A postoperative client suddenly develops shortness of breath, sharp chest pain, and oxygen saturation of 88%. Which action should the nurse take first?
1Apply oxygen and notify the rapid response team or provider.✓ Correct answer
2Encourage the client to ambulate in the hallway to improve breathing.
3Position the client flat with legs elevated above heart level.
4Administer an antacid and reassess the client's symptoms after eating.
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.
Clinical Judgment Acute hypoxemia after surgery is a respiratory emergency until proven otherwise.
Memory Tip Post-op sudden dyspnea: think PE.
Clinical Practice GuidePulmonary embolism evaluation considers sudden dyspnea, chest pain, tachycardia, hypoxemia, and risk factors such as surgery or immobility.
CautionDo not encourage activity during acute suspected embolism.
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.