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 B

Explanation

A. A fundal height of 2 fingerbreadths below the umbilicus in a client who is 2 days postpartum is within the expected range for that time frame and does not require immediate assessment.

B. A client who is 1 day postpartum and has not voided in 8 hours may be at risk for urinary retention, which can lead to complications such as bladder distension or urinary tract infection. Prompt assessment and intervention are needed.

C. Not having a bowel movement since prior to admission is not an urgent concern in the

immediate postpartum period, especially if the client is otherwise stable and not experiencing discomfort or other symptoms.

D. Lochia serosa, which is the normal vaginal discharge that occurs 3 to 10 days postpartum, is not an urgent concern and does not require immediate assessment.

A. Perform active range-of-motion exercises. B. Maintain the head at a midline position. C. Suction the airway frequently. D. Perform neurological checks every 4 hours.

Correct Answer is B

Explanation

A. Active range-of-motion exercises are not appropriate for a child with increased intracranial pressure and decreased level of consciousness, as they may increase intracranial pressure.

B. Maintaining the head at a midline position helps promote proper cerebral perfusion and reduces the risk of further increases in intracranial pressure.

C. Frequent suctioning of the airway can stimulate the gag reflex and increase intracranial pressure. Suctioning should only be done as needed to maintain a clear airway.

D. Neurological checks should be performed more frequently than every 4 hours in a child with increased intracranial pressure and decreased level of consciousness, ideally at least every hour or as indicated by the child's condition.

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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

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