A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position.
Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

The client's heart rate increases by 10/min.

The client's diastolic blood pressure increases by 10 mm Hg.

The client reports heart palpitations.

The client's systolic blood pressure decreases by 25 mm Hg.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

An increase in heart rate by 10 beats per minute when moving from a supine to a sitting position is a normal physiological response to compensate for decreased venous return and maintain cardiac output. This response does not indicate orthostatic hypotension.

Choice B rationale:

An increase in diastolic blood pressure by 10 mm Hg when moving from a supine to a sitting position is a normal response to compensate for the effects of gravity on blood flow. It helps maintain perfusion to vital organs and does not indicate orthostatic hypotension.

Choice C rationale:

Heart palpitations can occur due to various reasons, including anxiety or arrhythmias, but they are not specific signs of orthostatic hypotension. This symptom alone does not confirm the presence of orthostatic hypotension.

Choice D rationale:

A decrease in systolic blood pressure by 25 mm Hg or more when moving from a supine to a sitting position indicates orthostatic hypotension. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mm Hg or more or a drop in diastolic blood pressure of 10 mm Hg or more within 3 minutes of standing up. This condition can cause dizziness, lightheadedness, or fainting and can be a side effect of antihypertensive medications or other underlying medical conditions.

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Correct Answer is D

Explanation

A. Incorrect. Releasing the tourniquet is a step that can be taken after advancing the catheter into the vein.

B. Incorrect. Retracting the stylet at this point could disrupt the position of the catheter and cause leakage or damage.

C. Incorrect. Flushing the catheter with saline is an appropriate step after ensuring the catheter is correctly placed in the vein.

D. Correct. After noting a blood return in the flashback chamber, the next step is to advance the catheter into the vein to ensure proper placement for intravenous access.

A. Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge. B. Membranes intact. C. No uterine contractions noted. D. FHR baseline 138 E. minimal variability. F. No further reports of burning with urination. G. WBC 12.000/mm3 H. Platelet count 188,000/mm3 (150,000 to 400,000/mm3) I. Temperature 37.1° C (98.7° F) J. Blood pressure 120/78 mm Hg

Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

Explanation

Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge.

Membranes intact.

No uterine contractions noted.

FHR baseline 138, with minimal variability. No further reports of burning with urination.

Laboratory Results: WBC 12,000/mm3 (within the normal range of 5,000 to 10,000/mm3). Platelet count 188,000/mm3 (within the normal range of 150,000 to 400,000/mm3).

Vital Signs: Temperature 37.1°C (98.7°F), Blood pressure 120/78 mm Hg.

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A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position.Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for a peripheral IV catheter. After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next?

Correct Answer is D

Explanation

Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

Explanation

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A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position.
Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?