The nurse is assessing a patient who is 6 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 the nurse take first?

Question

Quizplus · Accepted Answer

The assessment findings suggest that the patient may be experiencing cardiac tamponade, which is a medical emergency. The nurse should notify the physician immediately to obtain a rapid intervention.

The Nurse Is Assessing a Patient Who Is 6 Hours