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. This is wrong because the ECG leads show ST segment elevation.

B. Stable angina may present with ST segment depression in an ECG unlike in the strip shown above which depicts an ST segment elevation.

C. This is correct because of the ST segment elevation.

D. Unstable angina may have hyperacute T wave, flattening of the T waves, inverted T waves or an ST depression unlike in the above ECG strip.

A. Notify the provider of the client's allergy. B. Notify the dietary department of the client's allergy. C. Ask the client if any other foods cause such a reaction. D. Attach a wrist band indicating the client's allergy

Correct Answer is A

Explanation

Rationale:

A. Notifying the provider of the client's allergy is the priority to ensure that appropriate precautions are taken during the cardiac catheterization.

B. Notifying the dietary department is not necessary in this situation.

C. Asking about other foods is important but not the priority at this time.

D. Attaching a wristband indicating the allergy may be done later but is not the priority at this time.

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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

A nurse is caring for a client with sudden onset of chest pain, the nurse completes the electrocardiogram (ECG). The nurse understands that this client is having what type of acute coronary syndrome?

Correct Answer is C

Explanation

The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action?

Correct Answer is A

Explanation

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Identify the following Cardiac Rhythm:

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