Question

The nurse monitors a client who is recovering from coronary artery bypass graft (CABG) surgery. Which finding most concerns the nurse?

1. The jugular veins are distended, but the lung sounds are clear.
2. The client reports sharp localized pain over the sternum.
3. Lab values of potassium 4.6 mEq/L, calcium 9.4 mg/dL (2.4 mmol/L), and magnesium 1.6 mg/dL (0.7 mmol/L).
4. The core body temperature is 97.2°F (36.2°C).

Answer 1

The finding that most concerns the nurse is sharp localized pain over the sternum, which could indicate potential problems after coronary artery bypass graft (CABG) surgery.

Step-by-step explanation:

The finding that most concerns the nurse is option 2 - the client reporting sharp localized pain over the sternum. This could indicate angina, which is chest pain or discomfort that occurs when the heart muscle doesn't receive enough oxygen-rich blood. After a coronary artery bypass graft (CABG) surgery, it is important for the nurse to monitor any signs of pain or discomfort in the chest, as it could indicate a potential problem with the new graft or obstruction in the coronary arteries. The nurse should notify the healthcare provider immediately for further evaluation and intervention.