A nurse is assessing a client who is postoperative following a coronary artery bypass graft surgery. The nurse should identify that which of the following findings is an early indication of cardiac tamponade?

Widening pulse pressure

Coarse lung sounds

Muffled heart sounds

Decreased jugular vein distention

Answer and Explanation

The Correct Answer is C

A. Widening pulse pressure. This is typically associated with conditions like increased intracranial pressure or severe aortic regurgitation, not cardiac tamponade. Tamponade usually results in narrowed pulse pressure.
B. Coarse lung sounds. These may indicate fluid overload or pulmonary congestion, but they are not specific to cardiac tamponade and occur later or in different conditions.
C. Muffled heart sounds. This is a classic early sign of cardiac tamponade, caused by fluid accumulation in the pericardial sac, which dampens heart sounds on auscultation. It is part of Beck’s triad (muffled heart sounds, hypotension, and jugular vein distention).
D. Decreased jugular vein distention. In cardiac tamponade, jugular vein distention increases due to impaired venous return to the heart. Decreased JVD would be an unexpected finding in this condition.

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Correct Answer is C,B,A,D

Explanation

C. Lubricate the catheter with sterile saline. After donning sterile gloves, the nurse should lubricate the catheter to reduce friction and prevent trauma to the tracheal mucosa during insertion.

B. Insert the catheter until resistance is felt. The catheter should be gently inserted into the tracheostomy until resistance is met, indicating that it has reached the carina. Inserting beyond this point may cause injury.

A. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in). Pulling back slightly after resistance ensures the catheter is not pressing directly on sensitive structures and is positioned correctly for effective suctioning.

D. Rotate the catheter while suctioning. Suction should be applied while withdrawing the catheter in a rotating motion to evenly clear secretions and minimize damage to the tracheal lining.

A. Activate the facility's fire alarm system. B. Close all nearby windows and doors. C. Use the unit's fire extinguisher to attempt to put out the fire. D. Transport the client to another area of the nursing unit.

Correct Answer is D,A,B,C

Explanation

D. Transport the client to another area of the nursing unit. The first priority is rescue ensuring the client’s safety by removing them from the immediate area of danger, which is consistent with the "RACE" fire safety protocol (Rescue, Alarm, Contain, Extinguish).

A. Activate the facility's fire alarm system. Once the client is safe, the next step is to activate the fire alarm to notify other staff and initiate emergency protocols throughout the facility.

B. Close all nearby windows and doors. Containing the fire by closing doors and windows limits the spread of smoke and flames, buying time for response teams to arrive and control the situation.

C. Use the unit's fire extinguisher to attempt to put out the fire. If it is safe and the fire is small and manageable, the final step is to extinguish the fire using a fire extinguisher, following appropriate safety procedures.

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A nurse is assessing a client who is postoperative following a coronary artery bypass graft surgery. The nurse should identify that which of the following findings is an early indication of cardiac tamponade?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

11. A nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps into the box, placing them in the selected order of performance. Use all the steps.)

Correct Answer is C,B,A,D

Explanation

A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box, placing them in the order of performance. Use all the steps.)

Correct Answer is D,A,B,C

Explanation

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