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 A
Explanation
The client is likely experiencing the acute illness stage of infection, which is characterized by the appearance of specific signs and symptoms of the disease. During this stage, the individual may feel ill and exhibit symptoms such as sneezing, productive cough, muscle aches, headache, and fever.
Correct Answer is D
Explanation
When performing perineal care for a female client, the nurse should use soap and water to clean the client’s perineum. This helps to remove any urine or fecal mater and prevent skin irritation or infection. The nurse should also use a clean section of the washcloth for each area cleaned and should clean from front to back to prevent the spread of bacteria from the rectal area to the urethra.
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