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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Decreased white blood cells: Erythropoietin specifically stimulates red blood cell production in the bone marrow. White blood cell counts are not directly affected by this medication, so a decrease would not indicate effectiveness.

B. Increased calcium: Calcium levels are unrelated to erythropoietin therapy. Changes in calcium do not reflect the medication’s ability to stimulate erythropoiesis.

C. Increased hemoglobin: Erythropoietin promotes red blood cell production, which increases hemoglobin and hematocrit levels. An elevation in hemoglobin indicates the medication is effectively stimulating erythropoiesis.

D. Decreased BUN: Blood urea nitrogen reflects kidney function and protein metabolism. While erythropoietin is often used in clients with chronic kidney disease, a decrease in BUN is not a direct measure of the drug’s effectiveness.

A. Weight gain B. Constipation C. Hypoglycemia D. Muscle pain

Correct Answer is D

Explanation

A. Weight gain: Ergotamine does not typically cause weight gain. Its primary adverse effects are related to vascular and neuromuscular systems rather than metabolic changes.

B. Constipation: Constipation is not a common adverse effect of ergotamine. The medication primarily affects smooth muscle in blood vessels rather than gastrointestinal motility.

C. Hypoglycemia: Ergotamine does not influence blood glucose levels, so hypoglycemia is not an expected adverse effect.

D. Muscle pain: Ergotamine can cause vasoconstriction of peripheral blood vessels, which may lead to muscle pain, weakness, or tingling in the extremities. This neuromuscular effect is a recognized potential adverse effect of the medication.

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A nurse is assessing a client who has hypertension and is receiving propranolol. Which of the following findings require an intervention by the nurse?

Nursing Test Bank

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