Difficulty: Medium
Average Score: 94%
Simulated
The nurse reviews the client's emergency department (ED) triage note. Which action should the nurse take first? See the image below.
Correct answer
A
Rationale
This client is showing manifestations of digitalis toxicity. The client's bradycardia, anorexia, and vomiting are classic signs of this potentially fatal toxicity. The nurse should immediately establish continuous cardiac monitoring because, if untreated, digitalis toxicity may cause multifocal premature ventricular contractions (PVCs) that may transition to ventricular tachycardia or ventricular fibrillation. Because of digitalis' ability to have a negative chronotropic effect, bradycardia is often seen in toxicity.