Cardiac-Vascular Nursing (CVRN) Practice Exam

What should the nurse's first action be if a patient develops sinus tachycardia after pacemaker wire removal?

1. Call the surgeon

2. Call the crash cart

3. Assess signs of cardiac tamponade

4. Call the respiratory therapist

The correct answer is: Assess signs of cardiac tamponade

In the context of a patient developing sinus tachycardia after pacemaker wire removal, the first action should involve assessing for signs of cardiac tamponade. Cardiac tamponade is a serious condition where fluid accumulates in the pericardial space, exerting pressure on the heart and compromising its ability to pump effectively. After pacemaker wire removal, there is a risk of bleeding or fluid accumulation that could lead to this condition. The symptoms of cardiac tamponade can include tachycardia, which is why identifying it as a potential cause of the patient’s sinus tachycardia is crucial. Early recognition and intervention are vital for patient safety and can be life-saving. If cardiac tamponade is present, prompt treatment is necessary to alleviate the pressure on the heart. While notifying the surgeon and calling the crash cart could be important steps in the event of a serious condition, the initial response should prioritize assessing the patient for signs of tamponade, as this condition requires immediate intervention if confirmed. Calling the respiratory therapist does not directly address the primary concern of possible hemodynamic instability that could arise from cardiac tamponade.