A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

Bradycardia.

Muffled heart sounds

Flattened neck veins.

Sudden lethargy.

Answer and Explanation

The Correct Answer is B

B. Muffled heart sounds, often described as distant or indistinct, are classic findings in cardiac tamponade. The accumulation of fluid in the pericardial sac dampens the transmission of sound from the heart to the chest wall, resulting in muffled heart sounds on auscultation. This finding is known as Beck's triad, which also includes hypotension and jugular venous distention.

A. Bradycardia is not a typical finding in cardiac tamponade. In fact, tachycardia is more commonly observed due to the compensatory response to decreased cardiac output and decreased stroke volume. The sympathetic nervous system is activated, leading to an increase in heart rate as a compensatory mechanism to maintain cardiac output.

C. Flattened neck veins are not consistent with cardiac tamponade. In cardiac tamponade, jugular venous distention (JVD) is typically observed due to increased venous pressure resulting from impaired right ventricular filling. The presence of JVD is an important clinical finding in cardiac tamponade and can help differentiate it from other causes of shock.

D. Sudden lethargy can occur in various medical emergencies, including cardiac tamponade, but it is not a specific or diagnostic finding for this condition. In cardiac tamponade, symptoms may include dyspnea, chest pain, hypotension, and signs of decreased cardiac output such as cool extremities and altered mental status. However, sudden lethargy alone may not be specific enough to confirm cardiac tamponade.

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Correct Answer is C

Explanation

C. Respiratory acidosis- The pH is acidic, and the PaCO2 is elevated, indicating respiratory acidosis. The client's hypoventilation (respiratory rate of 7/min) is causing retention of carbon dioxide, leading to respiratory acidosis.
A. Metabolic alkalosis- The ABG values do not support a diagnosis of metabolic alkalosis. The pH is acidic, and the base excess is negative, indicating a mild metabolic acidosis.
B. Respiratory alkalosis- The ABG values do not support a diagnosis of respiratory alkalosis. The pH is acidic, and the PaCO2 is elevated, indicating respiratory acidosis rather than alkalosis.
D. Metabolic acidosis- While there is evidence of a mild metabolic acidosis indicated by the negative base excess, the primary disturbance in this case is respiratory acidosis, as evidenced by the low pH and elevated PaCO2.

A. Give PRN lorazepam (Ativan) and cancel the transfer. B. Obtain an order for restraints as needed and transfer the patient. C. Notify the health care provider and postpone the transfer. D. Inform the receiving nurse and then transfer the patient.

Correct Answer is C

Explanation

C. This allows for the patient's condition to be re-evaluated, ensuring that they receive the necessary care and attention before being transferred.

A. Benzodiazepines can cause sedation, cognitive impairment, and delirium, which may worsen the patient's condition. Canceling the transfer without addressing the underlying cause of confusion may delay appropriate management.

B. Restraints can increase agitation, anxiety, and risk of injury, and they do not address the underlying cause of confusion. Restraints should only be considered as a last resort if all other measures to ensure patient safety have been exhausted.

D. This option is not appropriate because transferring the patient without addressing the new-onset confusion could compromise patient safety. It's essential to identify and manage the underlying cause of confusion before transferring the patient to another unit.

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A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGS? pH 7.22 PaCO2 68 mm Hg Base excess-2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L

Correct Answer is C

Explanation

An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. What should the nurse plan to do?

Correct Answer is C

Explanation

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