Difficulty: Medium
Average Score: 79%
Simulated
A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take first?
Correct answer
B
Rationale
The correct answer is B: Check the blood pressure with the client in a supine position. This is the first action the nurse should take because it establishes the baseline blood pressure of the client in a resting position. Orthostatic hypotension is characterized by a drop in blood pressure upon standing. By measuring the blood pressure in a supine position first, the nurse can accurately assess the extent of the blood pressure change when the client stands up.
Choices A, C, and D are incorrect because they involve positioning changes before establishing the baseline blood pressure. It is crucial to first determine the baseline blood pressure to accurately diagnose orthostatic hypotension. Choice A (Assist the client into a standing position) and D (Place the client in a sitting position) may exacerbate the client's symptoms if orthostatic hypotension is present. Choice C (Determine the client's blood pressure 1 min after each position change) is premature without knowing the baseline blood pressure.
Choices A, C, and D are incorrect because they involve positioning changes before establishing the baseline blood pressure. It is crucial to first determine the baseline blood pressure to accurately diagnose orthostatic hypotension. Choice A (Assist the client into a standing position) and D (Place the client in a sitting position) may exacerbate the client's symptoms if orthostatic hypotension is present. Choice C (Determine the client's blood pressure 1 min after each position change) is premature without knowing the baseline blood pressure.