Hesi rn health assessment proctored exam
During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?
Explanation & Rationale
A. Measure the blood pressure when the client is lying and standing. Measuring blood pressure in different positions assesses for orthostatic hypotension, not orthopnea. B. Ask the client how many pillows are used to sleep on at night. This is the best choice because orthopnea is often managed by sleeping with multiple pillows to relieve difficulty breathing when lying flat. C. Observe for jugular vein distention while the client is flat in bed. Jugular vein distention can indicate heart failure but does not directly assess orthopnea. D. Auscultate breath sounds while the client is supine. This assesses lung sounds but does not directly address the client's sleep position or orthopnea.
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