1. Before surgery, the surgical procedure and postoperative care were discussed with Mr.

Peterson and his wife. As part of this teaching, the Petersons were taught that coronary
artery bypass graft (CABG) surgery was being done to:
Hint

cure coronary artery disease

Coronary artery bypass graft (CABG) surgery is not a cure for coronary artery disease. Coronary
artery disease, characterized by insufficient blood supply to the myocardium, is generally caused
by coronary atherosclerosis. This disorder of lipid metabolism causes the accumulation of fatcontaining substances along the intima of coronary arteries. These substances narrow or
obstruct vessels, impairing blood flow to the areas perfused by the involved vessels.
Atherosclerosis can possibly be prevented, but not cured.

reopen blocked coronary arteries

Coronary artery bypass graft (CABG) surgery does not reopen blocked coronary arteries. Nonsurgical therapies, including fibrinolytic agents, and percutaneous coronary intervention (PCI),
which includes percutaneous transluminal coronary angioplasty (PTCA), laser angioplasty, and
artherectomy, are aimed at reopening narrowed or occluded vessels. Fibrinolytic agents, such as
tissue plasminogen activator (tPA), act directly in vessels to dissolve thrombi. PCI procedures
increase the lumen of narrowed vessels by various means.

improve myocardial blood flow Correct

Coronary artery bypass graft (CABG) surgery, the most common type of cardiac surgery
performed, improves myocardial perfusion by bypassing narrowed or obstructed coronary
vessels. During surgery, a graft from the internal mammary artery (IMA) and/or a saphenous
vein or radial artery, is attached to the aorta and anastomosed to the diseased coronary artery
(distal to the point of occlusion). Tissue perfusion is reestablished by this procedure. Patients
should experience symptomatic relief of chest pain, as well as an improved prognosis if that was
a goal.

halt the progression of atherosclerosis

Coronary artery bypass graft (CABG) surgery will not halt the progression of atherosclerosis.
Coronary artery disease, characterized by insufficient blood supply to the myocardium, is
generally caused by atherosclerosis. This disorder of lipid metabolism causes the accumulation
of fat-containing substances along the intima of coronary arteries. These substances narrow or
obstruct vessels, impairing blood flow to the areas perfused by the involved vessels.
Atherosclerosis can possibly be prevented, but not cured.
2.
Which of the following statements about cardiopulmonary bypass are true?
Select all that apply (there are 4 correct answers).
A.

Venous blood is drained into the cardiopulmonary bypass machine Correct

Cardiopulmonary bypass includes diversion of venous blood from the right atrium and/or vena
cavae into the cardiopulmonary bypass machine.
B.

Arterial blood is drained from the left side of the heart, reoxygenated, and returned to the

left side of the heart

These mechanisms are not consistent with the cardiopulmonary bypass procedure.
C.

Blood is oxygenated, filtered, and temperature-regulated as it circulates through the

cardiopulmonary bypass machine Correct

Cardiopulmonary bypass diverts blood from the body through the bypass machine where gas
exchange, temperature regulation, and filtration occur.
D.

Oxygenated blood is returned to the body Correct

Cardiopulmonary bypass includes the return of oxygenated blood to the body via the aorta or
femoral artery.
E.

A dry, easily-visualized operative area is obtained while a patient remains on

cardiopulmonary bypass Correct

One of the functions of cardiopulmonary bypass is to provide a bloodless, easily-visualized

operative area.
3. Body temperature is reduced during open heart surgery with cardiopulmonary bypass. Jane
correctly tells you that hypothermia helps to:
Select all that apply (there are 2 correct answers).
prevent bacterial growth and subsequent sepsis

Although preventing infection in open-heart surgery patients is a major concern, a hypothermic

state is not induced to prevent bacterial growth and subsequent sepsis. Aseptic technique and
prophylactic antibiotics are indicated to prevent infection.
decrease myocardial oxygen demand Correct

A hypothermic state causes vasoconstriction and decreases the metabolic needs in the area
affected. During open-heart surgery, hypothermia reduces myocardial oxygen demand.
decrease pain sensation

Although controlling pain is a major concern in open-heart surgery patients, a hypothermic state
is not induced for this reason. Anesthesia will prevent pain.
diminish intraoperative bleeding Correct

Hypothermia causes vasoconstriction and therefore diminishes blood loss during surgery.
4.

