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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A high HDL level (above 60 mg/dL) is protective against cardiovascular disease and does not contribute to hypertension.
B. A regular exercise routine is beneficial for cardiovascular health and helps lower blood pressure rather than increasing it.
C. Benazepril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension rather than causing it.
D. Obstructive sleep apnea (OSA) is a known risk factor for hypertension due to intermittent hypoxia and increased sympathetic nervous system activity, which contribute to elevated blood pressure.
Correct Answer is A
Explanation
A. Defibrillation is the priority intervention for pulseless ventricular tachycardia, as it can restore a normal rhythm. It should be performed as soon as possible.
B. Synchronized cardioversion is used for hemodynamically unstable tachyarrhythmias with a pulse, not for pulseless V-Tach.
C. CPR should be initiated if a defibrillator is not immediately available, but defibrillation is the definitive treatment.
D. Repeating an ECG does not address the immediate life-threatening situation.
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