A nurse is caring for a postoperative patient who suddenly develops severe dyspnea, chest pain, and anxiety. What is the nurse's priority action?
A 60-year-old patient underwent laparoscopic cholecystectomy 2 hours ago and was stable in the recovery room. The patient suddenly calls for help, reporting severe shortness of breath and sharp chest pain that worsens with deep breathing.
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.
Core Nursing ExplanationKey Concept Analysis: This question assesses the nurse's ability to recognize and prioritize immediate interventions for a suspected Pulmonary Embolism (PE). A postoperative patient with sudden onset of severe dyspnea, pleuritic chest pain (worsens with breathing), and anxiety is a classic presentation for PE, a life-threatening complication often caused by a deep vein thrombosis (DVT) that has traveled to the lungs.
Answer Rationale: Key Point! The nurse's priority action is always to address the ABCs (Airway, Breathing, Circulation). For a patient in acute respiratory distress, the first and most immediate nursing action is to position the patient to maximize lung expansion and oxygenation. High Fowler's position (sitting nearly upright) facilitates diaphragmatic excursion, improves ventilation, and can provide immediate, albeit temporary, relief of dyspnea. This action is taken while calling for help and preparing for further interventions like oxygen administration and diagnostic tests.
Distractor Analysis:
Watch out for confusion!Option 1 (Administer pain medication): While chest pain is present, the origin is likely pleuritic (from lung tissue irritation), and administering an opioid could depress the respiratory drive in a patient already struggling to breathe, masking symptoms and worsening hypoxia. Pain relief is important but is not the immediate life-saving priority.
Option 2 (Encourage deep breathing and coughing): This is a standard postoperative intervention to prevent atelectasis and pneumonia. However, in the context of acute, severe dyspnea and sharp pain, forcing deep breaths could exacerbate pain and anxiety. More importantly, it does not address the immediate threat to oxygenation.
Option 4 (Obtain a 12-lead ECG immediately): An ECG is a crucial diagnostic tool to rule out cardiac causes like myocardial infarction (MI), which can present similarly. However, the action of "obtaining" it yourself is not the nurse's first priority when the patient is in acute distress. The priority is to stabilize the patient (position, oxygen), call for help, and then the ECG will be part of the rapid diagnostic workup.
Related Concepts: The nursing process in an emergency follows the ABC priority framework. After positioning and administering oxygen, the nurse would immediately notify the physician/Rapid Response Team, prepare for diagnostic tests (CT pulmonary angiogram, V/Q scan), and anticipate anticoagulant therapy (e.g., heparin). Postoperative patients are at high risk for DVT/PE due to immobility, surgical trauma, and possible hypercoagulable state.
Concept Summary
High Fowler's, O2, prepare for chest tube insertion.
Anatomy, Physiology & Pharmacology PointsPathophysiology: A DVT (often from legs) breaks off, travels through the right side of the heart, and lodges in the pulmonary arterial circulation. This blocks blood flow to a segment of the lung, causing ventilation-perfusion (V/Q) mismatch (you ventilate but don't perfuse), leading to hypoxia.
Pharmacology: Initial treatment is anticoagulation (e.g., heparin drip) to prevent clot extension. Thrombolytics (e.g., alteplase) may be used for massive, life-threatening PE.
Memory TipsPE Symptoms: Think "Sudden SOB & Sharp pain" (The 3 S's).
Priority Action Mnemonic: "Position before Pills or Procedures." For respiratory distress, always optimize the patient's position first.
High-Frequency NCLEX TopicsPriority Setting (ABCs) is arguably the most frequently tested concept on the NCLEX. You will constantly be asked, "What is the nurse's first or priority action?" Always ask yourself: "What threatens life right now?" Airway and breathing compromise always come first.
Watch Out for Question Variations!
* Instead of asking for the action, it might ask: "The nurse suspects a pulmonary embolism. Which finding requires immediate intervention?" (Answer: Acute respiratory distress/O2 saturation < 90%).
* It could combine with medication: "After placing the patient in High Fowler's position and administering oxygen, which medication should the nurse anticipate administering first?" (Answer: Intravenous heparin).
* It could test knowledge of contraindications: "The patient with suspected PE has a history of recent brain surgery. Which anticipated order should the nurse question?" (Answer: Thrombolytic therapy, due to high risk of intracranial hemorrhage).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a surgical floor. Mr. Johnson, 60, had his gallbladder removed laparoscopically this morning. He was resting comfortably but now appears agitated, is using accessory muscles to breathe, and his SpO2 monitor reads 88% on room air. He says, "I can't catch my breath, and my chest hurts when I try."
Nursing Intervention Strategy:
1Immediate Action (Seconds)Sit him upright (High Fowler's). Call out to a colleague for help. Apply a non-rebreather mask at 15 L/min to achieve SpO2 > 92%.
2Assessment (Within a minute)Perform a focused assessment: Lung sounds (may have crackles or be clear), heart rate (tachycardic), blood pressure (may be low if massive PE), and pain description (sharp, stabbing, worse on inspiration).
3Communication & PreparationActivate the Rapid Response Team or call the physician STAT. State clearly: "Post-op lap chole patient with acute onset dyspnea, pleuritic chest pain, SpO2 88%, suspect PE." While waiting, ensure IV access is patent for possible medication administration.
4Safety & MonitoringDo not leave the patient alone. Reassure them. Continuously monitor vital signs and oxygenation. Prepare for transfer to a higher level of care (e.g., ICU).
Nursing Procedure & Medication FlowFor Suspected PE:
* Oxygen Administration: Start high-flow oxygen via non-rebreather mask. Titrate to maintain SpO2 > 92%.
* Anticipated Medications:
* Anticoagulant (Heparin): Given as a continuous IV drip. Nurse must monitor aPTT (activated Partial Thromboplastin Time) levels (therapeutic range typically 1.5-2.5 times control) and watch for signs of bleeding.
* Analgesia: May be given cautiously for severe pain, but respiratory status must be monitored closely.
* Diagnostic Tests: Nurse will assist with or prepare patient for CT pulmonary angiography (the gold standard), V/Q scan, or lower extremity Doppler ultrasound.
A Word from Your Senior Nurse
"In a crisis, your brain might scream 'Do something!' and that 'something' often feels like giving a medication or running a test. But the most powerful tool you have as a nurse is your own two hands and your clinical judgment. Positioning a patient properly is a simple, immediate, and profoundly effective intervention. It buys you time, shows the patient you are in control, and facilitates every other treatment that will follow. On the NCLEX and at the bedside, never underestimate the power of the basics: Position, Oxygen, Call for help. Master that sequence, and you'll handle emergencies with confidence."
Pulmonary Embolism — A sudden blockage in one of the pulmonary arteries in the lungs, most often caused by a blood clot that travels from the deep veins in the legs (Deep Vein Thrombosis).
High Fowler's Position — A patient position where the head of the bed is raised to 80-90 degrees. This position promotes maximal lung expansion and is the first-line intervention for patients in acute respiratory distress.
Pleuritic Chest Pain — Sharp, stabbing chest pain that worsens with deep breathing, coughing, or sneezing. It is caused by inflammation of the pleura (lining of the lungs) and is a classic symptom of Pulmonary Embolism and Pneumonia.
ABCs (Airway, Breathing, Circulation) — The fundamental priority framework in nursing and emergency medicine. Assessment and intervention always follow this order to address immediate life-threatening conditions first.
Deep Vein Thrombosis — The formation of a blood clot (thrombus) in a deep vein, usually in the leg. It is the most common precursor to Pulmonary Embolism. Postoperative patients are at high risk.