An 80-year-old male with heart failure is prescribed digoxin 0.125 mg daily. During morning assessment, he reports 2 days of nausea and vomiting and states he sees yellow-green halos around lights. His apical pulse is 46 bpm and regular. Which action should the nurse take first?

The client presents with the classic triad of digoxin toxicity: bradycardia (HR 46), gastrointestinal symptoms (nausea and vomiting), and visual disturbances (yellow-green halos). The nurse must hold the dose and notify the provider. Serum digoxin level confirms toxicity. IV atropine may be used for symptomatic bradycardia, but the priority is holding the drug. Administering or increasing the dose with active toxicity signs would worsen the condition.

In-depth explanation

<span class="merci-scenario-label">Clinical Judgment</span><br>Three simultaneous cues = digoxin toxicity: <span class="merci-value-abnormal">HR 46</span> (bradycardia) + nausea/vomiting (GI toxicity) + yellow-green halos (visual toxicity). All three together are pathognomonic. The narrow therapeutic index (0.5–0.9 ng/mL) makes elderly patients especially vulnerable.<br><br><span class="merci-scenario-label">Memory Tip</span><br><span class="merci-kw-mark">DIGOXIN TOXICITY = Brad-GI-Vision</span>: Bradycardia + GI upset + Visual halos (yellow/green/blurred). Hold → Notify → Level.<br><br><span class="merci-scenario-label">KR vs US</span><br>In Korea, digoxin is commonly used in older adults with AF/HF. NCLEX emphasizes the narrow therapeutic index and toxicity recognition; hold and report, not self-adjustment.

Clinical scenario

<span class="merci-scenario-label">Clinical Practice Guide</span><br>AHA/ACC HF Guidelines: digoxin therapeutic range 0.5–0.9 ng/mL for HF. Toxicity risk increases with hypokalemia, hypomagnesemia, renal impairment (common in elderly). Hold dose, obtain level, check electrolytes (K+, Mg2+), and prepare Digibind if severe toxicity.<br><br><span class="merci-scenario-label">Caution</span><br>NCLEX: "low dose" is a classic distractor — toxicity is about serum level and clinical signs, NOT dose size. An 80-year-old with decreased GFR accumulates digoxin faster at the same dose.

Key concepts

• Digoxin Toxicity — Serum digoxin > 2.0 ng/mL (adult). Classic triad: bradycardia, GI symptoms (nausea/vomiting/anorexia), visual disturbances (yellow-green halos, blurred vision). Risk factors: hypokalemia, renal impairment, advanced age.
• Digoxin in Heart Failure — Positive inotropic effect (increases contractility) + negative chronotropic effect (decreases HR). Therapeutic range in HF: 0.5–0.9 ng/mL. Renally excreted — dose adjustment required with renal impairment.
• Digibind (digoxin antibody) — Antidote for severe digoxin toxicity. Binds digoxin and promotes renal excretion. Indications: life-threatening dysrhythmia, serum level > 10 ng/mL, severe hyperkalemia. Monitor potassium after administration.