Which nursing intervention is appropriate for a client with orthostatic hypotension?
Administer a diuretic to decrease fluid volume
Instruct the client to increase sodium intake
Encourage the client to drink caffeinated beverages
Encourage the client to change positions slowly
The Correct Answer is D
Orthostatic hypotension is defined by a systolic decrease of ≥20 mmHg or a diastolic decrease of ≥10 mmHg upon standing. This condition stems from autonomic failure or hypovolemia, leading to inadequate cerebral perfusion and a high risk for falls or syncopal episodes.
A. Administering a diuretic is contraindicated in orthostatic hypotension because it promotes diuresis and further reduces intravascular volume. Lowering the blood volume would exacerbate the drop in pressure when the client stands. This could lead to severe hypovolemic shock or increased frequency of fainting spells.
B. While increasing sodium intake can help expand extracellular fluid volume in some chronic cases, it is not an immediate nursing intervention for a client experiencing the condition. Excessive sodium can also lead to complications like hypertension or edema. It requires medical oversight rather than being a primary intervention.
C. Caffeinated beverages are generally not recommended as a primary treatment for orthostatic hypotension. While caffeine causes temporary vasoconstriction, its diuretic effect can eventually lead to fluid loss. Reliance on stimulants does not address the underlying baroreceptor reflex dysfunction that typically causes the postural drop.
D. Encouraging the client to change positions slowly allows the autonomic nervous system more time to compensate for the gravitational shift of blood. Gradual movement prevents the sudden pooling of blood in the lower extremities. This nursing action is the most effective way to maintain cerebral perfusion and safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The assessment of peristalsis requires a systematic approach to avoid false-positive findings of bowel obstruction. Bowel sounds are naturally intermittent, often occurring at rates of 5 to 30 times per minute, necessitating prolonged observation to confirm a true absence of motility or a significant pathological decrease in gastrointestinal activity.
A. Notifying the healthcare provider immediately is premature if the sounds are merely diminished rather than absent. Diminished sounds can be a normal variation or a result of recent fasting. A comprehensive assessment must be completed before escalating the finding to a physician for medical intervention.
B. Proper nursing protocol for auscultating bowel sounds requires listening for at least 1 to 2 minutes in each quadrant. If sounds are diminished or absent, the nurse should continue to listen for a full 5 minutes before concluding that bowel sounds are truly absent or significantly abnormal.
C. Auscultating for only 10 seconds is insufficient to accurately assess bowel motility. Because bowel sounds are irregular and episodic, a 10-second window might simply coincide with a natural pause in peristaltic waves, leading to an inaccurate clinical conclusion regarding the client's gastrointestinal status and health.
D. Administering a laxative based solely on diminished bowel sounds in one quadrant is contraindicated. If the diminished sounds are due to a physical bowel obstruction, a laxative could increase intraluminal pressure and cause bowel perforation. Further assessment is required before any pharmacological intervention is initiated.
Correct Answer is ["A","B"]
Explanation
Normal adult vital signs reflect homeostatic stability across cardiac and pulmonary systems. Deviations such as tachypnea or hypoxemia indicate potential respiratory distress or metabolic derangements. Accurate monitoring is essential for identifying early signs of systemic deterioration and initiating appropriate supplemental oxygen or pharmacological interventions.
A. An SpO2 of 91% is below the normal reference range of 95% to 100% for a healthy adult. This indicates hypoxemia, which may be caused by impaired gas exchange or ventilation-perfusion mismatch. It requires immediate assessment of the respiratory system and may necessitate the administration of supplemental oxygen.
B. A respiratory rate of 28/min is classified as tachypnea, as the normal adult range is 12 to 20 breaths per minute. This elevated rate suggests that the body is attempting to compensate for low oxygen levels or metabolic acidosis. It is a significant clinical indicator of underlying pulmonary or systemic stress.
C. A blood pressure of 111/76 mm Hg is within the normal reference range for an adult. It indicates adequate perfusion without the presence of hypertension or hypotension. This finding does not suggest any immediate cardiovascular instability and is considered a healthy reading for most adult patients.
D. A temperature of 37.1°C (98.8°F) is within the normal physiological range for an adult, which typically centers around 37°C (98.6°F). It does not indicate a febrile state or hypothermia. This temperature reading reflects normal thermoregulation and is not a cause for clinical concern in this context.
E. A pulse of 69 beats/min is well within the normal adult heart rate range of 60 to 100 beats per minute. It indicates a stable cardiac rhythm and adequate stroke volume. This finding is considered normal and does not signify bradycardia or tachycardia in a resting adult.
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