A nurse is assessing a client who is postoperative following a coronary artery bypass graft surgery. The nurse should identify that which of the following findings is an early indication of cardiac tamponade?

Widening pulse pressure

Coarse lung sounds

Muffled heart sounds

Decreased jugular vein distention

Answer and Explanation

The Correct Answer is C

A. Widening pulse pressure. This is typically associated with conditions like increased intracranial pressure or severe aortic regurgitation, not cardiac tamponade. Tamponade usually results in narrowed pulse pressure.
B. Coarse lung sounds. These may indicate fluid overload or pulmonary congestion, but they are not specific to cardiac tamponade and occur later or in different conditions.
C. Muffled heart sounds. This is a classic early sign of cardiac tamponade, caused by fluid accumulation in the pericardial sac, which dampens heart sounds on auscultation. It is part of Beck’s triad (muffled heart sounds, hypotension, and jugular vein distention).
D. Decreased jugular vein distention. In cardiac tamponade, jugular vein distention increases due to impaired venous return to the heart. Decreased JVD would be an unexpected finding in this condition.

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Correct Answer is C,B,A,D

Explanation

C. Lubricate the catheter with sterile saline. After donning sterile gloves, the nurse should lubricate the catheter to reduce friction and prevent trauma to the tracheal mucosa during insertion.

B. Insert the catheter until resistance is felt. The catheter should be gently inserted into the tracheostomy until resistance is met, indicating that it has reached the carina. Inserting beyond this point may cause injury.

A. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in). Pulling back slightly after resistance ensures the catheter is not pressing directly on sensitive structures and is positioned correctly for effective suctioning.

D. Rotate the catheter while suctioning. Suction should be applied while withdrawing the catheter in a rotating motion to evenly clear secretions and minimize damage to the tracheal lining.

A. Silence the bed alarm when visitors are at the client's bedside. B. Establish an elimination schedule for the client. C. Raise all four bed rails on the client's bed. D. Allow the client to walk unassisted near the nursing station

Correct Answer is B

Explanation

A. Silence the bed alarm when visitors are at the client's bedside. Bed alarms are a critical safety device for clients on fall precautions and should never be silenced when the client is in bed, regardless of visitors. Alarms alert staff if the client attempts to get up unsafely.
B. Establish an elimination schedule for the client. A regular toileting schedule helps reduce the risk of falls by preventing unassisted attempts to get out of bed to use the bathroom. This proactive approach supports both safety and comfort.
C. Raise all four bed rails on the client's bed. Raising all four rails is considered a form of restraint and can actually increase the risk of injury if the client attempts to climb over them. Two rails up is generally acceptable for support and safety.
D. Allow the client to walk unassisted near the nursing station. Clients on fall precautions should always be supervised or assisted during ambulation to prevent accidents, even when close to staff. Being near the nursing station does not eliminate the risk.

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A nurse is assessing a client who is postoperative following a coronary artery bypass graft surgery. The nurse should identify that which of the following findings is an early indication of cardiac tamponade?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

11. A nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps into the box, placing them in the selected order of performance. Use all the steps.)

Correct Answer is C,B,A,D

Explanation

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Correct Answer is B

Explanation

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