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 A

Explanation

Rationale:

A. Obstructive sleep apnea is a risk factor for the development of hypertension.

B. Benazepril is an antihypertensive medication and is not a risk factor for hypertension.

C. A high HDL level is a protective factor against the development of hypertension.

D. A regular exercise routine is a protective factor against the development of hypertension.

A. Look for P waves on the strip B. Count how many QRS occur in a 6 second strip C. Read the monitor or electrocardiogram interpretation. D. Measure the T waves

Correct Answer is B

Explanation

Rationale:

A. Looking for P waves is important for assessing atrial activity, but it does not directly calculate heart rate.

B. Counting how many QRS complexes occur in a 6-second strip and multiplying by 10 is a quick and accurate way to calculate heart rate.

C. Reading the monitor or ECG interpretation provides information about the rhythm and morphology of the heart, but it does not directly calculate heart rate.

D. Measuring T waves is important for assessing cardiac repolarization, but it does not directly calculate heart rate.

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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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Explanation

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