An older client reports experiencing frequent dizzy spells. To assess for orthostatic hypotension, which action should the nurse take first?

Assist client to a supine position.

Instruct the client to stand upright.

Place the client in a semi-Fowler's position.

Help the client sit on the side of the bed.

Answer and Explanation

The Correct Answer is A

A. Assist client to a supine position: The initial step in assessing orthostatic hypotension is to have the client lie supine for several minutes. This allows baseline blood pressure and heart rate to be measured in a stable, resting position before changing posture.

B. Instruct the client to stand upright: Standing too soon without establishing baseline measurements may place the client at risk for falls or injury due to dizziness or sudden blood pressure changes.

C. Place the client in a semi-Fowler's position: A semi-Fowler’s position is partially upright, which does not provide an accurate baseline for assessing orthostatic changes compared to the supine position.

D. Help the client sit on the side of the bed: Sitting at the bedside is part of the assessment sequence, but it should occur after obtaining supine baseline readings to safely monitor changes in blood pressure and heart rate.

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Correct Answer is A

Explanation

A. Palpate the client's suprapubic area for distention: Palpating for bladder distention helps determine if urinary retention is present, which is common in older men with possible benign prostatic hyperplasia (BPH). Assessing retention is a priority because unresolved urinary obstruction can lead to hydronephrosis or kidney damage.

B. Instruct in effective techniques to cleanse the glans penis: Proper hygiene is important for preventing infection, especially in uncircumcised males, but it does not address the client’s primary problem of urinary retention and obstructive symptoms.

C. Obtain a urine specimen for culture and sensitivity: While urinary tract infections can occur in clients with urinary retention, the presenting symptoms here are more indicative of obstruction due to prostate enlargement. A culture may be ordered later, but not the first step.

D. Advise the client to maintain a voiding diary for one week: A voiding diary provides helpful long-term information about urinary patterns, but it does not address the acute issue of a bladder that may be distended and retaining urine.

A. Bring a sterile chest drainage unit from central supply to the unit. B. Evaluate a client's urinary catheter for proper drainage. C. Call the pharmacy to obtain a client's next antibiotic dose. D. Observe a client's gait to determine the need for assistance.

Correct Answer is A

Explanation

A. Bring a sterile chest drainage unit from central supply to the unit: This task is appropriate for delegation to a UAP because it involves transporting equipment and does not require clinical judgment or assessment.

B. Evaluate a client's urinary catheter for proper drainage: This requires assessment skills to determine whether the catheter is functioning correctly or if complications such as obstruction or infection are present.

C. Call the pharmacy to obtain a client's next antibiotic dose: Communicating directly with the pharmacy about medications is part of the nurse’s responsibilities. It involves ensuring accuracy, safety, and proper coordination of care, which cannot be delegated to unlicensed staff.

D. Observe a client's gait to determine the need for assistance: While a UAP can walk with a client or provide basic support, determining the level of assistance needed requires assessment skills. Evaluating gait involves clinical judgment and must be performed by a licensed nurse or physical therapist.

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An older client reports experiencing frequent dizzy spells. To assess for orthostatic hypotension, which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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