Because the older adult's blood vessels are nonelastic, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:

allow the patient to sit on the side of the bed for a minute before standing.

instruct the patient to use the wheelchair for all mobility activity.

keep the patient in bed in a high Fowler's position

help the patient to rise quickly and support the patient for a minute.

Answer and Explanation

The Correct Answer is A

A.   Allowing the patient to sit on the side of the bed helps to prevent sudden drops in blood pressure and allows the body to adjust to the change in position, reducing the risk of fainting or dizziness.
B.   Using a wheelchair for mobility may not address the root cause of orthostatic hypotension and may limit the patient's independence.
C.   Keeping the patient in a high Fowler's position could worsen the symptoms of orthostatic hypotension.
D.   Rising quickly could lead to a sudden drop in blood pressure and increase the risk of a fall or injury.

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Correct Answer is C

Explanation

A. Wrapping the cuff snugly around the arm is important for an accurate reading. The cuff should be snug but not tight to avoid false readings.
B. Positioning the cuff bladder over the brachial artery ensures the correct placement for accurate measurement.
C. Placing the arm above the level of the heart can lead to a falsely low blood pressure reading. The arm should be at heart level for an accurate measurement.
D. Ensuring the gauge starts at zero is critical for accurate measurement and avoids errors in reading.

A. directly below the sternum. B. the left of the sternum at the third intercostal space. C. the left midclavicular line at the fifth intercostal space D. tightly above the left nipple.

Correct Answer is C

Explanation

A. The area directly below the sternum is not the location for the apical pulse.
B. The third intercostal space is too high for the apical pulse, which is best heard at the fifth intercostal space.
C. The left midclavicular line at the fifth intercostal space is the proper location for auscultating the apical pulse.
D. Placing the stethoscope above the left nipple does not ensure accurate assessment of the apical pulse.

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Because the older adult's blood vessels are nonelastic, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

Correct Answer is C

Explanation

The nurse taking an apical pulse would place the stethoscope at:

Correct Answer is C

Explanation

The nurse tells a patient that he will be performing a visual acuity test using the Snellen eye chart. The patient asks how the test is done. The nurse's best reply is:

A nurse caring for a patient on bed rest with a history of respiratory health problems should:

A type of Korotkoff sound that indicates the diastolic pressure in children and in some adults is

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The nurse is informed that a patient had abnormal heart sounds during the night shift. When auscultating abnormal heart sounds, the nurse knows to listen to heart sounds with the:

When caring for a victim with a gunshot wound to the abdomen who has lost a significant amount of blood, the nurse would anticipate the vital signs to reflect:

Because the older adult's blood vessels are nonelastic, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:

When examining a patient's pupils with a light, the nurse notes that both pupils constrict, regardless of which eye is stimulated by the light. The nurse should document that the pupils exhibit: