A client has just gotten out of bed to go to the bathroom. As the nurs

A client has just gotten out of bed to go to the bathroom. As the nurse enters the room, the client says, “I feel dizzy.” The nurse should:

1. Go for help
2. Take the client’s blood pressure
3. Assist the client into a sitting position
4. Tell the client to take several deep breaths

ANSWER

ANS: 3
The nurse’s primary concern should be the patient’s safety and preventing an accidental fall. If the client just got up from bed and is complaining of dizziness, the client may be experiencing orthostatic hypotension. The nurse should first assist the client to sit down before performing any other assessment. The nurse should not leave the client and go for help. The nurse should assist the client to a sitting position. If help is required, the nurse can then put on the client’s call light.
The nurse may take the client’s blood pressure after assisting the client to a sitting position to prevent the client from falling. The nurse should first assist the client to sit down to prevent the client from falling accidentally. The nurse may then assess the client. If the nurse finds during the assessment that the client’s pulse oximetry is low, the nurse may instruct the client to take deep breaths.