Question

The nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4°F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action?

A) Apply oxygen.
B) Notify the healthcare provider.
C) Check for pulmonary embolism.
D) Administer pain medication.

Answer 1

The nurse should urgently apply oxygen to address the patient's potential hypoxemia and immediately notify the healthcare provider due to the concern for a critical condition such as pulmonary embolism.

Step-by-step explanation:

The priority nursing action for an older adult patient who reports shortness of breath, slight chest pain, and a feeling that "something is wrong", with vital signs including a respiratory rate of 36 breaths/min and an oxygen saturation of 91% on room air, after a left total knee arthroplasty should be to apply oxygen immediately to manage potential hypoxemia and then notify the healthcare provider without delay. The symptoms described are concerning for a pulmonary embolism (PE), which is a critical and life-threatening condition that requires urgent attention. Administering pain medication without addressing the potential respiratory issue could exacerbate the patient's condition.