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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
Step 1: Determine the dosage required. 1 mg
Step 2: Determine the dosage per tablet. 2 mg per tablet
Step 3: Calculate the number of tablets needed. 1 mg ÷ 2 mg per tablet = 0.5 tablets
The nurse should administer 0.5 tablets per dose.
Correct Answer is D
Explanation
A: Proceeding to measure the oral temperature immediately after the client has eaten ice chips is not appropriate. The cold temperature can affect the accuracy of the reading.
B: Documenting that the nurse was unable to measure the client’s temperature is unnecessary. The nurse can take steps to ensure an accurate measurement by waiting.
C: Providing the client a sip of warm water and waiting 5 minutes is not sufficient to counteract the effect of the ice chips on the oral temperature reading.
D: Waiting 30 minutes before measuring the oral temperature is the correct action. This allows time for the oral cavity to return to its normal temperature, ensuring an accurate reading.
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