NCLEX Question of the Day – Thursday, April 23, 2026

Today’s question targets early recognition of medication-related harm and the nurse’s first priority action. That skill matters because patients often show subtle warning signs before a serious event happens. A nurse who connects assessment findings to a high-risk drug can prevent respiratory failure, cardiac instability, or a rapid transfer to higher care.

Clinical Scenario

You are caring for a 72-year-old patient on a medical-surgical unit who was admitted with new-onset atrial fibrillation with rapid ventricular response. The patient has a history of heart failure with reduced ejection fraction, hypertension, and chronic kidney disease stage 3. Six hours ago, the provider ordered an IV digoxin loading dose, and the patient has now received the first two doses.

During your reassessment, the patient says, “I feel sick to my stomach and weirdly tired.” The patient also reports seeing “yellow-green halos” around the light above the bed. Vital signs are: temperature 98.4 F, blood pressure 98/58 mm Hg, heart rate 52/min, respiratory rate 18/min, oxygen saturation 96% on room air. Telemetry shows sinus bradycardia with occasional premature ventricular contractions. Morning labs show potassium 3.1 mEq/L and creatinine 1.9 mg/dL.

The Question

What is the nurse’s priority action?

Answer Choices

1. Administer the next scheduled digoxin dose and recheck the heart rate in 1 hour.
2. Hold digoxin, place the patient on continuous rhythm assessment, and notify the provider immediately.
3. Encourage oral fluids and document that mild nausea is an expected effect of atrial fibrillation treatment.
4. Give the prescribed PRN antiemetic first so the patient can tolerate the medication regimen.

Correct Answer

B. Hold digoxin, place the patient on continuous rhythm assessment, and notify the provider immediately.

Detailed Rationale

This patient is showing classic signs of digoxin toxicity. The nurse should recognize the pattern, not just one isolated symptom. The key findings are nausea, fatigue, visual changes with yellow-green halos, bradycardia, and ventricular ectopy. These findings are especially concerning because the patient also has hypokalemia and renal impairment, both of which increase digoxin toxicity risk.

The first nursing action is to hold the medication. If the drug is contributing to toxicity, giving more could worsen bradycardia or trigger dangerous dysrhythmias. The next step is to monitor the rhythm closely, because digoxin toxicity can cause conduction problems and ventricular arrhythmias. Then the nurse should notify the provider right away so the patient can be evaluated for further treatment, which may include a digoxin level, repeat electrolytes, potassium replacement, or other urgent interventions.

What should the nurse assess? Start with the heart rate and rhythm, then symptoms such as nausea, vomiting, confusion, weakness, and visual disturbances. Review the latest potassium and renal function results. Digoxin is cleared by the kidneys, so reduced kidney function can cause the drug to build up. Low potassium makes the myocardium more sensitive to digoxin, which is why a potassium of 3.1 mEq/L matters so much here.

What should the nurse do after holding the dose and notifying the provider? Keep the patient on cardiac monitoring, assess for worsening dizziness or decreased perfusion, and prepare to obtain ordered labs. If the patient becomes unstable, follow unit protocol and escalate quickly. The nurse should also review the medication record for other factors that may raise digoxin levels or slow the heart further.

What should the nurse monitor next? Watch for increasing bradycardia, new rhythm changes, worsening gastrointestinal symptoms, altered mental status, and signs of poor cardiac output such as hypotension, cool skin, or decreased urine output. Also monitor potassium closely, because correction of hypokalemia is often part of the treatment plan. The main point is simple: recognize toxicity early and stop the source before the patient deteriorates.

Why the Other Options Are Wrong

A. Administer the next scheduled digoxin dose and recheck the heart rate in 1 hour.

This is unsafe. A heart rate of 52/min is already low, and the patient has several toxicity signs. Digoxin is commonly held when the heart rate is below the ordered parameter, often below 60/min in adults, though the exact order matters. Waiting an hour after giving more medication could allow serious dysrhythmias to develop.

C. Encourage oral fluids and document that mild nausea is an expected effect of atrial fibrillation treatment.

Nausea alone can have many causes, but this patient has a cluster of findings that strongly points to toxicity. Visual halos and bradycardia are not findings the nurse should dismiss. Fluids do not address the immediate safety problem.

D. Give the prescribed PRN antiemetic first so the patient can tolerate the medication regimen.

This treats a symptom while ignoring the cause. The nausea is a warning sign, not the main problem. If the nurse gives an antiemetic and proceeds with the regimen, the patient could continue receiving a harmful drug and become more unstable.

Key Takeaways

• Digoxin toxicity often shows up as nausea, fatigue, visual changes, bradycardia, and dysrhythmias.
• Low potassium increases the risk because it makes digoxin’s cardiac effects stronger.
• Kidney impairment raises risk because digoxin is cleared renally.
• The priority is to hold the drug, monitor the rhythm, assess the patient, and notify the provider.
• Do not treat only the symptom when the full assessment points to a dangerous cause.

• What you’d do on shift: Check apical pulse and telemetry, review potassium and creatinine, hold digoxin, keep the patient on continuous monitoring, report the findings clearly, and watch for worsening instability.

Quick Practice Extension

1. A patient taking digoxin has a potassium of 2.9 mEq/L but no symptoms yet. What assessment and safety steps should the nurse prioritize before administering the next dose?

2. A patient with atrial fibrillation is receiving digoxin and a beta blocker. Which findings would make you suspect an additive effect on heart rate and conduction rather than a routine response to treatment?

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