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-11 Mains

Explanation

• Fever increases the body's metabolic rate and oxygen demand, leading to a compensatory increase in heart rate (sinus tachycardia).
• Administering a prescribed antipyretic directly addresses the underlying cause of the tachycardia.
• Reassessing the patient after 30 minutes allows the nurse to determine if the heart rate decreases as the temperature normalizes.
• Treating the fever first prevents the unnecessary administration of cardiac medications and safely reduces myocardial oxygen demand in a post-CABG patient.

Why Other Options Were Wrong

• Option A: While fever increases insensible fluid loss, there is no immediate evidence of severe dehydration or hypovolemia (blood pressure is stable). Antipyretics are the more direct first step.
• Option C: Administering a beta-blocker treats the symptom (tachycardia) rather than the underlying cause (fever), and it could cause unwanted hypotension.
• Option D: Physical cooling measures can induce shivering, which significantly increases metabolic rate and myocardial oxygen demand, potentially harming a post-CABG patient.

Related Visual

Clinical Relevance

• Nursing practice connection: Knowing Management of postoperative fever and secondary sinus tachycardia helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
• In post-CABG patients, minimizing myocardial oxygen demand is critical; fever and tachycardia both increase this demand and must be promptly managed.
• Always treat the underlying cause of sinus tachycardia (e.g., fever, pain, hypovolemia) before administering rate-controlling medications.
• What if? If the patient's heart rate remained at 130/min after the fever resolved, the nurse should then anticipate evaluating for other causes such as hypovolemia, pain, or arrhythmias, and notify the provider.

How to Approach the Question

• Identify the primary clinical problem: The patient has a fever (39°C) and sinus tachycardia (130/min).
• Recognize the physiological relationship: Fever causes a compensatory increase in heart rate to meet higher metabolic demands.
• Evaluate the options based on treating the root cause versus treating the symptom.
• Select the option that safely addresses the root cause (fever) first, which is administering an antipyretic.

Concept Tested & Keywords

• Concept Tested: Management of postoperative fever and secondary sinus tachycardia
• Stem keywords: postoperative day 5, coronary artery bypass grafting, temperature 39 degrees Celsius, heart rate 130 per minute, sinus rhythm
• Lead-in keywords: first
• Clinical cues: Temperature 39°C indicates a significant postoperative fever.
• Clinical cues: Heart rate 130/min in sinus rhythm is a normal compensatory response to fever.

Question ID

Q3FnzAOk8bEBMQMFMcDjsp

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 3 p. 18