A nurse is caring for a client who has postural hypotension. The nurse assists the client gradually from a lying down to standing position. The nurse should identify that which of the following findings indicates the intervention is effective?
The client’s systolic blood pressure decreases from 110 mm Hg to 105 mm Hg.
The client reports nausea.
The client’s heart rate increases from 100/min to 108/min.
The client reports dizziness.
The Correct Answer is A
Postural hypotension, also known as orthostatic hypotension, is a form of low blood pressure that occurs when standing up from a sitting or lying down position 1. An effective intervention for postural hypotension would be one that helps to prevent a significant drop in blood pressure when the client changes position. A small decrease in systolic blood pressure, such as from 110 mm Hg to 105 mm Hg, would indicate that the intervention is effective in preventing a larger drop in blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
When using an alcohol-based hand sanitizer, the nurse should apply the product to the palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry.
Correct Answer is A
Explanation
The chain of infection describes how an infection spreads based on six links of transmission: Infectious Agent, Reservoirs, Portal of Exit, Modes of Transmission, Portal of Entry, and Susceptible Host1. In this case, the client’s mouth is an example of a portal of entry, which is the route by which an infectious agent enters a new host1.
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