Based on your preliminary assessments, you:

notify the anesthesiologist regarding the SpO2 of 97%

An SpO2 (O2 saturation by pulse oximetry) of 97% is normal, is good for Mr. Peterson at this
time, and need not be reported.

notify the anesthesiologist regarding the respiratory rate of 16

Mr. Peterson is on a ventilator set at synchronized intermittent mandatory ventilation (SIMV) of 8

breaths per minute. His respiratory rate is 16. This means that he has 8 ventilator-delivered
mandatory breaths per minute, and is taking 8 spontaneous breaths per minute. This is
considered normal at this time, and need not be reported.

report the bloody chest tube drainage to the surgeon

Immediately after surgery, active bleeding, as evidenced by bright red blood in chest tube
drainage, is considered normal, and need not be reported.

report the unexpected ECG rhythm to the anesthesiologist

Mrs. Peterson's ECG rhythm is interpreted as normal sinus rhythm with an occasional premature
ventricular contraction (PVC). This is normal, and need not be reported.

record your data Correct

This data should be recorded, but need not be reported, since all data is normal or expected. An
SpO2 (O2 saturation by pulse oximetry) of 97% is normal, and is considered good for Mr.
Peterson at this time. Mr. Peterson is on a ventilator set at synchronized intermittent mandatory
ventilation (SIMV) of 8 breaths per minute. His respiratory rate is 16. This means that he has
eight ventilator-delivered mandatory breaths per minute, and is taking eight spontaneous breaths
per minute. This is considered normal at this time. Immediately after surgery, active bleeding, as
evidenced by bright red blood in chest tube drainage, is considered normal. Mrs. Peterson's
ECG rhythm is interpreted as normal sinus rhythm with an occasional premature ventricular
contraction (PVC
5. Which of the following also apply to Mr. Peterson at this time?
Select all that apply (there are 5 correct answers).
Hint

Risk for Hypothermia Correct

During surgery, Mr. Peterson was maintained in a hypothermic state that needs to be reversed
postoperatively. He is also predisposed to heat loss because of the frequent and rapid
assessments that are required, and for which he needs to be uncovered. His most recent
temperature was 35.6 degrees C (96.1 degrees F). Mr. Peterson remains at risk for a lowered
body temperature. Risk for Hypothermia (temperature below 35.5 degrees C, 96 degrees F)
applies to Mr. Peterson's care.

Ineffective Airway Clearance Correct

While Mr. Peterson is intubated, his ability to clear secretions from his airway is compromised. In
addition, his sedated/anesthetized state in the immediate postoperative period decreases or
eliminates any natural protective reflexes. Ineffective Airway Clearance applies to Mr. Peterson's
care. Nursing interventions such as suctioning are required to prevent accumulation of
secretions and maintain a clear airway.

Disturbed Body Image

In the immediate postoperative period, Mr. Peterson's body image is not a major concern. Both
nursing and medical efforts are directed at maintaining vital functions.

Risk for Infection Correct

Mr. Peterson is at significant risk for infection due to his invasive surgical procedure and the
presence of invasive lines (intravenous and arterial lines, hemodynamic monitoring, Foley
catheter, and chest tubes). Infection can occur in the sternum and/or leg incisions, as well as in
the pericardial sac. Risk for Infection applies to Mr. Peterson's care.

Impaired Verbal Communication Correct

While intubated, Mr. Peterson is not able to speak. His needs must be communicated in another
way once he is awake. Impaired Verbal Communication applies to Mr. Peterson's care.

Risk for Injury Correct

As long as he is not alert and responsive, Mr. Peterson is dependent on others to keep him safe
from physical injury. Risk for Injury applies to Mr. Peterson's care.
6. Rewarming of Mr. Peterson is a major concern. Which of the following best accomplishes
rewarming?
Hint

A heat lamp

A heat lamp, used alone, is not effective in reversing a hypothermic state.

