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 is correct because a client who is short of breath is in immediate danger, as it indicates a possible respiratory compromise or failure. The nurse should assess the client's oxygen saturation, respiratory rate, and lung sounds, and provide oxygen therapy as needed.

Choice B Reason: This is incorrect because a client who received oral pain medication 30 min ago is not in immediate danger, as it indicates that the client's pain has been managed and the medication has had time to take eﬀect.

Choice C Reason: This is incorrect because a client who is scheduled for an abdominal x-ray and is awaiting transport is not in immediate danger, as it indicates that the client's condition is stable and the diagnostic test is not urgent.

Choice D Reason: This is incorrect because a client who has a prescription for discharge is not in immediate danger, as it indicates that the client's condition has improved and the client is ready to leave the hospital.

A. Magnesium 2.5 mEq/L B. Serum osmolality 290 mOsm/kg H2O C. Blood urea nitrogen (BUN) 20 mg/dL D. Serum creatinine 1.8 mg/dL

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because magnesium 2.5 mEq/L is a normal value and does not indicate an increased risk of AKI. Magnesium is an electrolyte that plays a role in muscle and nerve function, blood pressure regulation, and energy production. The normal range for magnesium is 1.5 to 2.5 mEq/L.

Choice B Reason: This is incorrect because serum osmolality 290 mOsm/kg H2O is a normal value and does not indicate an increased risk of AKI. Serum osmolality is a measure of the concentration of solutes in the blood, such as sodium, glucose, and urea. The normal range for serum osmolality is 275 to 295 mOsm/kg H2O.

Choice C Reason: This is incorrect because blood urea nitrogen (BUN) 20 mg/dL is a normal value and does not indicate an increased risk of AKI. BUN is a measure of the amount of urea, a waste product of protein metabolism, in the blood. The normal range for BUN is 7 to 20 mg/dL.

Choice D Reason: This is correct because serum creatinine 1.8 mg/dL is an elevated value and indicates an increased risk of AKI. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys. The normal range for serum creatinine is 0.6 to 1.2 mg/dL for women and 0.7 to 1.3 mg/dL for men. An increase in serum creatinine indicates a decrease in kidney function and glomerular filtration rate (GFR).

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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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