A client has just gotten out of bed to go to the bathroom. As the nurse enters the room, the client states, "I feel dizzy." Which of the following actions should the nurse take first?
a. Go for help.
b. Take the client's blood pressure.
c. Assist the client to sit or lie down.
d. Tell the client to take deep breaths.
C
The nurse's primary concern should be the client's safety and preventing a fall. If the client just got up from bed and is complaining of dizziness, the client may be experiencing orthostatic hy-potension. The nurse should first assist the client to sit or lie down before performing any other assessment.
The nurse should not leave the client and go for help. The nurse should help the client sit or lie down. If help is required, the nurse can then put on the client's call light.
The nurse may take the client's blood pressure after assisting the client to a sitting position to prevent the client from falling.
The nurse should first assist the client to sit down to prevent the client from falling. The nurse may then assess the client. If the nurse finds during the assessment that the client's result from pulse oximetry is low, the nurse may instruct the client to take deep breaths.
You might also like to view...
Which of the following are causes of metabolic acidosis? (Select all that apply.)
a. diarrhea b. diabetes c. renal disease d. chronic obstructive pulmonary disease (COPD) e. pulmonary emboli f. lactic acidosis g. atelectasis
If you know the total amount of medication, the total volume of solution, and the volume of solution the
patient received you can A. determine the weight-based amount to deliver. B. determine the dosage on hand. C. determine the dosage ordered. D. determine the amount of medication received.
How often should a capped peripheral venous access device be flushed with NSS solution?
A) Every 8 hours B) Every 10 hours C) Every 12 hours D) Every 24 hours
The nurse prepares to administer an intermittent intravenous solution using a secondary administration set. Place the steps of assembling the secondary infusion in correct order. A) Insert the secondary tubing needleless cannula into the distal primary tubing port located above the infusion pump.B) Hang the secondary container above the level of the primary bag.C) Attach the appropriate label to the secondary tubing.D) Lower medication bag to clear tubing and back-prime tubing.E) Close the clamp on the secondary infusion tubing and spike the medication infusion bag.
Fill in the blank(s) with the appropriate word(s).