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: A trochanter roll is used to prevent external rotation of the hips, not to prevent plantar flexion contractures.

B: A sheepskin heel pad provides cushioning and helps prevent pressure ulcers on the heels but does not prevent plantar flexion contractures.

C: A footboard is used to prevent plantar flexion contractures by keeping the feet in a neutral position. This helps maintain proper alignment and prevents the muscles and tendons from shortening.

D: An abduction pillow is used to maintain hip abduction, typically after hip surgery, and does not prevent plantar flexion contractures.

A. Verifies the medication against the prescription and medication label. B. Documents medication administration prior to administering. C. Scans the bar code on the medication administration record and the client’s arm band. D. Checks the provider’s orders and confirms dosage in a.

Correct Answer is B

Explanation

A: Verifying the medication against the prescription and medication label is a correct and essential step in ensuring the right medication is given to the right patient.

B: Documenting medication administration prior to administering is incorrect and can lead to errors. Documentation should occur immediately after the medication is given to ensure accuracy and prevent discrepancies.

C: Scanning the bar code on the medication administration record and the client’s arm band is a correct practice that helps verify the patient’s identity and the medication being administered.

D: Checking the provider’s orders and confirming the dosage is a necessary step to ensure the correct medication and dose are given. This action is part of safe medication administration practices.

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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

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