A nurse is caring for a client in a critical care unit who is 4 hours post-operative coronary artery bypass surgery. The nurse performs the reassessment and suspects the client may be developing a pericardial effusion. What assessment findings would the nurse note in this case?

New systolic murmur

Diminished breath sounds

Diminished heart sounds

Increased blood pressure

Answer and Explanation

The Correct Answer is C

A. A new systolic murmur is more indicative of valvular dysfunction or a septal defect rather than pericardial effusion.
B. Diminished breath sounds may be associated with atelectasis or pleural effusion but are not a hallmark finding of pericardial effusion.
C. Diminished heart sounds occur due to fluid accumulation in the pericardial sac, which muffles heart tones and is a key sign of pericardial effusion.
D. Increased blood pressure is not characteristic of pericardial effusion. Instead, pericardial effusion can lead to cardiac tamponade, which typically causes hypotension.

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Correct Answer is C

Explanation

A. Cardiac enzymes do not diagnose pulmonary congestion. Pulmonary congestion is typically assessed using imaging, such as a chest X-ray or echocardiography.
B. Cardiac enzyme tests do not assess heart structure or valve mobility. An echocardiogram or cardiac MRI is used for that purpose.
C. Cardiac enzymes, such as troponins and creatine kinase-MB (CK-MB), indicate the extent of myocardial damage and are essential for diagnosing and managing acute myocardial infarction.
D. Cardiac enzymes confirm myocardial injury but do not pinpoint the exact location of the infarction. The location is determined using ECG findings and imaging studies.

A. Location B. Distribution C. Intensity D. Alleviated E. Onset F. Radiation

Correct Answer is ["A","B","C","E","F"]

Explanation

A. Location of the pain is an essential component of assessing cardiac pain, as MI-related pain is often described as substernal or radiating.
B. Distribution refers to how the pain spreads, such as from the chest to the jaw, neck, back, or arms, which is common in an MI.
C. Intensity helps determine the severity of pain and is often rated on a scale from 0 to 10.
D. While identifying factors that alleviate pain is important for overall assessment, it is not a core component of the initial pain assessment for MI.
E. Onset refers to when the pain began and whether it occurred suddenly or gradually, which helps in determining the cause.
F. Radiation is a critical aspect of cardiac pain assessment, as MI pain often radiates to the left arm, jaw, or back.

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A nurse is caring for a client in a critical care unit who is 4 hours post-operative coronary artery bypass surgery. The nurse performs the reassessment and suspects the client may be developing a pericardial effusion. What assessment findings would the nurse note in this case?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care and education to a client after an acute myocardial infarction. Which of the following statements should the nurse make regarding cardiac enzyme studies?

Correct Answer is C

Explanation

A nurse is caring for a client who is having an acute myocardial infarction (MI). The nurse is aware that which of the following are part of the assessment of cardiac pain? (SELECT ALL THAT APPLY).

Correct Answer is ["A","B","C","E","F"]

Explanation

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