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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Tenormin (Atenolol) is a beta-blocker that reduces the heart rate and may affect the results of the stress test. Therefore, it should be held the morning of the test.
B. Heparin is an anticoagulant and is not typically held before a stress test.
C. Keflex (Cephalexin) is an antibiotic and is not typically held before a stress test.
D. Holding all medications is not necessary for a stress test, but specific medications that may interfere with the test, such as beta-blockers, should be held.
Correct Answer is A
Explanation
Rationale:
A. Petechiae are small, pinpoint red or purple spots on the skin that may indicate bleeding or thrombocytopenia, which can be a side effect of heparin therapy.
B. Slowing pulse rate is not typically associated with heparin therapy.
C. Confusion is not typically associated with heparin therapy.
D. Pruritus (itching) is not typically associated with heparin therapy.
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