# A nurse is caring for a 58-year-old patient who underwent major orthopedic surgery 24 hours ago. The patient's vital signs have been stable, but the nurse notices subtle changes during the assessment. Which finding should be the nurse's HIGHEST priority for immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543600 > language: ko > subject: Next Gen NCLEX ## 문제 A nurse is caring for a 58-year-old patient who underwent major orthopedic surgery 24 hours ago. The patient's vital signs have been stable, but the nurse notices subtle changes during the assessment. Which finding should be the nurse's HIGHEST priority for immediate intervention? The nurse observes that the patient appears slightly more restless than earlier, with a respiratory rate that has increased from 16 to 22 breaths per minute over the past 2 hours. ## 보기 1. Blood pressure decreased from 125/75 mmHg to 115/70 mmHg 2. Urine output of 15 mL in the past hour with dark amber-colored urine 3. Heart rate increased from 78 bpm to 98 bpm with new onset of anxiety **✔ 정답** 4. Oral temperature elevated from 98.4°F to 99.8°F (37.7°C) **정답: 3** ## 해설 Tachycardia (HR increase to 98 bpm) with new anxiety suggests potential complications like bleeding or sepsis, requiring immediate intervention. Other findings (mild BP drop, low urine output, slight fever) are less urgent. ## 심화 해설 Priority Assessment: Recognizing Early Signs of a Pulmonary Embolism The nurse's highest priority is the finding described in option 3. In a postoperative orthopedic patient, the combination of an acutely elevated heart rate and new-onset anxiety is a classic early warning sign of a pulmonary embolism (PE). While the provided research focuses on emergence delirium in the immediate post-anesthesia period, the principle of vigilant monitoring for subtle changes in mental status and vital signs in elderly orthopedic patients is directly transferable to the later postoperative phase. The study by Lu et al. (2025) underscores how elderly orthopedic patients are a high-risk group for postoperative complications that manifest with altered mental status and physiological instability [1]. Here is a breakdown of why option 3 is the most critical finding: Analysis of the Correct Answer (Option 3) A heart rate increase from 78 bpm to 98 bpm represents a significant sinus tachycardia. When this is paired with a new, unexplained onset of anxiety in a patient who is 24 hours post-major orthopedic surgery, it creates a high-index of suspicion for a pulmonary embolism. The pathophysiological mechanism is a ventilation-perfusion (V/Q) mismatch caused by a thrombus obstructing pulmonary blood flow. This leads to acute hypoxemia, which triggers the sympathetic nervous system, resulting in tachycardia and a profound sense of apprehension or impending doom. Restlessness, as noted in the stem, is an early neurological manifestation of hypoxemia. This cluster of findings requires immediate intervention, including a rapid assessment of oxygen saturation, application of supplemental oxygen, and prompt notification of the rapid response team. Analysis of the Other Options * Option 1: Blood pressure decreased from 125/75 mmHg to 115/70 mmHg. This is a mild decrease in blood pressure and the values remain within a normotensive range. While a drop in blood pressure can be a late and ominous sign of a massive PE or hemorrhage, in isolation and without other signs of shock, it is not the highest priority finding. It requires continued monitoring but not the same level of immediate intervention as the cardiorespiratory and mental status changes in option 3. * Option 2: Urine output of 15 mL in the past hour with dark amber-colored urine. An output of less than 30 mL/hour is a key indicator of acute kidney injury or hypovolemia. The dark amber color suggests concentrated urine. This is a significant finding that points to possible fluid volume deficit, which is a common postoperative complication. However, it represents a developing problem that can be addressed with fluid resuscitation. The immediate threat to airway, breathing, and circulation (ABCs) presented by a suspected PE takes precedence over this renal perfusion concern. * Option 4: Oral temperature elevated from 98.4°F to 99.8°F (37.7°C). A low-grade fever (100.4°F/38°C) in the first 24-48 hours post-surgery is most often a non-infectious, inflammatory response to surgical trauma, frequently related to atelectasis. While the nurse should encourage incentive spirometry to address the respiratory rate increase and prevent pulmonary complications, this temperature elevation is an expected finding and does not signal an immediate life-threatening crisis like the clinical picture in option 3. Clinical Decision-Making and Prioritization This question requires the application of the nursing process and Maslow's hierarchy of needs, with a focus on the physiological survival needs of airway, breathing, and circulation. The subtle changes in the patient's mental status (restlessness, anxiety) and vital signs (tachypnea, tachycardia) form a cluster that points directly to a respiratory or circulatory compromise. The research on elderly orthopedic patients confirms that this population is vulnerable to such rapid changes, and that alterations in mental status are a critical assessment finding that should never be dismissed as simple anxiety without ruling out physiological causes [1]. The nurse must use clinical judgment to interpret these early cues and intervene before the patient's condition deteriorates into a full-blown emergency.References (research sources) - [1]Risk Factors for Emergence Delirium in Elderly Orthopedic Patients After General Anesthesia.Research articleLu Y, Wang L, Wang Y, Ruan B, Lu G, Lin X. (2025) · DOI: 10.1002/brb3.71047 ## 임상 시나리오 Post-Op PE RecognitionSubtle Signs, Critical Intervention In a patient 24 hours post-major orthopedic surgery, a new heart rate increase (e.g., from 78 to 98 bpm) coupled with new-onset anxiety or restlessness is a classic early warning sign of a pulmonary embolism (PE). The underlying mechanism is a ventilation-perfusion (V/Q) mismatch from a thrombus obstructing pulmonary blood flow, causing acute hypoxemia. This triggers the sympathetic nervous system, leading to tachycardia and a sense of impending doom. CautionDo not dismiss subtle mental status changes as simple anxiety. Immediately assess SpO2, auscultate lungs, and notify the rapid response team or provider while keeping the patient calm and on bed rest. ## 핵심 개념 - **Pulmonary Embolism (PE)** — A blockage in one of the pulmonary arteries in the lungs, often caused by a deep vein thrombosis (DVT) that travels from the legs, common after orthopedic surgery. - **Ventilation-Perfusion (V/Q) Mismatch** — An imbalance between the amount of air reaching the alveoli (ventilation) and the amount of blood flowing to the alveoli (perfusion), leading to hypoxemia. - **Virchow's Triad** — Three broad categories of factors that contribute to thrombosis: hypercoagulability, hemodynamic changes (stasis), and endothelial injury/dysfunction. ## 같은 주제 문제 - [A nurse is caring for a 72-year-old patient who underwent major abdominal surgery 24 hours…](https://mymerci.kr/pages/nclex_q.php?qn_id=543595) - [A nurse is caring for a 55-year-old patient who underwent major abdominal surgery 18 hours…](https://mymerci.kr/pages/nclex_q.php?qn_id=543596) - [A nurse is caring for a 65-year-old patient with chronic obstructive pulmonary disease (CO…](https://mymerci.kr/pages/nclex_q.php?qn_id=543597) - [A nurse is caring for a 68-year-old patient with chronic obstructive pulmonary disease (CO…](https://mymerci.kr/pages/nclex_q.php?qn_id=543598) - [A nurse is caring for a 72-year-old patient who underwent major abdominal surgery 18 hours…](https://mymerci.kr/pages/nclex_q.php?qn_id=543599) - [A nurse is caring for a 68-year-old patient who underwent major abdominal surgery 24 hours…](https://mymerci.kr/pages/nclex_q.php?qn_id=543601) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._