Page 1682 - Saunders Comprehensive Review For NCLEX-RN

h. Potassium is administered
intravenously as prescribed to
maintain the potassium level between
4 and 5 mEq/L (4 to 5 mmol/L) to
prevent dysrhythmias.
i. The client is monitored for signs of
cardiac tamponade, which will include
sudden cessation of previously heavy
mediastinal drainage, jugular vein
distention with clear lung sounds,
equalization of right atrial (RA)
pressure and pulmonary artery wedge
pressure, and pulsus paradoxus.
j. Pain is monitored, differentiating
sternotomy pain from anginal pain,
which would indicate graft failure.
4. Alarm safety and alarm fatigue: Refer to Chapter 69.

5. Transfer of the client from the cardiac surgical

unit
a. Monitor vital signs, level of
consciousness, and peripheral
perfusion.
b. Monitor for dysrhythmias.
c. Auscultate lungs and assess respiratory
status.
d. Encourage the client to splint the
incision, cough, deep breathe, and use
the incentive spirometer to raise
secretions and prevent atelectasis.
e. Monitor temperature and white blood
cell count, which, if elevated after 3 to
4 days, indicate infection.
f. Provide adequate fluids and hydration
as prescribed to liquefy secretions.
g. Assess suture line and chest tube
insertion sites for redness, purulent
discharge, and signs of infection.
h. Assess sternal suture line for instability,
which may indicate infection.
i. Guide the client to gradually resume
activity.
j. Assess the client for tachycardia,
postural (orthostatic) hypotension,
and fatigue before, during, and after
activity.
k. Discontinue activities if the BP drops
more than 10 to 20 mm Hg or if the

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