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 A

Explanation

Rationale:

A. Encouraging the client to participate in the cardiac rehab program is important for recovery and returning to an active lifestyle.

B. Acknowledging the doctor's expertise is important, but it does not address the client's concerns.

C. This statement may minimize the client's concerns and is not the best response.

D. This statement is not specific and may not address the client's concerns.

A. Amiodarone administration B. Synchronized Cardioversion C. Epinephrine administration D. Defibrillation

Correct Answer is D

Explanation

Rationale:

A. Amiodarone administration is used for the treatment of ventricular fibrillation (VF) and ventricular tachycardia (VT) that is unresponsive to cardioversion.

B. Synchronized Cardioversion is used for the treatment of atrial fibrillation (AF), atrial flutter (AFL), and unstable ventricular tachycardia (VT).

C. Epinephrine administration is part of the ACLS algorithm for the treatment of VF and pulseless VT. It is given after defibrillation.

D. Defibrillation is the immediate treatment for ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT).

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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 post transcatheter aortic valve replacement (TAVR). During the first cardiac rehabilitation session, the client tells the nurse, "I do not need to be here. I am feeling so much better, I can do this at home". Which of the following is the appropriate nursing response?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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