Which of the following findings is most concerning in a patient 24 hours post-CABG?
Oxygen saturation of 95
Temperature of 38.5°C (101.3°F).
Heart rate of 90 bpm.
Urine output of 30 mL/hour.
The Correct Answer is D
Choice A rationale
An oxygen saturation of 95.
Choice B rationale
A temperature of 38.5°C (101.3°F) in the initial 24 hours post-CABG is often related to the inflammatory response from the surgery, atelectasis, or transfusions, and is a common, often expected finding. Though it requires monitoring and possible antipyretics, it's generally less immediately concerning than signs of critical organ hypoperfusion.
Choice C rationale
A heart rate of 90 beats per minute (bpm) is within the expected and generally acceptable range for a patient 24 hours post-surgery, with a normal sinus heart rate being 60 to 100 bpm. This rate ensures adequate cardiac output unless associated with other signs of shock and does not signal a critical instability demanding immediate, focused intervention.
Choice D rationale
Urine output of 30 mL/hour for an adult is critically low, indicating inadequate renal perfusion and potential development of acute kidney injury (AKI), as the minimum acceptable threshold is often 0.5 mL/kg/hr or >30 mL/hr. This suggests severe hypovolemia, low cardiac output, or renal ischemia requiring immediate investigation and intervention to restore perfusion. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
An uncontrolled heart rate, such as sustained tachycardia, refers to a persistent heart rate above 100 beats per minute. While a patient in bigeminy may be tachycardic if the underlying rhythm is fast, the term bigeminy specifically describes the pattern of premature beats, not simply the overall heart rate or its lack of control.
Choice B rationale
A pattern where every third beat is a Premature Ventricular Contraction (PVC) is known as ventricular trigeminy. Bigeminy is characterized by a specific paired sequence, where the PVC alternates with a normal beat, making this choice incorrect for ventricular bigeminy.
Choice C rationale
A pattern where every fourth beat is a Premature Ventricular Contraction (PVC) does not have a specific named rhythm like bigeminy or trigeminy, and would simply be described as a frequent, repetitive PVC pattern. The definition of bigeminy is based on an alternating sequence, not a pattern of one PVC every four beats.
Choice D rationale
Ventricular bigeminy is a specific EKG pattern where a normal sinus beat is consistently followed by a Premature Ventricular Contraction (PVC), creating a recurring sequence of two beats. This alternating pattern means that every other beat on the EKG is a PVC, indicating significant ventricular irritability. —.
Correct Answer is B
Explanation
Choice A rationale
MRI generates powerful magnetic fields and radiofrequency pulses that can potentially interfere with the function of a pacemaker, reprogram it, heat the lead tips, or damage the device's circuitry. Patients must confirm if their pacemaker is specifically MRI-conditional or MRI-safe before undergoing the imaging procedure to prevent serious complications, a vital component of patient education.
Choice B rationale
Post-procedurally, patients should be instructed to keep the incision site clean and dry for a specified period, typically several days to a week, to promote healing and prevent infection. Showering is usually permitted but the site should be kept dry, or sponge bathing is recommended initially. The restriction is usually on submerging the site (baths, hot tubs, swimming), making the blanket "no restrictions on showering" advice unsafe.
Choice C rationale
Infection is a serious potential complication following any surgical procedure, including pacemaker insertion. Patients and caregivers must be taught to recognize the classic signs of a localized infection, which include erythema (redness), warmth, pain, and any type of purulent or non-purulent drainage from the incision site, necessitating prompt medical attention.
Choice D rationale
To prevent lead dislodgement from the endocardium before sufficient tissue growth secures it, patients are advised to restrict movement of the arm on the insertion side. Specifically, they should avoid vigorous activity, lifting more than a few pounds, and raising the arm above the shoulder for several weeks as directed by their cardiologist. —. ##.
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