The nurse is caring for a client who has been on complete bed rest for the past week. As the nurse assists the client to sit in the chair, the client becomes dizzy when the legs are dangled over the side of the bed
Which action by the nurse is the priority?
1. Returning the client to bed in the Trendelenburg position
2. Calling for help
3. Measuring the client's blood pressure
4. Having the client sit on the edge of the bed for several minutes, and encourage a few deep, slow breaths
Correct Answer: 4
It is not unusual for the client who has been on bed rest to experience orthostatic hypotension when he first sits up. The nurse should stay with the client, hold onto him in case he faints, and have the client sit on the edge of the bed taking slow, deep breaths until the symptoms abate. There is no need to place the client in the Trendelenburg position or to call for help. It is better that the nurse hold on to the client until the symptoms resolve rather than leave the client to obtain blood pressure equipment.
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