A postoperative client suddenly develops shortness of breath, sharp chest pain, and oxygen saturation of 88%. Which action should the nurse take first?

1 Apply oxygen and notify the rapid response team or provider. ✓ Correct answer
2 Encourage the client to walk in the hall.
3 Offer an antacid and reassess after meals.
4 Place the client in Trendelenburg position.

Explanation

Sudden dyspnea, pleuritic chest pain, and hypoxemia after surgery suggest possible pulmonary embolism. The nurse should support oxygenation and rapidly escalate care. Ambulation or delaying assessment can worsen instability.

In-depth explanation

Clinical Judgment
Acute hypoxemia after surgery is a respiratory emergency until proven otherwise.

Memory Tip
Post-op sudden dyspnea: think PE.

Clinical scenario

Clinical Practice Guide
Pulmonary embolism evaluation considers sudden dyspnea, chest pain, tachycardia, hypoxemia, and risk factors such as surgery or immobility.

Caution
Do not encourage activity during acute suspected embolism.

Key concepts

Pulmonary Embolism — A blockage in the pulmonary circulation, often from a blood clot.
Hypoxemia — Low oxygen level in the blood.
Pleuritic Chest Pain — Sharp chest pain that worsens with breathing.

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For study reference only. Always follow current clinical guidelines and your institution’s protocols.

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A postoperative client suddenly develops shortness of breath, sharp chest pain, and oxygen saturation of 88%. Which action should the nurse take first?

In-depth explanation

Clinical scenario

Key concepts

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