The patient has a history of orthostatic hypotension. What is the priority action of the nurse?
Always take the patient's blood pressure manually using a sphygmomanometer.
Monitor the patient's neurological status carefully for symptoms of a stroke.
Assist the patient to sit and stand slowly when getting out of bed.
Check the patient's blood pressure on a lower extremity using a thigh-sized cuff.
The Correct Answer is C
A. Always take the patient's blood pressure manually using a sphygmomanometer. While manual BP measurements can be more accurate, they are not the priority intervention for orthostatic hypotension, which primarily involves position changes and fall prevention.
B. Monitor the patient's neurological status carefully for symptoms of a stroke. Orthostatic hypotension can cause dizziness or fainting, but it is not a direct cause of stroke. Neurological assessment is important if symptoms arise but is not the primary intervention.
C. Assist the patient to sit and stand slowly when getting out of bed. Orthostatic hypotension causes a sudden drop in blood pressure upon standing, increasing the risk of falls and syncope. The priority action is to help the patient transition slowly from lying to sitting and standing to allow the body to adjust.
D. Check the patient's blood pressure on a lower extremity using a thigh-sized cuff. Lower extremity BP measurements are not standard for managing orthostatic hypotension. Blood pressure should be checked in both lying, sitting, and standing positions to monitor for significant drops.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2500"]
Explanation
Calculation:
To convert liters (L) to milliliters (mL), the conversion factor is:
1L = 1000mL
Given:
(2.5L×1000mL)/ 1L
= 2500mL
Thus, 2.5 L = 2500 mL.
Correct Answer is D
Explanation
A. Listening as the patient inhales and then going to the next site during exhalation. This method does not allow for a complete assessment of breath sounds, as abnormalities may be present during either phase of respiration.
B. If the patient is modest, listening to sounds over his or her clothing or hospital gown. Clothing can muffle or distort breath sounds, leading to inaccurate assessments. The stethoscope should be placed directly on the skin.
C. Instructing the patient to breathe in and out rapidly while listening to the breath sounds. Rapid breathing may lead to hyperventilation and dizziness, and it can make it difficult to detect subtle abnormalities such as crackles or wheezes.
D. Listening to at least one full respiration in each location. This is the correct technique because it allows the nurse to fully assess breath sounds during both inhalation and exhalation, ensuring accurate identification of any abnormal sounds.
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