A nurse in a critical care unit is caring for a client who suﬀered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

Flatened neck veins.

Bradycardia.

Sudden lethargy.

Muﬄed heart sounds.

Answer and Explanation

The Correct Answer is D

Choice A Reason: This choice is incorrect because ﬂatened neck veins are not a sign of cardiac tamponade. Cardiac tamponade is a condition in which ﬂuid accumulates in the pericardial sac that surrounds the heart, causing compression and impaired filling of the heart chambers. This leads to reduced cardiac output and hypotension. One of the manifestations of cardiac tamponade is distended neck veins due to increased venous pressure and impaired venous return.

Choice B Reason: This choice is incorrect because bradycardia is not a sign of cardiac tamponade. Bradycardia is a condition in which the heart rate is slower than normal (less than 60 beats per minute). It may be caused by various factors such as vagal stimulation, medication side eﬀects, hypothyroidism, or sinus node dysfunction. It may cause symptoms such as fatigue, dizziness, or syncope, but it does not indicate cardiac tamponade.

Choice C Reason: This choice is incorrect because sudden lethargy is not a specific sign of cardiac tamponade. Lethargy is a condition in which the person feels tired, sluggish, or drowsy. It may be caused by various factors such as sleep deprivation, depression, infection, anemia, or hypoglycemia. It may aﬀect the person's mental and physical performance, but it does not indicate cardiac tamponade.

Choice D Reason: This choice is correct because muﬄed heart sounds are a sign of cardiac tamponade. Muﬄed heart sounds are heart sounds that are fainter or softer than normal due to reduced transmission of sound waves through ﬂuid-filled pericardial sac. They may indicate that the heart function is compromised by cardiac tamponade and require immediate intervention such as pericardiocentesis (removal of ﬂuid from pericardial sac).

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Correct Answer is A

Explanation

Choice A Reason: This choice is correct because respiratory acidosis is a condition in which the lungs cannot eliminate enough carbon dioxide (CO2) from the blood, resulting in a high level of CO2 (PaCO2) and a low level of pH. A normal PaCO2 range is 35 to 45 mm Hg, so a value of 50 mm Hg indicates respiratory acidosis.

Choice B Reason: This choice is incorrect because HCO3 (bicarbonate) is a base that helps to buﬀer the excess acid in the blood. In respiratory acidosis, the kidneys try to compensate by retaining more HCO3 and excreting more hydrogen ions. Therefore, a high level of HCO3 (above 26 mEq/L) would indicate a chronic or compensated respiratory acidosis, not an acute or uncompensated one.

Choice C Reason: This choice is incorrect because pH is a measure of the acidity or alkalinity of the blood. A normal pH range is 7.35 to 7.45, so a value of 7.45 indicates a neutral or slightly alkaline blood, not an acidic one. A low pH (below 7.35) would indicate respiratory acidosis.

Choice D Reason: This choice is incorrect because potassium is an electrolyte that helps to regulate the nerve and muscle function, as well as the ﬂuid balance in the body. In respiratory acidosis, the increased hydrogen ions in the blood may shift into the cells in exchange for potassium, resulting in a high level of potassium (hyperkalemia).

Therefore, a low level of potassium (below 3.5 mEq/L) would indicate hypokalemia, not respiratory acidosis.

A. A client who is post-coronary artery bypass graft (CABG), has total cholesterol of 318 mg/dL, and is prescribed atorvastatin B. A client who has pneumonia, a WBC count of 11,500/mm³, and is prescribed piperacillin C. A client who has renal failure, a serum potassium of 5.8 mEq/L, and is prescribed sodium polystyrene sulfonate D. A client who has anemia, hemoglobin of 11 g/dL, and is prescribed epoetin alfa

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because a client who is post-CABG and has high cholesterol is not in immediate danger, as atorvastatin is a long-term medication that lowers cholesterol and prevents cardiovascular complications.

Choice B Reason: This is incorrect because a client who has pneumonia and a slightly elevated WBC count is not in immediate danger, as piperacillin is an antibiotic that treats bacterial infections.

Choice C Reason: This is correct because a client who has renal failure and a high serum potassium level is in immediate danger, as sodium polystyrene sulfonate is an emergency medication that lowers potassium and prevents cardiac arrhythmias.

Choice D Reason: This is incorrect because a client who has anemia and a mild hemoglobin deficiency is not in immediate danger, as epoetin alfa is a long-term medication that stimulates red blood cell production and improves oxygen delivery.

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A nurse in a critical care unit is caring for a client who suﬀered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

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