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 []

Explanation

Worsening of congestive heart failure is suggested by symptoms including labored breathing, coarse crackles, jugular vein distention (JVD), cool/clammy skin, and low oxygen saturation. These findings indicate pulmonary congestion due to fluid overload.
Applying O₂ at 6L/min helps improve oxygenation and alleviate respiratory distress. Lower-flow oxygen (such as 2L/min) may not be sufficient in acute heart failure exacerbation.
Monitoring respiratory rate is essential to track breathing effort and response to treatment.
Monitoring oxygen saturation helps assess oxygenation status and effectiveness of interventions.
Smoking cessation is important for long-term lung and cardiovascular health but does not address the acute issue.
WBC count and temperature are more relevant to infections like pneumonia rather than acute heart failure.

A. NSTEMI B. Stable Angina C. Unstable Angina D. STEMI

Correct Answer is D

Explanation

A. NSTEMI (Non-ST Elevation Myocardial Infarction) does not present with ST-segment elevation on the ECG. Instead, it shows ST-segment depression or T-wave inversion and is diagnosed with elevated cardiac biomarkers.
B. Stable angina is predictable chest pain that occurs with exertion and is relieved by rest or nitroglycerin. It does not cause acute ECG changes.
C. Unstable angina is characterized by chest pain that occurs at rest or with minimal exertion and is not relieved by nitroglycerin. However, it does not show ST-segment elevation or myocardial infarction markers.
D. STEMI (ST-Elevation Myocardial Infarction) is diagnosed when there is ST-segment elevation in two or more contiguous ECG leads, indicating complete occlusion of a coronary artery and requiring immediate intervention such as percutaneous coronary intervention (PCI) or thrombolytic therapy.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A nurse is caring for a client with sudden onset of chest pain, the nurse completes the electrocardiogram (ECG). The nurse understands that this client is having what type of acute coronary syndrome?

Correct Answer is D

Explanation

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