HESI Health Assessment WGU d344 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. Measuring blood pressure when lying and standing assesses for orthostatic hypotension, not orthopnea. B. Observing for jugular vein distention can indicate fluid overload but is not specific to orthopnea. C. Orthopnea is the discomfort or difficulty in breathing that occurs when lying flat. Asking the client how many pillows are used to sleep at night helps determine if they need to be propped up to breathe comfortably, which is a key indicator of orthopnea. D. Auscultating breath sounds while supine can provide valuable information but does not directly assess for orthopnea.
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