Difficulty: Medium
Average Score: 63%
Simulated
The nurse assessing the client with pericardial effusion at 1600 notes the apical pulse is 72 and the BP is 138/94. At 1800, the client has neck vein distention, the apical pulse is 70, and the BP is 106/94. Which action would the nurse implement first?
Correct answer
B
Rationale
JVD and hypotension (BP drop to 106/94) suggest cardiac tamponade; notifying the HCP (B) is urgent. Staying calm (A), lateral position (C), and morphine (D) are secondary.