A nurse is caring for a patient who is 12 hours post-op from a coronary artery bypass graft (CABG). The cardiac monitor shows new-onset atrial fibrillation with a rapid ventricular response. Which nursing actions should the nurse prioritize?

Hematocrit

Blood glucose

Urine output

Liver enzymes

Answer and Explanation

The Correct Answer is C

A. Hematocrit: While monitoring hematocrit is important post-CABG to detect bleeding or anemia, it does not provide immediate information about hemodynamic stability or perfusion in the setting of new-onset atrial fibrillation with rapid ventricular response.

B. Blood glucose: Blood glucose management is important for overall post-operative care, particularly in cardiac surgery patients, but it is not immediately related to acute hemodynamic changes caused by atrial fibrillation.

C. Urine output: Urine output is a key indicator of end-organ perfusion and cardiac output. In a patient with rapid atrial fibrillation post-CABG, decreased cardiac efficiency can reduce renal perfusion. Monitoring urine output allows early detection of hypoperfusion and guides interventions to maintain hemodynamic stability.

D. Liver enzymes: Liver function tests are important in assessing organ function over time, but acute changes in liver enzymes are not immediately sensitive indicators of cardiac output or perfusion. They are not the priority in the context of acute arrhythmia with rapid ventricular response.

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Correct Answer is C

Explanation

A. Sitting in the tripod position: Tripod positioning is a common compensatory mechanism in patients with COPD to maximize diaphragmatic expansion and ease breathing. While it indicates respiratory distress, it is an expected adaptive behavior and not immediately life-threatening.

B. O₂ saturation of 91%: An oxygen saturation of 91% is slightly below normal and should be monitored. In COPD patients, target saturations are often 88–92%, so this finding alone may not require urgent intervention if the patient is otherwise stable.

C. Respiratory rate has decreased from 30 to 10 breaths/min: A sudden drop in respiratory rate in a patient previously tachypneic is highly concerning, as it suggests impending respiratory failure or fatigue of the respiratory muscles. This change indicates inadequate ventilation and CO₂ retention, requiring immediate notification to the healthcare provider for urgent intervention.

D. Bilateral lung crackles: Crackles may indicate fluid overload, infection, or pulmonary edema, which are important to monitor and treat. However, in acute respiratory distress, a decreasing respiratory rate represents a more immediate threat to oxygenation and ventilation, making it the highest priority to report.

A. Avoid IM injections B. Avoid rectal thermometers C. Use a soft toothbrush D. Administer aspirin for headache E. Monitor stools for occult blood

Correct Answer is ["A","B","C","E"]

Explanation

A. Avoid IM injections: In immune thrombocytopenic purpura (ITP), platelet counts are low, increasing the risk of bleeding and hematoma formation with intramuscular injections. Using alternative routes such as oral or subcutaneous administration when possible reduces trauma to the tissues and prevents uncontrolled bleeding.

B. Avoid rectal thermometers: Rectal instrumentation can cause mucosal trauma and bleeding in patients with thrombocytopenia. Avoiding rectal thermometers helps prevent localized hemorrhage, which can be difficult to control in patients with ITP.

C. Use a soft toothbrush: Patients with ITP are at increased risk of oral mucosal bleeding due to low platelet counts. Using a soft-bristled toothbrush minimizes trauma to the gums during oral hygiene and reduces the risk of gingival bleeding.

D. Administer aspirin for headache: Aspirin has antiplatelet effects and can exacerbate bleeding tendencies in ITP. It should be avoided; alternative analgesics like acetaminophen are preferred. Administering aspirin could precipitate serious hemorrhagic complications.

E. Monitor stools for occult blood: Gastrointestinal bleeding is a potential complication of ITP. Monitoring stools for occult blood allows early detection of internal bleeding, even in the absence of overt symptoms, enabling timely intervention and management of hemorrhagic events.

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A nurse is caring for a patient who is 12 hours post-op from a coronary artery bypass graft (CABG). The cardiac monitor shows new-onset atrial fibrillation with a rapid ventricular response. Which nursing actions should the nurse prioritize?

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Naxlex Comprehensive Predictor Exams

A patient with chronic obstructive pulmonary disease arrives to the emergency department in acute respiratory distress. Which assessment finding, by the nurse is most important to report to the health care provider?

Correct Answer is C

Explanation

Which nursing interventions are appropriate for managing ITP? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

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A nurse is caring for a patient who is 12 hours post-op from a coronary artery bypass graft (CABG). The cardiac monitor shows new-onset atrial fibrillation with a rapid ventricular response. Which nursing actions should the nurse prioritize?