# A nurse is caring for a 72-year-old patient who underwent total hip replacement surgery 2 days ago. The patient reports sudden onset of chest pain, shortness of breath, and anxiety. Vital signs are: temperature 98.6°F (37°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?

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> language: ko  
> subject: Next Gen NCLEX

## 문제

A nurse is caring for a 72-year-old patient who underwent total hip replacement surgery 2 days ago. The patient reports sudden onset of chest pain, shortness of breath, and anxiety. Vital signs are: temperature 98.6°F (37°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?

## 보기

1. Administer prescribed pain medication for chest discomfort
2. Encourage deep breathing exercises and coughing
3. Position the patient in high Fowler's position
4. Apply supplemental oxygen and notify the physician immediately **✔ 정답**

**정답: 4**

## 해설

The priority is to apply supplemental oxygen and notify the physician immediately due to suspected pulmonary embolism, a life-threatening post-surgical complication. Other interventions are secondary to stabilizing oxygenation and obtaining urgent medical evaluation.

## 심화 해설

Core Nursing Explanation
**Key Concept Analysis**: This question assesses the nurse's ability to recognize and prioritize care for a postoperative complication, specifically a pulmonary embolism (PE). The patient is in a classic high-risk scenario: elderly, recent major orthopedic surgery (total hip replacement), and immobility. The sudden onset of chest pain, dyspnea (shortness of breath), tachycardia (heart rate 110 bpm), tachypnea (respiratory rate 28/min), hypotension (blood pressure 90/60 mmHg), hypoxemia (SpO2 88%), and anxiety are hallmark signs of PE. The pathophysiological mechanism involves a blood clot (often from a deep vein thrombosis (DVT) in the legs) traveling to and obstructing the pulmonary arteries, leading to impaired gas exchange and cardiovascular strain.

**Answer Rationale**: Key Point! The priority nursing intervention is always to address the most immediate threat to life, which follows the ABC (Airway, Breathing, Circulation) framework. Here, the patient's Breathing and Circulation are compromised (hypoxemia, tachypnea, hypotension). Therefore, Applying supplemental oxygen is the first action to correct hypoxemia and prevent tissue damage. Notifying the physician immediately is the concurrent critical action to activate the rapid medical response needed for diagnosis (e.g., CT pulmonary angiography) and treatment (e.g., anticoagulation, thrombolytics).

**Distractor Analysis**:
Watch out for confusion! Option ① (Administer pain medication) is incorrect because treating the symptom (pain) does not address the underlying life-threatening cause. It could also mask worsening symptoms and delay critical intervention.

Option ② (Encourage deep breathing and coughing) is a standard postoperative pulmonary hygiene measure but is **contraindicated** in a suspected PE. It could increase oxygen demand and worsen the patient's distress without fixing the root problem of impaired perfusion.

Option ③ (Position in high Fowler's) may provide some symptomatic relief for dyspnea by maximizing lung expansion, but it is a **supportive measure, not the priority**. It does not treat the hypoxemia or initiate the urgent medical evaluation required.

**Related Concepts**: This scenario integrates knowledge of postoperative care, Virchow's Triad (stasis, hypercoagulability, endothelial injury) as risk factors for DVT/PE, and emergency response protocols. The nurse's role is rapid assessment, stabilization, and communication.

Concept Summary

| Concept | Key Points |
| --- | --- |
| Pulmonary Embolism (PE) | Life-threatening blockage of pulmonary artery. S/S: Sudden dyspnea, pleuritic chest pain, tachycardia, hypoxemia, anxiety, hypotension (in massive PE). |
| Post-op Complication Prevention | DVT prophylaxis is critical after major surgery (e.g., hip/knee replacement). Includes early ambulation, SCDs (Sequential Compression Devices), anticoagulants (e.g., enoxaparin). |
| Nursing Priority (ABCs) | Airway, Breathing, Circulation. In suspected PE, priority is to ensure adequate oxygenation (Breathing) and support circulation while getting help. |
| Deep Vein Thrombosis (DVT) | Precursor to PE. S/S: Unilateral leg pain, swelling, warmth, redness. Homan's sign is unreliable and not recommended. |

Side-by-Side Comparison!

| Post-op Complication | Key Signs & Symptoms | Priority Nursing Action |
| --- | --- | --- |
| Pulmonary Embolism (PE) | Sudden dyspnea, chest pain, hypoxemia, tachycardia, anxiety, hypotension. | Apply O2, notify physician STAT, prepare for emergency care (IV access, monitor). |
| Atelectasis / Pneumonia | Fever, cough, crackles, localized diminished breath sounds, gradual onset dyspnea. | Encourage deep breathing, coughing, incentive spirometry, mobilize, administer antibiotics if ordered. |
| Hypovolemic Shock (e.g., from hemorrhage) | Hypotension, tachycardia, tachypnea, cool/clammy skin, decreased urine output, anxiety. | Stop bleeding (if visible), administer IV fluids/blood products per protocol, trend vital signs. |

Anatomy, Physiology & Pharmacology Points
**Pathophysiology**: A clot from a DVT (often in deep veins of pelvis or lower extremities) breaks off, travels through the right side of the heart, and lodges in the pulmonary arterial circulation. This causes:

1. Ventilation-Perfusion (V/Q) Mismatch: Lung areas are ventilated but not perfused, causing hypoxemia.

2. Increased Pulmonary Vascular Resistance: This strains the right ventricle (can lead to right-sided heart failure).

3. Release of Vasoactive Substances: Causes bronchoconstriction and further vasoconstriction.

**Pharmacology**: Initial treatment is anticoagulation (e.g., heparin drip, enoxaparin) to prevent clot extension. For massive, life-threatening PE, thrombolytics (e.g., alteplase) may be used to dissolve the clot.

