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 A

Explanation

Choice A rationale
Skin hyperpigmentation is a common symptom of chronic venous insufficiency. This happens because blood pools in the veins and can leak into the surrounding tissue, causing a change in skin color.
Choice B rationale
Gangrene is not a typical symptom of chronic venous insufficiency. Gangrene is a serious condition that occurs when tissue dies due to a lack of blood flow.
Choice C rationale
Edema, or swelling, is a common symptom of chronic venous insufficiency, but it typically occurs in the lower legs and ankles, not above the knee.
Choice D rationale
Deep vein thrombus formation is not a typical symptom of chronic venous insufficiency. However, a history of deep vein thrombosis can increase the risk of developing chronic venous insufficiency.

A. Elevate the leg above the level of the heart. B. Assist the patient in gently exercising the leg. C. Apply a compression stocking to the leg. D. Keep the patient in bed in the supine position.

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.

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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

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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