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 A

Explanation

A. Elevated troponins are the most specific and sensitive markers for myocardial injury. Troponin I and Troponin T levels rise within a few hours of an AMI and remain elevated for days, confirming cardiac damage.
B. Elevated hemoglobin is not an indicator of cardiac injury. Hemoglobin levels are used to assess oxygen-carrying capacity and anemia.
C. Elevated B-type natriuretic peptide (BNP) is a marker for heart failure, not acute myocardial infarction.
D. Elevated creatine kinase (CK), particularly CK-MB, can indicate muscle injury, including cardiac injury, but it is less specific than troponins for diagnosing AMI.

A. Amiodarone administration B. Defibrillation C. Epinephrine administration D. Synchronized Cardioversion

Correct Answer is B

Explanation

A. Amiodarone is an antiarrhythmic medication used after defibrillation and CPR in persistent ventricular fibrillation (VF) or ventricular tachycardia (VT). However, it is not the first priority.
B. Defibrillation is the immediate priority in a pulseless client with ventricular fibrillation. Early defibrillation increases the chances of survival. The shock should be delivered as soon as possible.
C. Epinephrine is given after the first defibrillation and CPR cycle, not before.
D. Synchronized cardioversion is inappropriate because it is used for unstable tachyarrhythmias with a pulse, not pulseless VF.

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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 caring for a client with a possible acute myocardial infarction (AMI). The electrocardiogram (ECG) shows no ST segment elevations or depression. The nurse is aware that an elevation of which lab result will determine if there has been cardiac injury?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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