# 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617291&lang=en  
> language: en  
> subject: Expected Actions/Outcomes  
> category: PPT

## Question

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.

1

Offer a sip of thin water afterward to clear puree left in the client's mouth

2

Crush the metoprolol tablet into puree, since the SLP order allows crushed medications

3

Reassess the headache rating within 30 to 60 minutes after the acetaminophen

4

Chart the acetaminophen before giving it so no one else gives a duplicate dose

5

Ask the prescriber or pharmacist for a metoprolol form that fits the swallowing plan

6

Crush the lisinopril tablet and give it mixed in a spoonful of the pureed food

## Explanation

The SLP order permits crushing only when appropriate, and metoprolol succinate extended-release must not be crushed, so the nurse asks for a suitable alternative; immediate-release lisinopril can be crushed into puree. A PRN dose is documented after it is given and its effect is reassessed within 30 to 60 minutes. Thin water violates the mildly thick liquid order and raises aspiration risk.

## In-depth explanation

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.

References
1Institute for Safe Medication Practices (ISMP)Oral dosage forms that should not be crushed and safe medication administration practices
2DailyMed (NLM) — drug labelingMetoprolol succinate ER labeling: tablets should not be crushed or chewed

## Clinical scenario

Scenario
Post-stroke dysphagia with an SLP plan of pureed diet, mildly thick liquids, and crushed medications when appropriate. Morning medications include an extended-release beta blocker, an immediate-release ACE inhibitor, and a PRN analgesic.

## Key concepts

- **Extended-release (ER) formulation** — A dosage form designed to release drug slowly; crushing it can cause dose dumping.
- **Dose dumping** — Rapid release of a dose intended to be delivered over many hours, causing toxicity.
- **Right response** — The medication right that requires evaluating the client's therapeutic and adverse response after administration.

## Related questions

- [Stage 2 — Analyze cues. For each finding, select the single role it plays in the current D…](https://mymerci.kr/pages/nclex_q.php?qn_id=372657&lang=en)
- [Stage 4 — Generate solutions. Review the confirmed DKA findings in the EHR. Which interven…](https://mymerci.kr/pages/nclex_q.php?qn_id=372659&lang=en)
- [Stage 5 — Take action. Arrange the major DKA protocol decision points from initial treatme…](https://mymerci.kr/pages/nclex_q.php?qn_id=372660&lang=en)
- [Stage 6 — Evaluate outcomes. Review the 6-hour trend and select the best interpretation an…](https://mymerci.kr/pages/nclex_q.php?qn_id=372661&lang=en)
- [The anticoagulation service reviews six clients taking warfarin. Match each situation to t…](https://mymerci.kr/pages/nclex_q.php?qn_id=393411&lang=en)
- [Place the actions in order after a postoperative client coughs and abdominal organs protru…](https://mymerci.kr/pages/nclex_q.php?qn_id=395474&lang=en)
- [A client with acute heart failure received intravenous furosemide for pulmonary congestion…](https://mymerci.kr/pages/nclex_q.php?qn_id=522681&lang=en)
- [Stage 1 — Recognize cues. A 42-year-old client is evaluated in the emergency department. R…](https://mymerci.kr/pages/nclex_q.php?qn_id=617307&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617291&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617291&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617291&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617291&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617291&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

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