a client who is post-op day 2 from a spinal fusion at L3-4 with a pain level of 4 on a scale of 1 – 10
a client with a peripheral IV on a 6-hour infusion with 42 cc remaining
a client who is 6 hours post–atrial fibrillation ablation, is agitated, has a HR of 130 with B/P at 90/50, and has a urine output of 30 cc in the last 2 hours
a client with a nasogastric tube in place who is complaining of gastric distress
Number 3 is correct.
The client who is post–atrial fibrillation ablation is experiencing symptoms of cardiac tamponade, a serious complication seen after this procedure. Cardiac tamponade occurs when the ablation penetrates the pericardium allowing fluid to collect, preventing the heart from expanding properly. Emergency intervention is required with this client, including a pericardiocentesis up to a thoracotomy to drain fluid. The other clients may be seen after assessing the client for a cardiac tamponade. While each of these needs is important to address quickly, the nurse first addresses situations that may be life-threatening for the client.
