A nurse is collecting data from a client prior to administering metoprolol. For which of the following findings should the nurse withhold the medication?
Blood pressure 160/94 mm Hg
Oxygen saturation 95%
Heart rate 50/min
Respiratory rate 18/min
The Correct Answer is C
(A) Blood pressure 160/94 mm Hg:
Metoprolol is a beta-blocker commonly used to treat hypertension. A blood pressure reading of 160/94 mm Hg indicates hypertension, which is an indication for administering metoprolol, not withholding it.
(B) Oxygen saturation 95%:
An oxygen saturation of 95% is within the normal range and does not provide a reason to withhold metoprolol. Oxygen saturation levels are not directly impacted by this medication in a way that would warrant withholding it.
(C) Heart rate 50/min:
A heart rate of 50/min is bradycardia (a slow heart rate). Metoprolol can further lower the heart rate, so it should be withheld if the client is already experiencing bradycardia. The nurse should notify the healthcare provider for further instructions.
(D) Respiratory rate 18/min:
A respiratory rate of 18/min is within the normal range (12-20 breaths per minute) and does not provide a reason to withhold metoprolol. Respiratory rate is not typically a contraindication for this medication unless there are specific respiratory conditions or other related symptoms present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
A) A client's response to interventions implemented: It's essential to document how the client responds to interventions implemented in response to their blood pressure. This provides valuable information on the effectiveness of the interventions and helps in assessing the client's condition.
B) The frequency in which a blood pressure is taken: Documenting the frequency of blood pressure measurements is crucial for tracking trends and changes over time. It ensures a comprehensive assessment of the client's cardiovascular status.
C) Interventions implemented in response to a client's blood pressure: Documenting the interventions implemented in response to a client's blood pressure helps in maintaining an accurate record of the care provided and ensures continuity of care among healthcare providers.
D) The site where the blood pressure was obtained: Documenting the site where the blood pressure was obtained is important for standardizing the measurement process and ensuring consistency. Common sites include the brachial artery, but documenting the specific site provides clarity and accuracy.
E) A client's position when the blood pressure was obtained: Documenting the client's position during blood pressure measurement is essential because blood pressure can vary based on body position. It ensures that accurate comparisons can be made between readings and provides valuable information for clinical decision-making.
Correct Answer is C
Explanation
(A) Treatment: While treatment is an important part of the client’s information, it is typically included in the “Recommendation” component of ISBARR, where the nurse would discuss the recommended treatment plan.
(B) List of medications: The list of medications a client is taking is crucial information, but it is usually included in the “Background” component of ISBARR, which provides context about the client’s medical history and current medications.
(C) Medical condition: This is the most appropriate answer. The “Situation” component of ISBARR is meant to provide a brief overview of the client’s current situation, which includes their current medical condition or reason for admission.
(D) Vital signs: Vital signs are typically included in the “Assessment” component of ISBARR, where the nurse would discuss the results of their assessment of the client, including vital signs.
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