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

Auscultate breath sounds.

Examine the surgical incision for drainage.

Palpate pulses distal to the graft donor site.

Measure the client's core body temperature.

Answer and Explanation

The Correct Answer is A

A. Auscultate breath sounds: Assessing breath sounds is the priority because postoperative cardiac clients are at risk for atelectasis, fluid accumulation, and respiratory compromise within the first hours after surgery. Early identification of decreased or absent breath sounds allows rapid intervention to maintain adequate oxygenation and prevent complications.

B. Examine the surgical incision for drainage: Inspecting the incision is important for monitoring bleeding or infection, but it is not the first priority within 1 hour postoperatively. Immediate postoperative priorities focus on airway and breathing before evaluating surgical sites, which can be assessed once respiratory stability is confirmed.

C. Palpate pulses distal to the graft donor site: Assessing peripheral perfusion is necessary to detect circulatory impairment after graft harvest, but this becomes a priority after airway and breathing have been evaluated. Ensuring adequate oxygenation takes precedence over extremity vascular assessment in the immediate postoperative period.

D. Measure the client's core body temperature: Temperature monitoring is required postoperatively, especially after cardiac surgery due to the risk of hypothermia, but it is not the first assessment needed. Respiratory evaluation and ensuring airway stability must occur before temperature or other secondary assessments.

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Correct Answer is B

Explanation

A. "I need to maintain pressure over the pacemaker site with an elastic bandage": Maintaining pressure with an elastic bandage is not necessary and could compromise circulation or irritate the pacemaker site. Proper care involves keeping the area clean and dry and avoiding heavy lifting, but applying pressure is not recommended.

B. "I need to check my pulse rate every day for a full minute.": Daily pulse checks help the client monitor for pacemaker function and detect possible bradycardia or missed beats. Recording the rate for a full minute ensures accuracy and allows early identification of any irregularities that may require medical evaluation.

C. “The pacemaker will deliver a shock if I develop a dysrhythmia.": Permanent pacemakers do not deliver shocks; they provide pacing to maintain an adequate heart rate. Devices that deliver shocks for dysrhythmias are implantable cardioverter-defibrillators (ICDs).

D. "When a microwave oven is in use, I need to stay out of the room.": Modern pacemakers are shielded from interference by household appliances like microwaves. Staying out of the room is unnecessary, as microwave use does not affect pacemaker function or pose a risk to the client.

A. Initiate cardiac monitoring B. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L C. Regular insulin 20 units subcutaneously D. 0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr E. Dextrose 5% in water (D5W) intravenous at 5 ml/kg/hr for 4 hr F. Insert indwelling urinary catheter G. Blood glucose checks every 4 hr H. Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L

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

Explanation

A. Initiate cardiac monitoring: Cardiac monitoring is important because the client has hyperkalemia (potassium 5.5 mEq/L) and is at risk for arrhythmias. Monitoring allows early detection of changes in cardiac rhythm, which can occur rapidly in electrolyte imbalances associated with hyperglycemic crises.

B. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L: Potassium replacement is not indicated at this time because the client’s serum potassium is elevated at 5.5 mEq/L. Administering potassium now could worsen hyperkalemia and increase the risk of life-threatening cardiac dysrhythmias.

C. Regular insulin 20 units subcutaneously: Subcutaneous insulin is not appropriate for severe hyperglycemia with ketoacidosis risk, as it has a slower onset and may not provide adequate glycemic control. Intravenous insulin infusion is preferred in this setting to allow rapid titration and prompt reduction of blood glucose and ketone levels.

D. 0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr: Aggressive IV fluid resuscitation with isotonic saline is indicated for dehydration from hyperglycemia and osmotic diuresis. Calculated fluid replacement helps restore intravascular volume, improve perfusion, and support renal function.

E. Dextrose 5% in water (D5W) intravenous at 5 ml/kg/hr for 4 hr: Dextrose is not indicated initially because the client’s blood glucose is extremely elevated at 468 mg/dL. Dextrose would worsen hyperglycemia at this stage. Dextrose is added later during insulin therapy when glucose levels fall to prevent hypoglycemia while continuing ketone clearance.

F. Insert indwelling urinary catheter: Routine catheterization is not indicated for this client, as there is no urinary retention or obstruction reported. Inserting a catheter unnecessarily increases the risk of infection without improving outcomes in hyperglycemia management.

G. Blood glucose checks every 4 hr: For a client with severe hyperglycemia and suspected DKA or hyperosmolar state, glucose monitoring every 4 hours is insufficient. Hourly monitoring is needed to safely titrate IV insulin and fluids, allowing rapid response to changing glucose and electrolyte levels.

H. Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L: Continuous IV insulin infusion is the treatment of choice for severe hyperglycemia with ketones and acidosis. It allows precise titration based on glucose levels while ensuring potassium levels are safe.

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

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