# A nurse is assessing a 58-year-old patient who underwent a total hip replacement 3 days ago. Which assessment finding would be the MOST concerning and require immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541319 > language: ko > subject: Adult Health ## 문제 A nurse is assessing a 58-year-old patient who underwent a total hip replacement 3 days ago. Which assessment finding would be the MOST concerning and require immediate intervention? ## 보기 1. Oxygen saturation of 94% on room air with mild shortness of breath 2. Calf pain and swelling in the operative leg with positive Homan's sign 3. Heart rate of 102 bpm with complaints of chest discomfort 4. Sudden onset of severe dyspnea with chest pain and hemoptysis **✔ 정답** **정답: 4** ## 해설 Sudden onset of severe dyspnea with chest pain and hemoptysis is the classic triad of massive pulmonary embolism, a life-threatening emergency requiring immediate intervention. Other findings, while concerning, represent less urgent complications like DVT or mild hypoxia. ## 심화 해설 Clinical Reasoning and Priority Setting This question tests your ability to recognize a life-threatening postoperative complication and prioritize nursing actions. After a total hip replacement (THR), patients are at significant risk for venous thromboembolism (VTE), including deep vein thrombosis (DVT) and its most lethal sequela, pulmonary embolism (PE). While all the options represent abnormal findings, you must differentiate between a common, expected postoperative concern and a rapidly fatal emergency. Analysis of the Correct Answer (Option 4) The sudden onset of severe dyspnea, chest pain, and hemoptysis is the classic clinical triad for an acute pulmonary embolism (APE), although the triad is not always present in its entirety. This presentation indicates a large, hemodynamically significant embolus has traveled from a deep vein, likely in the operative leg, and lodged in the pulmonary vasculature. This is the most concerning finding because APE is a life-threatening condition that can lead to obstructive shock and cardiac arrest within minutes [3]. Immediate intervention—including high-flow oxygen administration, notification of the rapid response team, and preparation for emergent diagnostic testing and anticoagulation—is required to prevent mortality. Analysis of Incorrect Options - Option 1: An oxygen saturation of 94% on room air with mild shortness of breath is a common postoperative finding. Atelectasis, the effects of anesthesia, and pain can all contribute to this. While it requires nursing intervention, such as incentive spirometry and mobilization, it is not immediately life-threatening compared to a massive PE. - Option 2: Calf pain and swelling in the operative leg with a positive Homan's sign is highly suggestive of a deep vein thrombosis (DVT). This is a serious complication that requires prompt intervention to prevent progression to a PE. Prophylactic anticoagulation, with agents like low-molecular-weight heparin (LMWH) or aspirin, is a standard of care after THR precisely to prevent this . However, a DVT itself is not as acutely life-threatening as a PE that has already occurred and is causing severe respiratory and cardiovascular symptoms. The presence of a DVT makes the findings in Option 4 even more likely. - Option 3: A heart rate of 102 bpm with chest discomfort is a concerning but nonspecific finding. Tachycardia can be a sign of pain, anxiety, hypovolemia, or a developing PE. While this patient requires a thorough assessment, the sudden, severe, and classic presentation in Option 4 represents a more definitive and critical emergency that demands the nurse's immediate attention. Pathophysiology and Clinical Integration The connection between these options lies in the pathophysiology of VTE. Orthopedic surgeries like THR fulfill all three components of Virchow's triad: venous stasis from immobility, endothelial injury from the surgery itself, and a hypercoagulable state postoperatively. This makes VTE a primary concern, and research consistently focuses on comparing prophylactic strategies to mitigate this risk [1,2]. A DVT (Option 2) is the source of the embolus. When a thrombus dislodges and travels to the lungs, it creates a ventilation-perfusion (V/Q) mismatch and increases pulmonary vascular resistance, leading to the sudden hypoxemia, chest pain from pulmonary infarction, and hemoptysis described in Option 4. The study on APE confirms that this condition demands precise and immediate risk stratification due to its high potential for early mortality [3].References (research sources) - [3]Does C-reactive protein exhibit high prognostic information value in acute pulmonary embolism? A novel structural pathway for disease progression beyond classical statistical associations.Research articleTukiendorf A, Feusette P. (2026) · DOI: 10.1371/journal.pone.0343108 ## 임상 시나리오 Recognizing Acute Pulmonary Embolism Post-THAClassic Triad Demands Immediate Action The most lethal complication after total hip replacement is acute pulmonary embolism (PE). The classic presentation is a sudden onset of severe shortness of breath, sharp chest pain that worsens with breathing, and coughing up blood. This indicates a large, hemodynamically significant embolus has lodged in the pulmonary vasculature. This is a life-threatening emergency that can rapidly progress to obstructive shock and cardiac arrest. The priority intervention is to administer high-flow oxygen, call a rapid response team, and prepare for emergent anticoagulation and diagnostic testing. CautionDo not delay intervention for diagnostic confirmation. A high clinical suspicion based on the classic triad, especially in a high-risk postoperative patient, is sufficient to initiate life-saving measures. The full triad is not always present, so any sudden, unexplained shortness of breath must be evaluated urgently. ## 핵심 개념 - **Pulmonary Embolism (PE)** — A life-threatening blockage of an artery in the lungs by a clot, often originating from a deep vein thrombosis, presenting classically with sudden dyspnea, pleuritic chest pain, and hemoptysis. - **Venous Thromboembolism (VTE)** — A condition encompassing both deep vein thrombosis (DVT) and pulmonary embolism (PE), a major risk after orthopedic surgeries like total hip replacement. - **Hemoptysis** — The coughing up of blood from the respiratory tract, a classic sign of pulmonary infarction due to PE. - **Homan's Sign** — A clinical sign of DVT characterized by calf pain upon passive dorsiflexion of the foot; it is not a reliable or definitive diagnostic indicator. - **Priority Setting** — The nursing process of ranking patient problems using frameworks like ABCs (Airway, Breathing, Circulation) or urgency to determine which requires immediate intervention. ## 같은 주제 문제 - [A nurse is assessing a 68-year-old patient who underwent total hip replacement surgery 3 d…](https://mymerci.kr/pages/nclex_q.php?qn_id=541320) - [A nurse is caring for a patient with suspected pulmonary embolism who has been receiving a…](https://mymerci.kr/pages/nclex_q.php?qn_id=541321) - [A nurse is caring for a patient with a confirmed pulmonary embolism who is stable on antic…](https://mymerci.kr/pages/nclex_q.php?qn_id=541322) - [A nurse is caring for a patient with a confirmed pulmonary embolism who is receiving antic…](https://mymerci.kr/pages/nclex_q.php?qn_id=541323) - [A nurse is caring for a client who is suspected of having a pulmonary embolism. 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