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?
Muffled heart sounds
Decreased jugular vein distention
Widening pulse pressure
Coarse lung sounds
The Correct Answer is A
A. Muffled heart sounds: Muffled or distant heart sounds occur due to accumulation of fluid in the pericardial sac, which dampens the transmission of heart sounds. This is an early and classic manifestation of cardiac tamponade, reflecting impaired ventricular filling and reduced stroke volume. Prompt recognition is critical to prevent hemodynamic compromise.
B. Decreased jugular vein distention: Cardiac tamponade typically causes increased jugular vein distention due to impaired right atrial filling and elevated central venous pressure. A decrease in jugular venous distention would be inconsistent with this condition.
C. Widening pulse pressure: Cardiac tamponade usually produces a narrowing pulse pressure due to reduced stroke volume and systolic pressure, rather than widening. A widened pulse pressure is more characteristic of conditions like aortic regurgitation.
D. Coarse lung sounds: Coarse lung sounds are associated with pulmonary edema or fluid in the alveoli, not with pericardial tamponade. Lung sounds are often normal in early tamponade unless concurrent pulmonary complications are present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hyperthyroidism: Hyperthyroidism is not an absolute contraindication to combination oral contraceptive (COC) use. While thyroid hormone levels should be monitored, estrogen-containing contraceptives generally do not exacerbate hyperthyroidism in otherwise stable clients.
B. Thrombophlebitis: A history of thrombophlebitis or thromboembolic disorders is a significant contraindication to COC use. Estrogen in COCs increases coagulation factors and the risk of venous thromboembolism, making use in clients with prior thrombotic events unsafe.
C. Diverticulosis: Diverticulosis does not increase the risk of complications from COCs, nor do COCs exacerbate this gastrointestinal condition. It is not considered a contraindication.
D. Hypocalcemia: Low serum calcium levels are unrelated to COC use. COCs do not significantly affect calcium metabolism, so hypocalcemia is not a contraindication to their use.
Correct Answer is C
Explanation
A. Fasting blood glucose 124 mg/dL (70 to 110 mg/dL): Mildly elevated fasting glucose indicates impaired fasting glucose or prediabetes but is not an absolute contraindication for clozapine. Monitoring glucose is important due to the risk of metabolic syndrome, but it does not preclude administration.
B. Heart rate 58/min: Mild bradycardia is not a contraindication for clozapine. Clozapine can cause tachycardia, hypotension, or orthostatic changes, so monitoring is necessary, but a heart rate of 58/min alone does not prohibit use.
C. Absolute neutrophil count 1,300/mm³ (2,500 to 8,000/mm³): Clozapine carries a risk of severe neutropenia and agranulocytosis. An ANC below 1,500/mm³ is a contraindication to starting or continuing clozapine because it significantly increases the risk of life-threatening infection.
D. Hgb 12.5 g/dL (14 to 18 g/dL): Mild anemia is not a contraindication for clozapine. Hemoglobin should be monitored, but this level does not directly increase the risk of clozapine-related adverse effects.
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