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Difficulty: Very hardPhysiological Adaptation

A nurse is caring for a client who is 4 hours postoperative following a coronary artery bypass grafting (CABG) procedure. The client suddenly exhibits profound hypotension, pronounced jugular venous distention, muffled heart sounds, and a precipitous drop in mediastinal chest tube drainage. Arrange the following nursing actions in the priority order they should be executed.

  1. 1Assess the mediastinal chest tubes for kinks or dependent loops
  2. 2Activate the rapid response team and notify the cardiothoracic surgeon
  3. 3Administer a rapid intravenous crystalloid bolus as prescribed
  4. 4Prepare the client for an immediate bedside echocardiogram
  5. 5Gather the pericardiocentesis tray and prepare for a potential emergent sternotomy

Answer

The correct sequence is: 1) Assess the mediastinal chest tubes for kinks, 2) Activate the rapid response team and notify the surgeon, 3) Administer a rapid intravenous crystalloid bolus, 4) Prepare for an immediate bedside echocardiogram, and 5) Gather the pericardiocentesis tray and prepare for sternotomy.
Cardiac tamponade post-CABG is a form of obstructive shock. The priority sequence reflects the nursing process and emergency prioritization: rapidly identify and reverse simple mechanical causes (kinked tubes), mobilize the emergency surgical team, support hemodynamics with increased preload (crystalloid fluids), assist with diagnostics (echocardiogram), and prepare for definitive surgical decompression.

Step-by-Step Solution

1
Assess the mediastinal chest tubes for kinks or dependent loops.
Ensures there is no mechanical obstruction preventing pericardial drainage.
Resolving an obstruction is the quickest, least invasive way to reverse the accumulating fluid causing the tamponade. Independent nursing assessment of the equipment takes priority.
2
Activate the rapid response team and notify the cardiothoracic surgeon.
Mobilizes necessary medical personnel for an escalating emergency.
Cardiac tamponade is a lethal surgical complication requiring advanced interventions beyond the independent nursing scope of practice.
3
Administer a rapid intravenous crystalloid bolus as prescribed.
Increases right ventricular preload and systemic venous pressure.
Elevating filling pressures is hemodynamically essential to temporarily overcome the restrictive pericardial pressure and maintain cardiac output until the fluid can be drained.
4
Prepare the client for an immediate bedside echocardiogram.
Facilitates diagnostic confirmation of pericardial effusion.
The provider must visually confirm the presence and severity of the tamponade before proceeding with high-risk invasive procedures.
5
Gather the pericardiocentesis tray and prepare for a potential emergent sternotomy.
Readies the clinical environment for definitive treatment.
Evacuation of the pericardial fluid is the ultimate curative step, requiring sterile equipment and immediate surgical readiness.

Key Concept

Cardiac Tamponade Recognition and Prioritization
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Topics

Physiological Adaptation

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