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Nursing QUESTION #9310
Question 1
A post-operative patient complains of sudden severe chest pain and shortness of breath on day 3. SpO₂ drops to 88%. Which is the nurse's first priority action?
  • Administer prescribed analgesic for pain
  • Perform a 12-lead ECG
  • Sit the patient upright and administer oxygen✔️
  • Call the physician and wait for orders
Correct Answer Explanation

Using the ABC (Airway, Breathing, Circulation) framework — the immediate first action is to address oxygenation:

  1. Sit patient upright (High Fowler's) — maximizes lung expansion
  2. Administer supplemental oxygen — target SpO₂ ≥ 94%
  3. Call for help / activate rapid response team
  4. 12-lead ECG (to differentiate PE vs MI)
  5. Establish IV access
  6. Prepare for further investigations (D-dimer, CT pulmonary angiography for PE)

This presentation on day 3 post-surgery is classic for Pulmonary Embolism (PE) — the peak incidence is 2–7 days post-operatively. Hypoxia is life-threatening and must be corrected before diagnostic workup. A nurse who waits for physician orders before applying oxygen is delaying potentially life-saving treatment.