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1. Question
The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective?
Correct
Answer: Option 2 is the correct answer.
Rationale: Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant and blood pressure increases. Distended neck veins are a sign of increased venous pressure, which occurs with cardiac tamponade. Test-Taking Strategy: Focus on the subject, expected outcome following pericardiocentesis, and note the strategic word, effective. Successful therapy is measured by the disappearance of the original signs and symptoms of cardiac tamponade. This will direct you to the correct option.
Incorrect
Answer: Option 2 is the correct answer.
Rationale: Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant and blood pressure increases. Distended neck veins are a sign of increased venous pressure, which occurs with cardiac tamponade. Test-Taking Strategy: Focus on the subject, expected outcome following pericardiocentesis, and note the strategic word, effective. Successful therapy is measured by the disappearance of the original signs and symptoms of cardiac tamponade. This will direct you to the correct option.
Cardiac Tamponade
Description
A pericardial effusion occurs when the space between
the parietal and visceral layers of the pericardium fills with fluid.
Pericardial effusion places the client at risk
for cardiac tamponade, an accumulation of fluid in the pericardial cavity.
Tamponade restricts ventricular filling, and
cardiac output drops.
