Difficulty: Medium
Average Score: 91%
Simulated
The nurse is assessing the client following cardiac surgery. Which assessment findings should be of the greatest concern to the nurse?
Correct answer
A
Rationale
The nurse should be most concerned with JVD, muffled heart sounds, and hypotension (BeckÔÇÖs Triad). This is a life-threatening event suggesting cardiac tamponade. Other findings are expected post-surgery or less critical.