A nurse is making initial client rounds at the beginning of the shift. Which client should the nurse see first?

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11ecbb05_c948_1e93_b433_59068129f1b0_MD0009_00 The client with pericardial effusion should be seen first. This client is exhibiting signs and symptoms (narrowed pulse pressure, hypotension, and jugular venous distension) of developing cardiac tamponade, a life-threatening complication of pericardial effusion in which fluid builds up in the pericardial sac and compresses the heart. The heart is unable to contract effectively against the fluid, and cardiac output can drop drastically. Emergency pericardiocentesis is needed. Other important manifestations of tamponade include muffled or distant heart tones, pulsus paradoxus, dyspnea, tachypnea, and tachycardia. (Option A) These are symptoms typically seen in the client with endocarditis. The nurse should further assess the murmur to see if it has worsened or changed, but this should be done after the client with pericardial effusion is seen. (Option C) The new onset of atrial fibrillation should be reported to the health care provider, but the client's vital signs are stable; this client is not a priority over the client with possible tamponade. Atrial fibrillation is often a chronic arrhythmia and is managed with ventricular rate control and anticoagulation. (Option D) Clients with advanced heart failure often have low cardiac output with resultant low blood pressure but remain asymptomatic. IV diuretics can worsen the hypotension. The client is watching TV, an indication that the client is stable. The nurse can delegate to the unlicensed assistive personnel directions for the client to stay in bed due to the hypotension until the nurse can perform further assessment. Educational objective: Clients with pericardial effusion should be monitored and assessed closely for the development of cardiac tamponade. Signs and symptoms of tamponade include muffled or distant heart tones, hypotension, narrowed pulse pressure, jugular venous distension, and pulsus paradoxus.

A Nurse Is Making Initial Client Rounds at the Beginning