# A nurse is caring for a 68-year-old client who underwent total hip replacement surgery 2 days ago. The client is receiving anticoagulant therapy and has been experiencing mild confusion since surgery. Which nursing action should be the PRIORITY to ensure client safety?

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> subject: Next Gen NCLEX

## 문제

A nurse is caring for a 68-year-old client who underwent total hip replacement surgery 2 days ago. The client is receiving anticoagulant therapy and has been experiencing mild confusion since surgery. Which nursing action should be the PRIORITY to ensure client safety?

## 보기

1. Implement fall prevention measures including bed alarm and frequent orientation **✔ 정답**
2. Monitor laboratory values for signs of bleeding complications
3. Assess pain level and administer prescribed analgesics
4. Encourage early ambulation to prevent blood clots

**정답: 1**

## 해설

Fall prevention is the priority due to postoperative status, anticoagulant therapy, and confusion, which increase bleeding risk if injured. Other actions are important but less immediate.

## 심화 해설

Clinical Context and Priority Setting

This client presents a classic NCLEX-RN priority scenario involving multiple competing safety concerns. The 68-year-old client is two days post-total hip replacement, receiving anticoagulant therapy, and exhibiting mild confusion. In NCLEX prioritization frameworks, the nurse must first address the issue that poses the most immediate threat to physical safety. While bleeding, pain, and immobility are all valid concerns, the combination of recent major orthopedic surgery, anticoagulation, and new-onset confusion creates an imminent risk for falls, which can lead to catastrophic outcomes such as periprosthetic fracture, surgical site disruption, or intracranial hemorrhage in an anticoagulated patient.

Why Fall Prevention Is the Priority

Postoperative confusion in elderly clients is a well-recognized phenomenon that significantly increases fall risk. The narrative review by Hu et al. highlights that perioperative complications, including sleep disturbance and pain, profoundly influence recovery trajectories in the elderly hip fracture and arthroplasty population [1]. Confusion can stem from multiple sources in this client: residual anesthetic effects, opioid analgesics, sleep disruption, or an underlying delirium. Regardless of etiology, a confused client with a recent hip replacement is unable to reliably follow weight-bearing precautions or call for assistance, making independent mobilization extremely dangerous. The priority nursing action is to implement environmental and behavioral safety interventions—specifically, a bed alarm to alert staff of unsupervised movement and frequent reorientation to reduce agitation and impulsive attempts to get up.

Analysis of Other Options

**Option 2: Monitor laboratory values for signs of bleeding complications.** Monitoring for bleeding is a critical component of anticoagulant therapy management. However, in the hierarchy of nursing priorities, a potential physiologic complication (bleeding) is addressed after securing immediate physical safety (fall prevention). The client is currently stable; there is no indication of active hemorrhage. Laboratory monitoring is an important but ongoing assessment, not the single most time-sensitive safety action.

**Option 3: Assess pain level and administer prescribed analgesics.** Pain assessment and management are essential, as uncontrolled pain can contribute to confusion and agitation in elderly clients [1]. However, administering analgesics—particularly opioids—before ensuring environmental safety could paradoxically increase fall risk by causing sedation or orthostatic hypotension. Pain must be addressed, but safety measures must be in place first.

**Option 4: Encourage early ambulation to prevent blood clots.** Early ambulation is a cornerstone of venous thromboembolism prevention and aligns with Enhanced Recovery After Surgery (ERAS) frameworks [1]. However, a confused client cannot safely ambulate without first establishing safety precautions and determining the underlying cause of the confusion. Attempting ambulation without these measures in place could lead to a fall during the activity.

Integration of Frailty and Postoperative Vulnerability

The client’s age and presentation align with the concept of frailty discussed in the stroke prevention review by Lucà et al., which emphasizes that elderly patients with cardiovascular comorbidities require an integrated, frailty-informed approach to care . While that review focuses on stroke, the principle applies broadly: a frail or confused elderly surgical patient has diminished physiologic reserve and cannot compensate for stressors such as medication side effects or environmental hazards. The bed alarm and reorientation interventions are low-risk, high-yield strategies that directly mitigate the vulnerability created by this intersection of advanced age, surgery, and altered mental status.

Medication Safety Considerations

The client’s anticoagulant therapy warrants consideration of medication-related confusion. Polypharmacy and potentially inappropriate medications are common in older adults and can contribute to cognitive changes . Additionally, the medication optimization pathway described by De Guio et al. underscores the importance of reviewing chronic treatments during hospitalization, as discrepancies and inappropriate changes can occur . While the nurse should certainly verify that the client’s confusion is not a sign of an adverse drug event (such as an interaction between anticoagulants and other medications), the immediate safety action remains environmental control. The clinical decision support systems evaluated by Bobrova et al. are designed to flag such risks, but the bedside nurse’s first responsibility is to prevent harm from the most immediate threat—an unsupervised fall .References (research sources)

- [1]Multimodal Perioperative Management of Elderly Hip Fracture Patients: Integrating Western and Traditional Chinese Medicine Approaches for Sleep, Pain, and PONV Control: A Narrative Review.Research articleHu R, Ding Y, Zhang J, Li C, Huang W, He J, Yue J. (2026) · DOI: 10.2147/jpr.s599583

## 임상 시나리오

Post-Op Hip Replacement: Fall Prevention PriorityManaging the confused patient on anticoagulation
For a client with a new total hip replacement, anticoagulation, and acute confusion, the immediate priority is fall prevention. A fall can cause a periprosthetic fracture or intracranial hemorrhage.

Implement a bed alarm, keep the bed in the lowest position, and provide frequent reorientation. Assess for reversible causes of confusion like hypoxia or urinary retention.

CautionDo not attempt early ambulation until confusion clears and safety is ensured. A confused patient cannot follow weight-bearing precautions.

## 핵심 개념

- **Periprosthetic fracture** — A bone fracture occurring around the components of a joint implant, a catastrophic complication often resulting from a fall after arthroplasty.
- **Postoperative delirium** — An acute, fluctuating disturbance in attention and cognition that is common in elderly surgical patients and significantly increases fall risk.
- **Anticoagulant therapy** — Medication to prevent blood clot formation, which increases the risk of serious bleeding, such as intracranial hemorrhage, if the patient falls.
- **NCLEX prioritization framework** — A decision-making model (e.g., Maslow's hierarchy, ABCs, safety) used to determine which patient need poses the most immediate threat and must be addressed first.

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