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The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?

Internal bleeding.

Right-sided heart failure.

Left ventricular dysfunction.

Cardiac tamponade.

Answer and Explanation

The Correct Answer is B

A. Internal bleeding typically presents with signs of hypovolemia, such as decreased blood pressure and increased heart rate, rather than pitting edema and jugular venous distention.

B. Right-sided heart failure is characterized by fluid overload, leading to symptoms like pitting edema in the extremities and jugular venous distention, which align with the findings observed in this client.

C. Left ventricular dysfunction primarily results in pulmonary congestion and respiratory distress rather than peripheral edema and jugular venous distention.

D. Cardiac tamponade may present with jugular venous distention, but it usually also involves hypotension and muffled heart sounds, which are not described in this scenario.

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A. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter. B. Medicate for pain and monitor vital signs according to protocol. C. Administer intravenous fluid bolus as prescribed by the healthcare provider. D. Encourage the client to splint the incision with a pillow to cough and deep breathe.

Correct Answer is A

Explanation

A. The elevated heart rate and respirations suggest the client may be experiencing hypoxia, especially following a thoracotomy. Administering oxygen will help improve oxygen saturation levels and address potential respiratory distress.

B. While pain management is essential, the immediate concern is ensuring adequate oxygenation.

C. Administering IV fluids may be necessary but is secondary to ensuring the client's oxygenation.

D. Encouraging the client to splint and cough is important for preventing complications but does not address the immediate issue of vital signs indicating possible respiratory compromise.

A. “Take the vital signs on all the patients in the lounge and tell me whether there are problems." B. "Do the morning care first on the patients in 205 and 206 who can't get out of bed." C. "Give the patient in 204A a shower after breakfast, and call me to check her feet before you get her dressed." D. "You take care of all the patients in 205 and 206. Let me know how you're doing and whether you need any help."

Correct Answer is C

Explanation

A. "Take the vital signs on all the patients in the lounge and tell me whether there are problems." This instruction is vague and lacks specific information about what "problems" to look for, which may lead to inconsistent reporting.

B. "Do the morning care first on the patients in 205 and 206 who can't get out of bed." This instruction is clear, but it does not specify important details like the specific type of care expected or additional needs.

C. "Give the patient in 204A a shower after breakfast, and call me to check her feet before you get her dressed." This instruction is specific, clear, and provides a follow-up action (check her feet) which is necessary. It allows the nursing assistant to understand exactly what to do and when.

D. "You take care of all the patients in 205 and 206. Let me know how you're doing and whether you need any help." This instruction lacks specificity and does not outline clear tasks or expectations, which may lead to confusion.

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Correct Answer is A

Explanation

Correct Answer is C

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Correct Answer is A

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Correct Answer is C

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