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 B
Explanation
Choice A rationale:
A brief episode of ventricular tachycardia, or a rapid heart rate, can occur in patients receiving thrombolytic therapy. However, it is not typically a reason to stop the drug infusion.
Choice B rationale:
Bleeding from the gums can be a sign of excessive bleeding, which is a major risk of thrombolytic therapy. This would be a reason to stop the drug infusion.
Choice C rationale:
A decreased level of consciousness can have many causes and is not specifically associated with thrombolytic therapy.
Choice D rationale:
An increase in blood pressure is not typically a reason to stop thrombolytic therapy.
So, the correct answer is B, after analyzing all choices.
Correct Answer is B
Explanation
Choice A rationale:
A patient who had a myocardial infarction (MI) 4 days ago and is anxious about today’s planned discharge would need reassurance and education, but it’s not an immediate concern.
Choice B rationale:
A patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI) is at risk for hemorrhage from the arterial access site. Immediate assessment of blood pressure, pulses, and the access site is required.
Choice C rationale:
A patient with variant angina who is scheduled to receive nifedipine (Procardia) would need monitoring, but it’s not the most urgent.
Choice D rationale:
A patient with pericarditis complaining of sharp, stabbing chest pain would need evaluation, but the risk of complications is less immediate than for Choice B1.
So, the correct answer is B, after analyzing all choices.
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