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 B
Explanation
A: Convection involves the movement of air or liquid around the body, which then carries heat away but does not involve phase change like evaporation.
B: Evaporation is the process where liquid (sweat) turns into vapor, removing heat from the surface it evaporates from, which is the primary cooling mechanism in sweating.
C: Conduction involves direct transfer of heat through contact with cooler objects, not relevant to the drying of sweat.
D: Radiation refers to heat transfer through electromagnetic waves and does not require the presence of an intervening medium, unlike the evaporation of sweat.
Correct Answer is C
Explanation
A: This is not suitable for assessing circulation issues specifically in the lower extremities as it is located on the upper body.
B: This is not suitable for assessing circulation issues specifically in the lower extremities as it is located on the upper body.
C: Palpating the posterior tibialis pulse is a logical next step for checking lower extremity circulation, particularly when dorsalis pedis is not palpable, helping localize the evaluation of blood flow in the foot and ankle.
D: The femoral pulse is useful for broader leg circulation issues. However, it is less targeted than posterior tibialis for checking blood flow in the lower extremities.
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