Post-CABG, the nurse observes 300 mL of bright red drainage from the chest tube in the first hour.
What is the most appropriate initial action?
Administer protamine sulfate.
Document the findings and continue monitoring.
Notify the surgeon immediately.
Increase IV fluid rate.
The Correct Answer is C
Choice A rationale
Protamine sulfate is the antidote for heparin and is used to reverse its anticoagulant effects. While bleeding is a concern, administering an antidote without a clear, documented reversal need and before notifying the surgeon for this major hemorrhage is an inappropriate initial action, as the patient needs surgical evaluation.
Choice B rationale
Documenting the findings is a standard nursing practice but is not the most appropriate initial action when facing a life-threatening complication. Drainage of 300 mL/hour of bright red blood is defined as excessive bleeding (typically >200 mL/hr for two consecutive hours or >300 mL in the first hour post-CABG) and requires urgent intervention.
Choice C rationale
Chest tube drainage exceeding 200 mL/hour for 2 consecutive hours, or >300 mL in the first hour, is considered surgical hemorrhage and indicates a potential need for surgical re-exploration to identify and control the source of bleeding. Notifying the surgeon immediately is the most critical and appropriate first step for this life-threatening finding.
Choice D rationale
Increasing the IV fluid rate may temporarily maintain cardiac output and blood pressure to treat anticipated hypovolemic shock. However, this action does not address the cause of the severe hemorrhage, and simply giving fluid without notifying the surgeon for definitive surgical management is an incomplete and dangerously delayed response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A 45-year-old female with chest pain is a non-specific presentation; the cause is unknown, and she may be successfully treated with medical management or a less invasive procedure like PCI if she has single-vessel disease, rather than needing major open-heart surgery like CABG.
Choice B rationale
Hyperlipidemia is a risk factor for Coronary Artery Disease, but a 60-year-old female with this alone, and without documented significant coronary artery obstruction or refractory angina, would typically be managed initially with lifestyle modifications and statin therapy, not major surgery.
Choice C rationale
A 55-year-old male with three-vessel disease (significant stenoses in three major coronary arteries) or left main coronary artery disease is the classic indication for CABG surgery. This complex anatomy makes PCI outcomes less favorable than surgery, which provides more complete revascularization and better long-term patency.
Choice D rationale
Chronic stable angina is often effectively managed with medical therapy (e.g., nitrates, beta-blockers) and risk factor modification. CABG is reserved for chronic stable angina that is refractory to optimal medical treatment or is associated with high-risk coronary anatomy, which is not specified here. —.
Correct Answer is B
Explanation
Choice A rationale
Administering epinephrine is typically reserved for pulseless electrical activity (PEA) or asystole during cardiac arrest. It is not the initial, first action for a wide-complex tachycardia where the patient's stability is yet to be determined by a prompt clinical assessment, which guides further therapy.
Choice B rationale
The initial and most crucial action in any sudden rhythm change, especially a potentially life-threatening wide-complex tachycardia (e.g., Ventricular Tachycardia), is to quickly assess the patient's hemodynamic stability, primarily by checking their level of consciousness, pulse, and blood pressure. This assessment determines the subsequent treatment, such as immediate cardioversion/defibrillation if the patient is unstable or antiarrhythmics if stable.
Choice C rationale
While a 12-lead ECG is essential for definitive diagnosis of the rhythm, it is not the first action. The immediate priority is the patient's stability, and treatment, guided by the patient's status, should precede the time taken to obtain a comprehensive ECG tracing.
Choice D rationale
Immediate defibrillation is indicated only if the patient with wide-complex tachycardia is pulseless (Ventricular Fibrillation or pulseless Ventricular Tachycardia). The nurse must first assess the patient's hemodynamic status (e.g., level of consciousness, presence of a pulse) to determine the appropriate intervention before proceeding with defibrillation. —.
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