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 D

Explanation

A. Regular pacemaker checks are scheduled periodically, not only when the battery needs replacement.
B. Modern pacemakers are well-shielded and are not affected by household microwaves.
C. Clients should check their pulse daily to ensure proper pacemaker function, not just weekly.
D. Many pacemakers can be checked remotely using telephone or wireless technology, allowing for convenient monitoring.

A. "I will call the provider to get a prescription for discontinuing the IV heparin today." B. "Both heparin and warfarin work together to dissolve the clots." C. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay." D. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level."

Correct Answer is D

Explanation

Rationale:

A. Discontinuing heparin abruptly without achieving therapeutic levels of warfarin increases the risk of thrombus formation.

B. Heparin and warfarin have different mechanisms of action, but they both serve to prevent clot formation.

C. Heparin and warfarin do not directly affect each other's therapeutic effects.

D. Warfarin takes time to reach therapeutic levels and become effective, so heparin is continued until warfarin is fully active.

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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 providing teaching to a client who has a permanent pacemaker and has just had the initial pacemaker check. Which of the following client statements indicates to the nurse that the teaching was effective?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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