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 D

Explanation

Choice A rationale
Elevating the leg above the level of the heart would not be beneficial in this case. This action would actually reduce blood flow to the leg, which is already compromised due to the arterial occlusion.
Choice B rationale
Exercising the leg would increase the oxygen demand of the tissues in the leg, which could exacerbate the problem. The tissues in the leg are already deprived of oxygen due to the arterial occlusion.
Choice C rationale
Applying a compression stocking to the leg would not be beneficial in this case. This action would further compromise blood flow to the leg, which is already reduced due to the arterial occlusion.
Choice D rationale
Keeping the patient in bed in the supine position is the correct action. This position will decrease the oxygen demand of the tissues in the leg and minimize ischemic damage until circulation can be restored.

A. Administer Ibuprofen as scheduled. B. Monitor the patient for complications of cardiac tamponade. C. Place the patient in a supine position to relieve pain. D. Monitor the patient for pulsus paradoxus and muffled heart sounds.

Correct Answer is C

Explanation

Choice A rationale
Administering Ibuprofen as scheduled is a proper nursing intervention for a patient with pericarditis. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can help reduce inflammation and relieve pain.
Choice B rationale
Monitoring the patient for complications of cardiac tamponade is a proper nursing intervention for a patient with pericarditis. Cardiac tamponade is a serious condition that can occur as a complication of pericarditis.
Choice C rationale
Placing the patient in a supine position to relieve pain is not a proper nursing intervention for a patient with pericarditis. This position could actually increase the patient’s discomfort.
Instead, the patient should be positioned upright and leaning forward to help relieve pain.
Choice D rationale
Monitoring the patient for pulsus paradoxus and muffled heart sounds is a proper nursing intervention for a patient with pericarditis. These are potential signs of worsening pericarditis or complications such as cardiac tamponade.

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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

An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg, consistent with acute arterial occlusion. After the nurse notifies the healthcare provider, what should the nurse do next?

Correct Answer is D

Explanation

You are providing care to a patient with pericarditis. Which of the following is NOT a proper nursing intervention for this patient?

Correct Answer is C

Explanation

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