Question

Assessment findings for a patient with acute pericarditis indicate neck vein distention, clear lungs, muffled heart sounds, tachycardia, tachypnea, and a greater than 10 mm Hg difference in systolic pressure on inspiration than on expiration. What is the nurse's first response to these assessment findings?

a. Continue to monitor the patient; these are normal signs of pericarditis.
b. Administer oxygen and immediately report the findings to the health care provider.
c. Monitor oxygen saturation and seek order for pain medication to control symptoms.
d. Check ECG, administer morphine for pain, and administer diuretics.

Answer 1

The nurse's first response to these assessment findings would be to administer oxygen and immediately report the findings to the healthcare provider.

Step-by-step explanation:

The nurse's first response to these assessment findings would be to b. Administer oxygen and immediately report the findings to the healthcare provider. These findings indicate potential complications of acute pericarditis, such as cardiac tamponade. Administering oxygen can help improve oxygenation, while reporting the findings to the healthcare provider allows for further evaluation and appropriate interventions.