A nurse is planning care for a client who is 8 hr postoperative following a coronary artery bypass grafting. Which of the following assessments should the nurse plan to perform first?

Rationale: A. Palpate pulses distal to the graft donor site: Assessing distal pulses is important to monitor for vascular compromise at the donor site, but it is not the highest priority immediately post-coronary artery bypass grafting. Circulatory assessment follows stabilization of airway and breathing. B. Auscultate breath sounds: Respiratory assessment is the priority because airway patency and oxygenation are critical for a postoperative cardiac client. After general anesthesia and cardiac surgery, clients are at high risk for atelectasis, pulmonary edema, or hypoventilation, which can rapidly compromise oxygen delivery to vital organs. C. Measure the client's core body temperature: Monitoring temperature is important for detecting infection or hypothermia, but it is not immediately life-threatening. Temperature assessment is secondary to ensuring adequate oxygenation and ventilation. D. Examine the surgical incision for drainage: Inspecting the incision helps identify bleeding or infection, which is important, but airway and breathing take precedence. Hemodynamic stability and oxygenation must be maintained before assessing the incision.