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 D

Explanation

A. Ask the chaplain to discuss death issues with the client: While spiritual support may be helpful, this does not address the client’s expressed conflict about continuing treatment to satisfy his family’s wishes.

B. Notify the family that treatments have been discontinued: The nurse cannot make the decision to discontinue treatments without the client’s and healthcare provider’s input. This would be outside the nurse’s scope of authority.

C. Request a consultation with the hospital social worker: Although a social worker can help with emotional support and end-of-life planning, the immediate concern is facilitating open communication between the client, family, and healthcare team about the client’s wishes.

D. Arrange a meeting with the family, healthcare provider, and client: This action supports the client’s autonomy and ensures his wishes are heard. It also promotes collaborative decision-making about continuing or stopping treatment, aligning care with the client’s goals and values.

A. IV site without redness or swelling B. Temperature: 98.8° F (37.1° C) C. Respirations: 28 breaths/minute D. Heart rate: 92 beats/minute E. Taking shallow breaths F. Alert and oriented to person, place, time and situation G. Pain 8 on a 0 to 10 scale H. Blood pressure: 138/82 mm Hg I. Blood pressure: 138/82 mm Hg

Correct Answer is ["C","E","G"]

Explanation

A. IV site without redness or swelling: The IV site appears normal with no signs of infiltration or infection, so no immediate follow-up is required. This finding indicates proper IV insertion and maintenance.

B. Temperature: 98.8° F (37.1° C): This is within normal limits and does not indicate fever or infection, so it does not require immediate follow-up.

C. Respirations: 28 breaths/minute: This is above the normal adult range (12–20 breaths/minute) and may indicate respiratory distress due to pain, shallow breathing, or possible pulmonary complications such as atelectasis or pneumonia, requiring close monitoring and follow-up.

D. Heart rate: 92 beats/minute: Slightly elevated but within mild tachycardia range, which could be related to pain or anxiety. It should be monitored but does not require urgent follow-up.

E. Taking shallow breaths: Shallow breathing is concerning in a client with rib fractures, as it increases the risk for hypoventilation, atelectasis, and pneumonia. This requires immediate intervention, such as pain management and respiratory support.

F. Alert and oriented to person, place, time, and situation: Cognitive status is normal, so no follow-up is needed.

G. Pain 8 on a 0 to 10 scale: Severe pain limits deep breathing and mobility, increasing the risk of complications. Pain management should be addressed promptly to improve comfort and respiratory function.

H. Blood pressure: 138/82 mm Hg: Slightly elevated, likely related to pain or stress. Monitor trends, but it does not require immediate follow-up at this time.

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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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Correct Answer is D

Explanation

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Correct Answer is ["C","E","G"]

Explanation

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