A patient who has recently had an acute myocardial infarction (AMI) ambulates in the hospital hallway. Which data would indicate to the nurse that the patient should stop and rest?.
Heart rate increases from 66 to 98 beats/min.
O2 saturation drops from 99% to 95%.
Respiratory rate goes from 14 to 20 breaths/min.
Blood pressure (BP) changes from 118/60 to 126/68 mm Hg.
Blood pressure (BP) changes from 118/60 to 126/68 mm Hg.
The Correct Answer is A
Choice A rationale:
An increase in heart rate from 66 to 98 beats/min indicates that the heart is working harder, which could be a sign of stress or exertion. This is a significant increase and could indicate that the patient needs to rest.
Choice B rationale:
While a drop in O2 saturation from 99% to 95% is noticeable, it is still within the normal range (95-100%). Therefore, it would not necessarily indicate a need for the patient to rest.
Choice C rationale:
A respiratory rate increase from 14 to 20 breaths/min is within the normal range (12-20 breaths/min) and would not necessarily indicate a need for the patient to rest.
Choice D rationale:
A blood pressure change from 118/60 to 126/68 mm Hg is within the normal range and would not necessarily indicate a need for the patient to rest.
So, the correct answer is Choice A, after analyzing all choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
This is correct. Standing still for prolonged periods can cause blood to pool in the legs, increasing blood pressure.
Choice B rationale:
This is also correct. Stopping the medication abruptly can cause a rebound increase in blood pressure.
Choice C rationale:
This is incorrect. Furosemide is a diuretic that can cause the body to lose potassium, so it’s important to consume potassium-rich foods.
Choice D rationale:
This is correct. Furosemide can cause orthostatic hypotension, a form of low blood pressure that happens when you stand up from sitting or lying down.
So, the correct answer is Choice C, after analyzing all choices.
Correct Answer is B
Explanation
Choice A rationale:
A weight increase from 120 pounds to 122 pounds over 3 days is within the normal fluctuation range.
Choice B rationale:
A serum potassium level of 3.0 mEq/L after 1 week of therapy is concerning because it’s below the normal range (3.5-5.0 mEq/L)171819. This could indicate hypokalemia, which can cause serious complications if left untreated.
Choice C rationale:
A palpable liver edge 2 cm below the ribs on the right side could suggest an abnormality such as an enlarged liver.
Choice D rationale:
The presence of 1+ to 2+ edema in the feet and ankles could indicate conditions like heart failure or venous insufficiency.
So, the correct answer is Choice B, after analyzing all choices.
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