# Situation: A 40-year-old man with tuberculous pericarditis, who takes antituberculosis drugs under the National Tuberculosis Program (NTP), is admitted to the medical ward with a large pericardial effusion. Bedside echocardiography shows early cardiac tamponade, and pericardiocentesis is being arranged. While the procedure is being prepared, his blood pressure is 92/70 mmHg, heart rate 124/min, and his neck veins are distended. Which prescribed order should the nurse question?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629891  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 40-year-old man with tuberculous pericarditis, who takes antituberculosis drugs under the National Tuberculosis Program (NTP), is admitted to the medical ward with a large pericardial effusion. Bedside echocardiography shows early cardiac tamponade, and pericardiocentesis is being arranged.

While the procedure is being prepared, his blood pressure is 92/70 mmHg, heart rate 124/min, and his neck veins are distended. Which prescribed order should the nurse question?

## 보기

1. Metoprolol 5 mg intravenously for the tachycardia **✔ 정답**
2. Oxygen by face mask to keep oxygen saturation at 94% or higher
3. 0.9% sodium chloride 500 mL intravenously over 15 minutes
4. Semi-Fowler's position with continuous cardiac monitoring

**정답: 1**

## 해설

In tamponade the heart can fill only a small volume with each beat, so the compensatory tachycardia is what keeps cardiac output up; a beta blocker that slows it can precipitate collapse. The distended neck veins reflect compression rather than fluid overload, so a modest fluid bolus is an acceptable bridge that raises preload to keep the right heart filling. Oxygen, upright positioning, and monitoring are appropriate bridges until the fluid is drained.

## 심화 해설

Tachycardia is keeping him alive
In cardiac tamponade, fluid in the pericardial sac raises the pressure around the heart and prevents the ventricles from filling. Each beat therefore ejects only a small stroke volume. Cardiac output equals stroke volume times heart rate, so when stroke volume is fixed and small, the compensatory tachycardia of 124/min is what keeps output up. A beta blocker such as metoprolol slows the heart and removes this compensation, which can drop cardiac output and cause collapse; this is the order to question.

Reading the signs
His blood pressure is 92/70 mmHg, giving a narrow pulse pressure of 22 mmHg, which reflects the small stroke volume. His neck veins are distended because blood cannot enter the compressed right heart, not because he has too much fluid. Together with the echocardiographic finding of early tamponade, these findings fit the classic picture of hypotension, jugular venous distension, and, often, muffled heart sounds. The definitive treatment is drainage by pericardiocentesis, and everything else is a bridge to that procedure.

| Order | Assessment | Reason |
| --- | --- | --- |
| Metoprolol 5 mg IV for tachycardia | Question | Removes the compensation that maintains cardiac output |
| Oxygen to keep SpO2 94% or higher | Appropriate | Supportive care |
| 0.9% sodium chloride 500 mL over 15 minutes | Acceptable bridge | Raises preload against high pericardial pressure |
| Semi-Fowler's with continuous monitoring | Appropriate | Eases breathing, detects deterioration |

Why the fluid bolus is not the order to question
It can seem wrong to give fluid to a client with distended neck veins. In tamponade, however, the high venous pressure is caused by compression, and the ventricle needs a higher filling pressure to overcome the pericardial pressure. A modest fluid bolus raises preload and can temporarily support filling and blood pressure, especially when the systolic pressure is below 100 mmHg. Oxygen to the target saturation, an upright position to ease breathing, and continuous cardiac monitoring are also appropriate while drainage is arranged.

Watch out! Drugs that reduce preload or heart rate, such as beta blockers, diuretics, and nitrates, are dangerous in tamponade. Positive-pressure ventilation can also reduce venous return and worsen the picture.

Exam takeaway
Key point! In tamponade, do not slow the heart or reduce preload: the fast heart rate and adequate filling are what maintain cardiac output. Support with oxygen, positioning, monitoring, and cautious fluid, and prepare for pericardiocentesis. His tuberculous pericarditis also means his NTP treatment continues.

## 임상 시나리오

Cardiac Tamponade: Orders to QuestionProtecting compensation until drainage
In tamponade, pericardial pressure limits filling, so each beat ejects a small stroke volume. The tachycardia of 124/min maintains cardiac output.

A beta blocker such as metoprolol removes this compensation and can cause collapse. Question it.

Oxygen, semi-Fowler's position, continuous monitoring, and a modest fluid bolus are acceptable bridges until pericardiocentesis.

CautionAvoid drugs that slow the heart or reduce preload, such as beta blockers, diuretics, and nitrates; the distended neck veins reflect compression, not fluid overload.

## 핵심 개념

- **Cardiac tamponade** — Compression of the heart by fluid in the pericardial sac that limits filling and lowers cardiac output.
- **Compensatory tachycardia** — A faster heart rate that maintains cardiac output when stroke volume falls.
- **Pericardiocentesis** — Needle drainage of fluid from the pericardial sac to relieve tamponade.
- **Pulse pressure** — The difference between systolic and diastolic pressure; it narrows when stroke volume is small.
- **Preload** — The filling of the ventricles before contraction, which a fluid bolus can raise.

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