The standard policy on the cardiac unit states, “Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.”. Which patient should the nurse call the health care provider about?

Newly admitted patient with a BP of 150/87 mm Hg.

Patient with left ventricular failure who has a BP of 110/70 mm Hg.

Postoperative patient with a BP of 116/42 mm Hg.

Patient with a myocardial infarction who has a BP of 140/86 mm Hg.

Answer and Explanation

The Correct Answer is C

The patient with a blood pressure of 116/42 mm Hg has a mean arterial pressure (MAP) of approximately 67 mm Hg, which is less than the standard policy of 70 mm Hg. This could indicate inadequate blood flow to the vital organs, necessitating notification of the healthcare provider.

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Correct Answer is C

Explanation

Choice A rationale
While assessing the gag reflex is important in certain situations, such as after surgery involving anesthesia, it is not typically a crucial assessment following Percutaneous Transluminal Angioplasty (PTA) of the lower extremity.
Choice B rationale
Checking for dye allergies is important before a procedure that uses contrast dye. However, it is not a crucial post-procedure assessment.
Choice C rationale
Monitoring of pedal pulses is crucial following PTA of the lower extremity. This is because the procedure involves the arteries in the legs, and monitoring pedal pulses can help assess blood flow to the area and detect potential complications such as occlusion or clot formation.
Choice D rationale
While the Ankle-Brachial Index can be used to diagnose Peripheral Arterial Disease (PAD), it is not typically a crucial assessment immediately following PTA3.

A. Reduce anxiety and relieve pain. B. Improve myocardial oxygenation and reduce cardiac workload. C. Eliminate family stressors and provide a calm environment. D. Start the client on a low-sodium diet and decrease fluid intake.

Correct Answer is B

Explanation

Choice A rationale
While reducing anxiety and relieving pain are important aspects of care, they are not the primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level. These findings indicate myocardial injury, which requires interventions to improve myocardial oxygenation and reduce cardiac workload.
Choice B rationale
The primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level is to improve myocardial oxygenation and reduce cardiac workload. This can be achieved through medications, oxygen therapy, and bed rest.
Choice C rationale
Eliminating family stressors and providing a calm environment can contribute to reducing anxiety and promoting relaxation, but it is not the primary goal in this situation.
Choice D rationale
Starting the client on a low-sodium diet and decreasing fluid intake are interventions for managing heart failure, not for an acute myocardial injury.

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The standard policy on the cardiac unit states, “Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.”. Which patient should the nurse call the health care provider about?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with Peripheral Arterial Disease (PAD) has recently undergone Percutaneous Transluminal Angioplasty (PTA) of the lower extremity. Which assessment is crucial for the nurse to perform post-procedure?

Correct Answer is C

Explanation

A client is admitted to the telemetry unit with an episode of substernal chest pain. His diagnostic studies reveal an elevated ST segment on the electrocardiogram (ECG) and an elevated cardiac troponin level. What would be an appropriate initial nursing goal?

Correct Answer is B

Explanation

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