A nurse is caring for a 60-year-old postoperative patient who underwent laparoscopic cholecystectomy 2 hours ago and was stable in the recovery room. The patient suddenly calls for help, reporting severe shortness of breath, sharp chest pain that worsens with deep breathing, and anxiety. What is the nurse's priority action?
1Administer prescribed pain medication for chest pain
2Encourage deep breathing and coughing exercises
3Place the patient in high Fowler's position✓ 정답
4Obtain a 12-lead ECG immediately
해설
Priority is improving oxygenation and breathing via high Fowler's position and oxygen for suspected pulmonary embolism. Other options are secondary or diagnostic.
Clinical Judgment
This question assesses the nurse's **priority decision-making** in a **life-threatening condition** that suddenly occurs after surgery. The key is to address the most immediate threat according to the **ABCs (Airway, Breathing, Circulation)** principle. The patient exhibits severe dyspnea, chest pain, hypoxemia (SpO2 88%), hypotension (BP 90/60), and tachycardia (HR 120), making **Pulmonary Embolism** the most likely cause. In this situation, the most urgent action is to resolve the **impaired gas exchange** and **hypoxemia**. The high Fowler's position helps lung expansion and reduces breathing effort, while oxygen administration immediately improves tissue oxygenation. Other options may aid in diagnosis or symptom relief, but they should be performed after stabilizing the life-threatening respiratory problem first.
Memory Tip
**P**osition and **O**xygen First! If Pulmonary Embolism is suspected, think of Position and Oxygen first. **P**E = **P**riority is **O**2 & **P**ositioning.
KR vs US
In Korea, when pulmonary embolism is suspected, the process of immediately reporting to a physician and waiting for orders may be emphasized. However, in NGN/US-style nursing, the nurse's **independent judgment and intervention** are very important. Oxygen administration and position changes often fall under standard protocols that can be performed without a physician's order. In other words, you need to understand the difference in approach: not "report and wait," but "report while simultaneously initiating interventions."
Clinical Practice Guide
For immediate nursing interventions for patients suspected of having a pulmonary embolism, remember MONA (different from the MONA for myocardial infarction).1. Monitor: Continuously monitor vital signs, oxygen saturation, and level of consciousness.2. Oxygen: Administer high-flow oxygen (e.g., non-rebreather mask) to maintain target SpO2 >90%.3. Notify: Immediately report to the physician/response team and clearly communicate "Possible PE".4. Assist: Help the patient into a comfortable position (usually High Fowler's) and provide calm explanations to relieve anxiety.
Caution
A common trap point in SATA (Select All That Apply) questions is "Perform diagnostic tests (e.g., ECG, D-dimer) first." While diagnosis is important, stabilizing the patient's physiological state takes priority before diagnosis. Additionally, the intervention of "encouraging deep breathing and coughing" is good for preventing atelectasis, but it is not appropriate for acute pulmonary embolism patients as it can worsen pain and destabilize their condition.
Pulmonary Embolism — Pulmonary embolism. A life-threatening condition that occurs when a blood clot (embolus) formed in the veins of the legs or pelvis breaks off and blocks the pulmonary artery. Major symptoms include sudden shortness of breath, chest pain, and coughing.
Dyspnea — Dyspnea. A subjective sensation of breathlessness and difficulty breathing. It can occur due to various causes such as pulmonary embolism, heart failure, and atelectasis.
High Fowler's Position — High Fowler's position. Raising the head of the bed to 60-90 degrees to place the patient in an upright sitting position. Used for patients with dyspnea to maximize lung expansion and assist the action of accessory respiratory muscles.
Hypoxia — Hypoxia. A condition where the amount of oxygen supplied to the tissues is insufficient. It can be indirectly assessed using pulse oximetry (SpO2) readings, and generally, a value below 90% is considered abnormal.
Venous Thromboembolism — Venous thromboembolism. A term encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE). Major risk factors include postoperative state, prolonged immobility, and cancer.