The nurse is caring for a patient with cardiac tamponade who underwent pericardiocentesis to remove fluid. What findings would indicate to the nurse that the procedure has been effective?
A) Hear rate 92 bpm
B) Respiratory rate 34 breaths/minute
C) Jugular venous distention
D) Pulsus paradoxus of 14 mm Hg
A) Hear rate 92 bpm
Explanation: A) Systemic and pulmonary hypoperfusion symptoms may be present and include dyspnea, edema, oliguria (low urine output), jugular venous distention, tachypnea, and tachycardia as a compensatory mechanism to maintain cardiac output. A heart rate of 92 is within normal limits.
B) Systemic and pulmonary hypoperfusion symptoms may be present and include dyspnea, edema, oliguria (low urine output), jugular venous distention, tachypnea, and tachycardia as a compensatory mechanism to maintain cardiac output. A respiratory rate of 34 breaths/minute is considered tachypneic.
C) Systemic and pulmonary hypoperfusion symptoms may be present and include dyspnea, edema, oliguria (low urine output), jugular venous distention, tachypnea, and tachycardia as a compensatory mechanism to maintain cardiac output.
D) A pulsus paradoxus of 14 mm Hg is a finding of cardiac tamponade.
You might also like to view...
Which client at term should go to the hospital or birth center the soonest after labor be-gins?
a. Gravida 2, para 1 who lives 10 minutes away b. Gravida 1, para 0 who lives 40 minutes away c. Gravida 3, para 2 whose longest previous labor was 4 hours d. Gravida 2, para 1 whose first labor lasted 16 hours
The family of an incapacitated patient desires one course of treatment that is against the decisions of the person with durable power of attorney. What should the nurse do?
1. Provide care according to the decisions of the person with durable power of attorney. 2. Ask the physician to talk with the family and the person with durable power of attorney. 3. Follow the family's desires. 4. Tell the person with durable power of attorney that he has to get the family's consent.
The nurse suspects that a client has been physically abused, but the woman refuses to report the abuse to the police
Which statement by the client suggests to the nurse that the relationship might be in the "honeymoon period" of the cycle of violence? 1. "My boyfriend says he will never hurt me again." 2. "My boyfriend only drinks alcohol on the weekends." 3. "My boyfriend yells less than he used to." 4. "My boyfriend has frequent bouts of insomnia."
The nurse prepares to administer gamma-hydroxybutyrate (Xyrem) to a patient with narcolepsy. The nurse provides education about the multiple side effects of this medication
Which statement by the patient best indicates the need for further education? a. "I may experience depression." b. "I may experience a headache or dizziness." c. "I may wet the bed." d. "I may experience an increase in heart rate."