After a cardiac procedure, a client develops hypotension, jugular venous distention, muffled heart sounds, and a narrowing pulse pressure. Which action should the nurse take first?
1Lower the head of the bed and reassess after a routine fluid bolus
2Encourage frequent coughing and deep breathing to expand postoperative lungs
3Activate emergency response and prepare for urgent pericardial drainage✓ Correct answer
4Administer a prescribed diuretic to reduce jugular venous distention
Explanation
The findings indicate cardiac tamponade with impaired ventricular filling and falling cardiac output. This is an obstructive shock emergency, so the nurse should activate an emergency response and prepare for urgent pericardial drainage rather than delay definitive treatment.
Quick answer Treat these findings as cardiac tamponade. Activate emergency help and prepare for urgent drainage of the pericardial fluid.
Why this is correct Pressure from fluid around the heart prevents the ventricles from filling, which lowers stroke volume and blood pressure while venous pressure rises. Pericardiocentesis or surgical drainage relieves the pressure causing the obstruction.
Easy analogy or mental picture Tamponade is like a strong bag tightening around a pump so the pump cannot refill. Removing pressure restores filling, but the analogy does not identify the cause or replace rapid hemodynamic assessment and resuscitation.
Memory hook Low pressure outside the veins plus high pressure in the neck plus quiet heart sounds means pressure around the heart must be relieved.
NCLEX decision rule When hypotension, venous distention, and muffled heart sounds appear after a cardiac procedure, prioritize emergency escalation and preparation for pericardial drainage. Do not treat the neck veins as simple fluid overload.
Why the other choices are wrong A routine reassessment delays emergency treatment. Coughing does not relieve pericardial pressure, and a diuretic can worsen preload and cardiac output in tamponade.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
AHA: Treatment of Pericarditis and Cardiac TamponadeAmerican Heart Association, reviewed 2026