HESI: Fluid and electrolyte Balance questions with complete solution

HESI: Fluid and electrolyte Balance questions with complete solution The nurse plans to assess Clara for orthostatic vital sign changes. What action will the nurse take first? a. Assist Clara to a standing position. b. Position Clara in a supine position. c. Elevate the head of Clara's bed. d. Dangle Clara's feet at the bedside. - ANSWER-b. Position Clara in a supine position. Orthostatic vital signs are measured in each position: lying, sitting, and standing. The client's vital signs are first assessed in the supine position so that changes that occur when the client sits and stands can be determined. During orthostatic vital sign measurement the client should be placed in another position (a). The client is assisted to a sitting position after vital signs are first measured in another position (c & d). The nurse takes the first blood pressure measurement. After recording the first blood pressure measurement, what action will the nurse take? a. Count the client's radial pulse rate. b. Remove the blood pressure cuff. c. Help the client change positions. d. Assess for an auscultatory gap. - ANSWER-a. Count the client's radial pulse rate. Both the blood pressure and pulse rate are typically measured in each position: lying, sitting, and standing. After the blood pressure cuff is deflated, it is left in the same position on the same arm for all three blood pressure readings (b). Another action should be taken before assisting the client to change positions (c). Assessment for an auscultatory gap is do