A nurse is caring for a client prescribed Digoxin. Which nursing action is most appropriate regarding assessing apical pulse and withholding the dose if signs of toxicity occur?
1Hold the dose and contact the prescriber to clarify, because severe renal impairment (CrCl <30 mL/min) requires dose adjustment to 1 mg/kg subcutaneously every 24 hours; consider periodic anti-Xa level monitoring or switch to UFH IV per protocol.✓ Correct answer
2For a patient with acute PE and a creatinine clearance of 22 mL/min, administer enoxaparin 0.5 mg/kg subcutaneously every 12 hours; this dose reduction accounts for the prolonged elimination half-life in renal impairment and maintains therapeutic anticoagulation.
3Administer the enoxaparin 1 mg/kg subcutaneously every 12 hours as prescribed; low-molecular-weight heparins rely on hepatic clearance and are not eliminated renally, so even with a creatinine clearance of 22 mL/min, the regimen is appropriate.
4Administer enoxaparin 1 mg/kg subcutaneously every 12 hours as prescribed; plan to obtain an anti-Xa level 4 hours after the third dose, because the patient's renal impairment may alter pharmacokinetics despite subcutaneous administration.
Explanation
When administering Digoxin, key nursing considerations include monitoring patient status, checking critical laboratory values, and providing appropriate safety education. Unsafe practices such as stopping medications abruptly or doubling missed doses are incorrect.
Clinical reasoning summary Enoxaparin and renal impairment Enoxaparin (LMWH) is renally cleared. In severe renal impairment (CrCl <30 mL/min) the drug accumulates, raising bleeding risk dramatically. Per FDA labeling and clinical guidelines:
• CrCl ≥30 mL/min: standard dosing — 1 mg/kg SC every 12 hours (treatment), or 30–40 mg SC daily (prophylaxis). • CrCl <30 mL/min: treatment dose reduced to 1 mg/kg SC every 24 hours (instead of every 12 h); prophylaxis dose 30 mg SC daily. • Dialysis / very low CrCl / unstable renal function: many institutions prefer UFH IV (shorter half-life, easier reversal, monitored by aPTT or anti-Xa) over LMWH because of accumulation risk. • Anti-Xa monitoring (peak 4 h after SC dose, target 0.5–1.0 IU/mL for treatment) is recommended in renal impairment, obesity, pregnancy, or extremes of age.
The nurse should NOT administer the order as-is — that risks major bleeding. Doubling the dose (option 3) makes accumulation worse. Switching independently to warfarin (option 4) is outside the nurse scope and requires bridge planning.