A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take first?
Check the blood pressure with the client in a supine position.
Place the client in a sitting position.
Assist the client into a standing position.
Determine the client’s blood pressure 1 min after each position change.
The Correct Answer is A
Orthostatic hypotension is defined as a decrease in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within three minutes of standing from the supine position1. The first step in assessing a client for orthostatic hypotension is to check their blood pressure while they are lying down (supine position)
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When using an alcohol-based hand sanitizer, the nurse should apply the product to the palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry.
Correct Answer is C
Explanation
Supplemental oxygen is administered to increase the amount of oxygen in the body and improve tissue oxygenation. The goal of this intervention is to improve the client's condition and reduce symptoms of hypoxia.
Options a, b, and d are all indicative of ongoing hypoxia and are not desirable outcomes. An increase in heart rate and respiratory rate and restlessness can be a sign that the client is still struggling to breathe and not getting enough oxygen.
Option c, pink mucous membranes, is indicative of improved tissue oxygenation. The mucous membranes, such as those in the mouth and nose, should be a healthy pink color when oxygen levels are adequate. Therefore, the nurse should identify pink mucous membranes as an indication that the intervention was effective in improving the client's hypoxia.
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