A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days.
Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?
“Perform regular isometric exercises.”.
“Increase your intake of protein.”.
“Dangle your legs over the side of the bed.”.
“Use your incentive spirometer.”.
The Correct Answer is C
The correct answer is choice C. “Dangle your legs over the side of the bed.” This helps prevent orthostatic hypotension, which is a form of low blood pressure that happens when standing after sitting or lying down.
Dangling the legs over the side of the bed allows blood to flow back to the heart and increases blood pressure before standing up.
Choice A is wrong because “Perform regular isometric exercises.” Isometric exercises are muscle contractions without movement, such as squeezing a ball or clenching a fist.
These exercises do not help with orthostatic hypotension because they do not improve blood circulation or blood pressure.
Choice B is wrong because “Increase your intake of protein.” Protein intake does not affect orthostatic hypotension directly.
However, staying hydrated by drinking plenty of fluids can help prevent or manage the condition by maintaining blood volume and blood pressure.
Choice D is wrong because “Use your incentive spirometer.” An incentive spirometer is a device that helps improve lung function after surgery by encouraging deep breathing.
It does not prevent orthostatic hypotension because it does not affect blood pressure or blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. The client who says “I need to learn how to perform a dressing change on my leg” is indicating an acceptance of the limb loss and a readiness to learn self-care skills.
This is a positive sign of coping and adaptation after an amputation surgery.
Choice A is wrong because the client who says “I am going to have to find someone who can take care of my leg at home” is expressing dependency and denial of the limb loss.
The client needs to be encouraged to participate in self-care activities and rehabilitation.
Choice B is wrong because the client who says “I stay awake at night because I keep thinking about my leg” is experiencing phantom limb sensation, which is a common phenomenon after amputation.
The client may benefit from pain management, distraction techniques, and counseling.
Choice D is wrong because the client who says “I know my family means well, but I don’t want visitors seeing my leg right now” is showing signs of social isolation and low self-esteem.
The client needs emotional support and reassurance from the nurse and family members.
Normal ranges for vital signs after amputation are blood pressure 120/80 mm Hg, pulse 60-100 beats/min, respiratory rate 12-20 breaths/min, and temperature 36.5-37.5°C.
Correct Answer is A
Explanation
This is because the nurse should first assess the client’s baseline knowledge and readiness to learn before providing any teaching.
The nurse should also tailor the teaching to the client’s individual needs and preferences.
Choice B is wrong because showing the client a video demonstration of peak flow meter use may not be the most effective way of teaching if the client has different learning styles or needs.
The nurse should also involve the client in the learning process and not just rely on passive methods.
Choice C is wrong because observing the client using the peak flow meter is an evaluation step that should be done after teaching and reinforcing the correct technique.
The nurse should not assume that the client knows how to use the peak flow meter without assessing their knowledge first.
Choice D is wrong because emphasizing the importance of the daily use of the peak flow meter is a motivational strategy that should be done after assessing the client’s knowledge and providing teaching.
The nurse should also explain the rationale and benefits of using the peak flow meter, not just tell the client to do it.
A peak flow meter is a small device that measures how fast a person can forcefully blow air out of their lungs in one fast breath.
It is one indicator of airways changes that may occur in people with asthma or COPD.
To get a peak flow meter, speak to a doctor.
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