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 ["2"]
Explanation
Step 1: Determine the dosage required. 650 mg
Step 2: Determine the dosage per tablet. 325 mg per tablet
Step 3: Calculate the number of tablets needed. 650 mg ÷ 325 mg per tablet = 2 tablets
The nurse should administer 2 tablets.
Correct Answer is A
Explanation
A: The nurse should check the medication order again to ensure that the correct medication is being administered. This response addresses the client’s concern and ensures patient safety.
B: Telling the client that this is the medication their doctor wants them to take does not address the client’s concern about the color difference and may not ensure the correct medication is given.
C: While it is true that the same medication can come in different colors, this response does not verify the accuracy of the medication being administered.
D: Explaining the purpose of the medication is important, but it does not address the immediate concern about the color difference and the need to verify the medication.
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