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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The nurse should choose a finger with good circulation, as indicated by a capillary refill time of less than 2 seconds, to obtain an accurate oxygen saturation reading.
Correct Answer is C
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The nurse should expect to find an increased heart rate in a client with a fever. An elevated body temperature can cause an increase in metabolic rate, which can lead to an increase in heart rate. This is a normal physiological response to fever and helps the body to generate heat and fight off infection.
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