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

Answer and Explanation

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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Correct Answer is C

Explanation

Rationale:

A. Epinephrine is not typically used to treat supraventricular tachycardia (SVT).

B. Atropine is not typically used to treat supraventricular tachycardia (SVT).

C. Adenosine is the medication of choice for terminating supraventricular tachycardia (SVT).

D. Lidocaine is not typically used to treat supraventricular tachycardia (SVT).

A. The client experiences sudden weakness of one arm and leg B. The client's ECG tracing shows irregular heart rate without P waves. C. The client's urine output is cloudy and odorous. D. The client has an aPTT of 80 seconds.

Correct Answer is A

Explanation

Rationale:

A. Sudden weakness of one arm and leg may indicate a stroke, which is a potential complication of atrial fibrillation.

B. An irregular heart rate without P waves is characteristic of atrial fibrillation and is expected.

C. Cloudy and odorous urine may indicate a urinary tract infection but is not the priority in this case.

D. An aPTT of 80 seconds is within the therapeutic range for heparin therapy.

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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

Correct Answer is C

Explanation

A nurse is caring for a client diagnosed with atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

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