The nurse is caring for a patient with muffled heart sounds, jugular venous distention and hypotension. The provider diagnoses the patient with cardiac tamponade. The nurse understands that the priority of treatment for this type of shock is
immediate removal of the cause of obstruction.
patient will be admitted for a cardiac catheterization.
administering furosemide for its diuretic effects.
withholding iv fluids due to fluid overload.
The Correct Answer is A
A. Immediate removal of the cause of obstruction.
Cardiac tamponade is a life-threatening condition caused by fluid accumulation in the pericardium, which compresses the heart. The definitive treatment is pericardiocentesis to remove the fluid and relieve the obstruction.
B. Patient will be admitted for a cardiac catheterization.
While catheterization may be performed later for underlying cardiac disease, tamponade requires urgent intervention, not just admission.
C. Administering furosemide for its diuretic effects.
Diuretics reduce preload, which can worsen hypotension in tamponade by further decreasing cardiac output.
D. Withholding IV fluids due to fluid overload.
IV fluids may be used to maintain preload while waiting for pericardiocentesis. The issue is not volume overload but rather mechanical obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Initial stage of septic shock
Septic shock typically presents with warm, flushed skin in the early phase due to vasodilation. This client has cold and clammy skin, which is more consistent with hypovolemic shock.
B. Refractory stage of obstructive shock
Obstructive shock (e.g., from cardiac tamponade or pulmonary embolism) would present with jugular vein distention, muffled heart sounds, or severe respiratory distress, which are not seen in this case.
C. Progressive stage of hypovolemic shock
The client has classic signs of hypovolemic shock due to fluid loss (nausea, vomiting, diarrhea). The progressive stage is indicated by hypotension, tachycardia, and end-organ dysfunction (altered mental status, cool/clammy skin).
D. Compensatory stage of diabetic shock
"Diabetic shock" is not a standard classification of shock. The compensatory stage would still have an adequate blood pressure due to SNS activation, but this patient already has profound hypotension.
Correct Answer is A
Explanation
A. D-dimer, fibrinogen, and fibrin degradation products is correct because these tests reflect the excessive clotting and fibrinolysis seen in DIC: D-dimer: Elevated due to fibrin breakdown. Fibrinogen: Decreased due to excessive consumption. Fibrin degradation products (FDPs): Increased due to breakdown of fibrin clots.
B. Fibrin degradation products, lactic acid, and complete blood count is incorrect because lactic acid is more useful in sepsis evaluation, not DIC diagnosis.
C. Complete blood count, platelets, and prothrombin time is incorrect because while platelets may be low and PT may be prolonged, these tests alone are not specific for DIC.
D. Prothrombin time, form level, and d-dimer is incorrect because “form level” is not a relevant test, and PT alone is not sufficient for DIC diagnosis.
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