The nurse is caring for a child after heart surgery. Which should the nurse do if evidence is found of cardiac tamponade?
a. Increase analgesia.
b. Apply warming blankets.
c. Immediately report this to physician.
d. Encourage child to cough, turn, and breathe deeply.
ANS: C
If evidence is noted of cardiac tamponade, which is blood or fluid in the pericardial space constricting the heart, the physician is notified immediately of this life-threatening complication. Increasing analgesia may be done before the physician drains the fluid, but the physician must be notified. Warming blankets are not indicated at this time. Encouraging the child to cough, turn, and breathe deeply should be deferred till after the evaluation by the physician.
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