# A nurse is reviewing newly written admission orders for a 78-year-old client with rapid atrial fibrillation. The medication list now includes metoprolol tartrate 25 mg orally every 12 hours AND verapamil 80 mg orally every 8 hours. Apical pulse is 58, BP is 96/58, and the client has a baseline EF of 35%. Which action by the nurse is most important?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374907&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

A nurse is reviewing newly written admission orders for a 78-year-old client with rapid atrial fibrillation. The medication list now includes metoprolol tartrate 25 mg orally every 12 hours AND verapamil 80 mg orally every 8 hours. Apical pulse is 58, BP is 96/58, and the client has a baseline EF of 35%. Which action by the nurse is most important?

## Option

1. Hold both medications, contact the prescriber to clarify the combination, and report the apical pulse, blood pressure, and reduced ejection fraction. **✔ Correct answer**
2. Encourage the client to drink coffee to raise the heart rate before administering both medications as ordered.
3. Give the metoprolol but hold the verapamil; combination of two rate-control agents is fine if separated by 4 hours.
4. Administer both medications now and reassess vital signs in 1 hour because each is appropriate for atrial fibrillation rate control.

**Correct answer: 1**

## Explanation

Verapamil + beta-blocker — synergistic cardiotoxicity
Concurrent use of verapamil (or diltiazem) with a beta-blocker produces additive depression of SA node, AV node, and myocardial contractility, causing severe bradycardia, complete heart block, hypotension, and acute heart failure. This is a well-recognized contraindicated combination, especially when the client already has bradycardia (HR 58), hypotension (BP 96/58), and reduced ejection fraction (EF 35%). The nurse must hold both medications and notify the prescriber with full assessment data (vitals, baseline EF, current rhythm) so the prescriber can choose ONE rate-control agent, switch to digoxin or amiodarone if needed, or reassess the entire plan. Administering either drug — alone or staggered — risks cardiogenic shock and death. Caffeine is not an appropriate intervention.

## In-depth explanation

Clinical reasoning summary
Verapamil + beta-blocker — synergistic cardiotoxicity
Concurrent use of verapamil (or diltiazem) with a beta-blocker produces additive depression of SA node, AV node, and myocardial contractility, causing severe bradycardia, complete heart block, hypotension, and acute heart failure. This is a well-recognized contraindicated combination, especially when the client already has bradycardia (HR 58), hypotension (BP 96/58), and reduced ejection fraction (EF 35%). The nurse must hold both medications and notify the prescriber with full assessment data (vitals, baseline EF, current rhythm) so the prescriber can choose ONE rate-control agent, switch to digoxin or amiodarone if needed, or reassess the entire plan. Administering either drug — alone or staggered — risks cardiogenic shock and death. Caffeine is not an appropriate intervention.

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