# 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?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

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?

## Option

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

**Correct answer: 2**

## 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
- **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.

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