Nokea
The nurse assesses a client three hours following cardiac surgery. Assessment findings were a blood pressure of 88/52 mm Hg, jugular venous distention, and muffled heart sounds. The nurse anticipates that this client will need an immediate
- A. thoracentesis.
- B. pericardiocentesis.
- C. arthrocentesis.
- D. paracentesis.
Correct Answer: B
Rationale: These findings suggest cardiac tamponade, requiring pericardiocentesis to remove fluid compressing the heart.
You may also like to solve these questions
The nurse is assisting a physician in performing a bronchoscopy. The nurse suspects the client is experiencing a vasovagal response as evidence by the client's
- A. hypertension.
- B. bronchodilation.
- C. increase in heart rate (HR).
- D. decrease in heart rate (HR).
Correct Answer: D
Rationale: A vasovagal response causes bradycardia due to vagal nerve stimulation during procedures like bronchoscopy.
The emergency department nurse is caring for a client with congestive heart failure who reports dyspnea and a persistent cough. The nurse obtains the client's vital signs and suspects that the client is experiencing which condition? See the image below.
- A. Pulmonary embolism
- B. Hypovolemic shock
- C. Disseminated intravascular coagulation (DIC)
- D. Pulmonary edema
Correct Answer: D
Rationale: Dyspnea and persistent cough in CHF suggest pulmonary edema due to fluid backup in the lungs.
The nurse is caring for a client receiving a continuous infusion of diltiazem who has the below tracing on the electrocardiogram (ECG). On assessment, the client has irregular peripheral pulses, an S3 heart sound, and 2+ pedal edema. The nurse should plan to take which priority action? See the image below.
- A. Assess the client for chest pain
- B. Perform a 12-lead electrocardiogram
- C. Stop the infusion
- D. Obtain an immediate troponin level
Correct Answer: C
Rationale: S3 and edema suggest heart failure, possibly exacerbated by diltiazem's negative inotropic effect. Stopping the infusion is the priority.
Which of the following interventions should the nurse implement to manage fluid volume overload in a client with heart failure? Select all that apply.
- A. Administer diuretics as prescribed
- B. Monitor daily weights
- C. Restrict fluid intake to 500 mL per day
- D. Assess lung sounds for crackles
- E. Encourage high-sodium diet
- F. Assess lung sounds for rhonchi
Correct Answer: A,B,D
Rationale: Diuretics reduce fluid overload. Daily weights monitor fluid status. C: Incorrect - 500 mL/day is too restrictive; 1.5-2 L is typical. D: Correct - Crackles indicate pulmonary edema. E: Incorrect - High-sodium diets worsen fluid retention. F: Incorrect - Rhonchi are not specific to fluid overload.
Which of the following findings would the nurse expect to observe in a client with peripheral arterial disease (PAD)? Select all that apply.
- A. Decreased peripheral pulses
- B. Pain with ambulation
- C. Reddish-brown ankle discoloration
- D. Bilateral dependent edema
- E. Protruding veins in the leg
Correct Answer: A,B,C
Rationale: Decreased pulses result from arterial obstruction. Pain with ambulation (claudication) is a hallmark of PAD. C: Correct - Reddish-brown discoloration indicates chronic arterial insufficiency. D: Incorrect - Edema is more typical of venous issues. E: Incorrect - Protruding veins suggest venous disease, not arterial.