Question

The client returns to the intensive care unit following a coronary artery bypass graft. The nurse notes that the client is suddenly experiencing shortness of breath with muffled heart sounds. The blood pressure is 90/40, and the pulse rate is 110 beats per minute. Which action is most appropriate initially? A. Check the mediastinal tube for drainage B. Recheck the vital signs C. Administer pain medication D. Decrease the intravenous flow rate

Short answer

Answer: Check the mediastinal tube for drainage.

Step-by-step solution

Evaluate Option A (Check the mediastinal tube for drainage)

Checking the mediastinal tube for drainage is essential after a coronary artery bypass graft. The tube collects any blood and fluid that accumulates around the heart. It may be a reason for the shortness of breath and muffled heart sounds, making it a reasonable initial action. Keep this as a possible answer.

Evaluate Option B (Recheck the vital signs)

Rechecking the client's vital signs may provide more information about the situation, but the vital signs have already been given (90/40 blood pressure and 110 pulse rate). Rechecking the vital signs would consume time without addressing the problem. Eliminate this answer.

Evaluate Option C (Administer pain medication)

Administering pain medication might provide temporary relief from the shortness of breath but does not address the cause of the situation. It is not the most appropriate initial action. Eliminate this answer.

Evaluate Option D (Decrease the intravenous flow rate)

Decreasing the intravenous flow rate might help stabilize the blood pressure, but does not address the shortness of breath or the muffled heart sounds. It is not the best initial action in this situation. Eliminate this answer.

Choose the most appropriate action

Based on the evaluation of all options, option A (Check the mediastinal tube for drainage) is the most appropriate initial action. It directly relates to the client's symptoms and may help identify the cause of the problem. The correct answer is A. Check the mediastinal tube for drainage.