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 A
Explanation
Choice A rationale:
Cardiac-specific troponin is a protein that is released into the bloodstream when there is damage to the heart muscle, such as during an acute myocardial infarction (AMI). It is considered the most specific marker for AMI because it is found only in heart muscle. The normal range for troponin I is between 0 and 0.04 ng/mL2.
Choice B rationale:
Myoglobin is a protein found in heart and skeletal muscles. While it can be elevated in AMI, it is not as specific as troponin because it is also found in skeletal muscles. The normal levels of myoglobin are 25 to 72 ng/mL4.
Choice C rationale:
Homocysteine is an amino acid in the blood, and high levels can increase the risk of heart disease. However, it is not specific for AMI5. The normal range of homocysteine levels are less than 15 micromoles per liter.
Choice D rationale:
C-reactive protein (CRP) is a marker of inflammation in the body and can be elevated in various conditions, including heart disease. However, it is not specific for AMI6. The normal CRP level is less than 0.9 milligrams per deciliter.
So, the correct answer is A, after analyzing all choices.
Correct Answer is B
Explanation
Choice A rationale:
Teaching the patient to take deep, slow breaths might not be effective in controlling the pain due to acute pericarditis.
Choice B rationale:
Placing the patient in Fowler’s position, leaning forward on the table, can help relieve the pain associated with acute pericarditis.
Choice C rationale:
Forcing fluids to 3000 mL/day to decrease inflammation is not a recommended action for managing pain due to acute pericarditis.
Choice D rationale:
Providing a fresh ice bag every hour for the patient to place on the chest is not a recommended action for managing pain due to acute pericarditis.
So, the correct answer is B, after analyzing all choices.
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