A nurse caring for a patient who has just been transferred from the PACU following coronary artery revascularization (CABG) performs frequent head-to-toe assessments for impending complications
The nurse finds the patient exhibits cyanosis of the mucous membranes, tachycardia, restlessness, and anxiety. The nurse is aware that these symptoms often are indicative of:
A) Acute pain
B) Infection
C) Fluid volume and electrolyte imbalance
D) Impaired gas exchange
Ans: D
Feedback: The common signs of impaired gas exchange are restlessness, anxiety, cyanosis of mucous membranes and peripheral tissues, and tachycardia. Acute pain and infection will also manifest restlessness and tachycardia; however, the cyanosis of mucous membranes and peripheral tissues indicates impaired gas exchange. Fluid and electrolyte imbalances are picked up through monitoring of intake and output, distention of neck veins, edema; and electrolyte levels.
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