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?

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.

Rationale:

A. Obtain the client's vital signs: While vital signs are important after a seizure, they are not the priority during the event. The first action should focus on protecting the client from injury and ensuring their airway remains open.

B. Notify the rapid response team: Notifying the rapid response team is not the first step. The nurse should prioritize ensuring the client’s safety during the seizure, including turning them on their side to prevent aspiration or injury.

C. Perform a neurologic check: A neurologic check is important after the seizure has ended to assess for changes in mental status or neurological function. However, during the seizure, the immediate priority is to ensure the client’s safety and airway.

D. Turn the client on their side: This priority action during a tonic-clonic seizure helps maintain the airway, prevents aspiration, and allows any secretions to drain from the mouth. Ensuring safety during the seizure is crucial before performing other assessments.