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:
Chest pain that lasts for 20 minutes or more is characteristic of an acute myocardial infarction (AMI)123.
Choice B rationale:
Changes in pain that occur with deep breathing are more typical of musculoskeletal pain or pericarditis.
Choice C rationale:
Stable angina is usually relieved when the patient takes nitroglycerin.
Choice D rationale:
Pain that is reproducible when the patient raises the arms is more typical of musculoskeletal pain.
So, the correct answer is A, after analyzing all choices.
Correct Answer is B
Explanation
Choice A rationale:
Checking the pulse rate before taking nitroglycerin is not necessary.
Choice B rationale:
Sitting down before taking nitroglycerin can prevent dizziness and fainting, which are potential side effects of nitroglycerin.
Choice C rationale:
There is no need to remove the nitroglycerin patch before taking sublingual nitroglycerin.
Choice D rationale:
The nitroglycerin patch should not be used to treat acute chest pain.
So, the correct answer is B, after analyzing all choices.
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