A client taking a blood pressure medication reports feeling dizzy when standing up from a lying position. How should the nurse respond?

"You should sit for a bit before standing up fully."

"You should stand quickly to avoid getting dizzy."

"You should not get out of bed if you are dizzy."

"You should restrict your daily amount of fluid."

Answer and Explanation

The Correct Answer is A

A. "You should sit for a bit before standing up fully.": Feeling dizzy when standing is indicative of orthostatic hypotension, a common side effect of antihypertensive medications. Gradually changing positions by sitting up and pausing before standing helps the body adjust blood pressure and prevents falls. This intervention promotes safety and self-management.

B. "You should stand quickly to avoid getting dizzy.": Rapidly standing exacerbates orthostatic hypotension and increases the risk of falls, injury, and syncope. Quick movements are contraindicated in clients experiencing dizziness related to blood pressure changes.

C. "You should not get out of bed if you are dizzy.": Avoiding mobility altogether can lead to deconditioning and does not address safe strategies for daily activities. The goal is to teach proper techniques to safely transition positions rather than restricting movement entirely.

D. "You should restrict your daily amount of fluid.": Fluid restriction is not appropriate for managing medication-induced dizziness unless medically indicated for other conditions such as heart failure. Limiting fluid intake could worsen hypotension or cause dehydration.

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Correct Answer is C

Explanation

A. "Visitors can bring you a potted plant for your room.": Live plants can harbor mold and bacteria, which pose a serious infection risk for immunocompromised clients on neutropenic precautions. Soil and water in potted plants are common sources of pathogens. Plants are contraindicated in neutropenic client rooms.

B. "Visitors can bring you fresh fruit from the market.": Fresh fruits and vegetables may carry bacteria, fungi, or pesticides that can cause infections in clients with neutropenia. Even if washed, they are not considered safe. Raw or unprocessed produce is restricted to minimize infection risk.

C. "Visitors can bring you paper flower arrangements.": Artificial items such as paper flowers do not carry microbes and are safe for clients on neutropenic precautions. They allow for decorative gifts without increasing infection risk. This aligns with safety guidelines for immunocompromised individuals.

D. "Visitors can bring you your favorite raw vegetables.": Raw vegetables can harbor pathogens despite cleaning and present a high risk of infection. Clients with neutropenia are advised to avoid raw produce, including salads and uncooked vegetables. Only thoroughly cooked or processed foods are considered safe.

A. Face the direction of movement. B. Stand with feet close together. C. Reach across the bed to grab clean linens. D. Maintain the bed in low and locked position.

Correct Answer is A

Explanation

A. Face the direction of movement: Facing the direction of movement promotes proper body alignment and reduces twisting of the spine during repositioning. This technique improves balance and decreases the risk of musculoskeletal injury. Correct body mechanics are essential when making an occupied bed.

B. Stand with feet close together: Standing with feet close together narrows the base of support and reduces stability. Proper body mechanics require feet to be shoulder-width apart to maintain balance during movement. A stable stance helps prevent falls and back strain.

C. Reach across the bed to grab clean linens: Reaching across the bed causes spinal twisting and overextension of the arms. This movement increases the risk of back injury and shoulder strain. Linens should be positioned within close reach to support ergonomic practice.

D. Maintain the bed in low and locked position: The bed should be locked for safety, but it should be raised to a comfortable working height during care. Keeping the bed low increases the need for bending and strain. Bed height adjustment is part of safe body mechanics.

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A client taking a blood pressure medication reports feeling dizzy when standing up from a lying position. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client on neutropenic precautions asks the nurse if visitors can bring gifts. How should the nurse respond?

Correct Answer is C

Explanation

The nurse is making an occupied bed. What action should the nurse implement?

Correct Answer is A

Explanation

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