ESTUDYR
NCLEX-RN Case Study: Cardiac Tamponade
Client Scenario
1100 Nurses' Notes: A 62-year-old male is 24 hours postoperative following a Coronary
Artery Bypass Graft (CABG). The nurse notes that the chest tube drainage, which was 100
mL/hr, has suddenly stopped. The client reports feeling "very short of breath" and "heavy"
in his chest.
Physical Assessment:
Cardiovascular: Heart sounds are very faint and difficult to hear (muffled). Jugular
venous distention (JVD) is noted while the client is sitting at 45 degrees.
Respiratory: Tachypnea; lungs are clear to auscultation.
Vital Signs: BP 92/78, HR 118, RR 24.
Hemodynamics: The nurse notes a 15 mmHg drop in Systolic BP during inspiration
(Pulsus Paradoxus).
Item 1: Recognizing Cues (Visual/Beck's Triad)
Question: The nurse identifies a specific cluster of signs. Which diagram correctly illustrates
the components of Beck’s Triad?
Correct Findings to Identify:
✅Muffled or Distant Heart Sounds (Fluid acts as an insulator)
✅Jugular Venous Distention (JVD) (Blood cannot enter the right atrium)
✅Hypotension with Narrowing Pulse Pressure (Reduced stroke volume)
Rationale: When fluid (blood or effusion) fills the pericardial sac, it compresses the heart
chambers. This prevents the heart from filling properly, leading to a backup of pressure in
the veins (JVD) and a massive drop in cardiac output (Hypotension).
Item 2: Analyzing Cues (Pulsus Paradoxus)
Question: The nurse measures the client's blood pressure and notes Pulsus Paradoxus.
Which description accurately defines this finding?
NCLEX-RN Case Study: Cardiac Tamponade
Client Scenario
1100 Nurses' Notes: A 62-year-old male is 24 hours postoperative following a Coronary
Artery Bypass Graft (CABG). The nurse notes that the chest tube drainage, which was 100
mL/hr, has suddenly stopped. The client reports feeling "very short of breath" and "heavy"
in his chest.
Physical Assessment:
Cardiovascular: Heart sounds are very faint and difficult to hear (muffled). Jugular
venous distention (JVD) is noted while the client is sitting at 45 degrees.
Respiratory: Tachypnea; lungs are clear to auscultation.
Vital Signs: BP 92/78, HR 118, RR 24.
Hemodynamics: The nurse notes a 15 mmHg drop in Systolic BP during inspiration
(Pulsus Paradoxus).
Item 1: Recognizing Cues (Visual/Beck's Triad)
Question: The nurse identifies a specific cluster of signs. Which diagram correctly illustrates
the components of Beck’s Triad?
Correct Findings to Identify:
✅Muffled or Distant Heart Sounds (Fluid acts as an insulator)
✅Jugular Venous Distention (JVD) (Blood cannot enter the right atrium)
✅Hypotension with Narrowing Pulse Pressure (Reduced stroke volume)
Rationale: When fluid (blood or effusion) fills the pericardial sac, it compresses the heart
chambers. This prevents the heart from filling properly, leading to a backup of pressure in
the veins (JVD) and a massive drop in cardiac output (Hypotension).
Item 2: Analyzing Cues (Pulsus Paradoxus)
Question: The nurse measures the client's blood pressure and notes Pulsus Paradoxus.
Which description accurately defines this finding?
