# A 78-year-old client with coronary artery disease and hypothyroidism returns 8 weeks after a levothyroxine increase from 75 to 125 mcg daily. Findings: HR 124 irregular, BP 158/92, palpitations, chest tightness, weight loss 4 kg, tremor, TSH 0.05 mIU/L (below reference), free T4 elevated, ECG atrial fibrillation with rapid ventricular response. Which is the priority nursing action?

> source: MyMerci (mymerci.kr)  
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> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

A 78-year-old client with coronary artery disease and hypothyroidism returns 8 weeks after a levothyroxine increase from 75 to 125 mcg daily. Findings: HR 124 irregular, BP 158/92, palpitations, chest tightness, weight loss 4 kg, tremor, TSH 0.05 mIU/L (below reference), free T4 elevated, ECG atrial fibrillation with rapid ventricular response. Which is the priority nursing action?

## Option

1. Continue the current dose because the symptoms will resolve once the body adapts.
2. Increase the dose further to 150 mcg because the patient has tachycardia which means the thyroid is still low.
3. Hold the next levothyroxine dose, place on continuous cardiac monitor, notify the prescriber for dose reduction and rate control, and assess for chest pain and ischemia. **✔ Correct answer**
4. Administer atropine 0.5 mg IV to slow the rhythm.

**Correct answer: 3**

## Explanation

The picture is iatrogenic thyrotoxicosis from over-replacement: suppressed TSH, elevated free T4, sinus tachycardia or atrial fibrillation with rapid ventricular response, hypertension, weight loss, tremor, and chest tightness. In an older adult with coronary artery disease, excess thyroid hormone increases myocardial oxygen demand and can precipitate angina, AFib with RVR, and heart failure. Priority nursing actions: (1) hold the next dose and notify the prescriber for dose reduction (often by 25 percent) with TSH recheck in 6 weeks, (2) continuous cardiac monitor and 12-lead ECG, (3) assess for chest pain, dyspnea, and signs of ischemia, (4) anticipate beta-blocker for rate control and symptomatic relief, (5) assess fall risk because of tremor and palpitations. Continuing or increasing the dose worsens the imbalance. Atropine accelerates rate and is contraindicated. The geriatric titration rule is start low (12.5 to 25 mcg) and go slow (titrate every 6 to 8 weeks).

## In-depth explanation

TSH suppressed plus tachy-AFib in a CAD patient is the classic over-replacement scenario tested on NCLEX. Hold and notify, monitor cardiac status, and prepare for dose reduction with beta-blocker rate control.

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