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)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When someone is having a seizure, it is important to protect their head from injury. One way to do this is by placing something soft and flat, like a folded jacket or towel, under their head1. It is also important to stay with the person until the seizure ends and they are fully awake, and to help them sit in a safe place after it ends1
Correct Answer is A
Explanation
The nurse should choose a finger with good circulation, as indicated by a capillary refill time of less than 2 seconds, to obtain an accurate oxygen saturation reading.
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