Which of the following clinical manifestations in a client being treated for heart failure who is undergoing progressive increase in activity indicates activity intolerance?
A. Oxygen saturation of 95%
B. Respiratory rate of 26 breaths/min
C. Systolic blood pressure change from 136 to 96 mm Hg
D. Heart rate increase from 86 to 110 beats/min
C
A blood pressure change (increase or decrease) of more than 20 mm Hg during or after activity indicates poor cardiac tolerance of the activity. A significant decrease in blood pressure during or following activity is especially ominous, because it indicates an inability of the left ventricle to maintain sufficient cardiac output.
You might also like to view...
A client has just been diagnosed with cervical dysplasia. The client demonstrates understanding of this condition when she states:
A) "Cervical dysplasia usually resolves without any invasive treatment, if I quit smoking, always use condoms, and avoid douching." B) "I will not be able to have any more children after laser treatments for removal of the cancerous tumor." C) "My tests show changes in the cells on my cervix that might have been caused by exposure to a virus." D) "Treatment will most likely begin with a hysterectomy, followed by chemotherapy."
The nurse is teaching a patient who will be discharged home with a prescription for an enteric-coated tablet. Which statement by the patient indicates understanding of the teaching?
a. "I may crush the tablet and put it in applesauce to improve absorption." b. "I should consume acidic foods to enhance absorption of this medication." c. "I should expect a delay in onset of the drug's effects after taking the tablet." d. "I should take this medication with high-fat foods to improve its action."
What findings does a nurse expect when inspecting and palpating a patient's nails?
a. A nail base angle of not more than 90 degrees b. Whitish to clear nails in darker-skinned patients c. Nail surface is smooth and rounded d. Transverse depression running across the nails
A patient with chronic back pain has a new order for a fentanyl (Duragesic) patch. As the nurse applies the patch, the patient states, "I'm really glad to get that patch on. I am really hurting bad." Which response by the nurse is correct?
a. "You should feel some relief of your pain within about half an hour." b. "The patch may take a while to work. Would you like a pain shot in the meantime?" c. "Other analgesics can't be given while the patch is on, so try to bear it until it takes effect." d. "Because it is absorbed right through the skin, you will feel relief within minutes after I apply this patch."