# A 64-year-old patient three days post-MI has BP 84/62, HR 124, distant heart sounds, jugular venous distention, and pulsus paradoxus of 16 mm Hg. The cardiac monitor shows narrow QRS sinus tachycardia. Which is the nurse's priority intervention?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372747&lang=en  
> language: en  
> subject: Complications of Procedures  
> category: ROR

## Question

A 64-year-old patient three days post-MI has BP 84/62, HR 124, distant heart sounds, jugular venous distention, and pulsus paradoxus of 16 mm Hg. The cardiac monitor shows narrow QRS sinus tachycardia. Which is the nurse's priority intervention?

## Option

1. Administer IV furosemide 40 mg to reduce venous congestion.
2. Place the patient supine and prepare for immediate intubation.
3. Notify the provider, prepare for emergent pericardiocentesis, give isotonic IV fluid bolus, and apply oxygen. **✔ Correct answer**
4. Initiate beta-blocker therapy to slow the heart rate and improve filling.

**Correct answer: 3**

## Explanation

Beck's triad — hypotension, distant heart sounds, and JVD — with pulsus paradoxus >10 mm Hg in a post-MI patient is cardiac tamponade. Tamponade is obstructive shock from fluid in the pericardial space compressing the heart and limiting diastolic filling. Priority: notify provider, prepare for emergent pericardiocentesis (definitive treatment), and bridge with IV fluid bolus to increase preload and oxygen support. Diuretics (choice 1) drop preload and worsen tamponade. Supine intubation (choice 2) without decompression worsens hemodynamics. Beta-blockers (choice 4) drop HR and CO and are contraindicated.

## In-depth explanation

Cardiac tamponade is obstructive shock from fluid in the pericardial space compressing the heart, limiting diastolic filling, and reducing cardiac output. Common causes are pericarditis, post-MI free wall rupture or Dressler syndrome, malignancy, trauma, and post-cardiac surgery. Hallmarks are Beck's triad (hypotension, distant heart sounds, JVD) plus pulsus paradoxus greater than 10 mm Hg. Pulsus paradoxus is a drop in systolic BP greater than 10 mm Hg during inspiration, detected by sphygmomanometer or arterial line, and is specific for diseases that exaggerate the normal inspiratory drop in left ventricular filling: tamponade, severe asthma, COPD exacerbation, and tension pneumothorax. Pericardiocentesis is the emergent percutaneous drainage of pericardial fluid via the subxiphoid or apical approach under echocardiographic or fluoroscopic guidance and is the definitive treatment; surgical window or drainage may follow if recurrent.

## Clinical scenario

A **64-year-old patient 3 days post-MI**: **BP 84/62, HR 124, distant heart sounds, JVD, pulsus paradoxus 16 mm Hg**. Cardiac monitor shows **narrow QRS sinus tachycardia**.

## Key concepts

- **Cardiac Tamponade** — Obstructive shock from fluid in the pericardial space compressing the heart, limiting diastolic filling, and reducing cardiac output. Common causes: pericarditis, post-MI free wall rupture or Dressler syndrome, malignancy, trauma, post-cardiac surgery. Hallmarks: Beck's triad (hypotension, distant heart sounds, JVD) plus pulsus paradoxus >10 mm Hg.
- **Pulsus Paradoxus** — A drop in systolic BP >10 mm Hg during inspiration. Detected by sphygmomanometer or arterial line. Specific for diseases that exaggerate the normal inspiratory drop in left ventricular filling — tamponade, severe asthma, COPD exacerbation, tension pneumothorax.
- **Pericardiocentesis** — Emergent percutaneous drainage of pericardial fluid via subxiphoid or apical approach under echocardiographic or fluoroscopic guidance. Definitive treatment for tamponade. Window or surgical drainage may follow if recurrent.

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