# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541039  
> language: ko  
> subject: Adult Health

## 문제

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?

## 보기

1. Encourage early ambulation and physical therapy exercises
2. Monitor surgical site for signs of infection
3. Assess for signs and symptoms of pulmonary embolism **✔ 정답**
4. Maintain proper alignment and positioning of the affected leg

**정답: 3**

## 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.

## 심화 해설

Understanding the Priority: Airway, Breathing, Circulation

When prioritizing care for a postoperative client, the nursing framework of Airway, Breathing, and Circulation (ABCs) is essential. While all the listed interventions are important, the nurse must first address the complication that poses the most immediate threat to life. For a client two days after a total knee replacement (TKA), the most serious and rapidly fatal postoperative complication is a pulmonary embolism (PE).

Why Pulmonary Embolism is the Priority

A pulmonary embolism is a direct threat to breathing and circulation. It occurs when a blood clot, most commonly a deep vein thrombosis (DVT) from the lower extremity, travels to the lungs and obstructs a pulmonary artery. This blockage causes a sudden and severe ventilation-perfusion mismatch, leading to rapid hypoxemia, and can precipitate right-sided heart failure and cardiovascular collapse.

The risk of developing a venous thromboembolism (VTE), which includes both DVT and PE, is significantly elevated after major joint surgery. Research confirms that patients undergoing total joint arthroplasty, including TKA, are at an increased risk for this specific postoperative complication [1]. The clinical burden of VTE is substantial, making its prevention and early detection a cornerstone of postoperative care [1]. Without prompt recognition and intervention, a massive PE can be fatal within minutes to hours. Therefore, actively assessing for its signs and symptoms, such as sudden dyspnea, pleuritic chest pain, tachycardia, and apprehension, is the most critical nursing action to prevent death.

Analyzing the Other Interventions

The other options are standard and necessary components of postoperative care, but they do not address the most immediate life-threatening risk.

-   Encourage early ambulation and physical therapy exercises: This is a crucial intervention for preventing VTE and other complications like pneumonia and ileus. However, it is a preventive measure, not an assessment for an active, life-threatening event. Once a clot has formed and embolized, ambulation will not reverse the PE.

-   Monitor surgical site for signs of infection: Surgical site infection is a serious complication that can lead to prolonged hospitalization, sepsis, and implant failure. However, its progression is typically slower than that of a PE. A wound infection does not pose the same immediate threat to the airway and circulation as a pulmonary embolus.

-   Maintain proper alignment and positioning of the affected leg: This intervention is vital for preventing prosthesis dislocation and promoting comfort. While improper positioning could theoretically contribute to venous stasis, the primary purpose is to protect the integrity of the new joint, not to prevent a systemic, life-threatening embolic event. The immediate risk of death from joint malalignment is negligible compared to a PE.

Clinical Application and Pathophysiology

The pathophysiology of VTE in TKA involves Virchow's triad: venous stasis (from immobility and tourniquet use during surgery), endothelial injury (from the surgical procedure itself), and a hypercoagulable state (as part of the body's physiological stress response to surgery). This triad creates a perfect environment for thrombus formation in the deep veins of the operated leg. The period around the second postoperative day is a high-risk window for a DVT to dislodge and become a PE.

Prophylactic anticoagulation is a cornerstone of care to mitigate this risk, with agents like rivaroxaban and low molecular weight heparin (LMWH) being commonly used . However, no prophylactic regimen is 100% effective, and a VTE can still occur [1]. This underscores why the nurse's vigilant assessment for the clinical manifestations of PE is non-negotiable and takes priority over other aspects of care. A nurse-led, systematic approach to monitoring and prevention is critical for improving patient outcomes . The best evidence for preventing DVT emphasizes a comprehensive strategy, but the nurse's role in early detection of a PE is the final safety net .References (research sources)

- [1]Determining the Appropriate Pharmaceutical Prophylaxis for Venous Thromboembolism Following Total Joint Arthroplasty: A Systematic Literature Review.Research articleLayne E. (2026) · DOI: 10.1097/nor.0000000000001208

## 임상 시나리오

Post-TKA Pulmonary Embolism AssessmentPrioritizing the most life-threatening postoperative complication
After total knee replacement, the ABC framework dictates that assessing for pulmonary embolism (PE) is the priority. PE directly threatens breathing and circulation and can be rapidly fatal.

The risk of venous thromboembolism (VTE) is highest between postoperative days 2 and 5. A deep vein thrombosis can dislodge and cause a sudden, severe ventilation-perfusion mismatch.

CautionImmediately report sudden-onset dyspnea, pleuritic chest pain, tachypnea, tachycardia, or hemoptysis. Do not mistake anxiety or incisional pain for these critical signs.

## 핵심 개념

- **Pulmonary Embolism (PE)** — A life-threatening blockage of a pulmonary artery by a blood clot, causing severe ventilation-perfusion mismatch, hypoxemia, and potential cardiovascular collapse.
- **Venous Thromboembolism (VTE)** — A condition encompassing both deep vein thrombosis (DVT) and pulmonary embolism (PE), for which risk is significantly elevated after major joint surgery.
- **ABC Framework** — A prioritization model in nursing (Airway, Breathing, Circulation) used to identify and address the most immediate life-threatening conditions first.

## 같은 주제 문제

- [A nurse is assessing a patient 24 hours after total knee replacement surgery. Which assess…](https://mymerci.kr/pages/nclex_q.php?qn_id=541035)
- [A nurse is assessing a 68-year-old patient on the second postoperative day following total…](https://mymerci.kr/pages/nclex_q.php?qn_id=541036)
- [A nurse is assessing a 72-year-old patient 48 hours after total knee replacement surgery. …](https://mymerci.kr/pages/nclex_q.php?qn_id=541037)
- [A nurse is caring for a client 1 day after total knee replacement surgery. Which nursing i…](https://mymerci.kr/pages/nclex_q.php?qn_id=541038)
- [A nurse is caring for a client 24 hours after open reduction internal fixation (ORIF) of a…](https://mymerci.kr/pages/nclex_q.php?qn_id=541040)
- [A nurse is caring for a patient on the first postoperative day following total knee replac…](https://mymerci.kr/pages/nclex_q.php?qn_id=541041)
- [A nurse is caring for a client 24 hours after total knee replacement surgery. Which assess…](https://mymerci.kr/pages/nclex_q.php?qn_id=541042)
- [A nurse is caring for a client 2 days after total hip replacement surgery. Which assessmen…](https://mymerci.kr/pages/nclex_q.php?qn_id=541043)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._