A client was successfully extubated after several days of sedation and mechanical ventilation and is currently receiving 40% oxygen via a face mask. While making rounds, the nurse finds the client confused and attempting to get out of bed. Current vital signs are an oral temperature 99.2°F (37.3° C), heart rate 112 beats/minutes, respirations 16 breaths/minute, blood pressure 100/70 mm Hg, and an oxygen saturation of 98%. Which intervention should the nurse implement?

A. Perform the Allen test. The Allen test is performed before inserting a radial arterial line to assess ulnar artery patency and ensure adequate collateral circulation. Since the arterial line is already placed and the client is showing signs of compromised circulation (pallor, paresthesia, and slow capillary refill), immediate intervention is required rather than further pre-insertion testing.
B. Elevate the client's right arm. Elevating the arm does not directly resolve arterial compromise and may further reduce perfusion by impairing arterial blood flow. The priority is to assess and address potential ischemia caused by arterial line complications.
C. Flush the line with heparinized saline. Flushing an arterial line is appropriate for maintaining patency, but in this case, it may worsen ischemia if the catheter is causing an obstruction or arterial spasm. Additionally, flushing should never be done forcefully due to the risk of embolization.
D. Notify the healthcare provider. The pallor, paresthesia, and delayed capillary refill suggest arterial insufficiency, possible thrombosis, or arterial spasm, which can lead to tissue ischemia and necrosis if not addressed promptly. The healthcare provider should be notified immediately to assess the need for interventions such as removal of the arterial line, vascular assessment, or anticoagulation therapy.

A. Notify healthcare provider (HCP) of the symptoms and administer a PRN pain medication. While notifying the HCP is necessary, administering pain medication does not address the underlying cause of the client’s acute chest pain and difficulty breathing. These symptoms suggest a possible pulmonary embolism (PE), a life-threatening complication after orthopedic surgery. Immediate supportive interventions should be initiated before notifying the provider.
B. Increase the client's IV flow rate and start low-flow oxygen. The client is experiencing acute respiratory distress, which could indicate a pulmonary embolism (PE), a fat embolism, or another postoperative complication. Providing oxygen helps improve oxygenation and reduce hypoxia, while increasing the IV flow rate helps maintain perfusion and prevent shock. These immediate interventions support vital functions while preparing for further medical management.
C. Position the client on the left side while immobilizing the affected leg. This position is used in air embolism management, not pulmonary embolism. In suspected PE, the priority is to optimize oxygenation and circulation rather than repositioning. The affected leg should be immobilized to prevent further embolization, but this is not the first priority.
D. Take the client's vital signs and auscultate all lung sounds. While assessing the client’s vital signs and lung sounds is important, intervention should not be delayed. The priority is to support oxygenation and circulation immediately, as PE can rapidly lead to hypoxia, hemodynamic instability, or cardiac arrest. Assessment should be done concurrently with emergency interventions.