The health care provider prescription reads "Metoprolol (Lopressor) 50 mg PO daily. Do not give if bloc pressure is less than 100 mm Hg systolic." The patient's blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take?

Documents that the medication was not given because of low blood pressure.

Does not inform the health care provider that the medication was held.

Does not tell the patient what the blood pressure is.

Documents only what the blood pressure was.

Answer and Explanation

The Correct Answer is A

A. Documents that the medication was not given because of low blood pressure:
This is the correct and required nursing action. It communicates the reason for withholding and ensures continuity of care.

B. Does not inform the health care provider that the medication was held:
The provider should be informed so they can reassess the treatment plan, especially if BP remains low.

C. Does not tell the patient what the blood pressure is:
Lack of communication with the patient is inappropriate. Patients have the right to know their vital signs and treatment decisions.

D. Documents only what the blood pressure was:
Incomplete documentation. It must also indicate that the medication was withheld and why.

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Correct Answer is C

Explanation

A. Radial:
The radial pulse is peripheral and may not be palpable during cardiac arrest due to low perfusion.

B. Apical:
The apical pulse requires a stethoscope and time to auscultate, which is not ideal during emergencies.

C. Carotid:
This is the most accessible and reliable central pulse during cardiac arrest and should be used to check circulation in unresponsive adults.

D. Brachial:
Used for infants and young children, not typically reliable for adults during cardiac arrest.

A. Flex the knees and keep the feet apart. B. Assume a position far enough away from the client. C. Twist the body in the direction of movement. D. Use the strong back muscles for lifting or moving.

Correct Answer is A

Explanation

A. Flex the knees and keep the feet apart:
This provides a stable base of support and reduces strain on the back when lifting or moving a patient.

B. Assume a position far enough away from the client:
Standing too far away increases the leverage and strain on muscles and makes lifting more dangerous.

C. Twist the body in the direction of movement:
Twisting should be avoided as it can injure the spine. Always pivot or turn with the whole body.

D. Use the strong back muscles for lifting or moving:
The legs, not the back, should do most of the work when lifting to prevent back injuries.

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The health care provider prescription reads "Metoprolol (Lopressor) 50 mg PO daily. Do not give if bloc pressure is less than 100 mm Hg systolic." The patient's blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The adult patient is found to be unresponsive and not breathing. Which pulse site will the nurse use?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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