The nurse administers the first dose of metoprolol 10 mg PO to a client. Which nursing action is most appropriate following the administration of this medication?
Place the call bell in reach of the client.
Take a pulse oximetry reading.
Record the client's weight.
Encourage oral fluids.
The Correct Answer is A
Choice A reason: Placing the call bell in reach of the client is the most appropriate nursing action following the administration of metoprolol, a beta-blocker that lowers blood pressure and heart rate. ¹ The client may experience dizziness, lightheadedness, or fainting as side effects of the medication, especially after the first dose. ² The call bell allows the client to alert the nurse if they need assistance or experience any adverse reactions.
Choice B reason: Taking a pulse oximetry reading is not the most appropriate nursing action following the administration of metoprolol. Pulse oximetry measures the oxygen saturation of the blood, which is not directly affected by metoprolol. ³ A more relevant vital sign to monitor is the blood pressure and heart rate, which can indicate the effectiveness and safety of the medication.
Choice C reason: Recording the client's weight is not the most appropriate nursing action following the administration of metoprolol. Weight is not a sensitive indicator of the immediate effects of metoprolol. Weight may be monitored periodically to assess the client's fluid status and possible signs of heart failure, which metoprolol can help prevent. ¹ However, this is not a priority action after the first dose of the medication.
Choice D reason: Encouraging oral fluids is not the most appropriate nursing action following the administration of metoprolol. Oral fluids may help prevent dehydration and constipation, which can occur as side effects of metoprolol. ² However, excessive fluid intake may worsen the client's blood pressure and heart function, which metoprolol aims to improve. The nurse should advise the client to drink fluids as directed by the provider and report any signs of fluid overload, such as swelling, shortness of breath, or weight gain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The pain you have is because your heart valves are damaged is not the most appropriate response. This statement may apply to a client with valvular heart disease, but not necessarily to a client with coronary artery disease. The nurse should explain that coronary artery disease is a condition that affects the blood vessels that supply the heart, not the heart valves.
Choice B reason: Your heart muscle is weak and is not pumping forcefully is not the most appropriate response. This statement may apply to a client with heart failure, but not necessarily to a client with coronary artery disease. The nurse should explain that coronary artery disease is a condition that reduces the blood flow to the heart, not the heart's contractility.
Choice C reason: The pain is caused by decreased oxygen to the heart muscle is the most appropriate response. This statement accurately describes the cause of angina, which is the chest pain that occurs when the heart does not receive enough oxygen due to narrowed or blocked coronary arteries. The nurse should also inform the client about the factors that can trigger or relieve angina, such as physical exertion, emotional stress, cold weather, or nitroglycerin.
Choice D reason: The layers of your heart are weak and thin is not the most appropriate response. This statement may apply to a client with cardiomyopathy, but not necessarily to a client with coronary artery disease. The nurse should explain that coronary artery disease is a condition that affects the blood vessels that supply the heart, not the heart's structure.
Correct Answer is D
Explanation
Choice A reason: Preparing for endotracheal intubation and ventilatory support is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with respiratory failure or impending airway obstruction, which are not the case for this client.
Choice B reason: Providing continuous sedation for pain relief is not the action that the nurse should take for a client with thyroid storm. This intervention may worsen the client's condition by suppressing the respiratory drive and lowering the blood pressure. The nurse should administer antithyroid medications, beta blockers, and corticosteroids as prescribed to reduce the thyroid hormone levels and the associated symptoms.
Choice C reason: Initiating cardiac monitoring and assessing for reflex bradycardia is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with hyperkalemia or digoxin toxicity, which are not the case for this client. The nurse should monitor the client's heart rate and rhythm, but not expect a reflex bradycardia, which is a paradoxical slowing of the heart rate in response to a rapid rise in blood pressure.
Choice D reason: Maintaining IV fluid infusion and assessing adequacy of hydration is the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with thyroid storm, as they are at risk of dehydration and electrolyte imbalance due to increased metabolic rate, fever, sweating, vomiting, and diarrhea. The nurse should administer isotonic fluids, such as normal saline, and monitor the client's fluid intake and output, urine specific gravity, and serum electrolytes.
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