HESI Registered Nurse EXIT Practice Exam

When should the nurse assess for orthostatic hypotension in clients?

1. After meal times

2. Before ambulation or standing

3. During medication administration

4. Before going to bed

The correct answer is: Before ambulation or standing

Assessing for orthostatic hypotension is most appropriately done before ambulation or standing. This is because orthostatic hypotension, characterized by a drop in blood pressure when a person rises from a sitting or lying position, can lead to dizziness, lightheadedness, or even fainting. Evaluating blood pressure in this context allows the nurse to identify any potential risks for falls or injury before the patient gets up. Measuring blood pressure after meals, during medication administration, or before bedtime may not provide the most relevant information regarding how a patient reacts to positional changes. The typical assessment for orthostatic hypotension involves checking the patient’s blood pressure and heart rate while they are lying down, then again sitting up, and finally when standing. This three-position assessment is crucial to detect the condition accurately, ensuring the patient’s safety in daily activities.