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 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.

A. Glasgow coma scale result B. Intracranial pressure readings C. Medication during the next shift D. History of the injury

Correct Answer is D

Explanation

(A) Glasgow coma scale result:
The Glasgow Coma Scale (GCS) result is important and would be included in the "Assessment" segment of SBAR, as it provides current data on the client's level of consciousness and neurological status.

(B) Intracranial pressure readings:
Intracranial pressure (ICP) readings are crucial for monitoring the client's condition but would be more appropriately included in the "Assessment" or "Background" segments, as they provide ongoing data relevant to the client's current health status and trends.

(C) Medication during the next shift:
Medication information, especially about what needs to be administered during the next shift, would fall under the "Recommendation" segment. This is where the outgoing nurse would specify what needs to be done next for the client's care.

(D) History of the injury:
The history of the injury is part of the "Situation" segment in SBAR reporting. This includes a brief description of why the client is being reported on, providing context for their current condition. For a client with a traumatic brain injury, this would involve a summary of how the injury occurred, which sets the stage for understanding the client's current status and care needs.

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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

Naxlex Comprehensive Predictor Exams

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