A client one (1) day postoperative for coronary artery bypass graft (CABG) reports chest pain.
Which intervention should the nurse implement first?

Choice A rationale

Checking the blood pressure is not the priority action in this case. The symptoms described may suggest compartment syndrome, which is a medical emergency and requires immediate intervention.

Choice B rationale

The correct action is to notify the health care provider immediately as this may indicate compartment syndrome, a serious complication that can occur after fractures and can lead to permanent damage if not treated promptly.

Choice C rationale

Assessing the incision for redness is not appropriate in this scenario as the symptoms suggest a more severe underlying issue such as compartment syndrome, which requires urgent attention.

Choice D rationale

Repositioning the leg may provide temporary relief but does not address the potential underlying issue of compartment syndrome. The priority is to notify the health care provider.

Choice A rationale

Administering insulin when the breakfast tray arrives may not provide sufficient time for the insulin to take effect before the client begins eating, potentially leading to hyperglycemia.

Choice B rationale

Administering insulin at 07: is too early and may result in hypoglycemia before the client eats breakfast.

Choice C rationale

Administering insulin at 07: allows sufficient time for the insulin to take effect before the client eats breakfast, helping to maintain appropriate blood glucose levels.

Choice D rationale

Administering insulin 30 minutes after breakfast is too late and could result in hyperglycemia since the client would have already consumed carbohydrates.