A client is on postoperative day 5 after coronary artery bypass grafting. Vital signs are temperature 39 degrees Celsius, heart rate 130 per minute in sinus rhythm, blood pressure 110/60 mmHg, and oxygen saturation 96 percent on room air. What should the nurse do first?

1. A

   Start IV fluids to correct dehydration

2. B

   Give the prescribed antipyretic and reassess after 30 minutes

3. C

   Give the prescribed beta-blocker to control the heart rate

4. D

   Apply cooling measures and reassure the client

Appeared in: NORCET Mains-11

Explanation

• The patient's primary problem is a significant fever (39°C), which directly causes an increase in the body's metabolic rate.
• This increased metabolic demand leads to a compensatory sinus tachycardia (130 bpm) as the heart works harder to supply oxygenated blood to the tissues.
• The priority nursing action is to treat the underlying cause of the physiological stress. Administering an antipyretic directly addresses the fever.
• Reducing the fever will decrease myocardial oxygen consumption, which is a crucial goal in a patient recovering from cardiac surgery.
• The intervention includes reassessment after 30 minutes, which is a key part of the nursing process to evaluate effectiveness and determine next steps.

Why Other Options Were Wrong

• Option A: While fever can lead to dehydration, there is no specific evidence (like poor skin turgor or low urine output) that the client is dehydrated. Starting IV fluids without a clear indication is not the first priority, especially in a post-CABG patient where fluid overload is a significant risk.
• Close distractor alert - Option C: This action treats the symptom (tachycardia) but not the underlying cause (fever). Masking the tachycardia with a beta-blocker without addressing the fever could hide the progression of a potential underlying infection and may not be safe if the tachycardia is a necessary compensatory response.
• Option D: Applying cooling measures is a supportive, non-pharmacological intervention that is less effective for reducing core body temperature than antipyretic medication. It is considered an adjunctive therapy, not the first-line action. Furthermore, if not done carefully, it can induce shivering, which is counterproductive as it increases metabolic rate and oxygen consumption.

Related Visual

Clinical Relevance

• Nursing practice connection: Knowing Prioritization of nursing interventions for postoperative complications, specifically fever and tachycardia helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
• In postoperative cardiac patients, it is critical to manage factors that increase myocardial oxygen demand, such as fever and tachycardia, to prevent complications like myocardial ischemia or arrhythmias.
• This question highlights the core nursing principle of treating the underlying cause of a problem rather than just the symptoms.
• A nurse must be vigilant for signs of infection in postoperative patients, as fever is often the earliest indicator.

How to Approach the Question

• First, carefully read the question and identify it as a priority-setting question by looking for the word 'first'.
• Analyze the patient's data: 5 days post-CABG, T 39°C (high), HR 130 (high), BP 110/60 (stable), SpO2 96% (normal).
• Identify the most critical abnormal findings and determine their relationship. The high fever is a very common cause of tachycardia.
• Evaluate the options based on the principle of treating the underlying cause versus treating the symptoms.
• Option B (antipyretic) treats the cause (fever). Option C (beta-blocker) treats the symptom (tachycardia). Options A and D are supportive but not the primary, most effective first action.
• Select the intervention that addresses the root cause safely and effectively, which is administering the antipyretic.

Concept Tested & Keywords

• Concept Tested: Prioritization of nursing interventions for postoperative complications, specifically fever and tachycardia.
• Stem keywords: postoperative day 5, coronary artery bypass grafting, temperature 39 degrees Celsius, heart rate 130, first
• Lead-in keywords: first
• Clinical cues: The combination of high fever (39°C) and significant tachycardia (130 bpm) in a post-cardiac surgery patient points to the fever as the primary driver of the increased heart rate.

Question ID

Q3FnzAOk8bEBMQMFMcDjsp

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 3 pp. 54-56, 17-19