An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit. The new RN is measuring orthostatic blood pressure (BP) for a client. Which situation would warrant intervention by the experienced nurse?

Question

An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit.  The new RN is measuring orthostatic blood pressure (BP) for a client.  Which situation would warrant intervention by the experienced nurse?

Quizplus · Accepted Answer

The experienced nurse should intervene if the new RN starts BP measurement with the client in the standing position. Orthostatic BP measurement may be done to detect volume depletion or postural hypotension caused by medications or autonomic dysfunction. Procedure for measurement of orthostatic BP Have the client lie down for at least 5 minutes (Option A) Measure BP and HR Have the client stand Repeat BP and HR measurements after standing at 1- and 3-minute intervals (Option D) A drop in systolic BP of ≥20 mm Hg or in diastolic BP of ≥10 mm Hg, or experiencing lightheadedness or dizziness is considered abnormal (Option B). Educational objective: To measure orthostatic BP, the nurse should have the client lie supine for 5-10 minutes and then measure BP and HR. The nurse should then have the client stand for 1 minute, measure BP and HR, and repeat the measurements at 3 minutes. Findings are significant if the systolic BP drops ≥20 mm Hg or the diastolic BP drops ≥10 mm Hg.

An Experienced Nurse Is Mentoring a New Registered Nurse (RN)