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?

New systolic murmur

Diminished breath sounds

Diminished heart sounds

Increased blood pressure

Answer and Explanation

The Correct Answer is C

A. A new systolic murmur is more indicative of valvular dysfunction or a septal defect rather than pericardial effusion.
B. Diminished breath sounds may be associated with atelectasis or pleural effusion but are not a hallmark finding of pericardial effusion.
C. Diminished heart sounds occur due to fluid accumulation in the pericardial sac, which muffles heart tones and is a key sign of pericardial effusion.
D. Increased blood pressure is not characteristic of pericardial effusion. Instead, pericardial effusion can lead to cardiac tamponade, which typically causes hypotension.

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Correct Answer is D

Explanation

A. A pressure dressing is already in place following the procedure, and additional dressing is not the priority. Instead, monitoring the TR band for bleeding or complications is essential.
B. Having the client flex and extend the right wrist is not recommended immediately after a radial artery catheterization, as movement can increase the risk of bleeding.
C. Oxygen therapy is not routinely required unless the client has hypoxia or respiratory distress.
D. Assessing the trans-radial (TR) band is the priority to ensure proper hemostasis at the puncture site, monitor for bleeding, and check distal circulation to the hand.

A. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. B. Call the provider if you gain 2 lbs. in 24 hours. C. Check weight daily when it is easiest. D. It is okay to skip a dose of diuretic.

Correct Answer is B

Explanation

A. A weight gain of 1 lb in a week may not indicate fluid overload, but a more rapid increase is concerning.
B. A weight gain of 2 lbs in 24 hours or 5 lbs in a week suggests worsening heart failure due to fluid retention, requiring immediate provider notification.
C. Daily weights should be taken at the same time each day, preferably in the morning, after urination and before eating, for accurate monitoring.
D. Skipping a diuretic dose can lead to fluid retention and worsening symptoms, so adherence to the medication regimen is crucial.

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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-cardiac catheterization with a right radial artery puncture site. The nurse performs which priority assessment on arrival to the unit?

Correct Answer is D

Explanation

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is reviewing cardiac rhythms and heart blocks for a critical care course. The nurse is aware that which of the following describes first-degree heart block?

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