When assisting a patient with edema due to heart failure who is taking Hydralazine and Isordil to the bathroom, what is the nursing priority?

• A. Measure and record urine voided.
• B. Assist the patient up slowly and gradually.
• C. Place the call light within reach.
• D. Provide privacy for the patient.

Answer: (B)

The main concept here is safety from orthostatic hypotension caused by vasodilator therapy in heart failure. Hydralazine and Isordil lower blood pressure, and transferring from bed to standing can trigger a sudden drop in BP with dizziness or fainting as blood pools in the legs. The nursing priority is to prevent a fall by assisting the patient to stand slowly and gradually. Start with keeping the patient seated and allow a moment for feet to dangle, then help them to stand with support (a gait belt or close steadying hold), and stay nearby to catch them if they feel lightheaded. This approach minimizes the risk of injury during ambulation to the bathroom. While other tasks like monitoring urine output or ensuring a call light is within reach are important for overall safety and care, they are not as urgent as preventing a fall during the transfer. Providing privacy is appropriate, but it does not address the immediate safety risk presented by the meds.