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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Diphenhydramine 50 mg PO
Diphenhydramine (Benadryl) treats mild allergic reactions but is not sufficient for anaphylaxis. The presence of SOB and angioedema suggests airway compromise, requiring epinephrine.

B. Famotidine 40 mg PO
Famotidine (H2 blocker) can help with allergic reactions but is not the priority in an emergency.

C. Epinephrine 1 mg IM
Epinephrine is the first-line treatment for anaphylaxis. It reverses airway swelling, hypotension, and bronchoconstriction. The standard IM dose is 0.3-0.5 mg, not 1 mg, but epinephrine remains the priority drug.

D. A fluid bolus of normal saline
IV fluids help treat hypotension in anaphylaxis, but epinephrine is the priority intervention.

A. Notify the physician and anticipate the need for endotracheal intubation B. Place the client in semi-fowler's position and administer albuterol breathing treatment C. Encourage the client to cough, take deep breaths, and then auscultate again D. Recommend a medical prescription for guaifenesin and encourage use of incentive spirometry

Correct Answer is A

Explanation

A. Notify the physician and anticipate the need for endotracheal intubation
The client is showing progressive airway obstruction due to inhalation injury. The absence of wheezes indicates impending respiratory failure, requiring immediate airway management.

B. Place the client in semi-Fowler's position and administer an albuterol breathing treatment
Albuterol may help bronchospasm, but this client's issue is upper airway swelling, not bronchospasm. Intubation is the priority.

C. Encourage the client to cough, take deep breaths, and then auscultate again
The loss of wheezes suggests airway swelling has worsened, not that secretions are the issue. Immediate intervention is needed.

D. Recommend a medical prescription for guaifenesin and encourage use of incentive spirometry
Guaifenesin and incentive spirometry help with secretion clearance, but they are not the priority in this emergent airway situation.

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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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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