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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "Limit your fluid intake to 500 milliliters per day.": Severely restricting fluid intake can lead to dehydration and concentrated urine, which can irritate the bladder and worsen incontinence. Adequate hydration is essential during bladder retraining.

B. "Take your diuretic medication with your evening meal.": Diuretics should generally be taken in the morning to avoid nocturia and sleep disturbances, which could interfere with bladder retraining efforts. Evening dosing may exacerbate incontinence at night.

C. "Plan to urinate every 3 hours while you are awake.": Scheduled voiding is a core strategy in bladder retraining. Urinating at regular intervals, such as every 2–3 hours, helps the bladder gradually increase its capacity and reduces episodes of urge incontinence.

D. "Decrease your intake of cranberry juice.": While certain irritants like caffeine, alcohol, and carbonated beverages should be avoided, cranberry juice is not a primary bladder irritant for most. In fact, it is often encouraged to prevent urinary tract infections (UTIs), which can cause temporary urge incontinence.

A. Perform the Credés maneuver. B. Maintain the irrigation solution rate. C. Replace the indwelling urinary catheter. D. Warm the irrigation solution.

Correct Answer is B

Explanation

A. Perform the Credés maneuver: The Credés maneuver involves applying manual pressure over the bladder to promote voiding. This technique is contraindicated in clients with continuous bladder irrigation post-TURP, as it can disrupt the surgical site and increase the risk of bleeding or trauma.

B. Maintain the irrigation solution rate: Pink-tinged urine is an expected finding in the immediate postoperative period following TURP. Maintaining the prescribed irrigation rate helps prevent catheter obstruction from clots, ensures continuous drainage, and reduces the risk of bladder distention and further bleeding.

C. Replace the indwelling urinary catheter: Catheter replacement is unnecessary when urine is draining and pink-tinged, indicating minor bleeding rather than obstruction or malfunction. Routine replacement could introduce infection and trauma.

D. Warm the irrigation solution: Warming the solution is generally not required unless the client experiences discomfort from cold fluid. It does not address the normal postoperative pink-tinged urine and does not influence clot prevention.

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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

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