A heating blanket Correct

A heating blanket is effective in raising core body temperature to normal. In most cases, a
heating blanket can raise body temperature to normal within four hours after open-heart surgery.
Avoiding skin exposure is also important. An uncovered patient loses a lot of heat when
compared to a covered patient. Mr. Peterson's body temperature should be raised to normal as
quickly as possible. Continued hypothermia could increase afterload (increasing workload of the
heart and myocardial oxygen demands) and decrease cardiac output (compromising systemic
circulation). Increased afterload could also cause rupture of a new graft anastomosis.

A generous number of cloth blankets Incorrect

Although they may be helpful in preventing heat loss, cloth blankets are not effective in actively
reversing a hypothermic state, although they do help to prevent heat loss.

Warming of intravenous fluids prior to administration

Warming of intravenous fluids is generally not done to rewarm patients after open-heart surgery.
Warming can be done in a simpler fashion.
7. Which of the following protocols for using a heating blanket should be followed when
attempting to raise Mr. Peterson's body temperature to normal?

Turn off the blanket when Mr. Peterson's temperature reaches the point at which the

blanket is set Correct

Warming with a heating blanket should continue until the patient's core body temperature
reaches the temperature at which the blanket is set. Peripheral warming would not be sufficient if
the warming blanket was turned off sooner. To prevent skin irritation, a sheet, but not a blanket,
can be placed between the patient's skin and the heating blanket. A blanket would interfere with
heat transfer from the heating blanket to the patient.

Turn off the blanket when Mr. Peterson's temperature is within two degrees of the point

at which the blanket is set

Warming with a heating blanket should continue until the patient's core body temperature
reaches the temperature at which the blanket is set. Peripheral warming would not be sufficient if
the warming blanket was turned off sooner.
Correct
Awarded 1.0 points out of 1.0 possible points.
8. Postoperative hypothermia could have detrimental effects on Mr. Peterson. Negative
consequences associated with perioperative hypothermia include:
Select all that apply (there are 4 correct answers).

increased risk for infection Correct

Hypothermia interferes with wound healing and increases a patient's susceptibility to infection.
Vasoconstriction associated with hypothermia decreases blood flow to the skin, thereby
decreasing oxygen and nutrient delivery and white cell migration to a wound area. In addition,
the stress of surgery suppresses immune defense mechanisms, and hypothermia increases this
suppression.

increased blood pressure Correct

Hypothermia causes vasoconstriction and increased systemic vascular resistance. This

increases blood pressure, myocardial afterload, and oxygen demand and consumption. It can

also contribute to thrombus formation, anginal attacks, and myocardial infarction. Myocardial
depression and slow conduction can lead to cardiac output, heart rate, and heart rhythm
disturbances.

increased serum catecholamine levels Correct

Adrenergic stimulation with a subsequent increase in serum catecholamine levels is seen with
hypothermia. This is part of the stress response associated with hypothermia.

impaired clotting Correct

Hypothermia causes impaired platelet function. Bleeding time increases dramatically as

temperature drops.

increased metabolism of drugs Incorrect

Hypothermia does not increase metabolism of drugs. Hypothermia delays the metabolism of
drugs and can result in prolonged emergence from anesthesia.
9. Jane is concerned about Mr. Peterson's blood pressure (170/88). Preoperatively, his blood
pressure averaged 140/80. You explain that:
Select all that apply (there are 2 correct answers).

elevations in systolic arterial pressure are commonly seen immediately after open-heart

surgery Correct
An elevated blood pressure is not uncommon after coronary artery bypass graft (CABG) surgery.
It is a result of hypothermia, cardiopulmonary bypass, and the patient emerging from anesthesia.
It would be appropriate to explain this to Jane.

systolic hypertension is desired after open-heart surgery to ensure adequate myocardial

perfusion

Postoperatively, an elevated blood pressure is NOT desired. An elevated blood pressure can
increase the risk of graft anastomosis rupture after coronary artery bypass graft (CABG) surgery.
It should be treated.

