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 the nurse take first?

Question

Quizplus · Accepted Answer

The patient is exhibiting signs of cardiac tamponade, a medical emergency that requires immediate intervention. The nurse should notify the physician immediately to facilitate further assessment and treatment.

The Nurse Is Assessing a Patient Who Is Six Hours