When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

Record the client's pulse rate and rhythm.

Assist the client to stand at the bedside.

Apply the blood pressure cuff securely.

Position the client supine for a few minutes.

Answer and Explanation

The Correct Answer is D

Choice A reason: Recording the client's pulse rate and rhythm is part of the assessment, but it is not the first action to take when assessing for orthostatic hypotension.
Choice B reason: Assisting the client to stand is part of the assessment process, but it should be done after the initial blood pressure and pulse have been measured while the client is supine.
Choice C reason: Applying the blood pressure cuff securely is necessary for an accurate reading, but it is not the first step in the process of assessing for orthostatic hypotension.
Choice D reason: The first action is to position the client supine for a few minutes before taking the initial blood pressure and pulse measurements, as this provides a baseline for comparison when the client stands.

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Correct Answer is A

Explanation

Choice A reason: The presence of soft, formed, and light brown feces is normal and does not preclude testing for occult blood. The nurse should proceed with obtaining the specimen as ordered.
Choice B reason: There is no need to contact the healthcare provider before obtaining the specimen if the stool appears normal and the test for occult blood has been ordered.
Choice C reason: Waiting for observable blood is not necessary for an occult blood test, which is designed to detect blood that is not visible to the naked eye.
Choice D reason: Withholding specimen collection until tarry black stool is observed is not indicated. Tarry black stool can indicate bleeding in the upper gastrointestinal tract, but the test for occult blood is used to detect blood that may not be visible in the stool. Bolded text indicates the correct answers and important information.

A. Offer to contact the family's spiritual counselor to meet with the client and spouse. B. Discuss comfort measures with the client and family that will be available during withdrawal. C. Inform the healthcare provider of the client's desire to have life support withdrawn. D. Explain the actions that the healthcare team will follow for the removal of life support.

Correct Answer is C

Explanation

Choice A reason: Offering to contact the family's spiritual counselor can provide emotional and spiritual support, but it is not the immediate priority in a situation where the client has expressed a desire to have life support withdrawn.

Choice B reason: Discussing comfort measures is important for the client and family to understand what to expect during the withdrawal process. However, this step comes after the healthcare provider has been informed and a plan of care is being developed.

Choice C reason: Informing the healthcare provider is the priority nursing intervention. The nurse acts as an advocate for the client's wishes and ensures that the appropriate steps are taken to respect the client's autonomy and decisions regarding their care.

Choice D reason: Explaining the actions that the healthcare team will follow is an essential part of the process, but it is not the first step. The healthcare provider must first be informed so that the proper orders and arrangements can be made.

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When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, formed, and light brown. Which action should the nurse implement?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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