Prior to the administration of a beta-adrenergic blocker, the nurse notes the patient to have a heart rate of 52 beats/min, peripheral edema, crackles in the bases of the lungs, and mottled skin. Which is the priority nursing action?
a. Administer the medication as ordered.
b. Reevaluate the patient in 20 minutes.
c. Obtain a serum blood level.
d. Withhold the medication and notify the health care provider.
ANS: D
These symptoms warrant the nurse's withholding the dose and then notifying the health care provider. The medication should not be administered if the patient's heart rate is low or the patient is experiencing symptoms of heart failure and poor perfusion. The patient should be assessed frequently after the medication is held and the health care provider is notified, but action needs to be taken immediately. Therapeutic blood levels for beta-adrenergic medications are not typically measured.
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