Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased.
The nurse should collaborate with the other members of the care team to prevent the development of which complication?
Pulmonary edema.
Cardiac tamponade.
Pericarditis.
Pericardiocentesis.
The Correct Answer is B
Choice A rationale
Pulmonary edema occurs when fluid backs up into the lungs, usually due to left-sided heart failure. While pericardial fluid can affect heart function, pulmonary edema is not the most immediate or direct complication of fluid accumulation within the pericardial sac itself. Instead, the fluid in the sac creates external pressure on the heart. The focus of care for increased pericardial fluid is the restriction of cardiac filling rather than the primary congestion of the pulmonary vasculature.
Choice B rationale
Cardiac tamponade is a life-threatening condition where the accumulation of fluid in the pericardial sac increases intrapericardial pressure. This pressure prevents the heart chambers from expanding fully during diastole, which severely reduces stroke volume and cardiac output. Common signs include Beck's triad: hypotension, jugular venous distention, and muffled heart sounds. Immediate intervention is required because the heart can eventually stop beating entirely as it becomes unable to fill with blood due to external compression.
Choice C rationale
Pericarditis is the inflammation of the pericardium, which is often the underlying cause of fluid accumulation, known as pericardial effusion. While the nurse monitors for signs of inflammation, the question asks for a complication resulting from the fluid being dangerously increased. Pericarditis is the state of the tissue rather than the acute hemodynamic consequence of fluid volume. Therefore, preventing the functional collapse of the heart takes precedence over managing the inflammatory process in an emergency.
Choice D rationale
Pericardiocentesis is a medical procedure used to drain excess fluid from the pericardial sac to relieve pressure on the heart. It is a treatment modality rather than a complication. The nurse collaborates with the team to perform this procedure in order to treat or prevent cardiac tamponade. Since the question asks for a complication to prevent, choosing a treatment is logically incorrect. The goal is to avoid the physiological crisis that necessitates such an invasive intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The normal range for serum creatinine is approximately 0.6 to 1.2 mg/dL for adults. A value of 2.1 mg/dL is significantly elevated, indicating a reduction in the glomerular filtration rate and impaired renal function. In the context of a myocardial infarction, low cardiac output can lead to pre-renal azotemia or acute tubular necrosis. This elevation serves as a primary marker for the development of acute kidney injury, reflecting the kidneys' inability to clear metabolic waste effectively.
Choice B rationale
Serum osmolality represents the concentration of particles dissolved in the blood, with a normal range typically between 275 and 295 mOsm/kg H2O. A value of 290 mOsm/kg H2O is within the normal physiological limits. This indicates a stable balance of electrolytes and water in the plasma. Since the value is normal, it does not suggest an increased risk or current state of acute kidney injury or fluid volume disturbances that would damage renal tissue.
Choice C rationale
The normal range for serum magnesium is approximately 1.3 to 2.1 mEq/L. A magnesium level of 2.0 mEq/L is within the normal therapeutic range. While electrolyte imbalances can occur during renal failure, a normal magnesium level does not indicate an increased risk of acute kidney injury. Magnesium is primarily excreted by the kidneys, so while its level might rise if injury occurs, the current value of 2.0 mEq/L indicates that renal clearance is currently sufficient.
Choice D rationale
The normal range for blood urea nitrogen (BUN) is typically 10 to 20 mg/dL. A BUN of 20 mg/dL is at the upper limit of the normal range but is not considered an elevated finding that signifies acute kidney injury on its own. BUN can be influenced by protein intake, hydration status, and liver function. Without an accompanying elevation in creatinine, this normal BUN level does not suggest that the patient is at high risk for kidney failure.
Correct Answer is A
Explanation
Choice A rationale
This client is the highest priority due to significant cardiovascular instability evidenced by the implantable cardioverter defibrillator firing twice. This indicates the client experienced life-threatening ventricular arrhythmias, such as ventricular tachycardia or fibrillation, within the last shift. The administration of amiodarone, a Class III antiarrhythmic, further highlights the severity of the irritability in the ventricular myocardium. The nurse must assess for continued arrhythmias, electrolyte imbalances like potassium 3.5 to 5.0 mEq/L, and signs of decreased cardiac output.
Choice B rationale
New onset atrial fibrillation requires medical management to control the ventricular rate and prevent thromboembolism, but it is generally less immediately life-threatening than recurring ventricular arrhythmias. Scheduled IV diltiazem is a calcium channel blocker used for rate control. While the client needs assessment for hemodynamic stability and a heart rate usually kept below 100 beats per minute, they do not take precedence over a client whose heart recently required internal shocks to maintain a rhythm.
Choice C rationale
A client who is 2 hours post-electrophysiology procedure reporting constipation is the lowest priority. While post-procedure assessments are important to check the insertion site for hematoma or hemorrhage and peripheral pulses, a complaint of constipation is a non-urgent gastrointestinal issue. It does not indicate a compromise in the ABCs (Airway, Breathing, Circulation) or a complication of the cardiac procedure itself. This can be addressed after the unstable cardiac clients have been thoroughly assessed and stabilized.
Choice D rationale
Elective cardioversion is a controlled procedure used to restore a normal sinus rhythm. A heart rate of 115 beats per minute 1 hour post-procedure indicates tachycardia, which may mean the procedure was unsuccessful or that the client is experiencing anxiety or pain. While this requires follow-up assessment and potentially further intervention, the client is currently more stable than the client in Choice A, whose device had to fire autonomously to prevent sudden cardiac death from a ventricular rhythm.
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