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.

Answer and Explanation

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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Correct Answer is A

Explanation

The client acquired the infection through indirect contact transmission by touching a contaminated towel. Indirect contact transmission occurs when a person comes into contact with an object or surface that has been contaminated with infectious agents.

A. Apply corn-starch to the client’s skin. B. Allow the client’s skin to air-dry after cleaning. C. Clean the client’s skin with a pH-balanced cleanser. D. Use hot water to clean the client’s skin.

Correct Answer is C

Explanation

Urinary incontinence can lead to skin irritation and breakdown if the skin is not properly cleaned 1. Using a pH-balanced cleanser can help maintain the skin’s natural acidity and prevent irritation.

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A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who acquired a Staphylococcus aureus infection from touching a contaminated towel. Through which of the following modes of transmission did the client acquire the infection?

Correct Answer is A

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Correct Answer is C

Explanation

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