HESI Compass exit proctored exam
A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?
Explanation & Rationale
Choice A reason: Observing for jugular vein distention is important but not the immediate intervention.Choice B reason: Monitoring oxygen saturation is necessary but secondary to preparing for pericardiocentesis.Choice C reason: Pericardiocentesis is the definitive treatment for cardiac tamponade, and notifying the healthcare provider to prepare for this procedure is the most important intervention.Choice D reason: Assessing for paradoxical blood pressure helps confirm cardiac tamponade but does not address the immediate need for treatment.
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