Practice Question
A client has just returned from the recovery room and asks to get out of bed to go to the bathroom. The nurse decides to obtain orthostatic vital signs first. How will the nurse position the client to begin this procedure?
Answer Choices:
Correct Answer:
Lying.
Rationale:
♦️Orthostatic vitals begin in the supine (lying) position for about 5 minutes to establish a stable baseline blood pressure and heart rate.
♦️Starting supine reduces fall risk in a client who has just returned from recovery and may be sedated, hypovolemic, or dizzy.
♦️After the supine measurement, the sequence proceeds to sitting (1–3 min) and then standing (1–3 min) while reassessing vitals.
♦️The goal is to detect a drop in systolic ≥20 mmHg, diastolic ≥10 mmHg, or ↑HR consistent with orthostatic hypotension.
♦️Beginning supine also allows the nurse to monitor for symptoms (lightheadedness, syncope) before attempting upright positions.
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This question is from HESI RN HEALTH ASSESSMENT WGU EXAM 2 which contains 58 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: HESI Exam(s)
- Domain: 🏡HESI-Health Assessment
- Answer Choices: 4