# Stage 1 — Recognize cues. Read the ED admission note. Highlight every finding that most directly increases concern for an acute pulmonary embolism or immediate cardiopulmonary compromise.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372442&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

Stage 1 — Recognize cues. Read the ED admission note. Highlight every finding that most directly increases concern for an acute pulmonary embolism or immediate cardiopulmonary compromise.

A 65-year-old male is postoperative day 7 after right total knee arthroplasty. History includes controlled hypertension, type 2 diabetes, and hyperlipidemia managed with prescribed outpatient medications and a 30 pack-year smoking history reported during intake. Prescribed prophylactic enoxaparin was interrupted 2 days ago when the medication supply ran out. Family brought him to the ED for sudden sharp right-sided chest pain that worsens with inspiration and shortness of breath. Assessment shows BP 92/58, HR 124, RR 28, and SpO2 88 percent on room air, temperature 36.7 C with no recent fever or chills, and diaphoresis with anxiety while accompanied by family. He denies prior cardiac symptoms before this event. The right calf is mildly tender without visible swelling.

## Explanation

Five high-priority cues
The strongest linked cues are recent total knee arthroplasty; interruption of prescribed thromboprophylaxis; sudden pleuritic chest pain with dyspnea; hypotension, tachycardia, tachypnea, and hypoxemia; and unilateral calf tenderness. Together they connect a recent venous-thromboembolism risk state, a possible deep-vein source, and acute cardiopulmonary compromise. Chronic conditions and smoking history matter to overall risk but are not the most direct cues in this acute pattern.

## In-depth explanation

Step 1 — Link risk to presentation
Recent major orthopedic surgery and interruption of prescribed prophylaxis create a strong venous-thromboembolism risk context. This is an access-related medication interruption, not a reason to label or blame the client.

Step 2 — Identify the acute syndrome
Sudden pleuritic chest pain and dyspnea plus BP 92/58, HR 124, RR 28, and SpO2 88 percent on room air indicate immediate cardiopulmonary compromise. Unilateral calf tenderness supports a possible deep-vein thrombus source even without visible swelling.

Step 3 — Control cue density
The task asks for the five most direct cues. Controlled chronic diagnoses, smoking history, normal temperature, diaphoresis/anxiety, and absence of prior cardiac symptoms do not carry the same case-specific weight.

Key concept
Recognize cues by connecting risk context + abrupt symptoms + physiologic instability + possible thrombus source.

## Clinical scenario

Scenario (Stage 1 — Recognize cues)
A 65-year-old client is postoperative day 7 after right total knee arthroplasty and arrives with sudden pleuritic chest pain and dyspnea. Identify the findings that most directly raise concern for acute pulmonary embolism or cardiopulmonary compromise.

Background
NCJMM Stage 1 — Distinguish the most relevant cues from background information before choosing a diagnosis.

## Key concepts

- **Pulmonary embolism (PE)** — Acute occlusion of one or more pulmonary arteries by thrombus, most often originating from a deep vein thrombosis. Classic presentation includes sudden dyspnea, pleuritic chest pain, and hypoxia disproportionate to lung exam.
- **Virchow triad** — Three contributors to thrombosis: venous stasis, endothelial injury, and hypercoagulability. Recent surgery (especially orthopedic) hits all three.
- **Postoperative venous-thromboembolism risk** — Recent major orthopedic surgery, reduced mobility, and interruption of prescribed thromboprophylaxis increase venous-thromboembolism risk. Describe the medication-access barrier objectively rather than using stigmatizing labels.

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