The nurse is caring for a child after heart surgery. What should she or he do if evidence is found of cardiac tamponade?
a. Increase analgesia.
b. Apply warming blankets.
c. Immediately report this to the physician.
d. Encourage the child to cough, turn, and breathe deeply.
ANS: C
If evidence is noted of cardiac tamponade (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 until after the evaluation by the physician.
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