The nurse is caring for a client with congestive heart failure who is scheduled for the morning dose of digoxin 0.125 mg PO. The client’s apical pulse is 54. Which is the priority nursing action?

  • place the client on 2L of oxygen via nasal cannula
  • hold the drug and notify the health care provider
  • wait an hour and recheck the pulse; then administer the drug
  • administer the drug and ask the unlicensed assistive personnel (UAP) to recheck the pulse in 30 minutes
Number 2 is correct.
If the client’s apical pulse is below 60, the nurse should hold the medication and notify the health care provider. Placing oxygen on the client will not have any effect on the pulse. Waiting an hour to recheck the pulse means a delay in medication administration, but also allows time for the pulse to drop lower, which may worsen client outcomes. There should never be a delay when there is a need to notify the health care provider. Administering the drug may cause the client to become severely bradycardic, and the UAP is not licensed to assess the client, especially when medications have been administered. The nurse is ultimately responsible for follow-up assessments on all clients.