A nurse is caring for a client in an outpatient health clinic.

For each potential nursing intervention, click to specify if the intervention is indicated or not indicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Rationale:

A. Shivering is an adverse reaction to external cooling measures such as a cooling blanket. It indicates that the client’s body is responding to the rapid decrease in temperature by generating heat through muscle activity. This response increases oxygen consumption and metabolic demand, which can counteract the goal of reducing fever and may place additional stress on the cardiovascular system.

B. Flushing is more commonly associated with fever itself, vasodilation, or inflammatory processes. It is not a typical adverse reaction to cooling therapy and does not indicate an inappropriate response to the cooling blanket.

C. Tachycardia may occur with fever, pain, dehydration, or anxiety. While temperature changes can influence heart rate, tachycardia alone is not a specific adverse reaction to cooling therapy. It is not the most direct indicator of intolerance to cooling.

D. Restlessness can be caused by fever, discomfort, hypoxia, or anxiety. Although it may be seen in clients experiencing shivering or discomfort from cooling, it is nonspecific and not the best indicator of an adverse reaction to the cooling blanket compared to shivering.

Rationale for correct choices:

• Pulmonary embolism: The client presents with sudden dyspnea, chest discomfort, tachypnea, tachycardia, hypoxia, and anxiety (“something is really wrong”), which are hallmark signs of a pulmonary embolism. The rapid onset is key—PE typically presents abruptly rather than gradually. Although crackles and S3/S4 may suggest fluid overload, the acute respiratory distress in a postoperative client strongly prioritizes PE as the most life-threatening and likely cause.
• Recent surgery: Total hip arthroplasty significantly increases risk for venous thromboembolism (VTE) due to immobility, venous stasis, endothelial injury, and hypercoagulability (Virchow’s triad). Clots formed in the deep veins can dislodge and travel to the lungs, causing a pulmonary embolism. This makes recent orthopedic surgery the strongest contributing factor.

Rationale for incorrect choices:

• Pneumonia: Typically develops gradually, with cough, sputum production, and localized lung findings, not sudden severe dyspnea and chest pain.
• Pneumothorax: Usually presents with unilateral absent breath sounds and sudden chest pain, not bilateral crackles.
• Activity level: The client was previously active and ambulated postoperatively; activity level does not explain the acute event.
• Tobacco use: The client denies tobacco use, so it is not a contributing factor.