standing orders for Nipride (nitroprusside) will be implemented to lower Mr. Peterson's

systolic pressure to a more desirable range Correct

After coronary artery bypass graft (CABG) surgery, to bring systolic pressure to normal range,
Nipride (nitroprusside) is commonly ordered. Typically, when Nipride (nitroprusside) is
administered after CABG surgery, systolic pressure is reduced to no more than 10 mm Hg below
preoperative baseline systolic pressure, to ensure adequate myocardial perfusion. Parameters
may vary by surgeon's request. Nitroglycerin may also be needed for its antihypertensive effect.
10. Jane assists you in preparing Nipride (nitroprusside). You ask Jane what she knows about
the drug. She correctly responds that it is:

an adrenergic agent that mimics sympathetic nervous system responses and causes

vasoconstriction
Nipride (nitroprusside) is not an adrenergic-stimulating agent. Adrenergic-stimulating agents
increase blood pressure.

a calcium channel blocker that dilates coronary and peripheral arteries

Nipride (nitroprusside) is not a calcium channel blocker, although some of the mechanisms of
drug action are similar.

a cardiac glycoside that increases the force of myocardial contraction while decreasing

heart rate
Nipride (nitroprusside) is not a cardiac glycoside. Cardiac glycosides are given for their effect on
myocardial contractility and heart rate, not for their effect on blood pressure.

a vasodilating agent that directly relaxes arteriolar smooth muscle and reduces

peripheral resistance Correct

Nipride (nitroprusside) is a vasodilating agent that directly relaxes arteriolar smooth muscle,
reducing peripheral vascular resistance, thereby decreasing afterload and blood pressure.
Nipride (nitroprusside) has a rapid onset and a brief half-life. When using Nipride (nitroprusside)
in large doses or over a prolonged period (3-5 days), serum thiocyanate and cyanide levels
should be monitored. Observe for thiocyanate toxicity -- abdominal pain and mental changes
(psychosis, confusion, weakness, tinnitus, hyperreflexia, seizures, headache, dilated pupils,
dizziness), and cyanide toxicity -- a decline in cardiac output, tachycardia, and acidosis.
Mr. Peterson is receiving an insulin IV drip. Preoperatively, he was well-controlled on oral meds for
treatment of diabetes. Mr. Peterson now requires insulin because he is NPO and:
the stress of surgery makes Mr. Peterson's blood glucose level unpredictable Correct

Under normal circumstances, Mr. Peterson's blood glucose level is predictable and stable, based
on a routine of exercise and food intake. Oral antidiabetic meds provide adequate glycemic
control. However, Mr. Peterson's blood glucose level is not predictable and likely to be unstable
at this time. Stress (of surgery) increases blood glucose and can lead to hyperglycemia. As part
of the stress response, serum glucose level rises as a result of the action of glucocorticoids
(which cause gluconeogenesis, the conversion of fats and proteins to glucose) and epinephrine
(which causes glycogenolysis, the breakdown of glycogen to glucose). In the immediate
postoperative phase of care, an insulin IV drip is indicated to keep blood glucose in an
acceptable range (e.g., less than 150 mg/dL). The IV drip is adjusted in response to capillary
blood glucose results, initially done hourly after surgery. IV drips are preferred for insulin
administration to avoid fluctuations in glucose level that occur with other means of
administration.
all persons with type 2 diabetes who undergo surgery are insulin-dependent after

surgery
Surgery does not make a person with type 2 diabetes insulin-dependent.
Jane has not worked with arterial lines before. You teach her that arterial line care includes:
Select all that apply (there are 5 correct answers).
Hint

ensuring that the transducer is always positioned level with the patient's atrium Correct

To ensure accurate pressure readings from an arterial line, the transducer should always be level
with the patient's atrium (fourth intercostal space at the midaxillary line). This anatomically
consistent site is called the phlebostatic axis.

