# A nurse is caring for a 58-year-old patient with sudden onset chest pain and dyspnea following hip replacement surgery 3 days ago, suspected of pulmonary embolism. Which assessment finding would be the MOST critical indicator requiring immediate intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541327  
> language: ko  
> subject: Adult Health

## 문제

A nurse is caring for a 58-year-old patient with sudden onset chest pain and dyspnea following hip replacement surgery 3 days ago, suspected of pulmonary embolism. Which assessment finding would be the MOST critical indicator requiring immediate intervention?

## 보기

1. Oxygen saturation of 92% on room air with mild dyspnea
2. Sudden onset of severe chest pain with hemoptysis **✔ 정답**
3. Heart rate of 110 beats per minute
4. Anxiety and restlessness

**정답: 2**

## 해설

Sudden severe chest pain with hemoptysis indicates massive PE with significant vascular compromise, requiring immediate emergency intervention like anticoagulation or thrombolysis. Other findings (mild hypoxia, tachycardia, anxiety) are less critical in this context.

## 심화 해설

Clinical Context and Initial Triage

This patient presents with a classic high-risk scenario: sudden-onset chest pain and dyspnea three days after major orthopedic surgery. Hip arthroplasty is a well-established major risk factor for venous thromboembolism (VTE), including both deep vein thrombosis (DVT) and pulmonary embolism (PE). The Caprini risk assessment model (RAM) has been validated to predict VTE risk in this exact population, and patients undergoing total hip or knee arthroplasty automatically fall into a high-risk category due to the nature of the surgery and postoperative immobility [2]. When a PE is suspected, the nurse's immediate priority is to identify signs of hemodynamic instability or impending respiratory failure, which would necessitate rapid escalation of care.

Analysis of Assessment Findings

The 2026 AHA/ACC guideline introduces a refined severity classification system for acute PE, emphasizing that therapeutic decision-making hinges on precise risk stratification at the bedside . Let's analyze each option through this lens:

**Option 1: Oxygen saturation of 92% on room air with mild dyspnea.** While hypoxemia is a common finding in PE due to ventilation-perfusion (V/Q) mismatch, an SpO2 of 92% indicates only a mild gas exchange abnormality. This finding warrants supplemental oxygen and close monitoring but does not, by itself, signal an immediate life threat. It does not reflect the highest-priority crisis.

**Option 2: Sudden onset of severe chest pain with hemoptysis.** This combination is the most critical finding. Hemoptysis in the setting of suspected PE is a hallmark sign of a pulmonary infarction. When an embolus obstructs a distal pulmonary artery, it can lead to tissue necrosis and alveolar hemorrhage. More importantly, this clinical presentation often correlates with a higher clot burden or a more central, unstable thrombus. The sudden worsening of severe pain indicates an acute change in the patient's condition, potentially heralding further hemodynamic deterioration or extension of the infarction. This finding demands immediate intervention, including urgent notification of the provider and preparation for advanced therapies, as it represents a clear transition from a stable to a potentially unstable clinical trajectory per the guideline's emphasis on dynamic reassessment .

**Option 3: Heart rate of 110 beats per minute.** Sinus tachycardia is a compensatory mechanism for reduced cardiac output and hypoxemia in PE. A rate of 110 bpm is significant and requires attention, but it is a relatively non-specific finding and a common physiological response. In isolation, without other signs of shock or severe distress, it is not the single most critical indicator for immediate intervention.

**Option 4: Anxiety and restlessness.** These are common neuropsychiatric manifestations of hypoxemia and the distressing sensation of dyspnea. While they contribute to the patient's overall clinical picture and should not be dismissed, they are subjective and non-specific symptoms. They are not as immediately actionable as a physical sign that directly confirms a severe complication like pulmonary infarction.

Pathophysiological Rationale and Nursing Priority

The core pathophysiological concern is the progression from a simple embolic event to tissue death (infarction) and potential right ventricular strain. The 2026 guideline highlights the importance of identifying clinical markers that predict an adverse prognosis, moving beyond simple vital sign abnormalities to a more nuanced assessment of end-organ impact . Hemoptysis provides direct evidence of lung parenchymal injury. The nurse's immediate intervention for this finding involves ensuring a patent airway, administering high-flow oxygen, positioning the patient to optimize ventilation-perfusion matching, and immediately alerting the rapid response team or primary provider for urgent diagnostic confirmation (such as CT pulmonary angiography) and likely escalation to anticoagulation or advanced reperfusion therapies. This finding directly aligns with the guideline's framework for identifying patients who may require more aggressive, time-sensitive management beyond initial anticoagulation .References (research sources)

- [2]Utilization of the Caprini risk assessment model(RAM) to predict venous thromboembolism after primary hip and knee arthroplasty: an analysis of the Healthcare Cost and Utilization Project(HCUP).Research articleLin Z, Sun H, Chen M, Li D, Cai Z, Wang Y, Xu J, Ma R. (2024) · DOI: 10.1186/s12959-024-00633-4

## 임상 시나리오

Postoperative PE TriageRecognizing Pulmonary Infarction Signs
In a postoperative patient with suspected pulmonary embolism, the onset of hemoptysis with severe chest pain is the most critical finding. This combination suggests pulmonary infarction and alveolar hemorrhage, indicating a high-risk state that requires immediate intervention.

Triage based on severity: High-risk PE involves cardiac arrest, obstructive shock, or persistent hypotension. Submassive PE features right ventricular strain without hypotension. Low-risk PE has neither. Hemoptysis often correlates with more distal emboli causing tissue necrosis.

CautionDo not delay escalation for isolated vital sign changes like mild tachycardia (110 bpm) or moderate hypoxemia (SpO2 92%). Prioritize signs of end-organ damage, such as hemoptysis, over compensatory physiological responses.

## 핵심 개념

- **Hemoptysis in PE** — Coughing up blood resulting from pulmonary infarction due to distal embolization, indicating alveolar hemorrhage and a high-risk PE state.
- **Pulmonary Infarction** — Lung tissue death caused by prolonged blockage of pulmonary arterial blood flow, often presenting with pleuritic chest pain and hemoptysis.
- **Ventilation-Perfusion (V/Q) Mismatch** — An imbalance in lung air and blood flow, the primary mechanism of hypoxemia in PE, where alveoli are ventilated but not perfused.
- **Caprini Risk Assessment Model** — A validated tool to stratify venous thromboembolism risk in surgical patients; major orthopedic surgery like hip replacement places patients in the highest risk category.
- **High-Risk Pulmonary Embolism** — PE causing hemodynamic instability (cardiac arrest, obstructive shock, or persistent hypotension), distinct from submassive or low-risk PE based on clinical severity.

## 같은 주제 문제

- [A nurse is assessing a 58-year-old patient who underwent a total hip replacement 3 days ag…](https://mymerci.kr/pages/nclex_q.php?qn_id=541319)
- [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. Which nurs…](https://mymerci.kr/pages/nclex_q.php?qn_id=541324)
- [A nurse is caring for a patient with a confirmed pulmonary embolism who is experiencing ac…](https://mymerci.kr/pages/nclex_q.php?qn_id=541325)
- [A nurse is caring for a 45-year-old patient with a history of deep vein thrombosis who pre…](https://mymerci.kr/pages/nclex_q.php?qn_id=541326)

---

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

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