A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Before administering the morning dose, the nurse assesses the client. Which finding requires the nurse to hold the medication and notify the provider?

1 Apical pulse 78 beats per minute
2 Blood pressure 118/72 mmHg
3 Reports mild fatigue
4 Apical pulse 52 beats per minute ✓ Correct answer

Explanation

Beta-blockers such as metoprolol reduce heart rate and contractility. Standard hold parameters are apical pulse below 60 bpm or systolic blood pressure below 90 mmHg. An apical pulse of 52 bpm is below threshold and requires holding the dose plus provider notification. The other findings are within acceptable limits.

In-depth explanation

Clinical Judgment Beta-blocker safe administration requires an apical pulse counted for 1 full minute before each dose. Hold thresholds: HR <60 bpm or SBP <90 mmHg. Mild fatigue is a known beta-blocker side effect but does not warrant holding. Memory Tip Beta-blocker hold: HR <60 or SBP <90 — count apical for 60 seconds KR vs US US standard: hold and notify provider if HR <60. Korean nursing curriculum aligns; some institutions list HR <50 as absolute hold. NCLEX expects HR <60 as the trigger.

Clinical scenario

Clinical Practice Guide ACC/AHA heart failure guidelines list beta-blockers (metoprolol succinate, carvedilol, bisoprolol) as Class I therapy for HFrEF. Titrate slowly. Hold parameters: HR <60 bpm or SBP <90 mmHg. Abrupt discontinuation can precipitate rebound hypertension or angina. Caution Do not skip apical assessment to save time. Radial pulse may underestimate heart rate when the rhythm is irregular. Always count apical for 60 seconds before any beta-blocker dose.

Key concepts

Metoprolol — Selective beta-1 adrenergic blocker. Reduces heart rate, contractility, and renin release. Standard agent for HF with reduced ejection fraction, post-MI, and chronic stable angina. Hold for HR <60 or SBP <90.
Apical pulse — Heart rate measured by auscultation at the fifth intercostal space, midclavicular line. Counted for one full minute before any cardiotonic or beta-blocker dose to detect irregular rhythm.
Bradycardia — Heart rate below 60 beats per minute in adults. Symptomatic bradycardia (dizziness, syncope, hypotension) requires intervention. Severe drug-induced bradycardia from beta-blockers may respond to atropine or glucagon.

Master the NCLEX-RN with MyMerci

Thousands of NCLEX-style questions with detailed rationale — in your language. Track your progress and study smarter.

Start for free

App Store Google Play

Read in another language: English 한국어 日本語繁體中文 Tiếng Việt

For study reference only. Always follow current clinical guidelines and your institution’s protocols.

성장을 멈추지 마세요

A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Before administering the morning dose, the nurse assesses the client. Which finding requires the nurse to hold the medication and notify the provider?

In-depth explanation

Clinical scenario

Key concepts

Master the NCLEX-RN with MyMerci