calibrating the system every two hours

Recalibration every two hours is not necessary and would increase risk for infection.
Recalibration is indicated if readings change significantly and do not seem to be clinically
accurate, or if cables become disconnected.

aspirating blood clots if observed in the system Correct

Blood clots and/or air in an arterial line can interfere with the accuracy of readings (tracing may
become overdamped). To ensure accurate readings, blood clots and air should be removed.

assessing the site for inflammation/infection Correct

An invasive procedure, arterial line insertion is traumatic and can cause inflammation and/or
infection. The site should be observed for erythema, swelling, tenderness, and drainage. Arterial
lines can also damage peripheral nerves or cause clots that can obstruct blood flow to the
involved extremity. To monitor for these complications, frequent assessment of neurovascular
status of the hand is indicated. Color, temperature, and pulse strength distal to the insertion site,
and sensation of the involved extremity, should be closely monitored.

keeping the alarm system on Correct

Monitor alarms should be on, with appropriate parameters set for each individual patient. Arterial
line alarms are triggered when pressure readings vary from predesignated settings and when
lines become detached. Alarms should be set at all times, except when drawing blood, or during
system recalibration. Recalibration is indicated if readings change significantly and do not seem
to be clinically accurate, or if cables become disconnected.

maintaining a flow of irrigant in the arterial line Correct

Accuracy of pressure readings depends on patency of the arterial line. To ensure patency,
intermittent or continuous irrigation with a solution of heparin or saline (depending on hospital
policy) is indicated.
Which of the following assessment findings should be reported?
Select all that apply (there are 2 correct answers).
Hint

Urine output of 20 mL in the past hour Correct

A urine output less than 30 mL per hour should be reported. Oliguria reflects reduced cardiac
output and a reduction in renal blood flow (which is 20% of cardiac output). This can predispose
Mr. Peterson to acute renal failure and needs to be corrected.

Temperature of 36 degrees C (96.8 degrees F)

A temperature of 36 degrees C (96.8 degrees F), while low, is rising and at a level expected in
the postoperative coronary artery bypass graft (CABG) surgery patient. Other parameters should
be reported.

Chest tube drainage amount (mediastinal chest tubes 150 mL - pleural chest tube 40

mL) Incorrect
In general, chest tube drainage exceeding 200 mL per hour over the first 3-4 hours after surgery
would be considered abnormal. It would not be necessary to report Mr. Peterson's chest
drainage. Increasing amounts of drainage could occur with a clotting problem or anastomosis
dehiscence.

Hemodynamic parameters (PAP: 20/3 mm Hg, PAOP/PCWP: 5 mm Hg, RAP: 2 mm Hg,

CO: 4 L/min, CI: 2 L/min/m2 Correct

All hemodynamic parameters are low normal or abnormally low. In conjunction with other
assessment parameters, they are significant.
Reduced cardiac output and hypovolemia commonly occur after cardiac surgery. Which of the
following can contribute to these problems?
Select all that apply (there are 3 correct answers).

Increased secretion of antidiuretic hormone (ADH) and aldosterone

After surgery, antidiuretic hormone (ADH) and aldosterone secretion increase, as part of the
stress response. However, increased ADH and aldosterone secretion would not contribute to
hypovolemia and a reduced cardiac output. ADH and aldosterone promote retention of sodium
and water, which results in an increase in circulating fluid volume and cardiac output.

Bleeding Correct

Bleeding, and other fluid losses, decrease circulating fluid volume, and can result in hypovolemia
and a subsequent reduction in cardiac output.

Preoperative fluid restriction Correct

Conservative administration of fluids in the preoperative and postoperative periods can cause a
decrease in circulating fluid volume and a subsequent reduction in cardiac output.

