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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Allergies to shellfish may indicate iodine allergy, relevant for procedures using iodine-based contrast, like PCI. The client’s shellfish allergy must be reported to the PHCP as a precautionary measure to prevent any allergic reaction.
Choice B rationale: Warm sensations during PCI are a common side effect of the contrast dye used in the procedure. This statement does not indicate an immediate concern requiring PHCP notification as it is a standard patient experience.
Choice C rationale: Anxiety in closed spaces, known as claustrophobia, may affect the client's comfort during PCI but can be managed with sedatives. The PHCP should be aware but it’s not as urgent as taking contraindicated medications.
Choice D rationale: Metformin can lead to lactic acidosis, especially when iodine contrast dye is used during PCI. This condition is serious and may result in adverse interactions. The PHCP must be notified immediately.
Correct Answer is B
Explanation
Choice A rationale
Sinus tachycardia is a regular, rapid heart rate caused by rapid firing of the sinoatrial node. It is characterized by a heart rate of greater than 100 beats per minute, and P waves are present before each QRS complex. This does not match the description given.
Choice B rationale
Ventricular tachycardia is a fast, regular beating of the ventricles that may last for only a few seconds or for much longer. In this condition, the ventricular rate is often between 120 and 200 beats per minute, and P waves are not associated with the QRS complexes. This matches the description given.
Choice C rationale
Ventricular fibrillation is a severe condition in which the heart beats with rapid, erratic electrical impulses. This causes the ventricles to quiver uselessly instead of pumping blood. The description does not match this condition.
Choice D rationale
Atrial flutter is a condition that shares similarities with atrial fibrillation, both involve an irregular heartbeat. However, atrial flutter is more organized and less chaotic than atrial fibrillation, which can make it more manageable. The description does not match this condition.
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