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 B
Explanation
Choice A reason: The Trendelenburg position is not indicated for increasing oxygen saturation and could be harmful, especially for clients with respiratory distress.
Choice B reason: Ensuring that the prongs of the nasal cannula are securely placed in the nostrils is important for effective oxygen delivery, especially if the oxygen saturation remains below the prescribed range.
Choice C reason: Placing the pulse oximeter on the client's earlobe is an alternative site for obtaining a saturation reading, but it does not address the issue of potentially inadequate oxygen delivery.
Choice D reason: While documentation is important, the nurse must first address the low oxygen saturation levels before documenting the readings.
Correct Answer is C
Explanation
Choice A reason: While a medication reference guide is useful, it does not replace the need for clarification from the prescribing healthcare provider regarding dosage discrepancies.
Choice B reason: The nursing unit charge nurse can be a resource, but the prescriber should be the first contact for medication orders.
Choice C reason: The healthcare provider who prescribed the medication is the most appropriate resource to clarify and potentially correct the dosage of the oral antibiotic.
Choice D reason: The hospital pharmacist is a valuable resource for medication information and can be consulted, but the prescriber should first be contacted to address the discrepancy in dosages.
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