A nurse is planning care for a client who is 8 hr postoperative following a coronary artery bypass grafting. Which of the following assessments should the nurse plan to perform first?

Examine the surgical incision for drainage.

Auscultate breath sounds.

Measure the client's core body temperature.

Palpate pulses distal to the graft donor site.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Examine the surgical incision for drainage: While it is important to monitor the surgical site for any signs of infection or drainage, assessing the client's respiratory status takes precedence. Ensuring proper breathing and oxygenation is critical immediately post surgery.

B. Auscultate breath sounds: Auscultating breath sounds should be the first priority. Respiratory complications like atelectasis or pneumonia are common after cardiac surgery, and it is crucial to assess for adequate ventilation and oxygenation in the early postoperative period.

C. Measure the client's core body temperature: Although monitoring body temperature is necessary, fever in the early postoperative period can be common. The priority is to evaluate the client's respiratory and circulatory stability.

D. Palpate pulses distal to the graft donor site: Checking pulses distal to the graft donor site is important for circulation monitoring, but it should not be the first assessment. Ensuring respiratory function is more urgent in the first 8 hours after CABG surgery.

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Correct Answer is ["A","D"]

Explanation

Rationale:

A. Strict I&O: Monitoring intake and output is essential due to decreased urination, flank pain, and impaired kidney function. The elevated BUN and creatinine levels suggest renal impairment, and strict I&O helps assess fluid balance.

B. Increase fluid intake: While hydration is important, increasing fluids should be done cautiously due to the client’s impaired kidney function. Given the elevated BUN and creatinine, the kidneys may not manage increased fluids without worsening fluid retention.

C. Encourage protein supplements: Protein supplements are not recommended in kidney dysfunction, as they can worsen renal strain. Elevated BUN and creatinine levels indicate kidney impairment, and protein intake may aggravate the condition.

D. Strain all urine: Straining all urine is necessary to capture any possible kidney stones, blood clots, or debris. The reddish-brown urine and positive blood in the urinalysis suggest hematuria, which may need further investigation.

A. Dyspnea at rest B. Pursed-lip breathing C. Clubbing of the fingers D. SP02 90%

Correct Answer is A

Explanation

Rationale:

A. Dyspnea at rest: Dyspnea at rest is a sign of advanced COPD, indicating that the client is experiencing significant respiratory difficulty. Pulmonary rehabilitation can help improve exercise tolerance and breathing, making this an appropriate reason for referral.

B. Pursed-lip breathing: Pursed-lip breathing is a technique often used by clients with COPD to help manage shortness of breath. It is not an indication for pulmonary rehabilitation, but rather a self-management strategy.

C. Clubbing of the fingers: Clubbing of the fingers can be a sign of chronic hypoxia and is commonly seen in advanced COPD. However, it does not directly indicate the need for pulmonary rehabilitation, although the condition may benefit from comprehensive care.

D. SPO2 90%: A SpO2 of 90% is low but not necessarily an indication for referral to pulmonary rehabilitation. It is important to monitor oxygen levels, but this alone does not trigger the need for rehabilitation.

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A nurse is planning care for a client who is 8 hr postoperative following a coronary artery bypass grafting. Which of the following assessments should the nurse plan to perform first?

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Naxlex Comprehensive Predictor Exams

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