NCLEX-RNPhysiological AdaptationMedium
A client 2 days postoperative from abdominal surgery suddenly develops sharp pleuritic chest pain, dyspnea, tachycardia, and an oxygen saturation of 88% on room air. Which action should the nurse take first?
- AEncourage the client to use the incentive spirometer
- BAdminister supplemental oxygen and notify the provider immediately
- CReposition the client onto the left side
- DAdminister the prescribed PRN acetaminophen for pain
Show answer & explanationAnswer & explanation
Correct answer: B. Administer supplemental oxygen and notify the provider immediately
This presentation is classic for pulmonary embolism, a medical emergency. The nurse should immediately apply supplemental oxygen to address hypoxemia and notify the provider for urgent diagnostic workup and anticoagulation therapy.
Why the other options are wrong
- A. Incentive spirometry does not address acute hypoxemia from a suspected embolism and delays urgent care.
- C. Repositioning does not treat the underlying vascular obstruction or hypoxemia.
- D. Pain management is secondary to correcting hypoxemia and identifying the emergent cause.
Pulmonary Embolism Recognition
Sudden pleuritic chest pain, dyspnea, tachycardia, and hypoxemia in a postoperative or immobile client suggest pulmonary embolism, a medical emergency.
- Risk factors: surgery, immobility, DVT history
- Immediate actions: oxygen, notify provider, prepare for imaging/anticoagulation
- Untreated PE can rapidly progress to cardiac arrest
Memory trick: Sudden SOB after surgery = think clot in the lung