Postsurgical third-spacing of fluids Correct

In response to the stress of surgery, an increase in capillary permeability occurs. This causes a
fluid shift from intravascular to interstitial spaces (third-spacing). A decrease in circulating fluid
volume and a reduction in cardiac output subsequently occur.
Mr. Peterson's cardiac index (CI) is 2 L/min/m2 and his cardiac output (CO) is 4.0 L/min. Clinically,
cardiac index and cardiac output are reflected in:
Select all that apply (there are 3 correct answers).
Hint

the quality of pedal pulses Correct

Cardiac output refers to the amount of blood ejected from the left ventricle per minute. Cardiac
index is the cardiac output adjusted by body size. A low cardiac index/cardiac output is
eventually reflected in all body tissues. Peripheral and then systemic circulation diminish as
cardiac output decreases. Reduction in cardiac output is reflected in peripheral pulses (e.g.,
pedal and radial pulses). Peripheral pulses are assessed in Mr. Peterson to determine whether
any circulatory impairment is present as a result of his low normal cardiac output. Peripheral
pulses are also assessed to determine if any circulatory impairment has occurred due to the
cross clamping of the aorta for bypass. Capillary refill time may also be affected.

rectal temperature

Core body temperature is generally not affected by a reduction in cardiac index/cardiac output.

the color of extremities Correct

Cardiac output refers to the amount of blood ejected from the left ventricle per minute. Cardiac
index is the cardiac output adjusted by body size. A low cardiac index/cardiac output is
eventually reflected in all body tissues. Peripheral and then systemic circulation diminish as
cardiac output decreases. Color changes in extremities from pink to pale often reflect this
decrease in circulation. Extremity color is also assessed in Mr. Peterson to determine whether
any circulatory impairment has occurred due to the cross clamping of his aorta for bypass.

the temperature of extremities Correct

Cardiac output refers to the amount of blood ejected from the left ventricle per minute. Cardiac
index is the cardiac output adjusted by body size. A low cardiac index/cardiac output is
eventually reflected in all body tissues. Peripheral and then systemic circulation diminish as
cardiac output decreases. Temperature changes in extremities from warm to cool often reflect
this decrease in circulation. Extremity temperature is also assessed in Mr. Peterson to determine
whether any circulatory impairment has occurred due to cross clamping of the aorta for bypass.

ability to feel pain

Pain sensation is generally unaffected by a reduction in cardiac index/cardiac output.

pupil reaction to light

Pupil reaction to light is generally unaffected by a reduction in cardiac index/cardiac output.

You discuss with Jane the factors that determine cardiac output. These include:
Hint

pulmonary artery pressure, blood pressure, and heart rate

Pulmonary artery pressure and blood pressure are not considered determinants of cardiac
output, although pulmonary artery pressure may affect cardiac output to some extent. Heart rate
is one determinant of cardiac output. An increase in heart rate augments cardiac output while a
decrease in heart rate diminishes cardiac output.

contractility, preload, and heart rate

Contractility, preload, and heart rate are all determinants of cardiac output. Cardiac output can
be augmented by increasing the strength of myocardial contraction, the amount of blood
returning to the left ventricle (preload), and the rate at which the heart beats. However, another
factor also determines cardiac output.

contractility, preload, afterload, and heart rate Correct

Contractility, preload, afterload, and heart rate are all determinants of cardiac output, and can be
manipulated if cardiac output falls. Cardiac output can be augmented by increasing the strength
of myocardial contraction, the amount of blood returning to the left ventricle (preload), the rate at
which the heart beats, and decreasing the force that resists ventricular contraction (afterload).

pulmonary artery pressure, preload, afterload, and heart rate

Pulmonary artery pressure is not considered a determinant of cardiac output, although

pulmonary artery pressure may affect cardiac output to some extent. Preload, afterload, and
heart rate are all determinants of cardiac output. Cardiac output can be augmented by increasing
the amount of blood returning to the left ventricle (preload), increasing the heart rate, and
decreasing the force that resists ventricular contraction (afterload). However, another factor also
determines cardiac output.
With regard to Mr. Peterson's chest tubes, which of the following is/are indicated?
Hint

Periodic clamping of the mediastinal tubes

Clamping the mediastinal tubes would be dangerous. Accumulation of drainage around the heart
could cause cardiac tamponade and a reduction in cardiac output.

Periodic clamping of the pleural tube

Clamping the pleural tube would be dangerous. It could cause a tension pneumothorax.

