The physician's order reads Lopressor (metoprolol) 50 mg PO daily.Do not give if blood pressure is less than 100 mm Hg systolic. The patient's blood pressure is 92/66.The nurse does not give the medication;what else does the nurse do?A) Does not tell the patient what the blood pressure is.B) Documents only what the blood pressure was.C) Documents that the medication was not given owing to low blood pressure.D) Does not need to inform the health care provider that the medication was withheld.

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Mohamed Yousef · Accepted Answer

Final Answer : C, Explanation :  The nurse must document any interventions initiated as a result of vital sign measurement,such as withholding an antihypertensive drug.The nurse should inform the patient of the blood pressure value and the need for periodic reassessment of the blood pressure.Documenting only the blood pressure is not sufficient;any intervention must be documented as well.Abnormal findings must be reported to the nurse in charge or to the health care provider.

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