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Which statement is true about assessing blood pressure in a patient with orthostatic
hypotension?
a. Blood pressure should only be measured in the supine position.
b. A drop in systolic BP of 10 mmHg is a diagnostic of orthostatic hypotension.
c. It is important to assess blood pressure in different positions (lying, sitting,
standing)
d. The assessment should not be repeated if the patient feels lightheaded.
Give this one a try later!
Answer: C. It is important to assess blood pressure in different positions
(lying, sitting, standing)
Rationale: Orthostatic hypotension is diagnosed by measuring blood
pressure in multiple positions to detect a drop when the patient moves
from lying to sitting or standing.
A nurse is caring for a patient with a pulse of 120 beats per minute. Which factor could
contribute to this funding?
, a. Hypovolemia
b. Stress
c. Fever
d. All of the above.
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Answer: D. All of the above.
Rationale: Hypovolemia, stress, and fever, can all lead to tachycardia ( a
pulse greater than 100 beats per minute) as the body attempts to
compensate for changes in volume, anxiety, or increased metabolic
demands.
A nurse is caring for a patient with a temperature of 101.5 F. Which intervention should
the nurse perform first?
a. Administer antipyretic medication
b. Assess the patient's pulse and respiratory rate.
c. Provide a cooling blanket.
d. Offer the patient cold fluids to drink
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Answer: B. Assess the patient's pulse and respiratory rate.
Rationale: Assessing vital signs, especially the pulse and respiratory rate, is
essential in determining the severity of the fever and its impact on the
patient's cardiovascular and respiratory systems.
Antipyretic or cooling measure may be necessary, but the first step is to
assess the patient.
Which of the following pulse sites would be most appropriate to assess in a patient
who has just undergone a right knee replacement?
a. Right popliteal
b. Right dorsalis pedis