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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Checking the dosage with a more experienced nurse is not the best action. While it may provide some guidance, it does not ensure the accuracy of the order.
B: Consulting a drug handbook and administering the normal dose is not appropriate. The nurse must verify the specific order for the patient rather than assuming a standard dose.
C: Contacting the hospital pharmacist about the order can be helpful, but the pharmacist may not be able to clarify the prescriber’s intent if the order is illegible.
D: Contacting the health care provider to clarify the illegible order is the best action. This ensures that the nurse administers the correct dose as intended by the prescriber, preventing medication errors.
Correct Answer is A
Explanation
A: The passage of flatus is a clear indication that intestinal function is returning. It shows that the gastrointestinal tract is beginning to move gas through the intestines, which is a positive sign of recovery after abdominal surgery.
B: A request for a cup of tea and some toast indicates that the client is feeling better and has an appetite, but it does not specifically indicate the return of intestinal function.
C: Hypoactive bowel sounds in two quadrants suggest reduced intestinal activity, which is not a sign of returning intestinal function. Normal bowel sounds should be present in all quadrants.
D: Abdominal distention can indicate a buildup of gas or fluid in the intestines, which is not a sign of returning intestinal function. It may suggest an obstruction or other complications.
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