Level: Advanced
Difficulty: Hard
Subtopic: Perioperative nursing
NCLEX: A client is 12 hours postoperative after abdominal surgery and reports sudden shortness of breath and chest pain….
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A client is 12 hours postoperative after abdominal surgery and reports sudden shortness of breath and chest pain. What should the nurse do first?
Question
A. Assess airway, breathing, circulation, and oxygenation; apply oxygen and notify the provider immediately.
B. Encourage deep breathing and coughing later when pain improves.
C. Document as expected postoperative pain without further assessment.
D. Administer the PRN antacid before assessing respirations.
B. Encourage deep breathing and coughing later when pain improves.
C. Document as expected postoperative pain without further assessment.
D. Administer the PRN antacid before assessing respirations.
Rationale
Correct answer: A. Assess airway, breathing, circulation, and oxygenation; apply oxygen and notify the provider immediately.
Rationale: Sudden dyspnea and chest pain after surgery raise concern for pulmonary embolism or cardiac event; immediate ABC assessment and escalation are required.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Sudden dyspnea and chest pain after surgery raise concern for pulmonary embolism or cardiac event; immediate ABC assessment and escalation are required.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.