Which client is at greatest risk for developing a pressure injury?

Rationale:

A. Assisting the client to a standing position and immediately measuring blood pressure is part of the orthostatic vital signs assessment, but it is not the first step. Jumping straight to standing measurements without a baseline can lead to inaccurate interpretations, because orthostatic hypotension is defined as a significant drop in blood pressure upon changing position from supine to standing. Starting with standing measurements alone would not allow the nurse to determine if a drop has actually occurred.

B. Encouraging the client to ambulate in the hallway to reproduce symptoms is inappropriate as an initial action. Since the client has reported dizziness upon standing, having them walk unsupervised could increase the risk of falls and injury. Patient safety is a priority, so controlled assessment of vital signs must occur before ambulation.

C. Measuring the client’s blood pressure and heart rate while lying supine is the correct first step. This provides a baseline reading of vital signs in a resting position, which is essential for accurate comparison. Once the baseline is obtained, the nurse can measure vital signs while the client is sitting and then standing. Orthostatic hypotension is diagnosed when there is a drop of 20 mmHg or more in systolic blood pressure, a drop of 10 mmHg or more in diastolic blood pressure, or a heart rate increase of 20 beats per minute or more upon standing. Obtaining a supine baseline ensures these changes are accurately detected.

D. Asking the client to sit at the side of the bed and report any dizziness is part of the assessment sequence, but it occurs after obtaining baseline supine measurements. Sitting at the side of the bed is a transitional position before standing, and allows the nurse to monitor for symptoms safely.

Rationale:

A. Asking the client to cough every 4 hours is insufficient in response to hypoxemia. Frequent coughing may help clear secretions, but it does not directly improve oxygen saturation and waiting several hours between coughs may delay intervention.

B. Requesting a prescription for an opioid analgesic is not appropriate because opioids can depress respiratory drive, which may worsen hypoxemia. Administering an opioid without respiratory assessment could be dangerous for a client with low oxygen saturation.

C. Encouraging the client to take deep breaths is correct. Deep breathing exercises, including techniques such as incentive spirometry, help expand the lungs, improve alveolar ventilation, and increase oxygenation. This intervention is noninvasive, safe, and directly addresses the low oxygen saturation.

D. Decreasing the head of the bed is incorrect. A supine or flat position can reduce lung expansion and worsen oxygenation. Elevating the head of the bed, or having the client sit upright, promotes better lung expansion and improves oxygen saturation.