Your patient just had CABG surgery.
Which of the following nursing interventions would you want to implement to help prevent respiratory compromise in this patient?
Order a breathing treatment.
Give patient pain medication.
Apply oxygen via nasal cannula.
Educate patient on use of an incentive spirometer.
The Correct Answer is D
Choice A rationale
Ordering a breathing treatment, such as a bronchodilator, is appropriate for a patient with documented bronchospasm or underlying reactive airway disease. Since CABG patients are generally high-risk for atelectasis due to incisional pain, a more generalized and preventative measure like an incentive spirometer is the priority intervention.
Choice B rationale
Giving adequate pain medication is crucial because post-surgical pain leads to shallow breathing and splinting, which directly increases the risk of atelectasis and pneumonia. However, while pain control facilitates respiratory efforts, the direct and most effective intervention to prevent collapse of the alveoli is mechanical lung inflation.
Choice C rationale
Applying oxygen via nasal cannula is used to treat or prevent hypoxemia by increasing the fraction of inspired oxygen (FiO_2). Unless the patient's oxygen saturation is low (normal SpO_2 is 95-100%), this is not a primary intervention to prevent respiratory mechanical compromise like atelectasis; it merely treats the resulting hypoxemia.
Choice D rationale
Incentive spirometry is the most crucial mechanical intervention for preventing postoperative respiratory complications in CABG patients. It encourages maximal inspiratory effort, which helps re-expand collapsed alveoli, preventing atelectasis and subsequent pneumonia caused by shallow, painful post-sternotomy breathing. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
An INR of 1.5–2.5 is subtherapeutic for mechanical valve prostheses. This range provides inadequate anticoagulation to prevent thrombus formation on artificial valve surfaces, where turbulent blood flow predisposes to platelet activation and fibrin deposition. Such inadequate anticoagulation increases the risk of valve thrombosis and systemic embolization, including stroke or arterial occlusion, making this INR unsuitable for prosthetic valve recipients requiring higher targets.
Choice B rationale
An INR of 2.0–3.0 is therapeutic for atrial fibrillation or venous thromboembolism but insufficient for mechanical heart valves. Mechanical prostheses have greater thrombogenic potential than biological valves, requiring stronger anticoagulation intensity. Maintaining INR below 2.5 increases the risk of thromboembolic events; therefore, this target range is used for less thrombogenic conditions rather than for mechanical valve replacement patients.
Choice C rationale
An INR of 2.5–3.5 is the appropriate target for mechanical heart valves due to elevated thrombotic risk. Warfarin inhibits hepatic synthesis of vitamin K-dependent clotting factors II, VII, IX, and X, prolonging prothrombin time. Maintaining INR within this range ensures optimal anticoagulation while minimizing hemorrhagic risk. The standard therapeutic range reflects the need to balance prevention of mechanical valve thrombosis against potential bleeding complications associated with over-anticoagulation.
Choice D rationale
An INR of 0.8–1.2 represents the normal range for individuals not receiving anticoagulants. This physiologic baseline reflects normal coagulation factor activity and provides no thromboembolic protection. Such INR levels indicate ineffective warfarin dosing in patients with prosthetic valves, predisposing to thrombus formation, mechanical obstruction, and systemic emboli. Therefore, this value range is far below therapeutic targets required for safe long-term anticoagulation management.
Correct Answer is B
Explanation
Choice A rationale
Hemoptysis (coughing up blood) is more commonly associated with conditions causing elevated pulmonary capillary pressure, such as mitral stenosis or severe left-sided heart failure leading to pulmonary congestion. Aortic valve stenosis primarily causes a pressure overload on the left ventricle, which may progress to failure, but hemoptysis is not a typical initial or specific finding.
Choice B rationale
Angina on exertion is a classic symptom of severe aortic stenosis. The stenotic valve limits the blood flow from the left ventricle into the aorta, reducing cardiac output and thus, coronary artery perfusion, especially when the myocardial oxygen demand increases during physical activity, leading to chest pain.
Choice C rationale
Ascites (fluid accumulation in the abdomen) is a sign of severe right-sided heart failure, which can occur late in the progression of aortic stenosis if the left-sided failure leads to pulmonary hypertension and subsequent right ventricular strain. It is generally not an expected initial clinical manifestation of isolated aortic stenosis.
Choice D rationale
Bradycardia (slow heart rate, normal range 60-100 beats/min) is uncommon in aortic stenosis unless there is coexisting conduction system disease. The body often attempts to compensate for the fixed, low cardiac output caused by the stenosis by maintaining or slightly increasing the heart rate. —.
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