A client who recently had a permanent pacemaker insertion is in the immediate post-op period. Which finding should the nurse observe?

A client who recently had a permanent pacemaker insertion is in the immediate post-op period. Which finding should the nurse observe?

• A. Jaundice
• B. Beck's triad
• C. Hemoptysis
• D. Hyperkalemia

Answer: (B)

After permanent pacemaker placement, the priority is to watch for signs of cardiac tamponade from bleeding into the pericardial space. Cardiac tamponade reduces the heart’s ability to fill properly, causing a drop in cardiac output. The best finding to observe is Beck’s triad: hypotension, jugular venous distention, and muffled heart sounds. Together, these reflect fluid around the heart constraining its chambers. Other options don’t fit this immediate post-op risk. Jaundice isn’t an expected acute post-op sign after this procedure, hemoptysis points to airway or lung issues, and hyperkalemia causes rhythm and conduction problems rather than the hemodynamic pattern seen with tamponade. Monitoring for the triad allows rapid prompt action to prevent shock.

After permanent pacemaker placement, the priority is to watch for signs of cardiac tamponade from bleeding into the pericardial space. Cardiac tamponade reduces the heart’s ability to fill properly, causing a drop in cardiac output. The best finding to observe is Beck’s triad: hypotension, jugular venous distention, and muffled heart sounds. Together, these reflect fluid around the heart constraining its chambers.

Other options don’t fit this immediate post-op risk. Jaundice isn’t an expected acute post-op sign after this procedure, hemoptysis points to airway or lung issues, and hyperkalemia causes rhythm and conduction problems rather than the hemodynamic pattern seen with tamponade. Monitoring for the triad allows rapid prompt action to prevent shock.