Question

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

Answer 1

A significant drop in systolic blood pressure from 136 to 96 mm Hg during ambulation is a sign that a nurse should stop a heart failure patient's activity.

Step-by-step explanation:

When assisting a client with heart failure to increase activity tolerance, the nurse must be vigilant for symptoms that signify the heart's inability to provide sufficient oxygen to the tissues. In this scenario, the most concerning symptom would be a systolic blood pressure change from 136 to 96 mm Hg. This significant drop could indicate poor cardiac output and warrants cessation of the activity to prevent further compromise to the client's condition.