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Nursing QUESTION #9244
Question 1
A Charge Nurse is caring for a post-cardiac surgery patient. The patient develops cardiac tamponade. Which clinical triad is MOST characteristic?
  • Hypertension, bradycardia, and widened pulse pressure
  • Hypotension, muffled heart sounds, and distended neck veins (Beck's Triad)✔️
  • Tachycardia, hypertension, and pulmonary edema
  • Fever, pericardial friction rub, and sharp chest pain
Correct Answer Explanation
Correct Answer: B — Beck's Triad

Cardiac Tamponade: Beck's Triad
  1. Hypotension — reduced cardiac output due to compression
  2. Muffled (distant) heart sounds — fluid surrounding the heart dampens sounds
  3. Jugular venous distension (JVD) — elevated venous pressure as blood cannot enter compressed heart
Additional signs:
  • Pulsus paradoxus \(> 10 \text{ mmHg}\): Exaggerated fall in systolic BP during inspiration
  • Tachycardia (compensatory)
  • Electrical alternans on ECG (alternating QRS amplitude)
  • Enlarged cardiac silhouette on CXR ('water bottle' heart)
Treatment: Pericardiocentesis (emergency needle drainage) — nurse must prepare equipment immediately. Do NOT give diuretics (worsens hypovolemia). Volume loading may temporarily support BP.