The client is at risk for orthostatic hypotension. The nurse should:

Question

A. Have the client sit slowly and dangle
B. Refer the client to physical therapy
C. Keep the side rails up all the time
D. Obtain a walker or cane for the client to use

Answer 1

A
A. Dangling provides adjustment to orthostatic hypotension, allowing blood pressure to stabilize before ambulating. Instruct the client to dangle the feet for a few minutes before standing, walk slowly, and ask for help if dizzy or weak.
B. The nurse would confer with physical therapy on feasibility of gait training and muscle-strengthening exercise.
C. Keep top two side rails up and bed in low position with bed wheels locked when client care is not being administered and client is an older adult, weak, confused, sedated, or sleeping.
D. Evaluate the need for assistive devices such as walker, cane, or bedside commode. Assistive device may provide more stability and help client assume a more active role.