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 D
Explanation
The correct answer is choice D. Unequal height of the shoulders.
This is because scoliosis is a condition characterized by sideways curvature of the spine that can cause asymmetry of the shoulders, shoulder blades, and hips.
A scoliosis screening is a test that checks for this asymmetry by having the child bend forward from the waist and looking for any prominence of the rib cage or the spine.
Choice A is wrong because expansion of the upper intercostal spaces is not a sign of scoliosis, but rather a sign of hyperinflation of the lungs due to conditions such as asthma or emphysema.
Choice B is wrong because increased convex curve of the cervical spine is not a sign of scoliosis, but rather a sign of kyphosis, which is an excessive outward curvature of the upper spine.
Choice C is wrong because increased concave curve of the thoracic spine is not a sign of scoliosis, but rather a sign of lordosis, which is an excessive inward curvature of the lower spine.
Correct Answer is A
Explanation
The correct answer is choice A: "I will speak with your provider on your behalf."
Choice A rationale: The principle of advocacy in nursing involves supporting and speaking up for clients to ensure their rights, needs, and preferences are respected. By offering to speak with the provider on the client's behalf, the nurse demonstrates advocacy by actively working to represent the client's interests and facilitate communication between the client and the health care team.
Choice B rationale: While promising to fulfill commitments is an aspect of maintaining professional integrity, it does not directly demonstrate advocacy. Advocacy is more about actively supporting the client's rights and needs rather than personal dedication to fulfilling promises.
Choice C rationale: Maintaining the privacy and confidentiality of client information is essential in nursing practice, but it is not specifically related to advocacy. Privacy is a separate ethical principle that focuses on protecting the client's personal information and upholding their right to privacy.
Choice D rationale: Encouraging clients to make decisions about their health care is important for promoting autonomy. However, advocacy involves actively supporting the client's decisions and ensuring their rights are respected, rather than simply allowing them to make decisions.
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