Aclient comes to the cardiovascular intensive care unit (cvicu) directly after a three-vessel coronary artery bypass graft (cabg). the client's orders state "maintain systolic blood pressure > 90 but < 120." how does this order affect the monitoring of the client's blood pressure?
a. the nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits
b. monitoring blood pressure once every hour is sufficient for this client
c. monitoring blood pressure every 4 hours is sufficient for this client
d. the nurse can delegate monitoring of the client's blood pressure to the patient care assistant

A. The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits

Explanation:

Systolic blood pressure, also known as “maximal pressure”, is the blood pressure at the time of cardiac systole, in other words, at the time of contraction of the heart, causing the blood to thrust into the arteries. Systolic blood pressure is the pressure exerted by the blood against the artery wall, that is, the more the heart contracts with emphasis, the more the systolic pressure will increase. However, when systolic blood pressure rises too much, it becomes very dangerous that can result in serious patient problems.

For this reason, in the case described above, the nurse should assess blood pressure more often to ensure that she does not exceed the prescribed limits.

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