Question

The nurse is assessing an intubated patient who returned from coronary artery bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain?

1)Blood pressure 160/92 mm Hg
2)Temperature 100.6F
3)Heart rate 80 beats/min
4)Oxygen saturation 95%

Answer 1

An elevated blood pressure of 160/92 mm Hg in an intubated patient who recently underwent coronary artery bypass surgery may indicate that the patient is experiencing pain, as it is a physiological response that can signal distress.

Step-by-step explanation:

In assessing an intubated patient post coronary artery bypass surgery, an elevated blood pressure such as 160/92 mm Hg could be indicative of pain. Although the patient is unable to verbalize discomfort due to intubation, physiological responses such as a spike in blood pressure can signal distress. An increased temperature could indicate inflammation or infection, a heart rate of 80 beats/min is within normal range post-surgery especially under the influence of medication, and an oxygen saturation of 95% is acceptable for a patient who has recently undergone major surgery. It is important to consider all assessment findings in concert with the patient's overall clinical picture, including any physical cues or changes from their baseline postoperative status.