A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension?

Blood pressure sitting 140/60; blood pressure 130/60 standing

Blood pressure sitting 130/60; blood pressure 110/60 standing

Blood pressure sitting 126/64; blood pressure 120/58 standing

Blood pressure sitting 130/64; blood pressure 140/70 standing

Answer and Explanation

The Correct Answer is B

A: A drop in systolic blood pressure of 10 mm Hg (from 140 to 130) does not meet the criteria for orthostatic hypotension, which requires a drop of at least 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure within three minutes of standing.

B: This finding shows a drop in systolic blood pressure from 130 to 110 mm Hg, which is a 20 mm Hg decrease. This meets the criteria for orthostatic hypotension, indicating that the patient may have this condition.

C: A drop in systolic blood pressure of 6 mm Hg (from 126 to 120) does not meet the criteria for orthostatic hypotension. The decrease is not significant enough to confirm the condition.

D: An increase in blood pressure (from 130/64 to 140/70) does not indicate orthostatic hypotension. This finding suggests that the patient’s blood pressure increases upon standing, which is not consistent with orthostatic hypotension.

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Correct Answer is C

Explanation

A: Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to the bed frame, not the side rail, to prevent injury.

B: Ensuring four fingers fit under the restraints is too loose. The correct fit is typically two fingers to ensure the restraint is secure but not too tight.

C: Securing the restraints using a quick-release tie is correct. This allows for quick removal in case of an emergency.

D: Anticipating removing the restraints every 4 hours is incorrect. Restraints should be checked and potentially removed more frequently, typically every 2 hours, to assess skin integrity and circulation.

A. Apply petroleum jelly to the client’s lips after oral care. B. Turn the client on his side before starting oral care. C. Use the thumb and index finger to keep the client’s mouth open. D. Use a stiff toothbrush to clean the client’s teeth.

Correct Answer is B

Explanation

A: Applying petroleum jelly to the client’s lips after oral care can help prevent dryness and cracking, but it is not the primary action to ensure safety during oral care.

B: Turning the client on his side before starting oral care is the correct action. This position helps prevent aspiration of fluids and secretions during the procedure, ensuring the client’s safety.

C: Using the thumb and index finger to keep the client’s mouth open is not safe or effective. A mouth prop or padded tongue blade should be used instead.

D: Using a stiff toothbrush can cause damage to the gums and oral tissues. A soft-bristled toothbrush is recommended for gentle and effective cleaning.

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A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension?

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