A patient has just gotten out of bed to go to the bathroom. As the nurse enters the room, the patient states, "I feel dizzy." Which of the following actions should the nurse take first?
a. Go for help.
b. Take the patient's blood pressure.
c. Assist the patient to sit or lie down.
d. Tell the patient to take deep breaths.
C
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A The nurse should not leave the patient and go for help. The nurse should help the patient sit or lie down. If help is required, the nurse can then put on the patient's call light.
B The nurse may take the patient's blood pressure after assisting the patient to a sitting position to prevent the patient from falling.
C The nurse's primary concern should be the patient's safety and preventing a fall. If the patient just got up from bed and is complaining of dizziness, the patient may be experiencing orthostatic hypotension. The nurse should first assist the patient to sit or lie down before performing any other assessment.
D The nurse should first assist the patient to sit down to prevent the patient from falling. The nurse may then assess the patient. If the nurse finds during the assessment that the patient's result from pulse oximetry is low, the nurse may instruct the patient to take deep breaths.
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