The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage to the subcutaneous tissues has occurred. How would the nurse document this wound?

A. Auscultation: When assessing blood pressure manually, the nurse listens for the sounds of Korotkoff using a stethoscope, which is called auscultation. This technique allows the nurse to determine the systolic and diastolic pressures as the blood flow returns to the artery.

B. Inspection: Inspection involves visually examining the patient for signs or symptoms, such as skin color, breathing patterns, or posture. It does not involve listening to or feeling for the sounds associated with blood pressure measurements.

C. Palpation: Palpation involves feeling for pulses or other sensations, but it is not used to assess blood pressure directly. While palpation may be used to estimate systolic pressure by feeling the pulse, it does not allow for accurate measurement of both systolic and diastolic pressures.

D. Percussion: Percussion involves tapping on the body to assess underlying structures, typically to evaluate organ size or detect fluid. It is not used for assessing blood pressure, which requires listening to sounds produced by blood flow.

A. Call the physician to get a hold order for the Metoprolol: A heart rate of 56 bpm may indicate bradycardia, which is a common contraindication to administering beta blockers like Metoprolol. The nurse should notify the physician before giving the medication.

B. Skip the dose and re-assess the patient's heart rate in 4 hours: Skipping medication without provider approval is unsafe. Re-assessment alone does not address the potential risk of bradycardia.

C. Administer the medication as ordered: Administering Metoprolol with a low heart rate risks worsening bradycardia and causing adverse effects such as dizziness or syncope. This can compromise cardiac output and patient safety.

D. Call the physician to get an order for Lasix: Lasix is a diuretic unrelated to heart rate management and is not appropriate in this situation. It does not address the bradycardia or the effects of Metoprolol on heart rate.