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? 1. Notify the physician immediately.
2. Recheck vital signs in 15 minutes.
3. Reposition the patient.
4. Increase the intravenous fluids.
1
Rationale 1: The patient is exhibiting signs of cardiac tamponade. This is a medical emergency, and the physician must be notified immediately.
Rationale 2: Delaying the response by 15 minutes will be ineffective.
Rationale 3: Repositioning the patient will be ineffective.
Rationale 4: No change in intravenous fluids should be made until a physician order is given to do so.
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