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?
Diminished breath sounds
Increased blood pressure
Diminished heart sounds
New systolic murmur
The Correct Answer is C
Rationale:
A. Diminished breath sounds are not typically associated with a pericardial effusion.
B. Increased blood pressure is not typically associated with a pericardial effusion but it can instead result in hypotension due to decreased cardiac output due to compression of the heart by the accumulated fluid.
C. The heart sounds may become faint or distant due to fluid accumulation around the heart.
D. A new systolic murmur may indicate a pericardial effusion and should be further evaluated.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Hypocalcemia is a decreased level of calcium in the blood and is not associated with furosemide use.
B. Hypernatremia is an increased level of sodium in the blood and is not associated with furosemide use.
C. Hyperkalemia is an increased level of potassium in the blood and is not associated with furosemide use.
D. Hypokalemia is a decreased level of potassium in the blood and is a major adverse effect of furosemide use.
Correct Answer is B
Explanation
Rationale:
A. Hyperkalemia is not typically associated with thiazide diuretics.
B. Cardiac dysrhythmias can occur with thiazide diuretics due to electrolyte imbalances.
C. Seizures are not typically associated with thiazide diuretics.
D. Hypoglycemia is not typically associated with thiazide diuretics.
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