A nurse is assessing a client 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.
Assist the client into a standing position.
Determine the client’s blood pressure 1 min after each position change.
The Correct Answer is A
Orthostatic hypotension is defined as a decrease in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within three minutes of standing from the supine position1. The first step in assessing a client for orthostatic hypotension is to check their blood pressure while they are lying down (supine position)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
An oxygen saturation of 88% is below the normal range of 95-100%, indicating that the client may be experiencing hypoxia. Encouraging the client to take deep breaths can help increase their oxygen saturation level.
Correct Answer is C
Explanation
When setting up a sterile field, it is important to inspect the sterile package for holes before opening it to ensure that the contents are still sterile1. The first flap of the package should be opened away from the body
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