A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?

Check the blood pressure with the client in a supine position.

Place the client in a sitting position.

Determine the client's blood pressure 1 min after each position change.

Assist the client into a standing position.

Answer and Explanation

The Correct Answer is A

A: To accurately assess for orthostatic hypotension, the initial blood pressure should be measured while the client is supine. This establishes a baseline for comparing subsequent measurements.
B: Placing the client in a sitting position is a subsequent step in the sequence to monitor changes but is not the first action.
C: Determining the client's blood pressure changes after each position is essential but follows the initial supine measurement.
D: Assisting the client into a standing position is also part of the assessment process for orthostatic hypotension but should occur after recording the supine and sitting blood pressures.

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Correct Answer is B

Explanation

A: The daughter's anxiety is secondary information and not directly related to the patient's health status.
B: The patient's self-reported medical history is primary data as it comes directly from the patient and provides essential information for the assessment.
C: The spouse's report of the patient's difficulty sleeping is secondary information and not directly observed or reported by the patient.
D: The caregiver's complaint is secondary information and does not provide direct insight into the patient's health status.

A. The nurse applies pressure over a bony prominence of the foot for 2 seconds. B. The nurse percusses the tissue that appears edematous C. The nurse elevates the patient's feet on a pillow to decease swelling. D. The nurse charts, "Patient's feet appear to be swollen."

Correct Answer is A

Explanation

A: Applying pressure over a bony prominence helps assess for pitting edema, a common indicator of fluid retention causing swelling. This action provides objective data to confirm the patient's subjective observation.
B: Percussion is not typically used to assess edema. It is more suitable for assessing the density of underlying structures.
C: Elevating the feet may help alleviate swelling but does not confirm the presence of edema.
D: Documenting the observation is important, but further assessment is needed to confirm the patient's concern.

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A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?

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