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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The client acquired the infection through indirect contact transmission by touching a contaminated towel. Indirect contact transmission occurs when a person comes into contact with an object or surface that has been contaminated with infectious agents.

A. A client fell out of bed and fractured their hip. B. A client was prescribed a medication they were allergic to, but the prescription was canceled before the medication was given. C. A client had bowel surgery and died from sepsis. D. A client was almost given another client’s medication.

Correct Answer is A

Explanation

A sentinel event is an unexpected event in a healthcare setting that causes or has the potential to cause death, serious physical or psychological injury, or loss of limb or function to a patient1. A client falling out of

bed and fracturing their hip would be considered a sentinel event because it is an unexpected event that resulted in serious physical injury.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who acquired a Staphylococcus aureus infection from touching a contaminated towel. Through which of the following modes of transmission did the client acquire the infection?

Correct Answer is A

Explanation

A charge nurse is providing an in-service to a group of staﬀ nurses about unexpected events. Which of the following should the nurse include in the teaching as an example of a sentinel event?

Correct Answer is A

Explanation

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