Question

A 68-year-old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to:

A. Inquire about the onset, duration, severity, and precipitating factors of the heaviness.
B. Administer oxygen via nasal cannula.
C. Offer pain medication for the chest heaviness.
D. Inform the physician of the chest heaviness.

Answer 1

The first nursing action when a post-operative hip surgery patient reports chest heaviness is to inquire about details of the heaviness to assess for potential complications.

Step-by-step explanation:

When a 68-year-old client on day 2 after hip surgery reports chest heaviness with no cardiac history, the first nursing action should be to: A. Inquire about the onset, duration, severity, and precipitating factors of the heaviness. This is crucial to gather more detailed information about the symptom and assess whether it might be related to a cardiac issue or other complications such as a pulmonary embolism, which could be a concern due to immobility post-surgery.

Given that immobility can lead to serious complications such as blood clots, respiratory failure, and pneumonia, a thorough assessment is critical. The actions that may follow, such as administering oxygen, offering pain medication, or informing the physician, would depend on the nurse's assessment and clinical judgment.