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 ["A","B","D"]
Explanation
Rationale:
A. Fluid overload can lead to increased blood pressure due to the excess fluid circulating in the body.
B. Increased heart rate is a compensatory mechanism in response to fluid volume overload.
C. Increased hematocrit is not typically associated with fluid volume overload.
D. Increased respiratory rate is a compensatory mechanism in response to fluid volume overload.
E. Increased temperature is not typically associated with fluid volume overload.
Correct Answer is C
Explanation
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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