A cardiac surgery client's new onset of signs and symptoms is suggestive of cardiac tamponade. As a member of the Interdisciplinary team, what is the nurse's most appropriate action?

Administer a dose of metoprolol as prescribed.

Reposition the client into a prone position.

Administer a bolus of normal saline as prescribed.

Prepare to assist with pericardiocentesis.

Answer and Explanation

The Correct Answer is D

A. Metoprolol is a beta-blocker and does not treat cardiac tamponade, which is a medical emergency.
B. Prone positioning is not indicated and may worsen hemodynamics in tamponade.
C. Administering fluids may temporarily improve preload but is not definitive treatment for cardiac tamponade.
D. Pericardiocentesis is the urgent procedure required to remove the excess fluid from the pericardial sac and relieve cardiac tamponade, making it the priority intervention. The nurse should prepare to assist with this procedure immediately.

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Correct Answer is A

Explanation

A. Morphine is administered after initial interventions if chest pain persists. It helps relieve pain and anxiety, reduces preload and afterload, and decreases myocardial oxygen demand—making it effective in managing symptoms during and after the acute MI phase.
B. Oxygen is typically given early in the acute phase if oxygen saturation is low (<90%) but is not used primarily for pain or anxiety relief.
C. Aspirin is an antiplatelet agent given immediately to reduce mortality but does not manage pain or anxiety.
D. Nitroglycerin is used early to relieve chest pain, but morphine is used when nitroglycerin is ineffective or insufficient for ongoing pain and anxiety control.

A. Perform neurovascular checks with vital signs. B. Instruct the client to perform range-of-motion exercises to his lower extremities. C. Ambulate the client 1 hr following the procedure. D. Restrict the client's fluid intake.

Correct Answer is A

Explanation

A. Neurovascular checks (e.g., assessing pulses, skin color, temperature, and movement) are critical after femoral artery catheterization to monitor for complications such as bleeding, hematoma, or impaired circulation.
B. Lower extremity range-of-motion exercises should be avoided initially, as movement can increase the risk of bleeding at the insertion site.
C. The client should remain on bed rest for several hours post-procedure to reduce bleeding risk at the femoral site.
D. Fluids should be encouraged, not restricted, to help flush out the contrast dye used during the procedure and protect kidney function.

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A cardiac surgery client's new onset of signs and symptoms is suggestive of cardiac tamponade. As a member of the Interdisciplinary team, what is the nurse's most appropriate action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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