An older adult becomes dizzy when standing after receiving a… | MyMerci
Accident/Error/Injury PreventionSIPC
Question
An older adult becomes dizzy when standing after receiving an antihypertensive medication. Which intervention should the nurse implement?
1Keep the bed in the highest position for easier transfers.
2Encourage the client to stand quickly to restore circulation.
3Limit fluid intake for the rest of the day.
4Assist the client to rise slowly and use call light before ambulating.✓ Correct answer
Explanation
Dizziness with position change suggests orthostatic hypotension and increases fall risk. The nurse should assist with slow position changes and ensure help is available before ambulation. A high bed, rapid standing, and fluid restriction can increase risk.
In-depth explanation
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Orthostatic hypotension fall risk.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical scenario
Clinical Practice Guide For Orthostatic hypotension fall risk, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
Caution Do not choose an action from one isolated cue when the full scenario changes priority or safety.
Key concepts
Orthostatic Hypotension — A drop in blood pressure that occurs when moving to an upright position.
Fall Prevention — Interventions that reduce the risk of falling or injury.
Call Light — A device clients use to request assistance from staff.