When caring for a client who has developed cardiac tamponade, what assessments should the nurse expect to find?

Pleural friction rub.

Distended neck veins.

Widening pulse pressure.

Bradycardia.

Answer and Explanation

The Correct Answer is B

Choice A rationale
A pleural friction rub, which is a grating sound caused by the inflammation of the pleural surfaces during respiration, is not typically associated with cardiac tamponade. It is more commonly associated with conditions affecting the lungs, such as pneumonia or pleurisy.
Choice B rationale
Distended neck veins are a classic sign of cardiac tamponade. This occurs due to increased pressure in the right atrium as a result of the impaired filling of the ventricles. This is a critical sign that should be reported immediately.
Choice C rationale
Widening pulse pressure (an increase in the difference between systolic and diastolic blood pressure) is not typically associated with cardiac tamponade. In fact, cardiac tamponade more commonly presents with a narrowed pulse pressure.
Choice D rationale
Bradycardia, or a slow heart rate, is not typically a sign of cardiac tamponade. More commonly, tachycardia, or a fast heart rate, is observed in response to decreased cardiac output.

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Correct Answer is A

Explanation

Choice A rationale
Providing a pressure-reducing mattress, while important for preventing pressure ulcers, is not directly related to improving gas exchange in the lungs. Therefore, it would be considered the least priority intervention for a nursing diagnosis of impaired gas exchange related to fluid in the alveoli.
Choice B rationale
Administering oxygen and monitoring for dry nasal mucus membranes is a crucial intervention for a patient with impaired gas exchange. Oxygen therapy can help increase the amount of oxygen in the blood and alleviate symptoms of hypoxemia.
Choice C rationale
Encouraging the client to turn, deep breathe, cough, and use the incentive spirometer can help improve lung ventilation, promote the clearance of secretions, and prevent atelectasis, thereby improving gas exchange.
Choice D rationale
Placing the client in Fowler’s position can help improve lung expansion and gas exchange by reducing pressure on the diaphragm, making it easier for the patient to breathe.

A. Ulceration on the medial surface of the lower legs. B. Brownish skin discoloration on the lower legs. C. Edema in the lower legs. D. Purple rash on the medial surface of the lower legs.

Correct Answer is B

Explanation

Choice A rationale
Ulceration on the medial surface of the lower legs is not the best description of stasis dermatitis in a patient with peripheral vascular disease (PVD). While ulcers can occur in severe cases, they are not the primary characteristic of stasis dermatitis.
Choice B rationale
Stasis dermatitis, also known as venous stasis dermatitis, is a skin inflammation that occurs in people with poor circulation. It most often happens in the lower legs because that’s where blood typically collects. When blood pools in the veins of the lower leg, it can cause a variety of symptoms, including a brownish skin discoloration on the lower legs. This discoloration is caused by the leakage of red blood cells into the skin due to increased pressure in the veins.
Choice C rationale
While edema in the lower legs can be a symptom of PVD and may accompany stasis dermatitis, it is not the best description of the condition. Edema is a general symptom that can occur in many conditions and is not specific to stasis dermatitis.
Choice D rationale
A purple rash on the medial surface of the lower legs is not a typical symptom of stasis dermatitis. While the skin may become discolored, it is usually a brownish color rather than purple.

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When caring for a client who has developed cardiac tamponade, what assessments should the nurse expect to find?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

How would a nurse best describe the assessment of stasis dermatitis in a patient with peripheral vascular disease (PVD)?

Correct Answer is B

Explanation

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