A client is scheduled for coronary artery bypass graft (CABG) surgery. Which assessment finding would indicate the most urgent need for intervention before the procedure?

The client is scheduled to receive preoperative antibiotics.

The client has a history of hypertension.

The client reports severe chest pain and diaphoresis.

The client expresses anxiety about the surgery.

Answer and Explanation

The Correct Answer is C

Coronary artery bypass graft (CABG) surgery is performed to restore adequate myocardial blood flow in clients with significant coronary artery disease. Preoperative assessment focuses on identifying unstable cardiac conditions that may increase perioperative risk. Signs of acute myocardial ischemia require immediate intervention because they indicate ongoing cardiac tissue hypoxia. Stabilizing the client before surgery is essential to reduce the risk of intraoperative complications and myocardial damage.

Rationale:
A. The client is scheduled to receive preoperative antibiotics is a routine perioperative measure and does not indicate an urgent problem. Antibiotics are commonly administered before CABG surgery to reduce the risk of postoperative infection, particularly mediastinitis. This is standard care and not a condition requiring immediate intervention.

B. The client has a history of hypertension is a common comorbidity in clients undergoing CABG surgery and is expected. While blood pressure must be controlled preoperatively, a history of hypertension alone does not represent an acute or urgent finding. Management typically involves continued medication and monitoring rather than emergency intervention.

C. The client reports severe chest pain and diaphoresis is the most urgent finding because it suggests ongoing myocardial ischemia or possible acute coronary syndrome. These symptoms indicate inadequate oxygen supply to the heart muscle and require immediate evaluation and stabilization before surgery. Proceeding with CABG without addressing active ischemia increases the risk of perioperative myocardial infarction.

D. The client expresses anxiety about the surgery is a common and expected psychological response. Preoperative anxiety can be addressed through education, reassurance, and emotional support. While important for holistic care, it does not represent an immediate physiological threat requiring urgent intervention compared to active cardiac ischemia.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Immunization assessment and appropriate nursing interventions for hepatitis B vaccination are vital for patients at risk. Hepatitis B is a viral infection transmitted through blood and body fluids, and vaccination is the primary method of prevention. Clients who have incomplete vaccination series require completion rather than delay, unless specific contraindications exist. Nursing care includes reviewing immunization history, educating about disease transmission, and ensuring timely vaccination to establish immunity.

Rationale:

• Review client's immunization history to assess previous hepatitis B vaccine administration: Reviewing immunization records is a foundational nursing responsibility to determine vaccination status and identify missing or incomplete doses. This ensures accurate assessment of immunity and prevents unnecessary delays in protection. In this case, the client has an incomplete hepatitis B series, making record review essential. It guides appropriate next steps in vaccination planning.

• Advise the client to complete the three-dose hepatitis B vaccination series for optimal protection: Completion of the hepatitis B vaccine series is necessary to achieve full and long-lasting immunity. A single dose does not provide adequate protection against infection. Since the client has only one documented dose, continuation of the series is recommended without restarting. This is standard preventive care in primary health settings.

• Provide education regarding the risk factors for hepatitis B transmission: Client education is essential to reduce exposure risk and promote understanding of disease prevention. Hepatitis B is transmitted through infected blood and body fluids, including sexual contact, needle sharing, and occupational exposure. Teaching reinforces the importance of vaccination and safe practices. This supports informed health decisions and prevention of infection.

• Recommend delaying the hepatitis B vaccine until the client has undergone hepatitis antibody testing: Delaying vaccination for routine antibody testing is not recommended in clients with incomplete immunization records and no contraindications. Hepatitis B vaccination can be safely administered without prior serologic testing in most cases. Delaying increases the risk of preventable infection.

A. 20 and 25 mm Hg B. 20 to 30 mm Hg C. 20 to 30 cm H20 D. 24 and 30 mm Hg

Correct Answer is C

Explanation

Endotracheal tube cuff inflation is critical for maintaining a secure airway in mechanically ventilated clients. The cuff creates a seal within the trachea to prevent air leaks and aspiration of secretions into the lower respiratory tract. However, excessive cuff pressure can compromise tracheal mucosal perfusion, leading to ischemia, ulceration, and long-term tracheal damage. Therefore, cuff pressure must be carefully maintained within a safe therapeutic range.

Rationale:
A. 20 to 25 mm Hg is incorrect because cuff pressure is measured in centimeters of water (cm H₂O), not millimeters of mercury (mm Hg). Using the wrong unit reflects a misunderstanding of airway pressure monitoring and may lead to improper interpretation of safe pressure ranges.

B. 20 to 30 mm Hg is also incorrect because both the unit and range are inappropriate for endotracheal cuff monitoring. Even if converted, this pressure would exceed safe tracheal mucosal perfusion limits, increasing the risk of ischemia and tissue necrosis. Accurate measurement in cm H₂O is essential for safe practice.

C. 20 to 30 cm H₂O is correct because this is the recommended safe range for endotracheal cuff inflation. Maintaining pressure within this range provides an effective seal to prevent aspiration while preserving capillary blood flow to the tracheal mucosa. Pressures above this range can impair perfusion and lead to tracheal injury.

D. 24 to 30 mm Hg is incorrect due to both incorrect units and excessive pressure values. This range would significantly exceed safe tracheal mucosal perfusion pressure if interpreted clinically. Sustained high cuff pressures increase the risk of tracheal necrosis, stenosis, and long-term airway complications.

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A client is scheduled for coronary artery bypass graft (CABG) surgery. Which assessment finding would indicate the most urgent need for intervention before the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

What is the recommended cuff inflation pressure for an endotracheal tube to prevent tissue necrosis in a client?

Correct Answer is C

Explanation

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