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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

Elevated troponin is a sign of heart damage, which could be caused by a heart attack or other stresses on the heart. This is a critical finding that needs immediate attention.

Choice B rationale:

Q waves on an ECG can indicate a previous heart attack or myocardial infarction. However, they can also be a normal variant, meaning they are a harmless variation in the electrical activity of the heart.

Choice C rationale:

Bilateral crackles in the lungs can indicate mucus or fluid in the base of the lungs, often associated with conditions like pneumonia, heart failure, or bronchitis.

Choice D rationale:

Hyperglycemia, or high blood glucose, can be a sign of diabetes. If untreated, it can lead to serious complications like ketoacidosis.

So, the correct answer is Choice A, after analyzing all choices.

A. Check the electrocardiogram (ECG) for ST segment changes. B. Assess for the presence of jugular venous distention (VD). C. Monitor for changes in the patient's sedimentation rate. D. Assess for the presence of a paradoxical pulse.

Correct Answer is B

Explanation

Choice A rationale:

ST segment changes on an ECG are not typically associated with chronic constrictive pericarditis.

Choice B rationale:

Jugular venous distention (JVD) is a common sign of chronic constrictive pericarditis. If JVD is not present, it may indicate that the therapies are effective.

Choice C rationale:

While the sedimentation rate can indicate inflammation, it is not specific to chronic constrictive pericarditis.

Choice D rationale:

The presence of a paradoxical pulse is not typically associated with chronic constrictive pericarditis.

So, the correct answer is B, after analyzing all choices.

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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?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information is most important for the nurse to communicate to the health care provider?.

Correct Answer is A

Explanation

Which action by the nurse will determine if therapies ordered for a patient with chronic constrictive pericarditis are effective?

Correct Answer is B

Explanation

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