A nurse is collecting data from a client prior to administering metoprolol. For which of the following findings should the nurse withhold the medication?

A. Moist mucous membranes: Moist mucous membranes are typically a sign of good hydration and are not usually associated with end-of-life stages. In fact, patients nearing the end of life often experience dryness of the mouth and mucous membranes due to decreased fluid intake and certain medications. This dryness can lead to discomfort and difficulties in swallowing or speaking, which is why oral care is an important part of end-of-life care.

B. Irregular respirations: This is correct. As the body’s systems start to shut down in the final stages of life, irregular respirations, including periods of rapid breathing and pauses (Cheyne-Stokes respirations), can be a common symptom. This happens because the body can no longer effectively remove carbon dioxide, and the automatic process of breathing becomes less coordinated. This can be distressing to witness, but it’s usually not uncomfortable for the patient.

C. Tachycardia: While some patients may experience changes in heart rate, tachycardia is not typically a consistent finding in patients at the end of life. As the body weakens, the heart has to work harder to pump blood, which can sometimes lead to a faster heart rate. However, as the end of life approaches, the heart rate often slows down, and blood pressure decreases.

D. Hypertension: Hypertension, or high blood pressure, is not typically a symptom associated with end-of-life care. In the final stages of life, the body’s systems begin to slow down, and blood pressure often decreases. This is due to a combination of factors, including a slower heart rate and a decrease in the body’s ability to regulate blood pressure. It’s also worth noting that pain, anxiety, and certain medications can temporarily increase blood pressure, even in the end-of-life stages.

A. Check for orthostatic hypertension: While checking for orthostatic hypertension is important; it is not the first action a nurse should take when administering an IV antihypertensive. The priority is to monitor the client’s response to the medication.

B. Instruct the client to restrict sodium intake: While dietary modifications such as sodium restriction can help manage hypertension, it is not the immediate concern when administering an IV antihypertensive. The priority is to monitor the client’s response to the medication.

C. Assist the client to make lifestyle changes: Lifestyle changes are a crucial part of managing hypertension, but they are not the immediate concern when administering an IV antihypertensive. The priority is to monitor the client’s response to the medication.

D. Monitor the client’s BP every 5 minutes: This is the correct answer. When administering an IV antihypertensive, it is crucial to closely monitor the client’s blood pressure to assess the effectiveness of the medication and to ensure the client’s safety. The client’s high blood pressure of 185/130 mm Hg is a serious condition that requires immediate and careful management.