A nurse is caring for a patient who underwent cardiac surgery 24 hours ago. The patient reports chest pain, shortness of breath, and has decreased urine output. On assessment, the nurse notes hypotension and tachycardia. What is the most appropriate initial nursing intervention?

1 Administer a prescribed laxative to stimulate bowel movement
2 Insert a nasogastric tube for gastric decompression
3 Notify the physician immediately and prepare for urgent assessment and emergency intervention ✓ 정답
4 Position the patient in high Fowler's position and apply heat to the abdomen

해설

Chest pain, shortness of breath, hypotension, tachycardia, and decreased urine output 24 hours post-cardiac surgery are classic signs of cardiac tamponade or low cardiac output syndrome (LCOS)—both hemodynamic emergencies. The most appropriate initial nursing intervention is to immediately notify the physician and prepare for urgent assessment and emergency interventions (e.g., echocardiogram, ECG, inotropes/vasopressors, or pericardiocentesis). The other options (laxative, NG tube, abdominal heat) address GI/abdominal complications and are not indicated in this scenario.

같은 주제 다음 문제A nurse is assessing a patient 24 hours after abdominal surgery. Which assessment finding …이 문제가 수록된 문제집[개념+기출] 엔클렉스(NCLEX),이거 하나면 됩니다89,000원 · 무료 체험 가능

심화 해설

Understanding the Clinical Presentation

The patient's symptoms 24 hours after cardiac surgery—chest pain, shortness of breath, hypotension, tachycardia, and decreased urine output—are hallmark signs of cardiac tamponade or low cardiac output syndrome (LCOS). In both conditions, effective stroke volume is severely compromised: cardiac tamponade results from pericardial fluid accumulation compressing the heart, while LCOS reflects transient myocardial stunning. The result is poor end-organ perfusion—oliguria from renal hypoperfusion, chest pain from coronary under-perfusion, and dyspnea from pulmonary congestion. Tachycardia is the compensatory response that further increases myocardial oxygen demand and worsens the cycle.

Why Immediate Physician Notification Is the Priority Intervention

This presentation constitutes a hemodynamic emergency. The most appropriate initial nursing action is to immediately notify the physician using structured communication (SBAR) and to prepare for urgent diagnostic and therapeutic interventions, which may include:

Emergent echocardiogram to rule out cardiac tamponade
12-lead ECG and chest X-ray
Laboratory tests: cardiac enzymes, ABG, lactate, electrolytes
Initiation or titration of inotropes/vasopressors (e.g., dobutamine, norepinephrine) as prescribed
Possible pericardiocentesis if tamponade is confirmed

Early escalation is the cornerstone of managing hemodynamic instability. Independent nursing interventions aimed at the gastrointestinal system are not appropriate and dangerously delay life-saving care.

Analyzing the Incorrect Options

Administering a laxative, inserting a nasogastric tube, and positioning in high Fowler's with abdominal heat are interventions for postoperative ileus or abdominal distension following abdominal surgery. These actions have no role in the management of cardiac tamponade or LCOS and must not delay escalation of care.

Encouraging oral fluid intake is contraindicated in this context. The problem is pump failure or pericardial compression, not volume depletion. Promoting oral fluids neither addresses hemodynamic instability nor is it safe: excessive fluid in a failing heart can precipitate pulmonary edema.

Key Nursing Takeaway

The nurse's role in hemodynamic emergencies is rapid recognition, immediate escalation, and preparation for provider-directed interventions. Applying GI-oriented interventions in a cardiac emergency reflects a failure to differentiate the clinical context and can result in catastrophic patient harm.

임상 시나리오

Clinical Practice Guide: Post-Cardiac Surgery Deterioration

Recognizing and Responding to Low Cardiac Output Syndrome (LCOS)

Clinical Scenario

A patient 24 hours post-cardiac surgery presents with a classic triad of chest pain, shortness of breath, and oliguria, accompanied by vital sign changes of hypotension and tachycardia. This presentation is a medical emergency requiring immediate provider notification, not independent nursing interventions for abdominal complications.

Key Assessment Findings

Cardiovascular: Hypotension, tachycardia, possible narrowed pulse pressure, chest pain.
Respiratory: Shortness of breath, tachypnea, crackles, hypoxia.
Renal: Decreased urine output (oliguria, less than 0.5 mL/kg/hr).
Peripheral: Cool, clammy skin, delayed capillary refill, altered mental status.

Priority Nursing Actions

Immediate Provider Notification: Report the full clinical picture using SBAR communication. This is the most critical initial action.
Hemodynamic Support: Prepare for potential interventions such as fluid resuscitation (with caution), initiation or titration of inotropic/vasopressor medications (e.g., dobutamine, milrinolone, norepinephrine) as prescribed.
Optimize Oxygenation: Apply oxygen to maintain SpO2, and prepare for possible non-invasive or mechanical ventilation if respiratory failure is imminent.
Continuous Monitoring: Closely monitor vital signs, cardiac rhythm, intake and output, and oxygen saturation every 5-15 minutes.
Diagnostic Preparation: Anticipate and prepare for a 12-lead ECG, chest X-ray, echocardiogram, and laboratory tests (cardiac enzymes, ABG, lactate, electrolytes).

Differential Considerations

While LCOS is the most likely diagnosis, the nurse must also consider other postoperative complications that present similarly, including cardiac tamponade, acute graft failure, pulmonary embolism, and tension pneumothorax. The immediate response is the same: rapid recognition and escalation of care.

Safety Alert

Do Not Delay Care: Do not implement interventions for ileus or abdominal distension (laxatives, NG tube, heat application) in a patient with clear signs of hemodynamic instability. These actions are not indicated and delay life-saving treatment. Fluid administration without a specific order can precipitate pulmonary edema in a failing heart.

핵심 개념

Low Cardiac Output Syndrome — A temporary state of decreased cardiac pump function after cardiac surgery, leading to inadequate tissue perfusion and symptoms like hypotension, tachycardia, and oliguria.
Hemodynamic Instability — A state of abnormal or unstable blood pressure and heart rate, indicating compromised cardiovascular function and poor organ perfusion.
Oliguria — Decreased urine output, often defined as less than 0.5 mL/kg/hour, a key sign of reduced renal perfusion and a hallmark of low cardiac output.
Tachycardia — An abnormally rapid heart rate, often a compensatory mechanism for low stroke volume to maintain cardiac output, but it can further impair cardiac function.
Cardiac Tamponade — A potential postoperative complication where fluid accumulates in the pericardial sac, compressing the heart and mimicking low cardiac output syndrome symptoms.

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A nurse is caring for a patient who underwent cardiac surgery 24 hours ago. The patient reports chest pain, shortness of breath, and has decreased urine output. On assessment, the nurse notes hypotension and tachycardia. What is the most appropriate initial nursing intervention?

심화 해설

임상 시나리오

핵심 개념

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