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:
Pericarditis is an inflammation of the pericardium and would not directly cause an S4 heart sound.
Choice B rationale:
Arterial obstruction or aneurysm would cause changes in blood flow, but not specifically an S4 heart sound.
Choice C rationale:
An S4 heart sound is an extra sound that is heard late in diastole just before S1. It occurs due to resistance to blood flow in an enlarged ventricle, often due to forceful atrial contraction to overcome ventricular resistance.
Choice D rationale:
An infectious valvular disorder could cause a variety of heart sounds, but not specifically an S42.
So, the correct answer is C, after analyzing all choices.
Correct Answer is C
Explanation
Choice A rationale:
Tylenol, or acetaminophen, is a common over-the-counter medication used to reduce fevers and manage mild aches and pains. It does not directly affect blood pressure.
Choice B rationale:
While stress can cause temporary spikes in blood pressure, it’s not clear whether stress can cause long-term increases in blood pressure34.
Choice C rationale:
Cocaine or crack use can cause a significant and dangerous increase in blood pressure. Given the patient’s history of drug abuse and the current high blood pressure reading, this is a critical question to ask.
Choice D rationale:
Eating salty foods can contribute to high blood pressure over time, but it’s unlikely to cause an immediate severe increase in blood pressure.
So, the correct answer is Choice C, after analyzing all choices. .
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