A nurse is assisting with the plan of care for a client who has osteoarthritis. The client reports knee pain that worsens with activity. Which of the following interventions should the nurse include in the plan of care?

Choice A reason: Withholding the medication if the systolic blood pressure is less than 90 mm Hg is an appropriate action, as propranolol is a beta-blocker that can lower blood pressure and cause hypotension, which can impair tissue perfusion and cause dizziness, fainting, or shock.

Choice B reason: Requesting a dosage increase if the apical heart rate is less than 60/min is an inappropriate action, as propranolol can slow down the heart rate and cause bradycardia, which can lead to fatigue, weakness, or cardiac arrest. The nurse should monitor the apical pulse before administering propranolol and withhold it if it is less than 60/min.

Choice C reason: Informing the client to expect increased hair growth is an incorrect statement, as propranolol does not cause hypertrichosis or excessive hair growth. However, another beta-blocker, minoxidil, can cause this side effect.

Choice D reason: Administering the medication with an antacid is not an appropriate action, as antacids can interfere with the absorption of propranolol and reduce its effectiveness. The nurse should administer propranolol on an empty stomach or with food that does not contain antacids.

Choice A Reason:

The statement “I will wrap the suction catheters in a clean towel to be used again at a later time” is incorrect. Suction catheters should be disposed of after each use to prevent infection. Reusing catheters, even if wrapped in a clean towel, can introduce bacteria into the tracheostomy site, leading to potential infections.

Choice B Reason:

The statement “I will set the suction pressure dial between 80 and 120” is correct. The recommended suction pressure for adults is typically between 80 and 120 mmHg. This range is sufficient to effectively clear secretions without causing trauma to the tracheal mucosa. Setting the suction pressure within this range ensures safe and effective suctioning.

Choice C Reason:

The statement “I will suction for less than 15 seconds while inserting the suction catheter” is incorrect. Suctioning should be performed intermittently and for no longer than 10-15 seconds at a time. However, suctioning should not occur while inserting the catheter. Suction should be applied only while withdrawing the catheter to minimize trauma to the tracheal mucosa.

Choice D Reason:

The statement “I will suction the mouth before inserting the suction catheter into the tracheostomy” is incorrect. Suctioning the mouth before the tracheostomy can introduce oral bacteria into the tracheostomy site, increasing the risk of infection. The correct procedure is to suction the tracheostomy first and then the mouth if needed.