The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the client's activity?
a. Decrease in oxygen saturation from 98% to 95%
b. Respiratory rate change from 22 to 28 breaths/min
c. Systolic blood pressure change from 136 to 96 mm Hg
d. Increase in heart rate from 86 to 100 beats/min
C
A blood pressure change (increase or decrease) of greater than 20 mm Hg during or after activity indicates poor cardiac tolerance of the activity. A significant decrease (>20%) in blood pressure during or after activity is especially ominous, because it indicates an inability of the left ventricle to maintain sufficient cardiac output.
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