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 ["B","C","D"]

Explanation

A. A high-calcium diet does not contribute to DVT development. DVT risk factors are related to venous stasis, hypercoagulability, and endothelial damage.
B. Prolonged bed rest leads to venous stasis, increasing the risk of clot formation.
C. Post-operative clients are at higher risk for DVT due to immobility and surgical trauma, which can activate clotting mechanisms.
D. Oral contraceptive use increases the risk of DVT due to hormonal effects that promote clot formation.
E. A low BMI is not a risk factor for DVT. In contrast, obesity is a recognized risk factor due to increased venous pressure and inflammation.

A. Count how many QRS complexes occur in a 6-second strip B. Measure the T waves C. Read the monitor or electrocardiogram interpretation D. Look for P waves on the strip

Correct Answer is A

Explanation

A. Counting the number of QRS complexes in a 6-second strip and multiplying by 10 provides an estimate of the heart rate per minute.
B. Measuring T waves is used to assess repolarization abnormalities, not to determine heart rate.
C. While the monitor provides a heart rate reading, manual calculation is essential for verifying accuracy.
D. P waves indicate atrial activity but are not used to calculate the overall heart rate.

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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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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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