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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale
While assessing the gag reflex is important in certain situations, such as after surgery involving anesthesia, it is not typically a crucial assessment following Percutaneous Transluminal Angioplasty (PTA) of the lower extremity.
Choice B rationale
Checking for dye allergies is important before a procedure that uses contrast dye. However, it is not a crucial post-procedure assessment.
Choice C rationale
Monitoring of pedal pulses is crucial following PTA of the lower extremity. This is because the procedure involves the arteries in the legs, and monitoring pedal pulses can help assess blood flow to the area and detect potential complications such as occlusion or clot formation.
Choice D rationale
While the Ankle-Brachial Index can be used to diagnose Peripheral Arterial Disease (PAD), it is not typically a crucial assessment immediately following PTA3.

A. Low urine osmolarity and creatinine clearance. B. Decreasing serum blood urea nitrogen (BUN) level. C. Urine output of less than 30 mL/hr. D. Urine specific gravity of less than 1.010.

Correct Answer is C

Explanation

Choice A rationale
Low urine osmolarity and creatinine clearance are not the primary indicators of inadequate renal perfusion in a patient being stabilized after an acute coronary syndrome. These measures reflect the concentration of the urine and the kidney’s ability to filter waste from the blood, respectively. While they can be affected by renal perfusion, they are not the most direct or reliable indicators.
Choice B rationale
A decreasing serum blood urea nitrogen (BUN) level is not typically associated with inadequate renal perfusion. In fact, a high BUN level may indicate that the kidneys aren’t working properly. However, BUN levels can be influenced by many factors, including protein intake and liver function, so they are not the most reliable indicator of renal perfusion.
Choice C rationale
A urine output of less than 30 mL/hr is a common sign of inadequate renal perfusion. The kidneys need adequate blood flow to filter waste products from the blood and produce urine. If renal perfusion is inadequate, urine output can decrease.
Choice D rationale
A urine-specific gravity of less than 1.010 is not typically associated with inadequate renal perfusion. Specific gravity is a measure of the concentration of solutes in the urine. It can be influenced by hydration status and certain kidney disorders, but it is not a direct measure of renal perfusion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with Peripheral Arterial Disease (PAD) has recently undergone Percutaneous Transluminal Angioplasty (PTA) of the lower extremity. Which assessment is crucial for the nurse to perform post-procedure?

Correct Answer is C

Explanation

What nursing assessment finding would suggest inadequate renal perfusion in a patient being stabilized after an acute coronary syndrome (myocardial infarction)?

Correct Answer is C

Explanation

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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?

After the shift change, which patient in the emergency department should the nurse prioritize for assessment?