A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension?

Blood pressure sitting 140/60; blood pressure 130/60 standing

Blood pressure sitting 130/60; blood pressure 110/60 standing

Blood pressure sitting 126/64; blood pressure 120/58 standing

Blood pressure sitting 130/64; blood pressure 140/70 standing

Answer and Explanation

The Correct Answer is B

A: A drop in systolic blood pressure of 10 mm Hg (from 140 to 130) does not meet the criteria for orthostatic hypotension, which requires a drop of at least 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure within three minutes of standing.

B: This finding shows a drop in systolic blood pressure from 130 to 110 mm Hg, which is a 20 mm Hg decrease. This meets the criteria for orthostatic hypotension, indicating that the patient may have this condition.

C: A drop in systolic blood pressure of 6 mm Hg (from 126 to 120) does not meet the criteria for orthostatic hypotension. The decrease is not significant enough to confirm the condition.

D: An increase in blood pressure (from 130/64 to 140/70) does not indicate orthostatic hypotension. This finding suggests that the patient’s blood pressure increases upon standing, which is not consistent with orthostatic hypotension.

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Correct Answer is B

Explanation

A: A BUN level of 165 mg/dL is extremely high and suggests severe dehydration or possible renal failure. This level is far above the normal range and indicates a critical condition.

B: A BUN level of 35 mg/dL is elevated and consistent with dehydration. Dehydration causes the kidneys to reabsorb more water, leading to higher concentrations of urea in the blood.

C: A BUN level of 10 mg/dL is within the normal range and does not indicate dehydration. This level suggests normal kidney function and hydration status.

D: A BUN level of 31 mg/dL is elevated and suggests dehydration. While not as high as 165 mg/dL, it still indicates that the patient is dehydrated and requires intervention.

A. Have another nurse witness the wasted medication. B. Return the wasted medication to the medication dispenser. C. Place the wasted portion of the medication in the sharps container. D. Exit the medication room to call the health care provider to request an order that matches the dosages.

Correct Answer is A

Explanation

A: Having another nurse witness the wasted medication is the correct procedure. This ensures accountability and compliance with regulations regarding the handling and disposal of controlled substances.

B: Returning the wasted medication to the medication dispenser is not appropriate. Once a narcotic has been withdrawn, it cannot be returned to the dispenser due to contamination and safety protocols.

C: Placing the wasted portion of the medication in the sharps container is not correct. Narcotics should be disposed of according to specific protocols, which typically involve witnessing and documentation, not simply placing them in a sharps container.

D: Exiting the medication room to call the health care provider to request an order that matches the dosages is unnecessary. The nurse should follow the proper procedure for wasting the medication with a witness.

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A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is dehydrated. Which BUN level should the nurse expect the client to have upon admission (Normal BUN 10-20)?

Correct Answer is B

Explanation

A nurse has withdrawn a narcotic from the medication dispenser and must waste a portion of the medication. What should the nurse do?

Correct Answer is A

Explanation

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