The nurse is recovering a client after insertion of an implantable cardioverter-defibrillator (ICD). What complication must the nurse intervene for immediately?
a. 2/4 bilateral peripheral edema
b. Heart rate of 56 beats/min
c. Temperature of 96° F (35.5° C)
d. Muffled heart sounds
D
In the postimplantation period, the nurse should be alert for complications of cardiac tamponade, bleeding, and dysrhythmias. Muffled heart sounds are a manifestation of cardiac tamponade. Edema and a lower temperature would not be indicative of a complication of this procedure. Bradycardia might need intervention, but this client's heart rate is not critically low.
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