The nurse is assessing a patient who is six hours postoperative ...

[jjjetplane]

The nurse is assessing a patient who is six hours postoperative from coronary artery bypass graft (CABG) surgery. The patient's heart rate is 120, blood pressure is 90/50, urine output is decreased, chest tube output is decreased,
 
  heart sounds are muffled, and peripheral pulses are diminished. What action should the nurse take first?
 
  1. Notify the physician immediately.
  2. Recheck vital signs in 15 minutes.
  3. Reposition the patient.
  4. Increase the intravenous fluids.

Question 2

The nurse suspects that a patient experienced a transmural myocardial infarction. What electrocardiogram finding did the nurse use to make this clinical decision?
 
  1. Q wave deepening
  2. ST segment elevation
  3. ST segment depression
  4. P wave inversion

[lindahyatt42]

Answer to Question 1

Correct Answer: 1
The patient is exhibiting signs of cardiac tamponade. This is a medical emergency, and the physician must be notified immediately. Delaying the response by waiting 15 minutes or repositioning the patient will be ineffective. No change in intravenous fluids should be made until a physician order is given to do so. Cardiac tamponade is a life-threatening postoperative complication that can lead to cardiogenic shock and possibly cardiac arrest.

Answer to Question 2

Correct Answer: 1
A significant Q wave develops with a transmural infarction, so this also may be called a Q-wave MI. ST segment elevation represents myocardial ischemia, which is reversible by increasing the blood flow to the heart. ST segment depression occurs when muscle ischemia involves only a portion of the heart wall. P wave inversion represents a junctional pacemaker in the heart and is not related to changes that occur with a myocardial infarction.

[jjjetplane]

Excellent

[fatboyy09]

TYSM