The nurse is caring for a client who is 6 hours post operative, and 4 hours post extubation following coronary artery bypass grafting (CABG) surgery. What nursing interventions are appropriate at this time to include in the plan of care? Select all that apply.

Up in chair at bedside.

Remove epicardial pacing wires.

Use incentive spirometer.

Dangle at the bedside.

Maintain NPO status.

Ambulate to bathroom.

Answer and Explanation

Correct Answer : A,C,D

A. Up in chair at bedside: Early mobilization after CABG, such as sitting in a chair at the bedside, promotes circulation, prevents venous stasis, reduces the risk of pulmonary complications, and supports overall recovery. At 6 hours post-op and 4 hours post-extubation, this level of activity is safe and appropriate under close monitoring.

B. Remove epicardial pacing wires: Epicardial pacing wires are removed 24–48 hours after surgery, depending on physician orders and patient stability. Removing them only a few hours post-op is unsafe and could lead to arrhythmias or bleeding, this is not appropriate at this stage.

C. Use incentive spirometer: Incentive spirometry is critical to prevent atelectasis and improve lung expansion following cardiac surgery. Encouraging the client to use the device frequently helps restore pulmonary function, especially after recent extubation.

D. Dangle at the bedside: Dangling (sitting at the edge of the bed with feet on the floor) is an early step in mobilization that helps the client regain balance, promote circulation, and reduce orthostatic hypotension before ambulating. It is appropriate at this stage of recovery.

E. Maintain NPO status: At 4 hours post-extubation, clients are generally allowed clear liquids if there is no nausea, swallowing difficulty, or risk of aspiration. Continuing NPO status unnecessarily could delay recovery and nutrition.

F. Ambulate to bathroom: Ambulation to the bathroom is typically not safe so soon after extubation and major cardiac surgery due to risk of hypotension, dizziness, or sternal instability. Mobility should begin with bedside sitting and dangling before progressing to walking.

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Correct Answer is C

Explanation

A. Allow the client to rest quietly: While rest is generally beneficial, the combination of tachycardia and hypotension suggests possible acute complications such as bleeding or cardiogenic shock. Simply allowing the client to rest does not address the underlying cause and could delay life-saving interventions.

B. Document the findings in the chart: Documentation is important for communication and legal purposes, but it is not an immediate intervention. The nurse must first assess the client for potential causes of hemodynamic instability before charting.

C. Assess the client for bleeding: A drop in blood pressure with a compensatory increase in heart rate may indicate hypovolemia from internal or external bleeding, especially if the client has invasive lines or recent procedures. Prompt assessment and intervention are crucial to prevent shock and organ damage.

D. Medicate the client for pain: Pain management is important, but administering analgesics in the context of hypotension and tachycardia could worsen hemodynamic instability. The priority is identifying and treating the underlying cause before giving medications that may further lower blood pressure.

A. Call the health care provider for a change in cardiac drugs. B. Place the client in a sitting position and administer oxygen. C. Call the Rapid response team to come and assess the client. D. Call a Code and initiate cardiopulmonary resuscitation

Correct Answer is D

Explanation

A. Call the health care provider for a change in cardiac drugs: Notifying the provider is important for ongoing management, but the rhythm shown in the image is ventricular fibrillation (VF), which is immediately life-threatening. Delaying action to call the provider risks the client’s survival.

B. Place the client in a sitting position and administer oxygen: Positioning and oxygen may support a stable client with mild symptoms, but VF causes ineffective cardiac output, so interventions that only support oxygenation are insufficient. Immediate resuscitative measures are required.

C. Call the rapid response team to come and assess the client: While the rapid response team can assist, VF requires immediate intervention—delaying defibrillation and CPR while waiting for others significantly reduces survival chances.

D. Call a code and initiate cardiopulmonary resuscitation: Ventricular fibrillation is a pulseless, life-threatening arrhythmia that requires immediate activation of a code and initiation of CPR, followed by defibrillation. Early chest compressions and defibrillation are critical to restoring cardiac output and preventing sudden cardiac death.

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The nurse is caring for a client who is 6 hours post operative, and 4 hours post extubation following coronary artery bypass grafting (CABG) surgery. What nursing interventions are appropriate at this time to include in the plan of care? Select all that apply.

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Correct Answer is C

Explanation

Correct Answer is D

Explanation

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The nurse is caring for a client who is 6 hours post operative, and 4 hours post extubation following coronary artery bypass grafting (CABG) surgery. What nursing interventions are appropriate at this time to include in the plan of care? Select all that apply.