An older client reports experiencing frequent dizzy spells. To assess for orthostatic hypotension, which action should the nurse take first?

Assist client to a supine position.

Instruct the client to stand upright.

Place the client in a semi-Fowler's position.

Help the client sit on the side of the bed.

Answer and Explanation

The Correct Answer is A

A. Assist client to a supine position: The initial step in assessing orthostatic hypotension is to have the client lie supine for several minutes. This allows baseline blood pressure and heart rate to be measured in a stable, resting position before changing posture.

B. Instruct the client to stand upright: Standing too soon without establishing baseline measurements may place the client at risk for falls or injury due to dizziness or sudden blood pressure changes.

C. Place the client in a semi-Fowler's position: A semi-Fowler’s position is partially upright, which does not provide an accurate baseline for assessing orthostatic changes compared to the supine position.

D. Help the client sit on the side of the bed: Sitting at the bedside is part of the assessment sequence, but it should occur after obtaining supine baseline readings to safely monitor changes in blood pressure and heart rate.

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Correct Answer is ["A","C","D"]

Explanation

A. Note and report the client's food and liquid intake during meals and snacks: UAPs can monitor and document intake and output, then report to the nurse for evaluation. This is within their role.

B. Assess the client for weakness and fatigue: Assessment requires nursing judgment and interpretation of findings, which cannot be delegated to UAPs.

C. Report any client mention of pain or discomfort: UAPs may report observations or client statements to the nurse. The nurse is responsible for further assessment and management.

D. Weigh the client and report any weight gain: Daily weights and reporting results are appropriate UAP tasks, as they are routine and measurable without requiring clinical judgment.

E. Evaluate the client for sleep disturbances: Evaluation involves analysis and clinical decision-making, which must be performed by the nurse, not the UAP.

A. Use a picture of clock to indicate the dose times. B. Mark the dose on the syringe using color coded tape. C. Instruct them to add the medication to formula or juice. D. Place a color code on the medication containers. E. Schedule medication times with feeding times.

Correct Answer is ["A","B","D","E"]

Explanation

A. Use a picture of a clock to indicate the dose times: Visual aids help parents with limited literacy or cognitive challenges understand when to give medications, improving adherence and safety.

B. Mark the dose on the syringe using color-coded tape: Color-coded markings provide a clear, simple guide for accurate dosing, reducing the risk of errors.

C. Instruct them to add the medication to formula or juice: Mixing medications with food or drink can alter absorption, interfere with effectiveness, or result in incomplete ingestion. This practice is generally discouraged unless specifically approved by the healthcare provider.

D. Place a color code on the medication containers: Color-coded containers help parents quickly identify the correct medication and dose, supporting safe administration.

E. Schedule medication times with feeding times: Aligning medication administration with regular daily routines such as feeding helps parents remember doses and promotes adherence to the prescribed schedule.

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An older client reports experiencing frequent dizzy spells. To assess for orthostatic hypotension, which action should the nurse take first?

Nursing Test Bank

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