.

Decide the appropriate nursing intervention

Since the apical pulse rate is below the threshold of 60 beats per minute, the appropriate nursing intervention would be to withhold the medication and notify the doctor, as they will be able to assess whether or not it is safe to continue the treatment. Therefore, the correct answer is Option C.