# A 58-year-old patient with metastatic lung cancer is admitted with progressive dyspnea, hypotension, jugular venous distention, and muffled heart sounds. Bedside echocardiography shows a moderate pericardial effusion with right ventricular collapse during diastole. Which actions should the nurse prioritize while preparing the patient for emergent pericardiocentesis? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372843&lang=en  
> language: en  
> subject: Physiological Adaptation  
> category: PA

## Question

A 58-year-old patient with metastatic lung cancer is admitted with progressive dyspnea, hypotension, jugular venous distention, and muffled heart sounds. Bedside echocardiography shows a moderate pericardial effusion with right ventricular collapse during diastole. Which actions should the nurse prioritize while preparing the patient for emergent pericardiocentesis? Select all that apply.

1

Establish two large-bore IV access sites and infuse normal saline boluses to support preload while obstructive shock is being addressed.

2

Position the head of bed at 30 to 45 degrees and apply supplemental oxygen to maintain SpO2 at or above 94 percent.

3

Place the patient on continuous cardiac monitoring with defibrillation pads in place because pericardial effusion can progress to PEA arrest.

4

Notify the cardiologist and prepare the pericardiocentesis tray, ensuring informed consent is documented before the procedure.

5

Administer sublingual nitroglycerin 0.4 mg now to reduce afterload and improve forward cardiac output in obstructive shock.

## Explanation

Cardiac tamponade is obstructive shock from pericardial fluid compressing the heart and limiting diastolic filling. Priorities are (1) preload support with IV fluids — preload-dependent physiology means dropping preload (e.g., nitroglycerin) is harmful, (2) continuous monitoring with defib pads ready because PEA arrest is a real risk, (3) oxygenation, and (4) emergent pericardiocentesis preparation. Choice 5 is contraindicated because nitroglycerin reduces preload and can precipitate cardiovascular collapse in tamponade physiology.

## In-depth explanation

Tamponade is preload-dependent: anything that drops preload (nitrates, diuretics, deep sedation) can convert compensated tamponade into PEA arrest. The first nursing actions are volume support, monitoring with defibrillation pads, oxygen, and procedural preparation — definitive treatment is needle/catheter drainage of the effusion under echo guidance.

## Clinical scenario

**58-year-old patient with metastatic lung cancer** develops progressive dyspnea, hypotension, jugular venous distention, and muffled heart sounds (Beck triad). **Bedside echocardiography** demonstrates a moderate pericardial effusion with right ventricular diastolic collapse. The provider has called for **emergent pericardiocentesis**.

## Key concepts

- **Cardiac tamponade** — Life-threatening compression of the heart by pericardial fluid causing obstructive shock; classic Beck triad of hypotension, jugular venous distention, and muffled heart sounds.
- **Pulsus paradoxus** — Inspiratory drop in systolic blood pressure greater than 10 mmHg; supports tamponade physiology when present.
- **Pericardiocentesis** — Emergent needle aspiration of pericardial fluid under echocardiographic guidance to relieve cardiac compression.

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