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?

A. Apply the largest cuff available. Using a cuff that is too large can result in falsely low readings. Cuff size should match the client’s arm circumference to ensure accuracy, but simply switching to the largest cuff does not resolve difficulty in auscultation.
B. Deflate the cuff quickly. Rapid deflation can cause the nurse to miss the systolic and diastolic sounds, making it harder to obtain an accurate reading. The cuff should be deflated at a steady rate of 2–3 mmHg per second.
C. Use the palpatory method to determine blood pressure. When sounds are difficult to auscultate, the palpatory method is a reliable alternative. This involves palpating the radial pulse while inflating the cuff to estimate systolic pressure, which helps guide a more accurate auscultatory attempt.
D. Place the arm above the level of the client's heart. Elevating the arm above heart level can lower the pressure artificially, resulting in an inaccurate measurement. For correct results, the arm should be supported at heart level.

A. Screen the child's visitors for active infections. Neutropenia places the child at high risk for infection due to a severely weakened immune system. Screening visitors for signs of illness is essential to minimize exposure to infectious agents.
B. Prepare the child for a platelet transfusion. Platelet transfusions are used to treat thrombocytopenia, not neutropenia. While leukemia may cause both conditions, neutropenia specifically increases infection risk, not bleeding risk.
C. Monitor the child for indications of active bleeding. While bleeding is a concern in leukemia, it is more directly linked to low platelet levels. The priority intervention for neutropenia is infection prevention, not bleeding control.
D. Initiate a low-protein diet for the child. A low-protein diet is not appropriate for a child with leukemia. These children need adequate protein for healing, immune support, and maintaining strength during treatment.