# Stage 3 — Prioritize hypotheses. The RN, working with one LPN/VN and one UAP, has completed focused assessments after handoff. Patient A, 72, is postoperative day 1 after right total hip arthroplasty and receives prescribed VTE prophylaxis. At 0500 he developed sudden shortness of breath with new right calf tenderness and unilateral swelling. BP is 138/86, HR 110, RR 24, temperature 37.6°C (99.7°F), and SpO2 89% on room air. He is anxious but alert and oriented, breath sounds are clear, and there are no petechiae. Patient D, 81, with a UTI, is oriented to person and place (baseline oriented x3) and is trying to get out of bed; a bed alarm is active. Patients B and C are stable. For Patient A, complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617391&lang=en  
> language: en  
> subject: Assignment/Delegation/Supervision  
> category: MOC

## Question

Stage 3 — Prioritize hypotheses. The RN, working with one LPN/VN and one UAP, has completed focused assessments after handoff. Patient A, 72, is postoperative day 1 after right total hip arthroplasty and receives prescribed VTE prophylaxis. At 0500 he developed sudden shortness of breath with new right calf tenderness and unilateral swelling. BP is 138/86, HR 110, RR 24, temperature 37.6°C (99.7°F), and SpO2 89% on room air. He is anxious but alert and oriented, breath sounds are clear, and there are no petechiae. Patient D, 81, with a UTI, is oriented to person and place (baseline oriented x3) and is trying to get out of bed; a bed alarm is active. Patients B and C are stable. For Patient A, complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Postoperative atelectasis
Fat embolism syndrome
Acute pulmonary embolism
Anxiety-related hyperventilation

Actions to take

Select 2
Have the UAP take his vital signs while the RN sees Patient D
Stay with him, stop activity, and apply prescribed oxygen
Coach incentive spirometry 10 times every hour
Assign the LPN/VN to complete his initial assessment
Notify the provider and activate the rapid response team

Parameters to monitor

Select 2
Oxygen saturation
Petechiae on the chest and axillae
Incentive spirometer volume
Heart rate
Daily calf circumference

## Explanation

Patient A's sudden dyspnea, SpO2 89%, tachycardia, tachypnea, and new unilateral calf tenderness and swelling the day after hip arthroplasty indicate a suspected acute pulmonary embolism and make him the first priority. The RN stays with him, stops activity, applies prescribed oxygen, and notifies the provider with a rapid response activation; an unstable client's assessment is not delegated. Oxygen saturation and heart rate show whether his cardiopulmonary status is improving.

## In-depth explanation

Quick answer
Acute pulmonary embolism in Patient A. Stay with him, stop activity, and apply prescribed oxygen; notify the provider and activate the rapid response team. Monitor oxygen saturation and heart rate.

Why this is correct
Hip arthroplasty is one of the highest-risk operations for VTE, and new unilateral calf tenderness and swelling suggest a DVT source. Sudden dyspnea with hypoxemia, tachycardia, and tachypnea despite clear breath sounds fits an embolus. An airway-breathing-circulation threat outranks Patient D's safety risk, which is covered by the bed alarm and can be handed to staff once help arrives for Patient A.

Easy analogy or mental picture
Four call lights are on, but only one is a fire alarm. The RN goes to the fire (Patient A), calls the fire department (rapid response), and sends others to watch the smaller risks.

Memory hook
"New hip + sudden breathless + one fat calf = PE; RN stays, calls, gives oxygen."

NCLEX decision rule
Use ABCs to pick the first client, keep assessment and evaluation of an unstable client with the RN, and delegate only stable, predictable tasks.

Why the other choices are wrong
Atelectasis is common after surgery and can cause low-grade fever, but it develops gradually with diminished breath sounds, so incentive spirometry and spirometer volumes do not fit sudden hypoxemia with clear lungs. Fat embolism syndrome can follow orthopedic surgery, but it brings petechiae and confusion, which are absent, so petechiae checks do not track progress. Anxiety can cause rapid breathing, but it does not drop SpO2 to 89%. Having the UAP take vital signs or the LPN/VN complete the initial assessment delegates the evaluation of an unstable client, and calf circumference tracks the DVT, not the embolism's effect on gas exchange.

References
1Pulmonary Embolism (StatPearls, NCBI Bookshelf)Sudden pleuritic chest pain, dyspnea, tachycardia, and hypoxemia after surgery suggest PE; oxygen, hemodynamic support, imaging, and anticoagulation
2NCSBN/ANA National Guidelines for Nursing DelegationAssessment of an unstable client and evaluation of interventions are retained by the RN and are not delegated

## Clinical scenario

Case update
Focused assessment confirms Patient A's hypoxemia and unilateral calf findings while Patient D remains at acute delirium and fall risk.

## Key concepts

- **Rapid response team** — A team that brings critical-care expertise to the bedside when a client shows early deterioration.
- **Fat embolism syndrome** — Fat globules entering the circulation after long-bone or orthopedic surgery, causing hypoxemia, confusion, and petechiae.
- **Delegation limits** — The RN keeps assessment, evaluation, and care of unstable clients and delegates only stable, predictable tasks.

## Related questions

- [A 67-year-old client with chronic obstructive pulmonary disease attends a routine primary …](https://mymerci.kr/pages/nclex_q.php?qn_id=360522&lang=en)
- [A registered nurse on a medical-surgical unit is delegating tasks at the start of shift. W…](https://mymerci.kr/pages/nclex_q.php?qn_id=360523&lang=en)
- [A 78-year-old male client with end-stage pancreatic cancer is enrolled in inpatient hospic…](https://mymerci.kr/pages/nclex_q.php?qn_id=362322&lang=en)
- [A nurse on a medical-surgical unit is starting a 0700 round and reviews these four assigne…](https://mymerci.kr/pages/nclex_q.php?qn_id=362403&lang=en)
- [An RN is assigning care on a medical-surgical unit to an LPN/VN and a trained unlicensed a…](https://mymerci.kr/pages/nclex_q.php?qn_id=362464&lang=en)
- [A registered nurse on a medical-surgical unit is assigning tasks to a licensed practical n…](https://mymerci.kr/pages/nclex_q.php?qn_id=363932&lang=en)
- [A charge nurse on a medical-surgical unit is making assignments for the day shift. The tea…](https://mymerci.kr/pages/nclex_q.php?qn_id=363953&lang=en)
- [A nurse manager is reviewing situations from the past week to identify potential HIPAA Pri…](https://mymerci.kr/pages/nclex_q.php?qn_id=364050&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617391&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617391&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617391&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617391&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617391&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._