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 A
Explanation
The correct answer is choice A. Use a communication board to interact with the client.
A communication board is a tool that allows the client to point to words, pictures, or symbols that express their needs, feelings, or pain level.
This is an effective way to communicate with a client who speaks a different language than the nurse and is unable to verbalize their pain.
Choice B is wrong because an assistive personnel who speaks the same language as the client is not a qualified interpreter and may not be able to convey the client’s pain accurately or maintain confidentiality.
Choice C is wrong because the FLACC scale is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain.
It is not appropriate for a client who is 6 hours postoperative and can communicate their pain using a communication board.
Choice D is wrong because the FACES pain scale is a self-report measure of pain intensity developed for children.
It uses facial expressions to rate the severity of pain in children from 0-103.
It is not suitable for a client who speaks a different language than the nurse and may not understand the meaning of the faces.
Correct Answer is D
Explanation
Beneficence is the ethical principle of doing good and acting in the best interest of the patient. By administering pain medication prior to turning the client, the nurse is reducing the client’s suffering and promoting their well-being.
Choice A. Autonomy is wrong because autonomy is the ethical principle of respecting the patient’s right to self-determination and decision-making. The nurse is not asking for the client’s consent or preference before giving pain medication or turning them.
Choice B. Fidelity is wrong because fidelity is the ethical principle of being faithful and loyal to the patient and honoring one’s commitments and promises. The nurse is not demonstrating fidelity by giving pain medication or turning the client.
Choice C. Veracity is wrong because veracity is the ethical principle of telling the truth and being honest with the patient. The nurse is not providing any information or education to the client before giving pain medication or turning them.
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