The nurse is caring for a client who presented to the Emergency Department with fever, chills, nausea, and loss of appetite. As a part of the initial assessment, the nurse tests the client for orthostatic hypotension

Question

What action should the nurse take? A)

Raise the client's legs above heart level and measure the blood pressure.
B)

Measure the client's heart rate and blood pressure in both the sitting and standing positions.
C)

Assess the client for dependent edema, and then raise the legs to the level of the heart and reassess for edema.
D)

Measure the client's blood pressure before, during, and after administration of a normal saline fluid challenge.

Answer 1

B