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 B

Explanation

A: A BUN level of 165 mg/dL is extremely high and suggests severe dehydration or possible renal failure. This level is far above the normal range and indicates a critical condition.

B: A BUN level of 35 mg/dL is elevated and consistent with dehydration. Dehydration causes the kidneys to reabsorb more water, leading to higher concentrations of urea in the blood.

C: A BUN level of 10 mg/dL is within the normal range and does not indicate dehydration. This level suggests normal kidney function and hydration status.

D: A BUN level of 31 mg/dL is elevated and suggests dehydration. While not as high as 165 mg/dL, it still indicates that the patient is dehydrated and requires intervention.

A. A client who has lactose intolerance B. A client who has had a cerebrovascular accident C. A client who has had prolonged diarrhea D. A client who has had trauma to the head and neck E. A client who is 4 hours postoperative following a leg amputation with general anesthesia

Correct Answer is ["B","D","E"]

Explanation

A: A client with lactose intolerance does not have an increased risk of aspiration while eating. Lactose intolerance affects the digestive system, causing symptoms like bloating and diarrhea when consuming dairy products, but it does not impact swallowing.

B: A client who has had a cerebrovascular accident (CVA) or stroke is at increased risk of aspiration. Strokes can affect the muscles involved in swallowing, leading to dysphagia (difficulty swallowing) and increasing the risk of food or liquid entering the airway.

C: A client who has had prolonged diarrhea is not typically at increased risk of aspiration. Diarrhea affects the gastrointestinal system but does not directly impact the swallowing mechanism.

D: A client who has had trauma to the head and neck is at increased risk of aspiration. Such trauma can damage the structures involved in swallowing, leading to dysphagia and a higher likelihood of aspiration.

E: A client who is 4 hours postoperative following a leg amputation with general anesthesia is at increased risk of aspiration. General anesthesia can depress the gag reflex and swallowing function, making it easier for food or liquid to enter the airway during the immediate postoperative period.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is dehydrated. Which BUN level should the nurse expect the client to have upon admission (Normal BUN 10-20)?

Correct Answer is B

Explanation

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk of aspiration while eating? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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