The nurse is caring for a client postoperative pacemaker insertion. The nurse observes the client for signs of cardiac tamponade that must be reported at once. Which of the following are signs of this serious condition? Select all answers that apply

A) Neck vein distention
B) Bradycardia
C) Muffled heart sounds
D) Crackles
E) Respiratory distress
F) Fever


A, C
Feedback:
The nurse should observe for neck vein distention or muffled heart sounds, which could indicate cardiac tamponade. These are serious signs that must be reported at once.

Nursing

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