Two days after hip surgery, a client develops sudden dyspnea, pleuritic chest pain, oxygen saturation of 86%, and unilateral calf swelling. Complete the priority response.
Drop-down Cloze
Choose your responses, then check the answer.
Explanation
Sudden dyspnea, pleuritic pain, hypoxemia, and unilateral calf swelling after hip surgery suggest acute pulmonary embolism. Stop activity, support oxygenation, activate urgent evaluation, and prepare for diagnostic testing, hemodynamic monitoring, and prescribed anticoagulation without massaging or ambulating the affected leg.
Quick answer Recognize possible acute pulmonary embolism, stop activity and support oxygenation while activating urgent help, then prepare for rapid diagnostic and treatment evaluation.
Why this is correct Hip surgery and immobility increase venous thromboembolism risk. The abrupt respiratory symptoms, hypoxemia, pleuritic pain, and unilateral calf swelling form a high-risk pattern rather than routine postoperative discomfort.
Easy analogy or mental picture Think of a clot traveling from a swollen leg into the pulmonary circulation and suddenly blocking blood flow through part of the lungs.
Memory hook Sudden breathlessness plus one swollen calf after surgery: oxygen, urgent help, no leg massage.
NCLEX decision rule Stabilize airway and breathing while escalating the suspected time-sensitive cause. Prepare for urgent evaluation, monitoring, and prescribed anticoagulation; do not create additional embolization risk through massage or ambulation.
Why the other choices are wrong Routine pain management, delayed reporting, calf massage, and hallway ambulation do not address severe hypoxemia and can postpone or worsen a suspected embolic emergency.
The nurse stops the activity and remains with the client. Oxygen and emergency-response resources are available, and the client requires rapid assessment for an acute postoperative cardiopulmonary complication.
Pulmonary embolism — Obstruction of pulmonary arterial blood flow, most often by a thrombus that traveled from a deep vein.
Pleuritic chest pain — Sharp chest pain that typically worsens with inspiration or coughing because the pleural surfaces are irritated.
Venous thromboembolism — The disease spectrum that includes deep vein thrombosis and pulmonary embolism.