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 ["B","C","D","F"]

Explanation

Choice A rationale:

The client’s temperature decreased from 37.6°C to 36.8°C1. This is within the normal body temperature range of 36.5°C to 37.2°C2, so it does not require further action.

Choice B rationale:

The client’s oxygen saturation decreased from 95% to 88%1. Normal pulse oximetry values are typically above 95%2. This decrease could indicate that the client is not getting enough oxygen, which requires further action.

Choice C rationale:

The client’s blood pressure increased from 108/50 mm Hg to 138/80 mm Hg. Normal blood pressure for adults is below 120/80 mm Hg. This increase could indicate worsening heart failure, which requires further action.

Choice D rationale:

The client’s weight increased from 80 kg to 82.1 kg. Rapid weight gain may be a sign of fluid retention, a common symptom of heart failure. This requires further action.

Choice E rationale:

The client’s urine output decreased from 480 mL/8 hr to 320 mL/8 hr.However it is still above 30ml/hr signifying normal renal function

Choice F rationale:

On Day 4, the client’s breath sounds were scattered, and crackles were heard bilaterally. This could indicate fluid accumulation in the lungs, a common symptom of heart failure. This requires further action.

So, the correct answer is Choices B, C, D, and F, after analyzing all choices.

A. "The pain is level 3 to 5 (0 to 10 scale).”. B. "The pain has gotten worse over the last week.”. C. "The pain wakes me up at night.”. D. "The pain goes away with a nitroglycerin tablet.”. .

Correct Answer is D

Explanation

Choice A rationale:

The pain level of 3 to 5 on a scale of 0 to 10 does not specifically indicate chronic stable angina.

Choice B rationale:

Pain that has worsened over the last week could indicate a number of conditions, not specifically chronic stable angina.

Choice C rationale:

Pain that wakes a patient up at night could be a sign of a number of conditions, not specifically chronic stable angina.

Choice D rationale:

Chronic stable angina is characterized by chest pain that is relieved by rest or nitroglycerin. Therefore, if the patient’s pain goes away with a nitroglycerin tablet, it would help confirm a diagnosis of chronic stable angina.

So, the correct answer is Choice D, 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

Correct Answer is ["B","C","D","F"]

Explanation

Which patient statement would help the nurse confirm the previous diagnosis of chronic stable angina?.

Correct Answer is D

Explanation

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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?.

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