A 78-year-old client is admitted to the orthopedic unit following surgical repair of a fractured hip with internal fixation. On the second postoperative day, the nurse notes that the client appears restless, confused, and has developed petechiae on the chest and neck. Vital signs are: temperature 101.2°F (38.4°C), heart rate 110 bpm, respiratory rate 28/min, blood pressure 90/60 mmHg, and oxygen saturation 88% on room air. What is the priority nursing intervention?

The client shows classic signs of fat embolism syndrome (FES) with respiratory compromise (O2 saturation 88%). Priority is immediate high-flow oxygen and preparation for intubation to address life-threatening hypoxia. Other options are secondary interventions.

Pathophysiology and Clinical Presentation

The client's sudden onset of restlessness, confusion, petechiae, and respiratory distress on the second postoperative day following a long bone fracture repair is a classic presentation of Fat Embolism Syndrome (FES). This condition occurs when fat globules from the bone marrow are released into the venous system, travel to the lungs, and cause mechanical obstruction and a subsequent systemic inflammatory response [2,3]. The pulmonary vasculature obstruction impairs gas exchange, leading to the hypoxemia evidenced by an oxygen saturation of 88% and tachypnea of 28/min. The petechiae on the chest and neck are a pathognomonic sign, resulting from microvascular occlusion and capillary fragility. The cerebral symptoms of restlessness and confusion indicate that fat emboli have crossed into the systemic circulation, likely through a patent foramen ovale or pulmonary capillaries, causing Cerebral Fat Embolism (CFE) [1,4]. The fever, tachycardia, and hypotension are part of the systemic inflammatory cascade triggered by the breakdown of fat into toxic free fatty acids ^[3].

Analysis of Nursing Interventions

The priority is to address the life-threatening hypoxemia that is driving the client's clinical deterioration. The client's respiratory and neurological status indicates a critical failure in oxygenation and perfusion.

- Option 1: Administer prescribed analgesics for pain management. While pain management is important postoperatively, analgesics will not correct the underlying hypoxemia and may further depress the respiratory drive and mental status, masking the progression of FES.
- Option 2: Apply high-flow oxygen and prepare for emergency intubation. This is the correct priority. The client’s oxygen saturation of 88% on room air with an altered mental status indicates severe hypoxemia and impending respiratory failure. High-flow oxygen is the immediate intervention to support oxygenation, and preparation for intubation is a critical anticipatory action for airway protection and mechanical ventilation, which is the mainstay of supportive care for severe FES [2,3].
- Option 3: Increase IV fluid rate to improve blood pressure. Fluid resuscitation is important for managing hypotension in FES, but it is not the first priority. The primary problem is hypoxemia due to pulmonary vascular obstruction. Aggressive fluid administration without first addressing oxygenation could worsen pulmonary edema and respiratory status.
- Option 4: Reposition the client to promote circulation. Repositioning is a general comfort and circulatory measure. It will not resolve the acute hypoxemia and hemodynamic instability caused by massive fat emboli. In the context of an unstable patient with suspected FES, minimizing movement is often preferred to prevent further embolization of fat globules ^[2].

Clinical Reasoning and NCLEX-RN Test-Taking Strategy

This question tests the ability to recognize a life-threatening postoperative complication and prioritize care using the ABC (Airway, Breathing, Circulation) framework. The client's presentation—a triad of respiratory symptoms, neurological changes, and petechial rash after a long bone fracture—should immediately raise suspicion for FES. The NCLEX-RN expects the nurse to identify that the most critical and immediate need is oxygenation. The data show a clear "Breathing" problem: tachypnea, low oxygen saturation, and altered mentation from cerebral hypoxia. Therefore, the intervention that directly supports ventilation and oxygenation takes absolute priority. The development of cerebral symptoms on the second postoperative day, as seen in this case, aligns with documented cases where CFE manifests after a lucid interval following the initial injury or surgery [1,4]. The nurse must act swiftly to prevent irreversible cerebral and pulmonary damage by ensuring adequate oxygenation as the foundational step before addressing circulatory support with fluids.