A nurse is caring for a 45-year-old client who underwent a sigmoid colectomy for diverticulitis 2 days ago. The client reports severe abdominal pain and nausea. Which nursing intervention should the nurse implement first?

Assessment (bowel sounds and distension) is the first nursing priority to evaluate for complications like ileus or obstruction before implementing interventions. Other actions (antiemetic, ambulation, NG tube) should follow assessment findings.

Core Nursing Explanation Key Concept Analysis: This question tests the fundamental nursing principle of Assessment before Intervention in the context of a post-operative patient with new, severe symptoms. The client is 2 days post-sigmoid colectomy for diverticulitis and reports severe abdominal pain and nausea. These symptoms could indicate a normal post-operative course, but the severity raises concern for complications like paralytic ileus or mechanical obstruction. The nurse's first action must always be to gather more data through a focused assessment to determine the cause and severity of the problem before taking action.

Answer Rationale: Key Point! The correct answer is to Assess bowel sounds and abdominal distension. This is the priority because it directly evaluates the function of the gastrointestinal (GI) tract. In the immediate post-operative period, the return of bowel function is a critical milestone. Severe pain and nausea, especially when new or worsening, are red flags. Assessing for the presence/absence of bowel sounds and the degree of abdominal distension provides essential information to differentiate between expected post-op discomfort and a serious complication like an ileus or early obstruction. This assessment guides all subsequent interventions.

Distractor Analysis:
• Watch out for confusion! Administer the prescribed antiemetic medication (Option 1): While treating nausea is important, administering medication without first assessing the underlying cause is unsafe. If the nausea is due to a developing ileus or obstruction, masking the symptom with an antiemetic could delay critical diagnosis and treatment.
• Encourage the client to ambulate in the hallway (Option 2): Ambulation is a key intervention to prevent complications and promote peristalsis. However, if the patient is in severe pain and potentially developing an ileus, encouraging ambulation without first assessing their condition is inappropriate and may cause harm or discomfort.
• Insert a nasogastric tube for decompression (Option 3): This is an invasive intervention that requires a physician's order. It is a treatment for confirmed ileus or obstruction, not a first-line assessment. Performing this without a proper assessment and order would be beyond the nurse's scope of practice and could be harmful if not indicated.

Related Concepts: This scenario reinforces the nursing process, where Assessment is always the first step. It also highlights post-operative care priorities for abdominal surgery, specifically monitoring for return of bowel function. Key signs of paralytic ileus include absent or hypoactive bowel sounds, abdominal distension, nausea/vomiting, and failure to pass flatus or stool.

Concept Summary • Nursing Process Priority: Always assess before you intervene (Assessment → Diagnosis → Planning → Implementation → Evaluation). • Post-Op Abdominal Surgery Complication: Paralytic ileus is a common concern, characterized by the temporary cessation of bowel peristalsis. • Key Assessment Findings for Ileus: Absent/hypoactive bowel sounds, abdominal distension, nausea/vomiting, inability to pass flatus. • Interventions Follow Assessment: Ambulation, medications, and NG tube placement are all based on the findings of the initial assessment.
Side-by-Side Comparison!

Condition	Bowel Sounds	Pain & Distension	Common Cause
Paralytic Ileus	Absent or markedly hypoactive	Diffuse discomfort, bloating, distension	Post-abdominal surgery, electrolyte imbalance, peritonitis
Mechanical Obstruction	Initially hyperactive (high-pitched, rushing), later absent	Colicky, cramping pain; localized distension	Adhesions, hernia, tumor
Normal Post-Op Bowel Recovery	Progresses from absent to hypoactive to normoactive	Incisional pain manageable with medication; mild distension may resolve	Expected healing process

