A nurse is assessing a 58-year-old patient who underwent a total hip replacement 3 days ago. Which assessment finding would be the MOST concerning and require immediate intervention?
1Oxygen saturation of 94% on room air with mild shortness of breath
2Calf pain and swelling in the operative leg with positive Homan's sign
3Heart rate of 102 bpm with complaints of chest discomfort
4Sudden onset of severe dyspnea with chest pain and hemoptysis✓ 정답
해설
Sudden onset of severe dyspnea with chest pain and hemoptysis is the classic triad of massive pulmonary embolism, a life-threatening emergency requiring immediate intervention. Other findings, while concerning, represent less urgent complications like DVT or mild hypoxia.
Core Nursing ExplanationKey Concept Analysis: This question tests the nurse's ability to prioritize life-threatening complications in a post-operative patient, specifically after Total hip replacement (THR). The core theme is recognizing the signs of a Pulmonary embolism (PE), a critical complication of Deep vein thrombosis (DVT). Patients undergoing major orthopedic surgery like THR are at high risk for DVT due to immobility, surgical trauma, and hypercoagulability. A PE occurs when a clot dislodges and travels to the pulmonary arteries, obstructing blood flow to the lungs, which can rapidly lead to Cardiopulmonary arrest.
Answer Rationale: Key Point! Option ④ describes the classic, acute presentation of a massive PE: Sudden dyspnea, Pleuritic chest pain (pain worsened by breathing), and Hemoptysis (coughing up blood). This triad indicates a severe, life-threatening obstruction of pulmonary circulation that requires immediate intervention, such as calling a rapid response team, administering high-flow oxygen, and preparing for anticoagulation or thrombolytic therapy. This is the highest priority finding.
Distractor Analysis:
Option ①: An Oxygen saturation (SpO2) of 94% on room air with mild shortness of breath is a common finding post-operatively, possibly due to atelectasis or mild pulmonary edema. It requires monitoring and interventions like incentive spirometry but is not immediately life-threatening.
Option ②: Calf pain, swelling, and a positive Homan's sign (pain in the calf on dorsiflexion of the foot) are classic signs of DVT. Watch out for confusion! While DVT is a serious complication that requires prompt treatment to prevent PE, the presence of DVT itself is not the most concerning finding among the options. The question asks for the finding requiring immediate intervention, implying an acute, life-threatening event has already occurred (PE).
Option ③: A heart rate of 102 bpm (tachycardia) with chest discomfort is concerning and could indicate several issues, including anxiety, pain, or early signs of cardiac ischemia or PE. However, it is a less specific and less acute presentation than the definitive, severe symptoms in option ④.
Related Concepts: This scenario integrates knowledge of post-operative care, complication recognition, and the nursing process, specifically the Assessment and Priority-setting phases. It also touches on Evidence-Based Nursing (EBN) practices for DVT prophylaxis, such as early ambulation, sequential compression devices (SCDs), and anticoagulant medications (e.g., enoxaparin).Nursing Clinical Practice GuideClinical Scenario: You are the day-shift nurse for Mr. Johnson, 58, post-op day 3 from a right total hip replacement. He has been using his incentive spirometer and was assisted to the chair this morning. During your afternoon rounds, he suddenly gasps, clutches his chest, and says, "I can't breathe!" You notice he is diaphoretic and anxious.
Nursing Intervention Strategy:
Immediate Assessment (ABCs): Call for help (activate rapid response/code blue if severe). Assess Airway, Breathing, Circulation. Listen to lung sounds (may hear crackles or diminished sounds), check SpO2, obtain vital signs.
Interventions:
Administer high-flow oxygen via non-rebreather mask.
Stay with the patient, keep them in a position of comfort (often high-Fowler's), and provide calm reassurance.
Prepare for stat orders: ECG, chest X-ray, CT pulmonary angiography, arterial blood gas (ABG).
Administer medications as ordered: anticoagulants (heparin drip) or thrombolytics for massive PE.
Do not massage the legs if DVT/PE is suspected.
Prevention is Key: From post-op day 1, ensure DVT prophylaxis is in place: SCDs are on and functioning, pharmacologic prophylaxis (e.g., Lovenox) is administered on time, and the patient is assisted with ambulation per protocol.
Patient Safety and Precautions: Never dismiss sudden-onset respiratory symptoms in a post-op patient. A "negative" Homan's sign does not rule out DVT. Be aware of contraindications for anticoagulants (active bleeding, history of hemorrhagic stroke).
SCDs: Apply correctly to ensure compression sleeves are smooth, not twisted. Remove periodically to assess skin.
Subcutaneous Anticoagulant (e.g., Enoxaparin): Administer in the abdomen, at least 2 inches from the umbilicus. Do not aspirate or massage the site. Rotate sites. Monitor for signs of bleeding (bruising, hematuria, melena).
A Word from Your Senior Nurse
"In the hustle of post-op care—vitals, meds, turns—it's easy to get task-focused. But your most critical job is being a detective. A patient saying 'I just feel a little short of breath' or having a slightly elevated heart rate could be nothing, or it could be the first whisper of a PE. Always connect the dots: major surgery + immobility = high clot risk. When you hear 'sudden' and 'severe,' your brain should scream 'PE until proven otherwise!' That vigilance saves lives."
Pulmonary Embolism — A life-threatening condition where a blood clot (usually from a DVT) travels to and blocks an artery in the lungs, causing sudden dyspnea, chest pain, and hypoxemia.
Deep Vein Thrombosis — The formation of a blood clot in a deep vein, typically in the legs. It is a major risk after surgery and can lead to PE if the clot breaks loose.
Homan's Sign — A physical exam maneuver where dorsiflexion of the foot causes pain in the calf. A positive sign may indicate DVT, but it is not highly reliable and should not be used alone for diagnosis.
Total Hip Replacement — A surgical procedure to replace a damaged hip joint with a prosthetic implant. Post-operative nursing care focuses on pain management, preventing dislocation, and avoiding complications like DVT/PE.
Hemoptysis — Coughing up blood or blood-streaked sputum from the respiratory tract. In a post-op patient, it is a classic and alarming sign of pulmonary infarction due to PE.