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 D

Explanation

D. Monitoring central venous pressure (CVP) is an appropriate nursing intervention for a patient with a pulmonary artery catheter. While the pulmonary artery catheter primarily provides information about pulmonary artery pressures and cardiac output, it can also be used to measure central venous pressure. Monitoring CVP can help assess the patient's fluid status, right ventricular function, and response to fluid resuscitation. This intervention is directly relevant to the presence of the pulmonary artery catheter and helps guide patient management.

A. Assist with ambulation: It's not typically appropriate to assist a patient with ambulation while they have a pulmonary artery catheter in place. This catheter is inserted into the pulmonary artery and is used to monitor various hemodynamic parameters such as pulmonary artery pressure, cardiac output, and mixed venous oxygen saturation. Ambulation could disrupt the catheter placement or lead to complications such as bleeding or dislodgement.

B. Administering a diuretic medication may not be directly related to the presence of a pulmonary artery catheter. The use of diuretics is typically based on the patient's clinical condition and the healthcare provider's assessment of their fluid status and renal function. While information obtained from the pulmonary artery catheter, such as pulmonary artery pressure and cardiac output, may inform the decision-making process regarding diuretic therapy, the catheter itself does not dictate the administration of diuretics.

C. Administering a vasopressor medication may be appropriate for a patient with a pulmonary artery catheter if they are experiencing hypotension or shock. However, the decision to administer vasopressors should be based on the patient's hemodynamic parameters as assessed through the pulmonary artery catheter monitoring, along with clinical judgment and consideration of the underlying cause of the hypotension.

A. Atorvastatin B. Metformin C. Carvedilol D. Nitroglycerin

Correct Answer is B

Explanation

B Metformin is an oral antidiabetic medication commonly used to treat type 2 diabetes. There is a potential risk of lactic acidosis when metformin is used in conjunction with contrast material, particularly in patients with underlying renal impairment. Contrast-induced nephropathy can exacerbate renal dysfunction, leading to increased levels of metformin and potentially increasing the risk of lactic acidosis. Therefore, metformin use before or after contrast administration should be carefully monitored, and in some cases, temporarily discontinued to reduce the risk of lactic acidosis.

A Atorvastatin is a statin medication commonly used to lower cholesterol levels. It does not have a direct interaction with contrast material used in cardiac catheterization. Therefore, it does not place the client at risk for acute kidney injury related to contrast-induced nephropathy (CIN).

C Carvedilol is a beta-blocker medication used to treat high blood pressure and heart failure. It does not have a direct interaction with contrast material used in cardiac catheterization. Therefore, it does not place the client at risk for acute kidney injury related to contrast-induced nephropathy (CIN).

D Nitroglycerin is a medication commonly used to relieve chest pain (angina) in patients with coronary artery disease. It does not have a direct interaction with contrast material used in cardiac catheterization. Therefore, it does not place the client at risk for acute kidney injury related to contrast- induced nephropathy (CIN).

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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?

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Naxlex Comprehensive Predictor Exams

Which of the following is an appropriate nursing intervention for a patient with a pulmonary artery catheter?

Correct Answer is D

Explanation

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

Correct Answer is B

Explanation

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