A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

A.

A. "Notify your provider if you experience muscle weakness." - Muscle weakness can be a sign of digoxin toxicity and should be reported to the provider immediately.

B. "Report a weight gain of one-half pound per day." - While weight gain can indicate fluid retention, it is not a specific symptom of digoxin toxicity.

C. "Expect this medication to increase your blood pressure." - Digoxin is not typically associated with increasing blood pressure.

D. "You will need to take a diuretic while taking this medication." - Diuretics are not typically required with digoxin unless there are specific indications for their use.

A. Administering furosemide may also be appropriate for managing heart failure symptoms, but the priority action based on the client's condition is to withhold digoxin.

B. The client's vital signs indicate bradycardia (pulse 52/min), which is a common adverse effect of digoxin, especially in the setting of heart failure. Withholding digoxin is necessary to prevent further exacerbation of bradycardia and potential toxicity.

C. Withholding spironolactone may be considered if there are concerns about electrolyte imbalances, but it is not the priority action in this scenario.

D. Administering ferrous sulfate is not indicated based on the client's chart findings; there is no indication of anemia or iron deficiency.