A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?
Monitor oxygen saturation (SpO2) via continuous pulse oximetry.
Observe neck for jugular vein distention.
Notify healthcare provider to prepare for pericardiocentesis.
Assess for paradoxical blood pressure.
The Correct Answer is C
A. Monitoring oxygen saturation is important but secondary to addressing the immediate cause of the cardiac tamponade.
B. Observing for jugular vein distention is relevant but not the priority compared to directly addressing the tamponade.
C. Notifying the healthcare provider to prepare for pericardiocentesis is the most critical intervention. Cardiac tamponade requires immediate decompression to relieve pressure on the heart and restore normal function.
D. Assessing for paradoxical blood pressure can provide additional information but does not address the immediate need for intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Select Response 1: First thing in the morning fasting
Monitoring blood glucose levels first thing in the morning while fasting helps assess the client’s baseline glucose level after an overnight fast. This is important for evaluating overall glucose control and adjusting treatment if necessary.
Select Response 2: Prior to each meal
Checking blood glucose levels before each meal provides insight into how well the client’s blood sugar is controlled throughout the day and helps adjust dietary and medication plans to maintain optimal glucose levels.
Correct Answer is B
Explanation
A. While reassuring the client about visiting arrangements is supportive, it is not as critical for ensuring continuity of care.
B. Obtaining a detailed report from the transferring nurse is crucial to ensure all relevant information and the client’s wishes are communicated effectively.
C. Providing written information about end-of-life care is helpful but secondary to ensuring accurate communication of the client’s care preferences.
D. Marking the chart is important, but the immediate priority is ensuring the complete and accurate transfer of care information.
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