A nurse is caring for a client 1 day after total knee replacement surgery. Which nursing intervention is the priority to prevent the most serious complication?
The client reports moderate pain and shows signs of anxiety about mobility.
1Encourage early ambulation and range of motion exercises as prescribed✓ 정답
2Administer prescribed analgesics before physical therapy sessions
3Apply ice packs to the surgical site for 20 minutes every 2 hours
4Elevate the affected leg on pillows to reduce swelling
해설
Early mobilization is the priority to prevent DVT and PE, the most serious complications after total knee replacement. Other interventions are supportive but do not directly address this life-threatening risk.
Core Nursing ExplanationKey Concept Analysis: This question tests the nurse's ability to prioritize interventions to prevent a life-threatening post-operative complication. After major orthopedic surgery like a total knee replacement (TKR), the patient is at high risk for venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). Immobility leads to venous stasis in the lower extremities, a primary component of Virchow's triad (stasis, hypercoagulability, endothelial injury). The most serious complication is a PE, which can be fatal. Therefore, the priority nursing intervention is one that directly addresses the root cause of stasis: immobility.
Answer Rationale: Key Point! The priority is Encourage early ambulation and range of motion exercises as prescribed. This is the single most effective independent nursing action to promote venous return, prevent blood stasis, and reduce the risk of DVT/PE. It aligns with the principle of "move them or lose them" in post-operative care. While pain management (option 2) is crucial for enabling mobility, it is a supportive measure *for* the priority intervention, not the priority itself in this context of preventing the most serious complication.
Distractor Analysis:
Watch out for confusion! Option ② (Administer analgesics) is important for comfort and facilitating mobility, but it is a means to an end. The NCLEX often tests the distinction between treating a symptom (pain) and preventing a life-threatening condition (VTE). The priority is the action that directly prevents the complication.
Option ③ (Apply ice) and Option ④ (Elevate the leg) are both correct and important interventions for managing post-operative edema and pain, but they are secondary to preventing VTE. Elevation aids venous return, but active muscle contraction from ambulation is far more effective.
Related Concepts: Post-operative nursing care is built on the ABCs (Airway, Breathing, Circulation) and complication prevention. For orthopedic patients, circulation complications (VTE) are a top priority. This integrates knowledge of pathophysiology (Virchow's triad), pharmacology (prophylactic anticoagulants like enoxaparin), and nursing fundamentals (early mobilization).
Concept Summary
Concept
Key Takeaway
Post-Operative Priority (Orthopedic)
Prevent VTE (DVT/PE) through early ambulation.
Virchow's Triad
Stasis, Hypercoagulability, Endothelial Injury – risk factors for thrombosis.
Nursing Role in VTE Prevention
Independent action: Encourage ambulation, ankle pumps. Dependent action: Administer anticoagulants.
Pain Management
Essential for enabling the priority intervention (mobility) but not the primary prevention itself.
Side-by-Side Comparison!
Intervention
Primary Purpose
Priority Level for VTE Prevention
Early Ambulation
Promotes venous return via muscle pump; prevents stasis.
Physiology: The calf muscle pump is crucial for venous return from the legs. Immobility disables this pump, causing blood to pool in the deep veins of the calf (stasis).
Pathophysiology: A DVT can break off, travel through the right heart, and lodge in the pulmonary arteries as a PE, obstructing blood flow to the lungs—a life-threatening emergency.
Pharmacology (Related): Patients post-TKR are almost always on prophylactic anticoagulants (e.g., low molecular weight heparin like enoxaparin). Nursing responsibilities include administering them on time and monitoring for signs of bleeding.
Memory Tips
Mnemonic: "MOVE After Surgery!" – Mobility Overcomes Venous Embolism.
Think: "What kills the patient fastest?" After airway/breathing, a massive PE is a top contender post-op. The intervention that most directly prevents that is the priority.
High-Frequency NCLEX Topics
The NCLEX-RN heavily tests priority-setting and complication prevention. You must differentiate between a correct intervention and the priority intervention. Post-operative care, especially for orthopedic and abdominal surgeries, always emphasizes early ambulation to prevent atelectasis (lung complication) and DVT (circulation complication).
