A nurse is caring for a postoperative patient who underwent abdominal surgery 6 hours ago. The patient reports severe incisional pain rated 8/10, has shallow breathing at 28 breaths per minute, and appears restless. The patient's urinary catheter has drained 30 mL of concentrated urine in the past 4 hours. What is the nurse's priority action?
1Administer the prescribed analgesic medication immediately
2Encourage the patient to use the incentive spirometer
3Assess the patient's blood pressure and pulse✓ 정답
4Increase the IV fluid infusion rate
해설
The priority is to assess vital signs (blood pressure and pulse) to evaluate for hypovolemic shock, as symptoms like severe pain, tachypnea, restlessness, and oliguria suggest potential cardiovascular compromise. Other interventions should follow after this critical assessment.
Clinical Judgment
This question evaluates the ability to analyze a post-operative patient's complex symptoms to identify the most threatening condition and determine the priority action accordingly. The key is recognizing that the patient's symptoms may indicate early signs of Hypovolemic Shock. Severe pain, tachypnea, anxiety, and critically, Oliguria are present together. While pain control or respiratory exercises are important, you must first assess the patient's hemodynamic status (blood pressure, pulse) to rule out or confirm a life-threatening situation like shock. The results of this assessment will determine the direction and urgency of all subsequent interventions.
Memory Tip: Prioritize Assessment Before Action (PABA). When there are complex symptoms, prioritize assessment before action. Especially, the combination of pain + anxiety + oliguria is a "suspect hypovolemia" signal.
KR vs US: The basic principles of post-operative patient monitoring are the same in both Korea and the US. However, the NGN exam heavily emphasizes the importance of the ABCs (Airway, Breathing, Circulation) approach and Systematic Assessment. Prioritizing pain control based solely on symptoms is a common mistake.
Clinical Practice Guide
In post-abdominal surgery patients, oliguria is defined as less than 0.5 mL/kg per hour (approximately less than 30 mL per hour for adults). This is an important indicator of decreased renal perfusion. Anxiety and tachypnea can be signs of pain as well as hypoxia due to hypovolemia.
Caution: In SATA (Select All That Apply) questions, it is important to distinguish between "What is the highest priority action?" and "What actions should be taken?" This question asks for the single highest priority action. While all options may be correct nursing interventions, assessment to first identify/rule out life-threatening conditions must always take precedence.
Hypovolemic Shock — Hypovolemic shock. A state of shock caused by insufficient tissue perfusion due to a sudden decrease in circulating blood volume. Causes include hemorrhage, dehydration, burns, etc.
Oliguria — Oliguria. A condition of abnormally low urine output. In adults, it is generally defined as less than 0.5 mL/kg per hour or less than 400 mL in 24 hours.
Incentive Spirometer — Incentive spirometer. It is a breathing exercise device that encourages the patient to take deep breaths, helping to expand the lungs and prevent atelectasis.
Tachypnea — Tachypnea. Breathing faster than the normal adult respiratory rate (12-20 breaths per minute). A rate of 28 breaths per minute clearly qualifies as tachypnea.
Hemodynamic Status — Hemodynamic status. The state of the circulatory system determined by the heart's pumping function, blood volume, vascular resistance, etc. It is assessed through blood pressure, pulse, central venous pressure, etc.