A nurse is caring for a client 2 days after total knee replacement surgery. Which nursing intervention is the priority to prevent the most serious postoperative complication?
1Encourage early ambulation and physical therapy exercises
2Monitor surgical site for signs of infection
3Assess for signs and symptoms of pulmonary embolism✓ 정답
4Maintain proper alignment and positioning of the affected leg
해설
Pulmonary embolism is the most serious complication after total knee replacement, making assessment for signs like dyspnea and chest pain the priority. Other interventions address important but less life-threatening issues.
Core Nursing ExplanationKey Concept Analysis: This question tests the ability to prioritize nursing interventions based on the risk of the most serious, life-threatening complication following a specific surgery. After Total knee arthroplasty (TKA), patients are at high risk for Venous thromboembolism (VTE), which includes Deep vein thrombosis (DVT) and its most dangerous sequela, Pulmonary embolism (PE). The priority in the nursing process is always to address threats to the patient's airway, breathing, and circulation (ABCs). A PE directly compromises breathing and circulation, making it an immediate, potentially fatal emergency.
Answer Rationale: Key Point! While all options are important aspects of post-TKA care, Assessing for signs and symptoms of pulmonary embolism is the priority because PE is the most serious and rapidly lethal complication. Early recognition of symptoms like sudden onset dyspnea, chest pain, tachycardia, and hypoxemia is critical for survival. This intervention aligns with the principle of assessing for and preventing the greatest threat to life first.
Distractor Analysis:
Watch out for confusion! Option ①, "Encourage early ambulation and physical therapy exercises," is a preventive measure for DVT/PE and is crucial for recovery, but it is not the priority assessment for a complication that may already be developing. The question asks for the priority intervention, which in this context is vigilant monitoring for the deadly outcome.
Option ②, "Monitor surgical site for infection," addresses a common and important complication, but surgical site infections typically develop more slowly and are not immediately life-threatening in the first 48 hours like a massive PE can be.
Option ④, "Maintain proper alignment and positioning," is essential for optimal surgical outcome and comfort but does not address an acute, life-threatening condition.
Related Concepts: Postoperative nursing care requires a hierarchy of concerns. The ABC (Airway, Breathing, Circulation) framework is the foundational guide for prioritization. Pharmacological VTE prophylaxis (e.g., enoxaparin, rivaroxaban) is almost always prescribed post-TKA, and nursing care includes ensuring its administration while monitoring for breakthrough events.
Sudden dyspnea, pleuritic chest pain, tachycardia, tachypnea, hypoxemia (SpO2 < 90%), anxiety, sense of doom.
Preventive Measures
Early ambulation (Option ①), SCDs (Sequential Compression Devices), anticoagulant therapy, leg exercises.
Side-by-Side Comparison!
Postoperative Complication
Typical Onset
Key Signs/Symptoms
Immediacy of Threat
Pulmonary Embolism (PE)
Sudden, often 2-5 days post-op
Dyspnea, chest pain, tachycardia, hypoxia
HIGH - Immediate life threat
Surgical Site Infection (SSI)
Gradual, days to weeks
Erythema, warmth, purulent drainage, fever
Lower (but requires intervention)
Deep Vein Thrombosis (DVT)
Gradual, days post-op
Calf pain, unilateral edema, warmth, redness
Medium (precursor to PE)
Anatomy, Physiology & Pharmacology Points
The risk stems from Virchow's Triad: Stasis (immobility), Hypercoagulability (surgical trauma), and Endothelial injury. Clots often form in the deep veins of the surgical leg. Prophylactic anticoagulants work by inhibiting clotting factors (e.g., Factor Xa inhibitors like rivaroxaban) or thrombin (e.g., low molecular weight heparin like enoxaparin).
Memory TipsPE = Priority Emergency after joint replacement. Remember the mnemonic for PE symptoms: Sudden Onset Dyspnea, Chest pain, Tachycardia (SOD CT).