Memory Tips
**PE Symptoms Mnemonic: "S.O.S. P.E."**

**S**udden onset

**O**xygen low (SpO2 ↓)

**S**hortness of breath

**P**leuritic chest pain

**E**levated heart rate (HR ↑)

**Priority Action**: Think **"O2 and MD GO!"** Your first two actions are always: 1) Give oxygen, 2) Get the doctor.

High-Frequency NCLEX Topics
This is a **classic NCLEX scenario** testing:

1. Prioritization (Which action comes first?)

2. Recognition of Medical Emergencies (Post-op complications like PE, MI, hemorrhage).

3. Application of the ABC Framework.

Expect questions that combine risk factors (surgery, immobility, cancer), symptoms, and the correct sequence of nursing actions.

Watch Out for Question Variations!
- Instead of asking for the *priority intervention*, the question might ask: "The nurse suspects a pulmonary embolism. Which finding **supports** this suspicion?" (Answer: Sudden onset dyspnea and hypoxemia).

- It might shift to **patient education**: "A patient is being discharged on enoxaparin after a hip replacement. Which statement by the patient indicates understanding?" (Answer: "I will report any unusual bleeding or bruising.").

- It could test **prevention**: "Which intervention is most important to prevent this complication postoperatively?" (Answer: Early ambulation and use of SCDs).

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario**: You are the nurse on a medical-surgical unit. Mr. Johnson, 72, s/p left total hip replacement 48 hours ago, calls you to his room. He is diaphoretic, clutching his chest, and says, "I can't catch my breath, and my chest hurts." You quickly assess his vital signs as listed.

**Nursing Intervention Strategy**:

1. **Immediate Action (Seconds)**: Stay calm. Call for help (use call bell or shout for colleague). Apply a non-rebreather mask (NRB) at 15 L/min to deliver high-flow oxygen and rapidly correct hypoxemia. Do not leave the patient.

2. **Assessment & Communication (Within 1-2 minutes)**: While oxygen is on, have your colleague notify the physician/provider **immediately** with a clear, concise report: "STAT call to Dr. Smith. Room 402, Mr. Johnson, s/p THR, suspected PE. Vital signs: BP 90/60, HR 110, RR 28, SpO2 88% on NRB. Sudden chest pain and dyspnea."

3. **Stabilization & Preparation (Next 5 minutes)**: Place patient in a position of comfort (often semi-Fowler's). Establish or check IV patency for a large-bore IV. Connect to continuous cardiac and SpO2 monitoring. Obtain a stat 12-lead ECG to rule out MI. Prepare for possible transfer to ICU.

4. **Ongoing Monitoring & Support**: Reassure the patient. Monitor for deterioration (increased work of breathing, dropping BP, decreasing LOC). Anticipate orders for stat labs (D-dimer, ABG), CT scan, and anticoagulant therapy.

**Patient Safety and Precautions**:
- Key Point! Do not massage the patient's legs if DVT/PE is suspected, as this could dislodge more clots.
- Administering opioids for pain in this setting can depress respiratory drive and mask clinical deterioration. Hold until the cause is identified.
- Be aware of contraindications for thrombolytics (e.g., recent surgery, active bleeding, history of hemorrhagic stroke).

Nursing Procedure & Medication Flow
**Supplemental Oxygen Administration**:
1. Select appropriate device: For severe hypoxemia (SpO2 < 90%), start with a **Non-Rebreather Mask (NRB)**.
2. Set flow rate to 10-15 L/min to ensure the reservoir bag remains inflated.
3. Monitor SpO2 continuously. Target is SpO2 > 92%.
4. Be prepared to assist with advanced airway management if the patient's respiratory status declines.

**Anticipated Medication Administration (Post-Diagnosis)**:
- **Anticoagulant (e.g., Heparin IV drip)**: Goal is to prevent new clots. Monitor aPTT (activated Partial Thromboplastin Time) per protocol. Watch for signs of bleeding (gums, urine, stool, injection sites).
- **Analgesia**: Once PE is confirmed and patient is stable, mild opioids may be used for pleuritic pain. Monitor respiratory rate closely.

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 sudden change in respiratory status post-op is a **red flag**. Trust your assessment. Your quick thinking to apply oxygen and call for help in this scenario is what saves lives. 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!"

## 핵심 개념

- **Pulmonary Embolism** — A life-threatening condition where a blood clot (usually from a DVT) travels to and blocks an artery in the lungs, causing impaired gas exchange and cardiovascular strain.
- **Deep Vein Thrombosis** — Formation of a blood clot in a deep vein, typically in the legs. It is the primary risk factor for pulmonary embolism.
- **Virchow's Triad** — The three broad categories of factors that contribute to thrombosis: venous stasis, hypercoagulability, and endothelial (vessel wall) injury.
- **Hypoxemia** — An abnormally low level of oxygen in the arterial blood (PaO2 < 80 mmHg or SpO2 < 95%). A key finding in pulmonary embolism.
- **Non-Rebreather Mask** — A high-flow oxygen delivery device with a reservoir bag and one-way valves, capable of delivering up to 90-100% FiO2. Used for severe hypoxemia.

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