After a client has undergone coronary artery bypass graft surgery (CABG), which nursing intervention should be prioritized to minimize the risk of complications?
Encouraging the client to eat a full meal shortly after the procedure.
Assessing the client's vital signs regularly and monitoring for signs of surgical site infection.
Encouraging the client to ambulate immediately after surgery.
Administering pain medication on a fixed schedule regardless of the client's reported pain level.
The Correct Answer is B
Postoperative care following coronary artery bypass graft (CABG) surgery focuses on early detection of complications such as bleeding, hemodynamic instability, respiratory compromise, and infection. Clients are at high risk for cardiac and systemic complications due to the invasiveness of the procedure and use of cardiopulmonary bypass. Continuous monitoring of vital signs and surgical sites is essential for identifying deterioration early and guiding timely intervention. Prioritizing assessment ensures patient stability before advancing to activity or other interventions.
Rationale:
A. Encouraging the client to eat a full meal shortly after surgery is not a priority immediately after CABG. Postoperative clients are often at risk for nausea, decreased gastrointestinal motility, and aspiration, especially after anesthesia. Oral intake is usually introduced gradually, starting with clear liquids once bowel sounds and swallowing reflexes are confirmed. Premature feeding may increase complications such as aspiration or vomiting.
B. Assessing the client's vital signs regularly and monitoring for signs of surgical site infection is the priority intervention. Post-CABG clients are at risk for bleeding, arrhythmias, hypotension, and decreased cardiac output, all of which can be detected early through frequent vital sign monitoring. Monitoring the incision site also helps identify early infection or impaired wound healing, which is critical in preventing sepsis or mediastinitis.
C. Encouraging the client to ambulate immediately after surgery is inappropriate because early ambulation must be gradual and based on hemodynamic stability. Immediate activity can increase myocardial oxygen demand and strain the surgical repair. Ambulation is typically initiated after stabilization, with close monitoring for tolerance such as heart rate, blood pressure, and oxygen saturation changes.
D. Administering pain medication on a fixed schedule regardless of the client's reported pain level is not the safest approach. While adequate pain control is essential to promote breathing exercises and mobility, analgesics should be titrated based on assessment to avoid over-sedation or respiratory depression. Overmedication may mask complications such as chest pain related to cardiac ischemia or graft issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Cancer staging using the TNM system helps determine the extent of malignant disease and guides treatment planning and prognosis evaluation. T refers to the size and extent of the primary tumor, N indicates whether regional lymph nodes are involved, and M describes the presence or absence of distant metastasis. Higher values for T and N usually indicate more advanced local or regional spread. Understanding TNM staging is essential for selecting surgery, chemotherapy, radiation, or combined treatment approaches.
Rationale:
A. N1 does not indicate absence of lymph node involvement; it specifically means there is spread to regional lymph nodes. M0 also means that distant metastasis has not occurred, not that it has occurred. Although T2 may represent a larger tumor than T1, the presence of metastasis stated here does not match the classification.
B. T2 indicates a larger or more invasive primary tumor than T1, depending on the cancer type. N1 means cancer has spread to nearby regional lymph nodes, showing local extension beyond the primary site. M0 confirms that there is no evidence of distant metastasis to organs such as the lungs, liver, or bones. Therefore this explanation is correct.
C. Localized cancer without lymph node involvement would be classified as N0 rather than N1. T2 also suggests progression beyond the earliest stage and is not simply described as fully localized disease. Since lymph nodes are involved in this case, the description does not accurately reflect the staging provided.
D. This option is incorrect because carcinoma in situ is usually represented by Tis rather than T2. In addition, M0 means there is no distant metastasis, while this option states that distant spread is present. The description of in situ disease with metastasis is also clinically inconsistent because in situ tumors have not invaded beyond the basement membrane.
Correct Answer is ["C","D","E"]
Explanation
Acute coronary syndrome (ACS) involves reduced blood flow to the myocardium due to partial or complete coronary artery obstruction. Percutaneous coronary intervention (PCI) is a time-sensitive procedure used to restore coronary perfusion and limit myocardial damage. During PCI, the nurse’s priority is to ensure hemodynamic stability, prevent thrombotic complications, and closely monitor for ischemic changes. Anticoagulation and continuous cardiac monitoring are essential for patient safety throughout the procedure.
Rationale:
A. Educating the client on lifestyle modifications after discharge is important but not an immediate priority during PCI. Patient education is part of long-term secondary prevention and is typically addressed after the client is stabilized. During the procedure, the focus is on real-time monitoring and acute intervention.
B. Transferring the client to a regular medical-surgical unit after the procedure is not an appropriate immediate intervention. Post-PCI clients require close monitoring in a specialized cardiac care or intensive care setting to detect complications such as bleeding, arrhythmias, or re-occlusion. Premature transfer may delay recognition of life-threatening complications.
C. Evaluating the client's ECG continuously during the procedure is essential because it allows immediate detection of ischemic changes, arrhythmias, or reperfusion events. Continuous cardiac monitoring ensures rapid intervention if complications arise during coronary artery manipulation. This is a critical safety measure in PCI.
D. Assessing the client's history of bleeding and current medications is crucial before and during PCI because anticoagulants and antiplatelet agents are used to prevent thrombus formation. Identifying bleeding risks helps guide safe medication administration and reduces the risk of hemorrhagic complications during the procedure.
E. Administering anticoagulants as prescribed is a priority because they prevent clot formation during PCI and reduce the risk of acute vessel occlusion. These medications help maintain coronary artery patency while the intervention is being performed. Proper dosing and timing are critical to ensure procedural success and patient safety.
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