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
Related Questions
Correct Answer is C
Explanation
Opioid toxicity can cause difficulties with breathing and an opioid overdose can lead to death1. A respiratory rate of 10/min is considered low and could be a sign of opioid toxicity.
Correct Answer is C
Explanation
Answer: C. Place a surgical mask on the client when they leave their room.
Rationale:
A) Wear a surgical mask when within 0.6 m (2 ft) of the client.
While it is necessary to wear a surgical mask when in close proximity to a client on droplet precautions, the distance specified (0.6 m or 2 ft) is less than the standard recommended distance of 1 meter (3 feet). Therefore, this option is not fully aligned with best practices.
B) Move the client to a positive airflow room.
Positive airflow rooms are typically used for clients with immunosuppression or those who need protection from airborne pathogens, not for those on droplet precautions. This action is not appropriate for a client requiring droplet precautions.
C) Place a surgical mask on the client when they leave their room.
This action is appropriate and essential to minimize the risk of transmission of infectious agents to others when the client is moving outside their isolation area. The client wearing a mask is a key part of droplet precautions.
D) Remove fresh flowers from the client’s room.
While it may be necessary to remove fresh flowers in certain cases (such as for neutropenic clients), this is not specifically related to droplet precautions. Droplet precautions focus primarily on respiratory secretions and do not directly involve the presence of flowers.
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