A Client with Suspected Moderate to Large Pericardial Effusion Is

A client with suspected moderate to large pericardial effusion is admitted for monitoring.  The nurse performs a head-to-toe assessment.  Which of these findings indicate likely cardiac tamponade and require immediate intervention?  Select all that apply.

A) Blood pressure of 90/70 mm Hg
B) Bounding peripheral pulses
C) Decreased breath sounds on left side
D) Distant heart tones
E) Jugular venous distension

Correct Answer:

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