The nurse on the telemetry unit has just received the A.M. shift report.
Which client should the nurse assess first?

Choice A rationale

Pulmonary edema occurs when fluid backs up into the lungs, usually due to left-sided heart failure. While pericardial fluid can affect heart function, pulmonary edema is not the most immediate or direct complication of fluid accumulation within the pericardial sac itself. Instead, the fluid in the sac creates external pressure on the heart. The focus of care for increased pericardial fluid is the restriction of cardiac filling rather than the primary congestion of the pulmonary vasculature.

Choice B rationale

Cardiac tamponade is a life-threatening condition where the accumulation of fluid in the pericardial sac increases intrapericardial pressure. This pressure prevents the heart chambers from expanding fully during diastole, which severely reduces stroke volume and cardiac output. Common signs include Beck's triad: hypotension, jugular venous distention, and muffled heart sounds. Immediate intervention is required because the heart can eventually stop beating entirely as it becomes unable to fill with blood due to external compression.

Choice C rationale

Pericarditis is the inflammation of the pericardium, which is often the underlying cause of fluid accumulation, known as pericardial effusion. While the nurse monitors for signs of inflammation, the question asks for a complication resulting from the fluid being dangerously increased. Pericarditis is the state of the tissue rather than the acute hemodynamic consequence of fluid volume. Therefore, preventing the functional collapse of the heart takes precedence over managing the inflammatory process in an emergency.

Choice D rationale

Pericardiocentesis is a medical procedure used to drain excess fluid from the pericardial sac to relieve pressure on the heart. It is a treatment modality rather than a complication. The nurse collaborates with the team to perform this procedure in order to treat or prevent cardiac tamponade. Since the question asks for a complication to prevent, choosing a treatment is logically incorrect. The goal is to avoid the physiological crisis that necessitates such an invasive intervention.

Choice A rationale

This client is the highest priority due to significant cardiovascular instability evidenced by the implantable cardioverter defibrillator firing twice. This indicates the client experienced life-threatening ventricular arrhythmias, such as ventricular tachycardia or fibrillation, within the last shift. The administration of amiodarone, a Class III antiarrhythmic, further highlights the severity of the irritability in the ventricular myocardium. The nurse must assess for continued arrhythmias, electrolyte imbalances like potassium 3.5 to 5.0 mEq/L, and signs of decreased cardiac output.

Choice B rationale

New onset atrial fibrillation requires medical management to control the ventricular rate and prevent thromboembolism, but it is generally less immediately life-threatening than recurring ventricular arrhythmias. Scheduled IV diltiazem is a calcium channel blocker used for rate control. While the client needs assessment for hemodynamic stability and a heart rate usually kept below 100 beats per minute, they do not take precedence over a client whose heart recently required internal shocks to maintain a rhythm.

Choice C rationale

A client who is 2 hours post-electrophysiology procedure reporting constipation is the lowest priority. While post-procedure assessments are important to check the insertion site for hematoma or hemorrhage and peripheral pulses, a complaint of constipation is a non-urgent gastrointestinal issue. It does not indicate a compromise in the ABCs (Airway, Breathing, Circulation) or a complication of the cardiac procedure itself. This can be addressed after the unstable cardiac clients have been thoroughly assessed and stabilized.

Choice D rationale

Elective cardioversion is a controlled procedure used to restore a normal sinus rhythm. A heart rate of 115 beats per minute 1 hour post-procedure indicates tachycardia, which may mean the procedure was unsuccessful or that the client is experiencing anxiety or pain. While this requires follow-up assessment and potentially further intervention, the client is currently more stable than the client in Choice A, whose device had to fire autonomously to prevent sudden cardiac death from a ventricular rhythm.