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 B
Explanation
Choice A rationale
Calcium channel blockers are primarily used to treat hypertension, angina, and certain heart arrhythmias. They work by relaxing the muscles of your heart and blood vessels. While they can affect heart rate and blood pressure, they would not typically have immediate implications for a patient presenting with intermittent chest pain.
Choice B rationale
Phosphodiesterase 5 enzyme inhibitors, such as sildenafil (Viagra), are used to treat erectile dysfunction and pulmonary arterial hypertension. These medications can interact with nitroglycerin, a common medication used to treat chest pain, to cause a severe and life-threatening drop in blood pressure. Therefore, it’s crucial to know if a patient is taking this type of medication when they present with chest pain.
Choice C rationale
Anticoagulants are used to prevent blood clots. If a patient is taking an anticoagulant, it could affect their clotting times and could be important if the patient needs surgery or if the cause of their chest pain is a clot. However, this would not typically have immediate implications for the treatment of chest pain.
Choice D rationale
Loop diuretics are strong diuretics that are used to treat edema and hypertension. They work by preventing your body from absorbing too much salt, allowing the salt to instead be passed in your urine. While important to know for overall patient care, they would not typically have immediate implications for a patient presenting with chest pain.
Correct Answer is D
Explanation
Choice A rationale
Cramping of the toes is not typically associated with a positive Homans sign. Homans sign is a test used to check for deep vein thrombosis (DVT), a blood clot in a deep vein of the leg. While cramping can occur with DVT, it is not specific to this condition and can occur with many other conditions.
Choice B rationale
Blanching of the sole is not associated with a positive Homans sign. Blanching, or whitening of the skin, can occur with various conditions, but it is not a typical sign of DVT45.
Choice C rationale
Resisting dorsiflexion is not a typical response indicating a positive Homans sign. While pain or resistance during dorsiflexion of the foot can occur with various conditions, it is not a specific sign of DVT45.
Choice D rationale
Pain in the calf area during dorsiflexion of the foot (Homans sign) can indicate a positive sign for DVT. However, it’s important to note that Homans sign is not a reliable or definitive test for DVT. Other diagnostic tests, such as ultrasound, are needed to confirm the diagnosis.
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