A nurse is caring for a client 2 days after total hip replacement surgery. Which assessment finding requires the nurse's immediate attention?
1Mild incisional pain rated 4/10 on the pain scale
2Sudden onset of severe chest pain and shortness of breath✓ 정답
3Knee swelling with moderate drainage from the surgical site
4Temperature of 100.2°F (37.9°C) with slight fatigue
해설
Sudden chest pain and shortness of breath indicate pulmonary embolism, a life-threatening post-op complication requiring immediate intervention. Other findings like mild pain or low-grade fever are expected and less urgent.
Core Nursing ExplanationKey Concept Analysis: This question tests the nurse's ability to prioritize post-operative complications, specifically after total hip replacement (THR). The core theme is recognizing a life-threatening emergency versus expected post-operative findings. Following orthopedic surgery, especially of the lower extremities, patients are at high risk for venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). Immobility, surgical trauma, and hypercoagulability (Virchow's triad) create the perfect storm for clot formation.
Answer Rationale: Key Point! The correct answer is Sudden onset of severe chest pain and shortness of breath. This classic presentation strongly suggests a pulmonary embolism (PE), where a clot (often from a DVT in the legs) travels to the lungs, obstructing blood flow. This is an ABC (Airway, Breathing, Circulation) priority and requires immediate intervention such as calling a rapid response, administering oxygen, and preparing for anticoagulant therapy. Delay can lead to cardiovascular collapse and death.
Distractor Analysis:
Option 1 (Mild incisional pain): Expected post-operative finding. Pain should be managed but is not an immediate life threat.
Option 3 (Knee swelling with moderate drainage): While concerning for possible infection or hematoma, it is a localized issue. The nurse should assess and document, but it does not threaten airway, breathing, or circulation immediately like a PE does.
Option 4 (Low-grade fever with fatigue): A temperature of 100.2°F (37.9°C) is common in the first 48-72 hours post-op due to the body's inflammatory response to surgery (atelectasis). This is often called "post-op fever" and is monitored but not an immediate emergency.
Related Concepts: This integrates knowledge of post-operative nursing, complication recognition, and the nursing process (specifically assessment and prioritization). It also touches on the importance of prophylactic measures for VTE (e.g., anticoagulants, sequential compression devices, early ambulation) after THR.
Pathophysiology: Virchow's Triad (stasis, hypercoagulability, endothelial injury) explains VTE risk post-surgery. A DVT from the deep veins of the leg can embolize to the pulmonary arteries.
Pharmacology: Prophylaxis includes low molecular weight heparin (LMWH) (e.g., enoxaparin) or direct oral anticoagulants (DOACs). Treatment for PE involves therapeutic anticoagulation.
Memory Tips
PE = Sudden "Can't Breathe, Can't Speak": The classic presentation is abrupt and dramatic.
Post-op Fever "W" Mneumonic: Wind (atelectasis/pneumonia, days 1-2), Water (UTI, days 3-5), Wound (infection, days 5-7), Walking (DVT/PE, anytime), Wonder drugs (drug fever). Day 2 fever is often "Wind."
High-Frequency NCLEX Topics
NCLEX loves testing prioritization and post-operative complication recognition. PE is a classic "immediate action" scenario. Know the signs of PE, MI, hemorrhage, and infection. Remember: ABCs always come first.
Watch Out for Question Variations!
Instead of asking for the finding, it may ask: "The nurse suspects a pulmonary embolism. Which action should be taken first?" (Answer: Ensure a patent airway/administer O2/activate emergency response).
It could present a list of interventions and ask which to implement for a patient with these symptoms.
It might combine with medication knowledge: "The patient is receiving enoxaparin for DVT prophylaxis. Which lab value should the nurse monitor?" (Answer: For LMWH, monitor anti-Xa levels only in specific cases; platelet count for heparin-induced thrombocytopenia).
Nursing Clinical Practice GuideClinical Scenario: You are the day-shift nurse for Mr. Johnson, 68, post-op day 2 from a left total hip replacement. He has been using the incentive spirometer and was assisted to the chair this morning. During your afternoon rounds, he suddenly clutches his chest, appears pale and diaphoretic, and says, "Nurse, I can't catch my breath!"
Nursing Intervention Strategy:
Immediate Assessment (Seconds): Check responsiveness. Assess airway, breathing (rate, effort, O2 saturation), circulation (pulse, BP). He is tachycardic and hypoxic (SpO2 88% on room air).
Immediate Action (Minutes):
Stay with the patient. Call for help (Use call light, shout for colleague, or hit the code button if unstable).
Administer high-flow oxygen via non-rebreather mask to target SpO2 >90%.
Place patient in High-Fowler's position to ease breathing if tolerated.
Notify the provider/Rapid Response Team immediately. Clearly communicate: "Suspected PE, patient in acute respiratory distress."
Remain calm and reassure the patient.
Ongoing Care & Preparation:
Obtain stat orders: Chest CT with angiography (CTPA) (gold standard for PE diagnosis), EKG, ABG, D-dimer.
Establish IV access if not present.
Prepare for potential administration of anticoagulants (e.g., heparin drip) per protocol.
Continuously monitor vital signs and oxygen saturation.
Patient Safety and Precautions:
Do not leave the patient alone. Do not delay oxygen administration to take a full set of vitals.
If the patient becomes unresponsive/apneic, initiate CPR and activate the code blue team.
Be aware of contraindications to anticoagulation (active bleeding, recent brain surgery).
Mechanical: Apply sequential compression devices (SCDs) to both lower extremities while in bed. Ensure they are on and functioning.
90 degrees, no adduction, no internal rotation).
Anticoagulant Administration Caution: Monitor for signs of bleeding (gums, urine, stool, incisional oozing). Use a soft-bristle toothbrush. Avoid IM injections.
A Word from Your Senior Nurse
"Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In clinical practice, recognizing subtle changes in a patient's vital signs early can prevent deterioration. A patient saying 'I just feel a bit off' or a slight increase in respiratory rate can be the only warning before a major event like a PE. After a hip replacement, your eyes should be constantly scanning for signs of VTE. When studying for your boards, don't just memorize — connect everything to a real patient situation and always ask 'why?' That mindset will not only earn you a great score on the NCLEX but will make you a truly confident, professional nurse!"