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Home Q & A Board Biology-Related Homework Help Medicine Nursing and Clinical
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colleen colleen
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11 years ago
The nurse is assessing a patient who is six hours postoperative from coronary artery bypass graft (CABG) surgery. The patient’s heart rate is 120, blood pressure is 90/50, urine output is decreased, chest tube output is decreased, heart sounds are muffled, and peripheral pulses are diminished. What action should be taken by the nurse first?
1. Notify the physician immediately.
2. Recheck vital signs in 15 minutes.
3. Reposition the patient.
4. Increase the intravenous fluids.
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Sunshine ☀ ☼

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wrote...
#1
11 years ago
1. Notify the physician immediately
Bc These Are Signs Of Cardiac Tamponade
wrote...
#2
Valued Member
11 years ago
The patient is exhibiting signs of cardiac tamponade. This is a medical emergency, and the physician must be notified immediately. Delaying the response by waiting 15 minutes or repositioning the patient will be ineffective. No change in intravenous fluids should be made until a physician order is given to do so. Cardiac tamponade is a life-threatening postoperative complication that can lead to cardiogenic shock and possibly cardiac arrest.
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