Frequent assessment and recording of drainage levels Correct

Mr. Peterson's chest tube drainage has not been excessive. However, it is important that
drainage be monitored continuously to detect hemorrhage. Chest tube drainage exceeding 200
mL per hour over the first 3-4 hours after coronary artery bypass graft (CABG) surgery would be
considered abnormal. Increasing amounts of mediastinal drainage could indicate a clotting
disorder or anastomosis dehiscence. After CABG surgery, patent chest tubes drain the surgical
sites of accumulating blood and other drainage. Clamping of tubes should be avoided. Clamping
the mediastinal tubes could cause accumulation of drainage around the heart with cardiac
tamponade and a reduction in cardiac output. Clamping the pleural tube could cause a tension
pneumothorax. Milking chest tubes is generally contraindicated. Stripping chest tubes is not
recommended due to the high negative pressures it generates at the chest tube eyes inside the
chest.

Frequent milking of tubes to maintain patency

Milking chest tubes is generally contraindicated. Stripping chest tubes is not recommended due
to the high negative pressures it generates at the chest tube eyes inside the chest.
A recent activated clotting time (ACT) is 380 seconds. Which medication is likely to be ordered stat?
Hint

Heparin

Heparin is not indicated, and would be dangerous at this time.

Protamine sulfate Correct

Protamine sufate is needed to reverse the effects of heparin. Anticoagulation with heparin is
necessary during cardiopulmonary bypass and open-heart surgery. For cardiopulmonary bypass
and open-heart surgery, the activated clotting time (ACT) is maintained at 400-480 seconds with
heparin. This anticoagulation can cause postoperative bleeding if not adequately reversed after
surgery. The ACT is a reliable method for monitoring the level of high-dose anticoagulation with
heparin. An ACT of 380 seconds at this time after surgery indicates insufficient reversal of
heparin after surgery, which can result in extended postoperative bleeding. A normal ACT is 70120 seconds. A therapeutic anticoagulation level is 150-210 seconds. Protamine sulfate
antagonizes heparin and reverses its effect. Occasionally, additional protamine sulfate is
required postoperatively to achieve reversal of anticoagulation.

Vitamin K

Vitamin K reverses the effects of anticoagulation with coumadin. It is not indicated for use at this
time.
Mr. Peterson's hemoglobin (Hgb) and hematocrit (Hct) are low. You anticipate an order for which of
the following?
Hint

Packed red cells Correct

Packed red cells are indicated for correction of red cell deficit. Circulating fluid volume will also
be increased with the administration of packed red cells.

Platelets Incorrect

Platelets should be given only when deficiencies are present. Mr. Peterson's platelet count is low
normal. Platelets are not administered prophylactically.

Fresh frozen plasma

Fresh frozen plasma is indicated when clotting factor deficiencies are present. Mr. Peterson's
clotting factors are all normal. Fresh frozen plasma is not used prophylactically.
Which of the following should be reported?
Hint

Na 138 mEq/L

A sodium (Na) level of 138 mEq/L is within normal range and acceptable for Mr. Peterson at this
time.

K 3.5 mEq/L Correct

To prevent postoperative dysrhythmias, especially premature ventricular contractions (PVCs),

potassium (K) level is maintained at or cautiously above normal range (4 mEq/L) in the
immediate postoperative period. Premature ventricular contractions (PVCs) can precede lifethreatening ventricular tachycardia or fibrillation.

Cl 100 mEq/L

A chloride (Cl) level of 100 mEq/L is within normal range and acceptable for Mr. Peterson at this
time.

PaO2 95 mm Hg (on FIO2 0.4)

The partial pressure of oxygen dissolved in arterial blood (PaO2) of 95 mm Hg is within normal
range (80-100 mm Hg) and acceptable for Mr. Peterson at this time.
Mrs. Peterson and her daughter have just arrived to visit Mr. Peterson. Which approach is best?
Hint

Before escorting them to the bedside, explain the purpose of each tube they will see

It is appropriate to discuss the tubes and lines that are attached to Mr. Peterson. However, too
much detail should be avoided, since it will not be understood and will probably further increase
anxiety.