Anatomy, Physiology & Pharmacology Points • Physiology: Peristalsis is the coordinated, wave-like muscular contraction of the GI tract that moves contents forward. Surgery, anesthesia, and manipulation of the bowel can temporarily paralyze this function (ileus). • Anatomy: A sigmoid colectomy involves removal of part of the sigmoid colon, which is the S-shaped final portion of the colon before the rectum. This area is a common site for diverticulitis. • Pharmacology: Antiemetics (e.g., ondansetron) work on receptors in the chemoreceptor trigger zone (CTZ) to reduce nausea/vomiting but do not address the underlying GI motility problem.
Memory Tips • ABCs with a twist for surgical patients: After Airway, Breathing, Circulation, think "Assess the Belly First!" for any new abdominal complaint post-op. • Ileus vs. Obstruction sounds: Ileus = Idle (quiet). Obstruction = Obstructed but trying (initially loud).
High-Frequency NCLEX Topics The NCLEX heavily tests priority-setting and the nursing process. Questions often present a patient with multiple potential problems and ask, "What should the nurse do first?" The correct answer is almost always an assessment action unless an immediate, life-threatening situation (like airway compromise or severe hemorrhage) requires intervention. This question is a classic example of that pattern.
Watch Out for Question Variations! • Instead of asking for the first action, the question might ask for the priority nursing diagnosis. The answer would likely be Risk for (or Actual) Ineffective Gastrointestinal Perfusion or Acute Pain. • The scenario could change to include vital signs (e.g., tachycardia, fever) pointing more strongly toward peritonitis or sepsis, shifting the priority intervention to notifying the provider immediately after a quick assessment. • The question might ask which finding is most concerning for the nurse, testing your knowledge of abnormal assessment data (e.g., absent bowel sounds and board-like abdomen vs. mild hypoactive sounds).

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse on a surgical floor. Mr. Johnson, 45, had a sigmoid colectomy two days ago. He was making good progress but now calls you to his room, stating his pain is much worse than before and he feels nauseated. He is lying very still in bed.

Nursing Intervention Strategy: 1. Immediate Assessment (Your First Action): Introduce yourself, provide reassurance, and perform a focused abdominal assessment. • Inspect: Look for distension, asymmetry, discoloration around the incision. • Auscultate: Listen in all four quadrants for at least 1-2 minutes per quadrant to accurately assess for bowel sounds. Note character: absent, hypoactive, normoactive, hyperactive? • Palpate Gently: Assess for tenderness, guarding, rigidity. Do not palpate deeply if peritonitis is suspected. • Ask: "Have you passed any gas or had a bowel movement?" "Can you describe the pain (location, type, severity on a 0-10 scale)?" • Vital Signs: Check temperature, heart rate, blood pressure, and respiratory rate. Fever and tachycardia are signs of infection or inflammation. 2. Analysis & Communication: Based on your assessment, formulate your findings. If you discover absent bowel sounds, significant distension, and worsening pain, this indicates a potential paralytic ileus or obstruction. • Notify the surgeon or advanced practice provider immediately with your findings using the SBAR (Situation, Background, Assessment, Recommendation) format. 3. Implementation of Ordered Interventions: • NPO (Nothing by mouth): The provider will likely order this to rest the GI tract. • NG Tube Placement: If ordered for decompression, you will insert the tube and connect it to low intermittent suction to relieve distension. • IV Fluids & Electrolytes: Administer as ordered to maintain hydration and correct imbalances (like hypokalemia, which can worsen ileus). • Analgesia: Administer pain medication as ordered, often via IV patient-controlled analgesia (PCA) to manage pain without oral medications. • Ambulation: Once the acute issue is addressed and the patient is stable, encourage and assist with ambulation to stimulate peristalsis.

Patient Safety and Precautions: • Never administer a laxative or enema to a post-op patient without a specific order, as it could cause perforation if an obstruction or ileus is present. • Monitor for signs of perforation or peritonitis: Sudden increase in pain, rigid "board-like" abdomen, fever, tachycardia, hypotension. This is a surgical emergency. • NG Tube Care: Ensure the tube is properly secured, check patency, provide frequent oral and nasal care, and monitor output.
Nursing Procedure & Medication Flow Assessing Bowel Sounds: 1. Position the patient supine with knees slightly bent to relax abdominal muscles. 2. Warm the diaphragm of your stethoscope. 3. Listen systematically in all four quadrants (RLQ, RUQ, LUQ, LLQ). 4. Document findings clearly: "Absent in all 4 quadrants x 5 minutes," "Hypoactive sounds heard in RLQ and LUQ," etc. Medication Caution: Opioid analgesics, while necessary for pain, can contribute to ileus. Balance pain management with mobility. Antiemetics are supportive but do not treat the root cause of an ileus.
A Word from Your Senior Nurse "In the fast-paced world of post-op care, your assessment skills are your superpower. That moment when a patient says, 'This pain is different' – that's your cue to dig deeper. Don't just reach for the medication cart or the ambulation protocol. Put your stethoscope on that abdomen, listen carefully, and look at the whole picture. Catching a complication like an ileus early, based on your thorough assessment, can prevent a lot of suffering and get your patient back on the road to recovery faster. On the NCLEX and in real life, remember: Look, Listen, and Think before you Act."