When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?
Record the client's pulse rate and rhythm.
Assist the client to stand at the bedside.
Apply the blood pressure cuff securely.
Position the client supine for a few minutes.
The Correct Answer is D
Choice A reason: Recording the client's pulse rate and rhythm is part of the assessment, but it is not the first action to take when assessing for orthostatic hypotension.
Choice B reason: Assisting the client to stand is part of the assessment process, but it should be done after the initial blood pressure and pulse have been measured while the client is supine.
Choice C reason: Applying the blood pressure cuff securely is necessary for an accurate reading, but it is not the first step in the process of assessing for orthostatic hypotension.
Choice D reason: The first action is to position the client supine for a few minutes before taking the initial blood pressure and pulse measurements, as this provides a baseline for comparison when the client stands.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The results are within the normal reference range for both potassium and sodium, which is expected unless the client's condition has led to significant electrolyte imbalances.
Choice B reason: A serum potassium level of 4.5 mEq/L is at the higher end of the normal range, which might not be expected in a client with vomiting and diarrhea, conditions that often lead to lower potassium levels.
Choice C reason: A serum potassium level of 5.0 mEq/L is at the upper limit of the normal range and could indicate hyperkalemia, especially in the context of severe dehydration.
Choice D reason: A serum sodium level of 149 mEq/L is slightly above the normal range and could indicate hypernatremia, which may occur in dehydration but would require further assessment and intervention.
Correct Answer is A
Explanation
Choice A reason: If the oxygen reservoir bag of a partial rebreather mask does not deflate completely during inspiration, it may indicate that the flow rate is too low. Increasing the liter flow ensures adequate delivery of oxygen.
Choice B reason: Encouraging the client to take deep breaths is beneficial for overall respiratory function but will not address the issue of the reservoir bag not deflating properly.
Choice C reason: Removing the mask to deflate the bag is not a standard practice and could interrupt the delivery of oxygen to the client.
Choice D reason: Documentation of the assessment data is important, but the nurse must first address the issue with the oxygen delivery system to ensure the client is receiving the proper amount of oxygen.
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