# A 45-year-old client with persistent asthma is admitted for atrial fibrillation with rapid ventricular response. The provider writes a new order for propranolol 40 mg orally every 6 hours. Which action by the nurse takes priority?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374894&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

A 45-year-old client with persistent asthma is admitted for atrial fibrillation with rapid ventricular response. The provider writes a new order for propranolol 40 mg orally every 6 hours. Which action by the nurse takes priority?

## Option

1. Hold the dose and contact the prescriber to clarify or change the order because of the asthma history. **✔ Correct answer**
2. Administer the first dose with food and recheck the apical pulse in 30 minutes.
3. Administer the dose and have a salbutamol nebulizer at the bedside in case of bronchospasm.
4. Administer the dose and document the asthma history in the medication administration record.

**Correct answer: 1**

## Explanation

High-alert beta-blocker contraindication
Non-selective beta-blockers (propranolol, nadolol, timolol) block β2 receptors in bronchial smooth muscle and can precipitate life-threatening bronchospasm in patients with asthma or severe bronchospastic disease — this is an FDA-recognized contraindication. Even pretreatment with a SABA does not reliably prevent the reaction. The nurse must hold the medication and contact the prescriber per the institutional policy on contraindicated orders. The provider should consider a beta1-cardioselective agent (metoprolol, bisoprolol — at low dose with caution) or a non-dihydropyridine calcium channel blocker (diltiazem, verapamil) for rate control. Documenting alone (option 4), giving with food (option 2), or relying on rescue therapy (option 3) all expose the client to preventable harm.

## In-depth explanation

Why option 2 is correct
Nonselective beta-blockers such as propranolol, nadolol, and timolol block beta2 receptors in bronchial smooth muscle and can trigger life-threatening bronchospasm in clients with asthma or severe bronchospastic disease. This is a recognized contraindication, and pretreatment with a SABA does not reliably prevent the reaction. The priority is to hold the medication and notify the prescriber according to the facility policy for contraindicated orders.

Safer alternatives
The prescriber may consider a beta1-selective agent such as metoprolol or bisoprolol at a cautious low dose, or a non-DHP calcium channel blocker such as diltiazem or verapamil for rate control. For atrial fibrillation with RVR, IV diltiazem or a cardioselective beta-blocker may be considered based on the clinical picture.

Distractor review
Option 1: giving with food does not prevent beta2 blockade. Option 3: relying on rescue albuterol permits preventable harm and respiratory arrest risk. Option 4: documentation alone does not protect the client; the unsafe order must be held and clarified using SBAR.

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