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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Obtain the client’s consent: It is not the nurse’s responsibility to obtain the client’s consent for a procedure. This responsibility lies with the healthcare provider performing the procedure.

B. Describe the consequences of forgoing treatment: While it’s important for the client to understand the consequences of not undergoing the procedure, it is the healthcare provider’s responsibility to explain these consequences, not the nurses.

C. Witness the client’s signature: This is correct. The nurse’s role in the informed consent process is to witness the client’s signature on the consent form and to verify that the client is consenting voluntarily and appears to be competent to do so.

D. Explain the risks and benefits of the procedure: While the nurse can reinforce information, it is the healthcare provider’s responsibility to explain the risks and benefits of the procedure. The nurse should ensure that the client understands the information provided by the healthcare provider

A. Lean back in the chair. B. Use intermittent eye contact. C. Have a pen and paper. D. Sit side-by-side with the client.

Correct Answer is B

Explanation

(A) Lean back in the chair: Leaning back in the chair can be perceived as a relaxed posture, but it might also convey disinterest or detachment in the conversation. Active listening involves being engaged and showing interest in what the client is saying.

(B) Use intermittent eye contact: This is the most appropriate answer. Maintaining eye contact is an important part of active listening as it shows that the nurse is focused and interested in what the client is saying. However, constant eye contact can be intimidating or uncomfortable for some clients, so intermittent eye contact is often more appropriate.

(c) Have a pen and paper: Having a pen and paper can be useful for note-taking, but it is not a direct action of active listening. It’s important to maintain focus on the client during the conversation, and excessive note-taking can be distracting.

(D) Sit side-by-side with the client: While sitting side-by-side with the client can create a more relaxed and equal atmosphere, it is not a direct action of active listening. The nurse should face the client and maintain appropriate eye contact to show engagement and interest.

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

Nursing Test Bank

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