In the context of a patient who has undergone coronary artery bypass grafting using a right radial artery graft, which observation is most crucial for the nurse to report to the healthcare provider?
Redness on both sides of the sternal incision.
Fine crackles heard at both lung bases.
Complaints of incisional chest pain.
Pallor and weakness of the right hand.
The Correct Answer is D
Choice A rationale
Redness on both sides of the sternal incision could indicate a normal inflammatory response post-surgery or could be a sign of infection. However, it is not the most crucial observation to report in the context of a patient who has undergone coronary artery bypass grafting using a right radial artery graft.
Choice B rationale
Fine crackles heard at both lung bases could indicate fluid accumulation in the lungs, possibly due to heart failure or pneumonia. While this is a significant finding that requires further investigation, it is not the most crucial observation in this specific context.
Choice C rationale
Complaints of incisional chest pain are common after coronary artery bypass grafting. Pain management is an important part of post-operative care, but this symptom is not the most crucial to report in this context.
Choice D rationale
Pallor and weakness of the right hand could indicate compromised blood flow to the hand, which is a serious complication considering the right radial artery was used for the graft. This could lead to ischemia and tissue damage in the hand, thus it is the most crucial observation to report to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Stable angina typically occurs with exertion and goes away with rest. The symptoms described, including substernal pain, discomfort in the left shoulder and jaw, which subside with rest, are characteristic of stable angina.
Choice B rationale
Prinzmetal angina, also known as variant angina, is a type of angina (chest pain) caused by spasms in the coronary arteries. These spasms occur most often in coronary arteries that have not become hardened due to plaque buildup. However, they can also occur in hardened arteries. The symptoms can be similar to those of stable angina, but the typical triggers for the episodes are different.
Choice C rationale
A myocardial infarction (MI), or heart attack, occurs when one of the coronary arteries becomes blocked, often by a blood clot, causing part of the heart muscle to be damaged or die. The symptoms are usually more severe than what is described and do not typically subside with rest.
Choice D rationale
Unstable angina is a condition in which the angina symptoms become more severe, occur more frequently, or occur at rest. This is a medical emergency as it can often lead to a heart attack.
Correct Answer is C
Explanation
Choice A rationale
Diltiazem does not increase the contractile force of the heart. In fact, it is classified as a negative inotrope, meaning it decreases the force of heart contractions.
Choice B rationale
While diltiazem can affect heart rhythm, it does not specifically reduce heart palpitations. Its primary effect is to slow the heart rate and relax the blood vessels.
Choice C rationale
Diltiazem is a calcium channel blocker used to manage cardiovascular conditions such as hypertension, chronic stable angina, atrial fibrillation, and Prinzmetal’s angina. It works by inhibiting the calcium influx into cardiac and vascular smooth muscle during depolarization. This results in vasodilation, or the widening of blood vessels, which can help decrease coronary artery spasms, a characteristic feature of Prinzmetal’s angina.
Choice D rationale
Diltiazem does not prevent the formation of plaque in the coronary arteries. It primarily acts to relax the blood vessels and slow the heart rate.
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