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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
Option C 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
Option C 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 is the compression of the heart as a result of fluid within the pericardial sac. It usually is caused by blunt or penetrating trauma to the chest. A penetrating wound of the heart is associated with a high mortality rate.
Cardiac tamponade also may follow diagnostic cardiac catheterization, angiographic procedures, and pacemaker insertion, which can produce perforations of the heart and great vessels. Pericardial effusion with fluid compressing the heart also may develop from metastases to the pericardium from malignant tumors of the breast, lung, and mediastinum and may occur with lymphomas and leukemias, renal failure, TB, and high-dose radiation to the chest.