High-Frequency NCLEX Topics
Prioritization ("which action is the priority?"), post-operative complications, and VTE/PE prevention and recognition are High Yield topics. NCLEX often tests your ability to differentiate between important nursing tasks and the one that is most critical for patient safety at a given moment.
Watch Out for Question Variations!
The same concept can be tested by: 1) Asking for the first action if a patient exhibits PE symptoms (Answer: Administer oxygen and call for help). 2) Asking which patient is at highest risk for PE (e.g., a patient with history of DVT, obesity, on bed rest). 3) Shifting to medication administration: "The nurse is administering enoxaparin for DVT prophylaxis. Which finding requires immediate follow-up?" (Answer: Signs of active bleeding or heparin-induced thrombocytopenia).
Nursing Clinical Practice GuideClinical Scenario: You are caring for Mr. Johnson, 68, post-op day 2 from a right TKA. He is on enoxaparin 40 mg subcutaneously daily, using a continuous passive motion (CPM) machine, and has sequential compression devices (SCDs) on when in bed. During your afternoon assessment, he says, "I just feel short of breath all of a sudden," and appears anxious. His vital signs show: HR 118, RR 28, SpO2 88% on room air, BP 148/90.
Nursing Intervention Strategy:
1Immediate Assessment & Action (ABCs)Apply supplemental oxygen via nasal cannula or non-rebreather mask to target SpO2 > 92%. Stay with the patient, call for help (rapid response team), and notify the provider STAT. Elevate the head of the bed.
2Focused AssessmentAuscultate lung sounds (may hear crackles or be clear), assess for chest pain (ask if it's worse with inspiration—pleuritic), check for calf pain/unilateral edema (signs of DVT). Do NOT vigorously massage the legs.
3Prepare for Diagnostics & TreatmentAnticipate orders for stat labs (D-dimer, ABG), CT pulmonary angiography (CTPA), and EKG. Prepare for possible administration of therapeutic anticoagulation (e.g., heparin drip).
Patient Safety and Precautions: Never discontinue mechanical (SCDs) or pharmacological prophylaxis without a clear, documented reason (e.g., active bleeding). Be aware of anticoagulant contraindications and monitor for signs of bleeding (gums, urine, stool, injection sites). Ensure clear handoff communication about the patient's VTE risk and prophylaxis plan.
1PharmacologicalAdminister anticoagulants on time. For subcutaneous injections (enoxaparin), rotate sites, do not aspirate or massage.
2MechanicalApply SCDs correctly—ensure sleeves are smooth, connected, and cycling. Remove for ambulation.
3MobilityAssist with ambulation per protocol (often POD 1). Supervise during first attempts due to fall risk and dizziness from opioids/anesthesia.
4EducationTeach patient to report any calf pain, chest pain, or shortness of breath immediately. Teach ankle pump exercises to do hourly while awake.
A Word from Your Senior Nurse
"Remember, our job is to be the patient's early warning system. After major surgery like a knee replacement, we're not just checking boxes—we're thinking, 'What is the biggest thing that could go wrong right now?' For this patient, it's a clot traveling to their lung. That 'sense of doom' a patient with a PE often describes is a real clinical sign. Trust your assessment skills. If something feels 'off'—even before vital signs change drastically—dig deeper. That vigilance is what saves lives and defines great nursing. For the NCLEX, always ask yourself: 'What kills first?' That will guide you to the correct priority."
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, hypoxia, and potential cardiovascular collapse.
Venous Thromboembolism — An umbrella term for blood clots that form in the veins, encompassing both Deep Vein Thrombosis (DVT) and its complication, Pulmonary Embolism (PE).
Total Knee Arthroplasty — Surgical replacement of the knee joint with a prosthesis. Postoperative care heavily emphasizes VTE prevention due to high risk from immobility and surgical trauma.
Virchow's Triad — The three primary factors that contribute to thrombosis: Venous stasis, Hypercoagulability, and Endothelial (vessel wall) injury.
Sequential Compression Devices — Mechanical prophylaxis for DVT. Inflatable sleeves that rhythmically compress the legs, mimicking muscle pump action to promote venous return and reduce stasis.