Discuss Mr. Peterson's condition and tubes in general with them before escorting them

to the bedside Correct

It is appropriate to discuss tubes and lines in general and answer questions that Mrs. Peterson
and her daughter have. Entering Mr. Peterson's room without any prior preparation would be very
traumatic for Mrs. Peterson and her daughter. They would probably be overwhelmed and
consider Mr. Peterson's condition more serious than it actually is.

Encourage Mrs. Peterson and her daughter to wait a few hours before visiting Mr.

Peterson Incorrect
Encouraging Mrs. Peterson and her daughter to wait before visiting Mr. Peterson would not
support their needs. They will be reassured through physical contact with him. And, Mr. Peterson
will benefit from a visit from loved ones.

Advise Mrs. Peterson and her daughter to avoid looking at any tubes when visiting with

Mr. Peterson

It would be unrealistic to expect that Mrs. Peterson and her daughter could visit Mr. Peterson
without looking at his tubes.
On his third postoperative day, Mr. Peterson seems down. Postoperative feelings of depression are
not uncommon. Postoperative depression may be influenced by which of the following?
Select all that apply (there are 4 correct answers).

Pain Correct

A mild depression (dysphoria) is not uncommon 2-3 days after coronary artery bypass graft
(CABG) surgery. The presence of pain may contribute to this dysphoria. Adequate pain control is
important, especially as activities are increased.

Sleep deprivation Correct

A mild depression (dysphoria) is not uncommon 2-3 days after coronary artery bypass graft
(CABG) surgery. Sleep deprivation may contribute to this dysphoria. Patients should be disturbed
as little as possible during rest and sleep periods, and environmental stimuli should be
minimized, to help avoid sleep deprivation.

Change in diet Incorrect

A mild depression (dysphoria) is not uncommon 2-3 days after coronary artery bypass graft
(CABG) surgery. Change in diet does not contribute to this mood change.

Loss of control Correct

A mild depression (dysphoria) is not uncommon 2-3 days after coronary artery bypass graft
(CABG) surgery. Loss of control may contribute to this dysphoria. Patients should be allowed to
make decisions and provided with some sense of control when possible.

Isolation Correct

A mild depression (dysphoria) is not uncommon 2-3 days after coronary artery bypass graft
(CABG) surgery. Isolation from family and friends may contribute to this dysphoria. As possible,
contact with family and friends should be encouraged and allowed.
As Mr. Peterson progresses through the immediate recovery period from coronary artery bypass
graft (CABG), and as his family prepares for his return home, which of the following signs/symptoms
should family members be instructed to observe for and report?
Select all that apply (there are 4 correct answers).

Redness, swelling, and/or pain in either leg Correct

Redness, warmth, swelling, and/or and pain in either leg (especially calf tenderness and
swelling) should be reported. These might occur with deep vein thrombosis (DVT), and should
be checked. Some swelling of the foot and ankle in the leg used for obtaining the graft is
common and expected, however, a result of loss of a vein. This swelling eventually subsides as
remaining leg veins assist with blood return.

Sudden dyspnea Correct

Sudden dyspnea could occur with pulmonary embolus (PE), development of a

hemo/pneumothorax, or dysrhythmia, and should be evaluated immediately.

Fluttering feeling in the chest Correct

Fluttering in the chest could occur with atrial or ventricular dysrhythmias, and should be
reported and evaluated.

Yellow-green drainage from any incision Correct

Any purulent or foul-smelling drainage from an incision would indicate wound infection, and
should be reported and treated.

Inability to remember being in the Intensive Care Unit (ICU) Incorrect

It is a common finding that patients who have undergone coronary artery bypass graft (CABG)
surgery experience amnesia of the hours and days in the Intensive Care Unit (ICU). This can be
a result of lengthy anesthesia, potent analgesics, anxiolytics given during anesthesia, sleep cycle
interruption, ICU disorientation/psychosis, and/or the stress of the whole event. Patients and
families should be advised that this is common and to be expected.