A nurse is assessing a client who has hypertension and is receiving propranolol. Which of the following findings require an intervention by the nurse?
Heart rate of 56/min
SaO2 95% on 2 L/min of oxygen
Blood pressure 106/68 mm Hg
Respirations 22/min
The Correct Answer is A
A. Heart rate of 56/min: Propranolol is a beta-blocker that can lower heart rate. A heart rate below 60/min may indicate bradycardia, which can be dangerous and requires intervention before administering the next dose.
B. SaO2 95% on 2 L/min of oxygen: Oxygen saturation of 95% on supplemental oxygen is within an acceptable range and does not require immediate intervention.
C. Blood pressure 106/68 mm Hg: While slightly on the lower side, this blood pressure is generally considered acceptable for many adults and does not typically necessitate an immediate intervention.
D. Respirations 22/min: A respiratory rate of 22/min is mildly elevated but usually not critical. It does not require withholding propranolol or immediate intervention in a stable client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hyperglycemia: TPN contains high concentrations of glucose, which can lead to elevated blood sugar levels. Clients receiving TPN should have frequent blood glucose monitoring, and insulin may be required to manage hyperglycemia.
B. Hyperkalemia: While electrolyte imbalances can occur with TPN, potassium is typically added in controlled amounts to the solution. Hyperkalemia is not a common direct adverse effect unless the formulation is incorrect or the client has impaired renal function.
C. Hypermagnesemia: Magnesium levels in TPN are carefully regulated, and hypermagnesemia is uncommon. Over-supplementation could cause this, but it is not a typical adverse effect for most clients receiving standard TPN.
D. Urine output of 160 mL in 4 hr: This urine output falls within normal limits (approximately 0.5 mL/kg/hr). Oliguria or significantly reduced urine output would be concerning, but 160 mL in 4 hours does not indicate an adverse effect of TPN.
Correct Answer is B
Explanation
A. Ranitidine: Ranitidine is an H2 receptor blocker that generally has minimal interaction with warfarin and does not significantly affect its anticoagulant effect.
B. Naproxen: Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding when taken with warfarin. NSAIDs inhibit platelet function and can potentiate the anticoagulant effect, making concurrent use dangerous.
C. Flaxseed: Flaxseed may have mild anticoagulant properties, but it does not pose as significant a risk as NSAIDs. It can usually be consumed with caution while monitoring for bleeding.
D. Soy: Soy products can have minor effects on warfarin metabolism, but they are not typically associated with a high risk of serious interactions. Monitoring may be sufficient rather than strict avoidance.
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