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?

Diminished breath sounds

Increased blood pressure

Diminished heart sounds

New systolic murmur

Answer and Explanation

The Correct Answer is C

Rationale:

A. Diminished breath sounds are not typically associated with a pericardial effusion.

B. Increased blood pressure is not typically associated with a pericardial effusion but it can instead result in hypotension due to decreased cardiac output due to compression of the heart by the accumulated fluid.

C. The heart sounds may become faint or distant due to fluid accumulation around the heart.

D. A new systolic murmur may indicate a pericardial effusion and should be further evaluated.

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Correct Answer is B

Explanation

Rationale:

A. This describes a second-degree heart block, specifically Mobitz Type I (Wenckebach).

B. A PR interval greater than 0.20 seconds is characteristic of first-degree heart block.

C. This describes third-degree heart block, also known as complete heart block.

D. An irregular R-R interval is not specific to first-degree heart block.

A. Unable to lie flat B. Feeling fatigued C. Distended neck veins D. Increased appetite E. Weight gain 2 in 24hours F. Worsening Lower extremity edema

Correct Answer is ["A","B","C","E","F"]

Explanation

Rationale:

A. Unable to lie flat due to orthopnea is a sign of worsening heart failure.

B. Feeling fatigued is a general symptom of heart failure but can worsen as heart failure progresses.

C. Distended neck veins indicate increased central venous pressure, which is a sign of worsening right-sided heart failure.

D. Increased appetite is not typically associated with worsening heart failure.

E. Weight gain of 2 pounds in 24 hours indicates fluid retention and worsening heart failure.

F. Worsening lower extremity edema is a sign of worsening heart failure.

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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

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Correct Answer is B

Explanation

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Explanation

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