A patient recovering from coronary artery bypass graft surgery is being assessed for potential postoperative complications. Which of the following findings should prompt the nurse to take immediate action?

Choice A rationale A blood pressure of 88/50 mmHg is significantly below the normal range (typically 120/80 mmHg) and indicates hypotension. In a postoperative CABG patient, this may signal hypovolemia, hemorrhage, or cardiogenic shock. Adequate mean arterial pressure is necessary to ensure the newly grafted vessels remain patent and that vital organs receive oxygen. Hypotension can lead to graft failure or acute kidney injury, making this a critical finding that requires immediate fluid resuscitation or vasopressor support. Choice B rationale A heart rate of 82 bpm is within the normal adult range of 60 to 100 bpm and suggests a stable cardiac rhythm. Following surgery, the heart rate is monitored closely for tachycardia or arrhythmias like atrial fibrillation, which are common complications. However, a regular rhythm at this rate indicates that the patient is currently compensating well and the conduction system is functioning appropriately. This finding would be documented but does not require any immediate emergency intervention. Choice C rationale Redness and serous drainage at a surgical site can be normal in the early inflammatory phase of healing, provided there is no purulent discharge, foul odor, or extreme heat. Serous drainage is clear or yellowish and thin. While the nurse should monitor for signs of infection, such as increased pain or fever, this finding is not as immediately life-threatening as hemodynamic instability. Routine wound care and assessment are standard, but they do not take precedence over an unstable blood pressure. Choice D rationale Clear lung sounds on auscultation are an expected and positive finding in a postoperative patient. It indicates that the lungs are well-ventilated and free of fluid (pulmonary edema) or atelectasis, which are common risks after anesthesia and bypass. This assessment suggests that the patient's respiratory status is stable. The goal of postoperative care includes maintaining these clear sounds through incentive spirometry and early mobilization, so this finding would not prompt an emergency response.