The nurse wants to assess a client for orthostatic hypotension. What action should the nurse take?
1. Assess the client for dependent edema and then raise the legs to the level of the heart and reassess for edema.
2. Measure the client's heart rate and blood pressure in both the sitting and standing position.
3. Measure the client's blood pressure before, during, and after administration of a normal saline fluid challenge.
4. Raise the client's legs above heart level and measure the blood pressure.
Correct Answer: 2
Rationale 1: Assessment of edema is not a part of the assessment of orthostatic hypotension.
Rationale 2: The nurse should measure the client's blood pressure and heart rate in the sitting position and then again in the standing position.
Rationale 3: Normal saline challenges are often administered to clients who are dehydrated, but they are not part of assessment of orthostatic hypotension.
Rationale 4: The nurse should measure the client's blood pressure and heart rate in the sitting position and then again in the standing position.
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