Question

A nurse is caring for a client in the first 8 hr following coronary artery bypass graft surgery. Which of the following client findings should the nurse report to the provider?

a. mediastinal drainage 100 mL/hr
b. BP 160/80 mmHg
c. Temp 37.1 (98.8)
d. K 3.8 mEq/L

Answer 1

The nurse should report mediastinal drainage of 100 mL/hr post-coronary artery bypass graft surgery. Excessive drainage can indicate hemorrhage or complications. The other values given are within expected postoperative ranges. The correct option is A.

Step-by-step explanation:

The nurse should report mediastinal drainage of 100 mL/hr to the provider following coronary artery bypass graft surgery. This amount of drainage could indicate postoperative hemorrhage or other complications. Normal values for mediastinal drainage should be less than 50 mL/h in the first few hours postoperatively. The other findings, such as a blood pressure (BP) of 160/80 mmHg, a temperature (Temp) of 37.1 C (98.8 F), and a potassium (K) level of 3.8 mEq/L, are within normal ranges or expected postoperative values and may not warrant immediate concern unless there are other corresponding symptoms or orders from the provider regarding specific parameters for the patient.

The nurse should report finding mediastinal drainage at a rate of 100 mL/hr to the provider. After coronary artery bypass graft surgery, mediastinal drainage should gradually decrease over time. A drainage rate of 100 mL/h is higher than the expected range and may indicate postoperative bleeding or other complications that require medical attention.