# A 72-year-old client with chronic heart failure and atrial fibrillation takes oral digoxin and furosemide. Which actions should the nurse include in follow-up care? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=369683&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

A 72-year-old client with chronic heart failure and atrial fibrillation takes oral digoxin and furosemide. Which actions should the nurse include in follow-up care? Select all that apply.

1

Review renal function, potassium and magnesium, clinical response, and a correctly timed digoxin level interpreted in clinical context

2

Restrict potassium-rich foods and stop any prescribed potassium supplement because a low serum potassium level protects the myocardium from digoxin-related dysrhythmias

3

Check the pulse for 1 full minute before digoxin; hold the dose and call the prescriber when it is below the prescribed parameter or markedly irregular

4

Omit electrolyte monitoring because long-term furosemide has only a mild, self-limited diuretic effect and does not cause clinically meaningful potassium or magnesium loss

5

If a digoxin dose is missed, take two doses at the next scheduled time to restore the therapeutic concentration, unless gastrointestinal symptoms have already developed

6

Assess nausea, vomiting, anorexia, confusion, weakness, visual changes, bradycardia, and new dysrhythmias as possible toxicity findings

## Explanation

Digoxin dosing and toxicity are influenced by renal function, age, electrolytes, interacting medications, and serum concentration. Monitor renal function, potassium, magnesium, response, and a properly timed digoxin level, and interpret the result in the full clinical context (Choice 1). Heart-failure benefit is generally associated with lower concentrations, while adverse reactions rise as concentrations increase; a single universal target of 0.5 to 2.0 ng/mL should not be used to titrate every client. Teach pulse monitoring and follow the individualized hold-and-call parameter (Choice 3). Gastrointestinal, neurologic, visual, and cardiac changes can indicate toxicity (Choice 6). Hypokalemia and hypomagnesemia increase toxicity risk, and furosemide can cause both, so electrolyte restriction and omitted monitoring are unsafe (Choices 2 and 4). A missed dose is never corrected by doubling the next dose (Choice 5).

## In-depth explanation

Clinical Judgment
Digoxin works by inhibiting the cardiac sodium-potassium pump. Hypokalemia magnifies that effect because potassium normally competes with digoxin at the same binding site. The dual layer of safety is therefore apical pulse before every dose + serum potassium and digoxin level monitoring.

Memory Tip
Digoxin hold rules: adult HR < 60, child HR < 70, infant HR < 90. Toxicity mnemonic = HALOS (Halos · Anorexia · Loss of vision color · Off heart rhythm · Stomach upset).

KR vs US
In Korea digoxin is still commonly used in elderly heart-failure patients. NCLEX-RN expects the nurse to know that the antidote for severe toxicity is digoxin immune Fab (Digibind) and to identify hypokalemia and renal impairment as the two leading risk factors.

## Clinical scenario

Clinical Practice Guide
ACC/AHA heart-failure guidelines list digoxin as a high-alert medication reserved for symptomatic heart failure with reduced ejection fraction or rate control in atrial fibrillation. Therapeutic level is 0.5 to 2.0 ng/mL (some guidelines use 0.5–0.9 in HFrEF). Always check potassium and renal function with the level.

Caution
NCLEX traps include doubling missed doses, recommending a low-potassium diet, and taking the radial instead of apical pulse. Remember: low K+ + high digoxin level = lethal dysrhythmias risk.

## Key concepts

- **Digoxin** — A cardiac glycoside that increases myocardial contractility (positive inotrope) and slows conduction through the AV node (negative chronotrope). Used for symptomatic systolic heart failure and rate control in atrial fibrillation. Therapeutic level 0.5–2.0 ng/mL. NCLEX exam tip: take apical pulse for 1 full minute before each dose and hold for HR < 60 in adults; monitor potassium and creatinine because hypokalemia and renal impairment trigger toxicity.
- **Digoxin Toxicity** — Adverse effects from a serum level above 2.0 ng/mL or from increased sensitivity in hypokalemia or renal impairment. Early signs: nausea, vomiting, anorexia, fatigue, headache. Visual: halos, blurred or yellow-green vision. Cardiac: bradycardia, heart block, ventricular dysrhythmias. NCLEX exam tip: antidote is digoxin immune Fab (Digibind); first action for suspected toxicity is to hold the next dose and notify the provider.
- **Hypokalemia** — Serum potassium below 3.5 mEq/L. Common causes include loop diuretics (furosemide), thiazides, vomiting, diarrhea, and inadequate intake. Risks: muscle weakness, U waves on ECG, ventricular dysrhythmias, and potentiation of digoxin toxicity. NCLEX exam tip: when a client is on digoxin and a potassium-wasting diuretic, serum potassium must be checked routinely and replaced to maintain 3.5 to 5.0 mEq/L.

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