Mr. Flynn, a 38-year-old businessman, is admitted for severe chest pain unrelieved by sublingual nitroglycerin. Mr. Flynn is diagnosed with acute myocardial infarction and kept in complete bed rest to prevent myocardial stress. After six days, the nurse is preparing the client for ambulation, as ordered by the physician. The client is at risk of orthostatic hypotension. Which of the following activities prevents orthostatic hypotension related to hypovolemia?
Explanation
Answer: B - Encouraging the client to sit on the bed three times daily is an appropriate nursing action to prevent orthostatic hypotension During prolonged immobility, the vasoconstriction mechanism in the lower extremities does not function with efficiency. When the client attempts to sit or stand, blood pools in the lower half of the body, causing hypotension, lightheadedness, and syncope. Sitting on the bed facilitates gradual adaptation of blood circulation before transferring to a chair or commode. Option A is incorrect; the nurse must initially assist the client when transferring or ambulating. Performing leg and foot exercises are pre-ambulatory activities primarily used to strengthen the muscles used for walking. Incentive spirometry is done every 2 hours to prevent decreased respiratory movement.
