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Difficulty: MediumPhysiological Adaptation

A nurse is caring for a client who is 6 hours postoperative following a coronary artery bypass graft (CABG). The nurse notes that the client's mediastinal chest tube drainage has abruptly stopped over the past hour. Which of the following assessment findings indicate the client is developing cardiac tamponade? Select all that apply.

  1. Jugular venous distention with clear lung auscultationAnswer
  2. B
    A steady widening of the pulse pressure on the arterial monitor
  3. Muffled and distant heart sounds upon auscultationAnswer
  4. D
    Arterial blood gas showing uncompensated respiratory alkalosis
  5. A decrease in systolic blood pressure of 15 mm Hg during inspirationAnswer
  6. F
    Sudden onset of profound bradycardia

Answer

The correct findings indicating cardiac tamponade are jugular venous distention with clear lungs, muffled and distant heart sounds, and a decrease in systolic blood pressure of 15 mm Hg during inspiration (pulsus paradoxus).
Cardiac tamponade is a life-threatening complication characterized by the accumulation of fluid in the pericardial sac, which compresses the heart and prevents adequate ventricular filling. This obstructive shock state classically presents with Beck's triad: jugular venous distention (due to right-sided filling resistance), muffled heart sounds (due to fluid muffling the acoustics), and hypotension with a narrowing pulse pressure. Additionally, pulsus paradoxus—a drop in systolic blood pressure greater than 10 mm Hg upon inspiration—is a hallmark assessment finding.

Step-by-Step Solution

1
Analyze the clinical scenario and the specific risk factors involved.
The client is post-CABG with an abrupt cessation of chest tube drainage, which strongly suggests blood is pooling in the mediastinum or pericardial space, leading to cardiac tamponade.
Identifying the complication allows the nurse to anticipate the expected physiological manifestations of obstructive shock.
2
Recall the classic clinical manifestations of cardiac tamponade.
The hallmark signs are Beck's triad (hypotension, jugular venous distention, muffled heart sounds) and pulsus paradoxus.
These findings reflect the pathophysiology of fluid compressing the heart, reducing diastolic filling, and severely decreasing stroke volume.
3
Evaluate each option against the physiological changes of tamponade.
Select the options representing Beck's triad and pulsus paradoxus, while eliminating options that represent incorrect hemodynamic shifts (such as widened pulse pressure or bradycardia).
Accurate interpretation of vital signs and physical assessments is critical to distinguishing tamponade from other post-operative complications.

Key Concept

Clinical manifestations of cardiac tamponade and obstructive shock
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Topics

Physiological Adaptation

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