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 C

Explanation

A: Requesting the risk manager to obtain consent for HIV testing from the client is important but should not be the first action. Immediate steps to reduce the risk of infection are more urgent.

B: Completing an incident report is necessary for documentation and follow-up but is not the immediate priority following a needle stick injury.

C: Washing the site of injury with soap and water is the first and most immediate action. This helps to reduce the risk of infection by removing any potential contaminants from the wound.

D: Consenting to post-exposure treatment with antiretroviral medications is important if there is a risk of HIV exposure. However, this should follow the initial step of cleaning the wound.

A. Check the client’s motor strength. B. Turn the client’s head to the side. C. Document the time the seizure began. D. Loosen the clothing around the client’s waist.

Correct Answer is B

Explanation

A: Checking the client’s motor strength is not the first priority during a seizure. Ensuring the client’s safety and airway patency is more important.

B: Turning the client’s head to the side is the first action. This helps maintain an open airway and prevents aspiration of saliva or vomit.

C: Documenting the time the seizure began is important for medical records but is not the immediate priority during the seizure.

D: Loosening the clothing around the client’s waist can help with comfort but is not the first action to take during a seizure.

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

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Naxlex Comprehensive Predictor Exams

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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