NCLEX-RNReduction of Risk PotentialHard
A client is postoperative day 2 following a total hip arthroplasty. The client suddenly reports shortness of breath and sharp chest pain, and the nurse notes a heart rate of 128 beats/min and SpO2 of 88% on room air. What is the nurse's priority action?
- AEncourage incentive spirometry and ambulate the client in the hallway
- BReposition the client to the left lateral position and reassess in 15 minutes
- CApply supplemental oxygen and notify the provider immediately
- DAdminister the client's scheduled oral pain medication
Show answer & explanationAnswer & explanation
Correct answer: C. Apply supplemental oxygen and notify the provider immediately
Sudden dyspnea, pleuritic chest pain, tachycardia, and hypoxemia after orthopedic surgery are classic signs of pulmonary embolism, a life-threatening complication requiring immediate oxygen therapy and provider notification for diagnostic workup and anticoagulation. Delaying care with repositioning, oral medications, or ambulation could be fatal.
Why the other options are wrong
- A. Ambulation could dislodge additional emboli and worsens the client's condition.
- B. Repositioning does not address the underlying emergency and delays treatment.
- D. Pain medication does not treat the hypoxemia or underlying embolism.
Postoperative Pulmonary Embolism
Sudden blockage of a pulmonary artery by a clot, often from DVT, presenting with dyspnea, chest pain, tachycardia, and hypoxia.
- High risk after orthopedic surgery (hip/knee replacement)
- Classic triad: dyspnea, pleuritic chest pain, tachycardia
- Priority: oxygen, notify provider, prepare for CT angiogram/anticoagulation
Memory trick: 'Sudden SOB + hip surgery = think clot to lung.'