A nurse is preparing to administer metoprolol to a client. Which of the following vital signs should the nurse assess before administration?

The client presents with hypoglycemia (capillary glucose 64 mg/dL), hypotension (90/70 mm Hg), tachycardia, and fever. They are scheduled to receive both metoprolol and insulin aspart, which can further lower heart rate, blood pressure, and glucose levels. Priority nursing care requires immediate correction of life-threatening metabolic instability before administering medications that may worsen the condition.

Rationale:

• Capillary glucose: The capillary glucose of 64 mg/dL indicates hypoglycemia, which is an immediate priority because it can rapidly progress to neurological impairment, seizures, or loss of consciousness. Insulin aspart is scheduled for administration, but giving insulin in the presence of low blood glucose would worsen hypoglycemia. The nurse must first address and correct the glucose level to prevent acute neurological deterioration. Stabilizing blood sugar takes precedence over other abnormal findings in this scenario.

• Blood pressure: The blood pressure of 90/70 mm Hg indicates hypotension, which may compromise tissue perfusion to vital organs such as the brain, heart, and kidneys. Metoprolol is a beta-blocker that can further lower blood pressure and heart rate, increasing the risk of hemodynamic instability. After correcting hypoglycemia, blood pressure must be addressed to ensure safe medication administration.

• Reported pain: A pain level of 4/10 is considered mild to moderate and is not the highest priority in this situation. Although pain management is important, it does not pose an immediate threat to life compared to hypoglycemia or hypotension. The client’s metabolic and cardiovascular instability must be corrected first before addressing comfort measures. Pain can be reassessed and treated after stabilization.

• Temperature: The elevated temperature of 38.2°C (100.8°F) reflects an infectious process consistent with pneumonia, but it is not the most immediate life-threatening concern. Fever contributes to increased metabolic demand but does not require urgent correction before hypoglycemia or hypotension. Antipyretics and antibiotic therapy can address this once the client is hemodynamically stable. Priority remains with glucose and perfusion issues.

• Heart rate: The heart rate of 104/min is mildly elevated and likely secondary to fever, infection, or hypoglycemia. While it requires monitoring, it is not as critical as the low blood glucose or low blood pressure in terms of immediate risk. Tachycardia is compensatory and should not be treated in isolation. Addressing underlying instability will normalize the heart rate.

Enoxaparin is a low-molecular-weight heparin(LMWH) that exerts anticoagulant effects by accelerating the activity of antithrombin III, primarily inhibiting factor Xa. It is used for the prophylaxis and treatment of deep vein thrombosisand pulmonary embolism. Unlike unfractionated heparin, it has a more predictable pharmacological profile and typically does not require routine laboratory monitoring of clotting times.

Rationale:

A.Diarrhea is not a common or expected side effect of enoxaparin therapy, as the drug does not significantly affect the gastrointestinal microbiome. The most concerning side effects are related to bleeding or heparin-induced thrombocytopenia. If a patient experiences diarrhea, the nurse should investigate other causes such as dietary changes, infections, or different medications.

B.Monitoring the skin for bruising is a vital safety instruction because enoxaparin increases the risk of bleeding and hemorrhage. Bruising or ecchymosis can indicate that the medication is excessively thinning the blood or that the patient has experienced minor trauma. Early detection of bleeding allows for prompt medical intervention to adjust the dosage or manage complications.

C.Enoxaparin must be injected into the subcutaneous tissue, typically in the abdomen, and should never be injected into a muscle. Intramuscular injection of anticoagulants can cause the formation of painful and dangerous hematomas due to the high vascularity of muscle tissue. The nurse must ensure the client understands the correct technique for deep subcutaneous administration.

D.Weekly INR checks are required for patients taking warfarin, but they are not necessary for those on enoxaparin. Enoxaparin provides a very stable and predictable anticoagulant response that does not require the frequent dose adjustments associated with Vitamin K antagonists. This lack of required blood work is one of the primary benefits of LMWH therapy.