The nurse is assessing the cardiac status of a client with lung cancer. During the assessment the nurse notes that the client has muffled heart sounds and weak pulses during inspiration. What should the nurse do first?
1. Give the client a back rub.
2. Raise the head of the bed.
3. Notify the physician.
4. Assess urinary output.
Answer: 3
1. The client is most likely experiencing cardiac tamponade, which is an emergency. A back rub is inappropriate.
2. Raising the bed might help the client to breathe better, but the priority is to notify the physician and the emergency care team.
3. This is an emergency, and notifying the physician and others, such as the code team, are the priority for the nurse.
4. Assessing urinary output will be important after the client has been stabilized.
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