A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best?
a. Instruct the patient not to get up without help.
b. Document the findings and continue to monitor.
c. Reassure the patient that these findings are normal.
d. Reassess the blood pressures in 1 hour.
ANS: A
This patient has orthostatic hypotension, which is a drop of 20 mm Hg in systolic reading and 10 mm Hg in diastolic reading when the patient stands up from a sitting or lying position. The patient's cardiovascular system does not compensate for this, so the patient is at risk of becoming dizzy and fainting. The nurse instructs the patient to call for assistance before getting up to prevent a fall. The nurse should document the findings but needs to do more. These findings are not normal, so the nurse should not tell the patient that they are. The patient may need to be assessed sooner than 1 hour.
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