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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
Implementing a smoking cessation program, while beneficial for overall health and cardiovascular risk reduction, is not the primary therapeutic goal for secondary hypertension. Secondary hypertension is high blood pressure caused by an underlying condition. Therefore, the primary goal is to treat the underlying condition.
Choice B rationale
Treating the specific etiological disease is the primary therapeutic goal for secondary hypertension. By treating the underlying cause, blood pressure can often be lowered or returned to normal.
Choice C rationale
Initiating a rapid weight-loss program is not the primary therapeutic goal for secondary hypertension. While weight loss can help lower blood pressure in general, the primary goal in secondary hypertension is to treat the underlying cause.
Choice D rationale
Starting a rigorous exercise regimen, while beneficial for overall health and cardiovascular risk reduction, is not the primary therapeutic goal for secondary hypertension. The primary goal is to treat the underlying condition causing the high blood pressure.

A. Begin cardiopulmonary resuscitation (CPR). B. Cardiovert the client with a biphasic defibrillator. C. Assess airway, breathing, and circulation. D. Administer an amiodarone bolus followed by a drip.

Correct Answer is C

Explanation

Choice A rationale
Beginning cardiopulmonary resuscitation (CPR) is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Choice B rationale
Cardioverting the client with a biphasic defibrillator is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Choice C rationale
The first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern is to assess the patient’s airway, breathing, and circulation.
Choice D rationale
Administering an amiodarone bolus followed by a drip is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the primary therapeutic goal for secondary hypertension?

Correct Answer is B

Explanation

A nurse is caring for a client on a cardiac monitor. The patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. What is the first action the nurse should take?

Correct Answer is C

Explanation

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?

During a stress test on a treadmill, which observation by the nurse would necessitate immediate action?

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