A nurse in a critical care unit is caring for a client who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
Flatened neck veins.
Bradycardia.
Sudden lethargy.
Muffled heart sounds.
The Correct Answer is D
Choice A Reason: This choice is incorrect because flatened neck veins are not a sign of cardiac tamponade. Cardiac tamponade is a condition in which fluid accumulates in the pericardial sac that surrounds the heart, causing compression and impaired filling of the heart chambers. This leads to reduced cardiac output and hypotension. One of the manifestations of cardiac tamponade is distended neck veins due to increased venous pressure and impaired venous return.
Choice B Reason: This choice is incorrect because bradycardia is not a sign of cardiac tamponade. Bradycardia is a condition in which the heart rate is slower than normal (less than 60 beats per minute). It may be caused by various factors such as vagal stimulation, medication side effects, hypothyroidism, or sinus node dysfunction. It may cause symptoms such as fatigue, dizziness, or syncope, but it does not indicate cardiac tamponade.
Choice C Reason: This choice is incorrect because sudden lethargy is not a specific sign of cardiac tamponade. Lethargy is a condition in which the person feels tired, sluggish, or drowsy. It may be caused by various factors such as sleep deprivation, depression, infection, anemia, or hypoglycemia. It may affect the person's mental and physical performance, but it does not indicate cardiac tamponade.
Choice D Reason: This choice is correct because muffled heart sounds are a sign of cardiac tamponade. Muffled heart sounds are heart sounds that are fainter or softer than normal due to reduced transmission of sound waves through fluid-filled pericardial sac. They may indicate that the heart function is compromised by cardiac tamponade and require immediate intervention such as pericardiocentesis (removal of fluid from pericardial sac).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Infection is a serious complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should monitor the client's wound healing, temperature, white blood cell count, and signs of sepsis, and administer antibiotics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.
Choice B Reason: Airway obstruction is the priority risk for assessment and intervention for a client who has burns of the head, neck, and chest. The nurse should assess the client's airway patency, respiratory rate, oxygen saturation, breath sounds, and signs of respiratory distress, such as stridor, wheezes, or cyanosis. The nurse should also provide humidified oxygen, suction secretions, elevate the head of the bed, and prepare for endotracheal intubation if needed. Airway obstruction can occur due to edema, inflammation, or inhalation injury of the upper airway, and can quickly lead to hypoxia, respiratory failure, and death.
Choice C Reason: Paralytic ileus is a potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's bowel sounds, abdominal distension, nausea, vomiting, and stool output, and administer fluids, electrolytes, and nutritional support as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.
Choice D Reason: Fluid imbalance is another potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's fluid status, urine output, vital signs, weight, and serum electrolytes, and administer intravenous fluids as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.
Correct Answer is A
Explanation
Choice A Reason: This choice is correct because respiratory acidosis is a condition in which the lungs cannot eliminate enough carbon dioxide (CO2) from the blood, resulting in a high level of CO2 (PaCO2) and a low level of pH. A normal PaCO2 range is 35 to 45 mm Hg, so a value of 50 mm Hg indicates respiratory acidosis.
Choice B Reason: This choice is incorrect because HCO3 (bicarbonate) is a base that helps to buffer the excess acid in the blood. In respiratory acidosis, the kidneys try to compensate by retaining more HCO3 and excreting more hydrogen ions. Therefore, a high level of HCO3 (above 26 mEq/L) would indicate a chronic or compensated respiratory acidosis, not an acute or uncompensated one.
Choice C Reason: This choice is incorrect because pH is a measure of the acidity or alkalinity of the blood. A normal pH range is 7.35 to 7.45, so a value of 7.45 indicates a neutral or slightly alkaline blood, not an acidic one. A low pH (below 7.35) would indicate respiratory acidosis.
Choice D Reason: This choice is incorrect because potassium is an electrolyte that helps to regulate the nerve and muscle function, as well as the fluid balance in the body. In respiratory acidosis, the increased hydrogen ions in the blood may shift into the cells in exchange for potassium, resulting in a high level of potassium (hyperkalemia).
Therefore, a low level of potassium (below 3.5 mEq/L) would indicate hypokalemia, not respiratory acidosis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today