Watch Out for Question Variations!
Instead of "priority," the question may ask: "The nurse should include which intervention in the plan of care to prevent a pulmonary embolism?" The answer remains the same.
The scenario could change: "A patient is reluctant to get out of bed due to pain." The correct action would then integrate options 1 and 2—administer analgesia to facilitate ambulation.
It could be a "select all that apply" question asking for VTE prevention measures: Correct answers would include ambulation, SCDs, anticoagulants, and leg exercises.
Nursing Clinical Practice GuideClinical Scenario: Mr. Johnson, 68, post-op day 1 from a left total knee replacement. He is on patient-controlled analgesia (PCA) and has sequential compression devices (SCDs) on his calves when in bed. He tells you, "It hurts too much to move. Can't I just rest today?"
Nursing Intervention Strategy:
Assessment: Assess pain level (use a 0-10 scale), vital signs, surgical site (dressing intact, minimal drainage), neurovascular status of the foot (color, warmth, sensation, pulses, movement), and understanding of the importance of mobility.
Nursing Diagnosis: Risk for Venous Thromboembolism related to surgical trauma and immobility. Acute Pain related to surgical incision and tissue trauma.
Planning & Implementation:
Education & Motivation: Explain to Mr. Johnson in simple terms: "Moving your legs is the best way to prevent dangerous blood clots, which are the biggest risk after this surgery. Let's work together to manage your pain so you can move safely."
Pain Management: Administer prescribed analgesics (e.g., 30 minutes before physical therapy or planned ambulation) to ensure he can participate effectively.
Execute Priority: Encourage and assist with early ambulation as per the physical therapist's and surgeon's orders (e.g., ambulate with walker, 10 feet bid). Supervise for safety.
Supportive Measures: Ensure SCDs are on and functioning whenever he is in bed or sitting. Teach and encourage ankle pump exercises ("point and flex your toes") every hour while awake.
Monitor for Complications: Assess for signs of DVT (unilateral calf pain, warmth, redness, swelling, Homan's sign—though not reliable) and PE (sudden shortness of breath, chest pain, tachycardia, hypoxemia).
Patient Safety and Precautions:
Never massage the calf if a DVT is suspected, as this could dislodge the clot.
When administering prophylactic anticoagulants (e.g., enoxaparin), use proper subcutaneous injection technique (pinch the skin, inject at a 90-degree angle into abdominal fat) and rotate sites. Monitor lab values like aPTT or anti-Xa levels if ordered, and watch for signs of bleeding (bruising, hematuria, melena).
During ambulation, ensure the patient wears non-skid socks/shoes, the floor is dry, and assistive devices are properly fitted to prevent falls.
Nursing Procedure & Medication FlowAssisting with Early Post-Op Ambulation:
1. Pre-medicate for pain as needed/ordered.
2. Perform safety checks: bed in lowest position, brakes locked.
3. Assist patient to sit at edge of bed (dangle) for 1-2 minutes to assess for orthostatic hypotension.
4. Apply gait belt. Assist patient to stand with walker in front.
5. Provide stand-by assist or contact guard as needed. Encourage good posture.
6. Ambulate prescribed distance. Praise effort.
7. Assist back to bed or chair. Reapply SCDs if returning to bed.
Medication Note: Analgesics (e.g., opioids) can cause sedation, dizziness, and respiratory depression. Always assess respiratory rate and sedation score (e.g., Pasero Opioid-Induced Sedation Scale) before administering and before ambulation.
A Word from Your Senior Nurse
"In the hustle of post-op care, it's easy to get focused on the tasks: vitals, dressings, meds. But your most powerful tool is your voice and your ability to educate and motivate. Getting a fearful, painful patient out of bed is challenging but non-negotiable for their safety. Remember, you're not just following an order to 'ambulate.' You are actively preventing a catastrophe. That mindset shift—from task-doer to prevention advocate—is what defines great nursing. On the NCLEX and at the bedside, always ask yourself: 'What is the worst thing that could happen to this patient right now, and what can I do to stop it?'"