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

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.

A. Osler Nodes B. Splinter Hemorrhages C. Petechial Hemorrhaging D. Janeway Lesions E. Fever with Chills

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

Explanation

A. Osler Nodes – These are tender, painful nodules on the fingers and toes, a classic sign of infective endocarditis.
B. Splinter Hemorrhages – Tiny blood clots under the fingernails occur due to microembolization from infected heart valves.
C. Petechial Hemorrhaging – Small red or purple spots on the skin or mucous membranes occur due to embolization of infected material.
D. Janeway Lesions – Painless, flat, red spots on the palms and soles caused by microemboli.
E. Fever with Chills – A common systemic symptom due to infection and inflammation.

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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 chest pain who becomes unresponsive. The client is pulseless and apneic. The code team places the client on the monitor, which indicates ventricular fibrillation. What is the next priority action?

Correct Answer is B

Explanation

A nurse is caring for a patient diagnosed with infectious endocarditis. The nurse is aware that which of the following are potential assessment findings? (SELECT ALL THAT APPLY)

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

Explanation

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