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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: The cuff should ideally cover about 80% of the circumference of the upper arm, not just 50%.
B: The cuff should be placed level with the client's heart, specifically aligned with the brachial artery for accurate measurement.
C: Elevating the arm above the level of the heart can lead to an inaccurately low reading.
D: Proper alignment with the brachial artery ensures that the sensor correctly detects the arterial pressure, crucial for accurate readings.
Correct Answer is D
Explanation
A: Low blood pressure is an objective finding that can be measured directly.
B: Shortness of breath is a subjective symptom reported by the patient.
C: Wound drainage is an objective finding that can be observed directly.
D: Feelings of fatigue are subjective symptoms reported by the patient, reflecting their personal experience rather than directly observable physical signs.
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