A nurse is getting a client out of bed to ambulate for the first time.
The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak.
Let me sit on the side of the bed for a minute.” What finding should the nurse document?
A normal reaction to a position change.
Gait belt applied.
Orthostatic hypotension noted with dangling.
Elevated blood sugar probable.
The Correct Answer is C
Orthostatic hypotension noted with dangling.
This means that the client’s blood pressure drops when changing position from lying down to sitting or standing. This can cause symptoms such as paleness, sweating, rapid pulse, weakness, and dizziness.
The nurse should document this finding and report it to the physician.
Choice A is wrong because a normal reaction to a position change would not cause such severe symptoms.
Choice B is wrong because the gait belt applied is not a finding but an intervention.
Choice D is wrong because elevated blood sugar probable is not a finding but a speculation.
Choice E is wrong because spot accucheck obtained is not a finding but an action.
Choice F is wrong because fear of falling expressed by a client is not a finding related to the client’s vital signs or physical condition.
Choice G is wrong because provided reassurance is not a finding but a nursing measure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
30 mL. This is because one ounce is equal to 29.57353 milliliters, so one ounce of an elixir medication is approximately 30 milliliters.
The nurse should instruct the client to take 30 milliliters of the medication during discharge teaching.
Choice A is wrong because 5 milliliters is much less than one ounce. Choice B is wrong because 15 milliliters is half of one ounce.
Choice C is wrong because 25 milliliters is slightly less than one ounce.
The nurse should use a conversion factor or a calculator to convert ounces to milliliters accurately.
Correct Answer is C
Explanation
This would help the client to feel valued, respected and involved in their own care, which can enhance their self-esteem.
Choice A is wrong because adding a nursing diagnosis of lowered self-esteem to the care plan does not address the underlying causes of the problem or provide any interventions to improve it.
It may also label the client and make them feel worse.
Choice B is wrong because giving praise for every decision the client makes is not realistic or sincere.
It may also undermine the client’s confidence and autonomy by implying that they need constant approval from others.
Choice D is wrong because modeling competent care for the client does not necessarily help them to maintain their self-esteem.
It may even make them feel inadequate or dependent on the nurse.
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