Examkin

Question

Difficulty: HardReduction of Risk Potential

An adult client is receiving care on the orthopedic unit 48 hours after undergoing a right total hip arthroplasty. The client is prescribed prophylactic subcutaneous enoxaparin and scheduled oral analgesics. While the practical nurse (PN) collects morning data, several findings are noted. Which specific assessment finding indicates a life-threatening complication that requires the PN to immediately escalate care to the registered nurse?

  1. The client develops sudden-onset pleuritic chest pain, tachypnea, and an oxygen saturation of 88% on room air.Answer
  2. B
    The client's morning laboratory report indicates a hemoglobin level of 10.6 g/dL and a hematocrit of 32%.
  3. C
    The client exhibits a temperature of 99.6°F (37.6°C), a heart rate of 92 beats/min, and a blood pressure of 130/82 mmHg.
  4. D
    The client's hospital identification wristband has been removed from their arm and is placed on the bedside table.

Answer

The correct finding is the development of sudden-onset pleuritic chest pain, tachypnea, and an oxygen saturation of 88% on room air.
The finding of sudden-onset pleuritic chest pain, tachypnea (rapid breathing), and hypoxia (oxygen saturation of 88%) strongly indicates a pulmonary embolism. Clients recovering from total hip arthroplasty are at high risk for blood clots. A pulmonary embolism compromises pulmonary circulation and oxygenation, creating an immediate, life-threatening airway and breathing emergency that requires rapid escalation to the registered nurse and medical team for oxygen therapy and anticoagulation.

Step-by-Step Solution

1
Analyze the client's clinical context and risk factors.
The client is 48 hours post-operative following a total hip arthroplasty.
Major lower extremity orthopedic surgeries place clients at a significantly elevated risk for venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE).
2
Evaluate each assessment finding using the ABC (Airway, Breathing, Circulation) prioritization framework.
The respiratory symptoms (hypoxia, tachypnea, chest pain) indicate an acute compromise of airway and breathing.
Physiological emergencies that threaten oxygenation must always be prioritized over routine post-operative findings or administrative safety protocols.
3
Differentiate between expected post-operative findings and critical complications.
Mild anemia (Hgb 10.6 g/dL) and low-grade inflammatory vitals (Temp 99.6°F) are expected 48 hours post-surgery. The missing ID band is a safety issue but not an immediate physiological threat.
Understanding normal post-operative physiological responses prevents the nurse from falsely escalating expected findings while missing a true life-threatening event.

Key Concept

Prioritization of Post-operative Complications and ABCs
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic