The nurse is caring for a patient with muffled heart sounds, jugular venous distention and hypotension. The provider diagnoses the patient with cardiac tamponade. The nurse understands that the priority of treatment for this type of shock is
immediate removal of the cause of obstruction.
patient will be admitted for a cardiac catheterization.
administering furosemide for its diuretic effects.
withholding iv fluids due to fluid overload.
The Correct Answer is A
A. Immediate removal of the cause of obstruction.
Cardiac tamponade is a life-threatening condition caused by fluid accumulation in the pericardium, which compresses the heart. The definitive treatment is pericardiocentesis to remove the fluid and relieve the obstruction.
B. Patient will be admitted for a cardiac catheterization.
While catheterization may be performed later for underlying cardiac disease, tamponade requires urgent intervention, not just admission.
C. Administering furosemide for its diuretic effects.
Diuretics reduce preload, which can worsen hypotension in tamponade by further decreasing cardiac output.
D. Withholding IV fluids due to fluid overload.
IV fluids may be used to maintain preload while waiting for pericardiocentesis. The issue is not volume overload but rather mechanical obstruction.
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Related Questions
Correct Answer is B
Explanation
A. Assessment of neurologic status
While neurological assessment is important, it is not the priority in this situation. The immediate priority is managing the chest wound and airway to ensure oxygenation and prevent further complications.
B. Obtain IV access with two large bore lines and blood for lab studies
IV access is important for fluid resuscitation and medication administration but is not the immediate priority compared to securing the airway and ensuring ventilation.
C. Placement of a naso-gastric tube to decompress the stomach
Although the naso-gastric tube may be necessary to decompress the stomach later, it is not the priority in the initial management of a client with a gunshot wound to the chest.
D. Placement of an indwelling catheter (Foley) to measure urine output
While measuring urine output is important for monitoring renal function and fluid balance, it is not the priority in this emergency situation.
Correct Answer is B
Explanation
A. Mini mental status exam at admission and discharge
Useful for cognitive function but not for acute changes.
B. Performing serial Glasgow Coma Scale exams
The GCS is the best tool for tracking changes in neurologic status over time.
C. Assessing pupils for reactivity, equality, symmetry, and accommodation
Important but not comprehensive.
D. Obtaining vital signs every four hours
Useful but does not specifically assess neurologic function.
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