Question

A nurse is assessing for cardiac tamponade in a patient who had coronary artery bypass graft. Which of the following actions should the nurse take?

A) Administer nitroglycerin to relieve chest pain
B) Monitor for pulsus paradoxus
C) Instruct the patient to perform Valsalva maneuver
D) Encourage deep breathing exercises

Answer 1

The correct action for assessing cardiac tamponade in a patient post-coronary artery bypass graft is to monitor for pulsus paradoxus, which involves using a blood pressure cuff and listening for changes in blood pressure indicative of this condition.

Step-by-step explanation:

The question asks which action a nurse should take when assessing for cardiac tamponade in a patient who has had a coronary artery bypass graft. Among the options provided, the correct action to take is to monitor for pulsus paradoxus.

Cardiac tamponade is a medical emergency where fluid accumulates in the pericardium (the sac around the heart), leading to reduced heart function. Pulsus paradoxus is a sign of cardiac tamponade, characterized by a decrease in systolic blood pressure during inspiration by more than 10 mmHg. The way to assess for pulsus paradoxus involves the following steps:

1. The clinician wraps an inflatable cuff around the patient's arm at the level of the heart.
2. The clinician raises the pressure in the cuff by inflating it with a rubber pump, temporarily halting blood flow in the arm.
3. Using a stethoscope placed on the antecubital region, the clinician listens for Korotkoff sounds while gradually letting air out of the cuff.

Monitoring for pulsus paradoxus is a method to measure changes in blood pressure that can indicate cardiac tamponade, thus guiding further diagnostic and therapeutic measures.