A 74-year-old client with dysphagia after a stroke has a speech-language pathology order for a pureed diet, mildly thick liquids, and "medications crushed in puree when appropriate." The 0900 medications are metoprolol succinate extended-release 50 mg PO and lisinopril 10 mg PO. At 0915 the client rates a headache 5/10, and the nurse is also giving the PRN acetaminophen 650 mg PO ordered for mild to moderate pain. Which actions should the nurse take? Select all that apply.

Quick answer
Get an alternative for the ER metoprolol, crush the lisinopril into puree, and reassess the PRN acetaminophen.

Why this is correct
The key is applying the SLP order to each specific drug. "Crushed when appropriate" does not override the manufacturer's labeling: crushing metoprolol succinate ER destroys the release mechanism and delivers the full dose at once, risking bradycardia and hypotension. Lisinopril is immediate-release and can be crushed and given in puree. For the PRN, the Right Response step means evaluating relief within 30 to 60 minutes for an oral analgesic, and documentation follows administration.

Easy analogy or mental picture
An extended-release tablet is a time-release capsule of fuel; crushing it is like dumping the whole tank into the engine at once.

Memory hook
SLP says how to swallow; the label says whether it can be crushed.

NCLEX decision rule
When a diet or swallowing order conflicts with a drug's dosage form, clarify with the prescriber or pharmacist rather than altering the form yourself.

Why the other choices are wrong
Crushing the metoprolol is tempting because the SLP order explicitly allows crushed medications, but the dosage form overrides it. Charting a PRN before giving it seems to prevent duplication, yet it records something that has not happened and becomes wrong if the client refuses or vomits. A sip of thin water is a common habit to clear the mouth, but this client is ordered mildly thick liquids, so thin water increases aspiration risk.