A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication?

Blood pressure 156/90 mm Hg

Pulse 54/min

Potassium 5.2 mEq/L

Sodium 130 mEq/L

Answer and Explanation

The Correct Answer is B

A. While a blood pressure of 156/90 mm Hg may be elevated, it is not necessarily an indication to withhold propranolol, which is commonly used to treat hypertension.

B. A pulse rate of 54/min suggests bradycardia, which is a potential side effect of propranolol and may warrant withholding the medication.

C. A potassium level of 5.2 mEq/L is within the normal range (3.5-5.0 mEq/L) and is not typically a reason to withhold propranolol.

D. A sodium level of 130 mEq/L is within the normal range (135-145 mEq/L) and is not typically a reason to withhold propranolol.

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Correct Answer is A

Explanation

A. Visible contusions on all four extremities may indicate physical abuse, especially in the context of being brought to the emergency department by a family member. Reporting the

incident to Adult Protective Services is essential to ensure the safety and well-being of the client.

B. Interviewing the client with his adult child present may not be appropriate if there are concerns about potential abuse or coercion.

C. Forcing the client to answer every assessment question may not be appropriate if the client is in distress or unable to communicate freely.

D. Advising the client to consult a social worker may be appropriate, but reporting suspected abuse to Adult Protective Services is the priority action in this situation.

A. Infuse 0.9% sodium chloride IV. B. Administer an antipyretic. C. Decrease the infusion rate to 75 mL/hr. D. Place the client in a left lateral position.

Correct Answer is A

Explanation

A. Infuse 0.9% sodium chloride IV - In the event of a hemolytic reaction, it's important to stop

the blood transfusion immediately and infuse normal saline to maintain intravascular volume and support renal perfusion.

B. Administer an antipyretic - While fever may occur with a hemolytic reaction, the priority is to stop the transfusion and provide supportive care with fluids.

C. Decrease the infusion rate to 75 mL/hr - Lowering the infusion rate is not appropriate when a hemolytic reaction occurs; stopping the transfusion is necessary.

D. Place the client in a left lateral position - Positioning changes will not address the hemolytic reaction; stopping the transfusion and providing supportive care are the priority.

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A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is A

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