In the context of a patient who has undergone coronary artery bypass grafting using a right radial artery graft, which observation is most crucial for the nurse to report to the healthcare provider?
Redness on both sides of the sternal incision.
Fine crackles heard at both lung bases.
Complaints of incisional chest pain.
Pallor and weakness of the right hand.
The Correct Answer is D
Choice A rationale
Redness on both sides of the sternal incision could indicate a normal inflammatory response post-surgery or could be a sign of infection. However, it is not the most crucial observation to report in the context of a patient who has undergone coronary artery bypass grafting using a right radial artery graft.
Choice B rationale
Fine crackles heard at both lung bases could indicate fluid accumulation in the lungs, possibly due to heart failure or pneumonia. While this is a significant finding that requires further investigation, it is not the most crucial observation in this specific context.
Choice C rationale
Complaints of incisional chest pain are common after coronary artery bypass grafting. Pain management is an important part of post-operative care, but this symptom is not the most crucial to report in this context.
Choice D rationale
Pallor and weakness of the right hand could indicate compromised blood flow to the hand, which is a serious complication considering the right radial artery was used for the graft. This could lead to ischemia and tissue damage in the hand, thus it is the most crucial observation to report to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Providing a pressure-reducing mattress, while important for preventing pressure ulcers, is not directly related to improving gas exchange in the lungs. Therefore, it would be considered the least priority intervention for a nursing diagnosis of impaired gas exchange related to fluid in the alveoli.
Choice B rationale
Administering oxygen and monitoring for dry nasal mucus membranes is a crucial intervention for a patient with impaired gas exchange. Oxygen therapy can help increase the amount of oxygen in the blood and alleviate symptoms of hypoxemia.
Choice C rationale
Encouraging the client to turn, deep breathe, cough, and use the incentive spirometer can help improve lung ventilation, promote the clearance of secretions, and prevent atelectasis, thereby improving gas exchange.
Choice D rationale
Placing the client in Fowler’s position can help improve lung expansion and gas exchange by reducing pressure on the diaphragm, making it easier for the patient to breathe.
Correct Answer is D
Explanation
Choice A rationale
Exercise electrocardiography, also known as a stress test, is not typically the first-line emergent procedure for a patient with an acute myocardial infarction (AMI). This test is often used to diagnose coronary artery disease, but it is not typically used to treat an AMI5.
Choice B rationale
A computed tomography (CT) scan of the chest with contrast could be used to visualize the heart and surrounding structures, but it is not typically the first-line emergent procedure for a patient with an AMI5.
Choice C rationale
An echocardiogram could be used to visualize the heart’s structure and function, but it is not typically the first-line emergent procedure for a patient with an AMI5.
Choice D rationale
Percutaneous coronary intervention (PCI) is the correct answer. This procedure is often used as an emergent treatment for an AMI. It involves using a catheter to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by plaque buildup.
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