A nurse is assessing a client who has heart failure and is taking digoxin. Which of the following manifestations should the nurse report to the provider as an indication of digoxin toxicity?

Choice A rationale Vomiting is a significant indication of digoxin toxicity. Digoxin can cause gastrointestinal distress, including anorexia, nausea, and vomiting, by stimulating the chemoreceptor trigger zone (CTZ) in the medulla. This effect is a common early sign of toxicity, occurring as serum digoxin levels rise above the therapeutic range, which is typically 0.5 to 2 ng/mL. The manifestation of vomiting is due to digoxin's central nervous system effects. Choice B rationale Digoxin toxicity does not typically cause pupillary dilation. Instead, visual disturbances such as blurred vision, yellow-green halos, and diplopia are more characteristic due to its effects on the central nervous system and retinal cone cells. Pupillary changes, such as dilation or constriction, are usually associated with other drug classes like opioids, anticholinergics, or sympathomimetics, not digoxin. Choice C rationale Bruising is not a recognized manifestation of digoxin toxicity. Bruising is more commonly associated with anticoagulants like warfarin, antiplatelet drugs, or conditions that affect coagulation factors and platelet function. Digoxin does not interfere with the clotting cascade or platelet function, so it would not be a direct cause of easy bruising. Choice D rationale Peripheral edema is a symptom of worsening heart failure, not digoxin toxicity. Digoxin is prescribed to improve cardiac output and reduce the symptoms of heart failure, including edema, by increasing the force of myocardial contraction. Therefore, an increase in peripheral edema would suggest that the medication is not being effective, or that the heart failure is progressing, not that the client is experiencing toxicity from the medication.