A nurse is reviewing the medical record of a client who has hypertension and a new prescription for propranolol. Which of the following findings should the nurse identify as a contraindication for taking propranolol?

The correct answer is Choice C.

Choice A rationale: Applying traction weight to the external fixator is not recommended, as it can cause excessive stress on the pins and wires, leading to complications such as infection, loosening, or breakage1.Traction is usually applied to skeletal pins that are inserted into the bone without an external frame2.

Choice B rationale: Monitoring the neurovascular status of the affected limb is important, but every 8 hours is not frequent enough.The nurse should perform neurovascular checks every 2 to 4 hours for the first 24 hours, then every 4 to 8 hours, according to the facility policy3. This is to assess for signs of nerve damage, compartment syndrome, or impaired circulation, which can result from the injury or the device.

Choice C rationale: Administering pain medication 30 min prior to pin care is a correct intervention, as it can help reduce the discomfort and anxiety associated with the procedure. Pin care involves cleaning the pin sites with an antiseptic solution and applying sterile dressings to prevent infection and promote healing. The frequency and technique of pin care may vary depending on the type of device, the condition of the wound, and the facility protocol.

Choice D rationale: Adjusting the clamps on the device’s frame daily is not a nursing intervention, as it can alter the alignment and stability of the fracture. The clamps should be tightened only by the orthopedic surgeon or a trained technician, and only when necessary. The nurse should inspect the device for any loose or broken parts and report any problems to the surgeon.

So, the correct answer is Choice C, after analysing all choices.

Answer is a. Check for neck vein distention.

a. Check for neck vein distention: Correct. Assessing for neck vein distention is an essential intervention for a client receiving IV fluid replacement, especially for dehydration. Neck vein distention can indicate fluid overload, a potential complication of IV fluid therapy. By monitoring for this sign, the nurse can promptly recognize and intervene to prevent fluid overload-related complications such as pulmonary edema and hypertension. Regular assessment of neck vein distention provides valuable information about the client's fluid status and guides adjustments to the IV fluid infusion rate to maintain fluid balance and prevent adverse outcomes.

b. Offer oral fluids every 4 hr: This option is incorrect because offering oral fluids every 4 hours may not be appropriate for a client receiving IV fluid replacement for dehydration. IV fluid replacement is typically indicated when oral rehydration is insufficient or impractical, such as in cases of severe dehydration, altered consciousness, or gastrointestinal disturbances. The frequency and volume of oral fluid intake should be individualized based on the client's condition, fluid requirements, and ability to tolerate oral intake. Therefore, the nurse should prioritize IV fluid therapy and adjust oral fluid intake accordingly based on ongoing assessment of the client's hydration status.

c. Monitor pulse pressure every 6 hr: While monitoring pulse pressure can provide valuable information about fluid status and cardiac function, it may not be as specific or sensitive as other signs such as neck vein distention when assessing for fluid overload in clients receiving IV fluid replacement. Pulse pressure is the difference between the systolic and diastolic blood pressure readings and can be affected by various factors, including cardiac output, vascular resistance, and volume status. However, changes in pulse pressure may not always correlate directly with fluid overload, especially in clients with underlying cardiovascular conditions or receiving vasopressor medications. Therefore, more frequent and comprehensive assessments, including physical examination findings such as neck vein distention, are necessary to evaluate fluid balance accurately.

d. Limit oral fluids prior to bedtime: This option is incorrect because limiting oral fluids prior to bedtime is generally not indicated for dehydrated clients, especially those receiving IV fluid replacement. Restricting fluid intake may exacerbate dehydration and compromise the effectiveness of IV fluid therapy. Instead, the nurse should encourage adequate fluid intake throughout the day and evening to promote hydration and support the client's recovery from dehydration. Individualized fluid management strategies should be based on the client's fluid requirements, renal function, underlying condition, and response to therapy.

In summary, the correct answer is a because checking for neck vein distention is an essential intervention for monitoring fluid status and detecting potential complications such as fluid overload in clients receiving IV fluid replacement for dehydration. This assessment helps ensure safe and effective fluid management and prevents adverse outcomes associated with fluid overload.