A nurse is caring for a client who underwent a splenectomy 12 hours ago. Which assessment finding would be the nurse's priority concern?

Left shoulder pain (Kehr's sign) with restlessness suggests internal bleeding and diaphragmatic irritation, requiring immediate intervention for potential hypovolemic shock. Other findings are less urgent post-operative concerns.

Core Nursing Explanation Key Concept Analysis: This question tests the nurse's ability to recognize a Key Point! post-operative emergency sign specific to a splenectomy patient. The spleen is a highly vascular organ, and a splenectomy carries a significant risk for post-operative hemorrhage. The priority finding is one that indicates a life-threatening complication requiring immediate intervention.

Answer Rationale: The correct answer is ④ Left shoulder pain and restlessness. This combination is highly suggestive of Kehr's sign, which is referred pain to the left shoulder caused by irritation of the diaphragm (phrenic nerve, C3-C5) from blood or fluid accumulating under it (subdiaphragmatic). In the context of a recent splenectomy, this is a classic indicator of internal bleeding into the abdominal cavity. Restlessness is an early, subtle sign of hypovolemia and hypoxia, often preceding more obvious vital sign changes. This finding requires immediate assessment for hemorrhage and shock.

Distractor Analysis:
Watch out for confusion! ① Mild incisional pain rated 4/10: Expected post-operative pain is common and managed with prescribed analgesics. It is not a priority concern unless severe, uncontrolled, or accompanied by other alarming symptoms.
② Absent bowel sounds in all quadrants: While this indicates post-operative ileus, which is common in the first 24-48 hours after abdominal surgery, it is not an immediate life-threatening concern. It requires monitoring but not urgent intervention.
③ Urine output of 35 mL/hour for the past 2 hours: This output is actually within the acceptable range. The minimum acceptable urine output for an adult is 0.5 mL/kg/hour. For a standard adult, this is often rounded to >30 mL/hour. An output of 35 mL/hour indicates adequate renal perfusion and is not a cause for immediate alarm.

Related Concepts: Recognizing Kehr's sign is crucial for abdominal trauma and post-splenectomy care. Immediate nursing actions would include notifying the surgeon STAT, assessing for other signs of hemorrhage (tachycardia, hypotension, decreasing hemoglobin/hematocrit, abdominal distension), and preparing for possible emergency re-exploration.

Concept Summary

Concept	Description	Clinical Significance
Splenectomy	Surgical removal of the spleen.	High risk for post-op hemorrhage and infection (due to loss of immune function).
Kehr's Sign	Referred pain to the left shoulder due to diaphragmatic irritation (often from blood).	A red flag for intra-abdominal bleeding, especially after splenic injury or surgery.
Post-operative Ileus	Temporary cessation of bowel motility after abdominal surgery.	Expected finding; managed with NPO (Nothing by mouth), IV fluids, and ambulation.
Urine Output Monitoring	Key indicator of fluid status and renal perfusion.	Normal: >0.5 mL/kg/hr. Concern: 임상 시나리오 Nursing Clinical Practice Guide Clinical Scenario: You are the nurse on a surgical floor. Mr. Jones, 65, is 12 hours post-op from an emergency splenectomy after a car accident. His initial vitals were stable. During your routine assessment, he seems fidgety and keeps trying to adjust his position. He mentions, "My left shoulder is really aching, worse than my belly." Nursing Intervention Strategy: Immediate Assessment (Do NOT wait): Perform a focused assessment. Check vital signs (looking for tachycardia, hypotension, tachypnea). Gently palpate the abdomen for distension, rigidity, or tenderness. Assess the surgical dressing for excessive drainage. Communication & Collaboration: Notify the surgeon or rapid response team immediately. Report using SBAR (Situation, Background, Assessment, Recommendation). Prepare for Intervention: Anticipate orders for stat labs (CBC to check H&H), possible bedside ultrasound (FAST exam), and preparation for return to the operating room. Ensure IV access is patent for rapid fluid or blood administration. Ongoing Monitoring & Support: Stay with the patient. Provide reassurance. Monitor vital signs every 5-15 minutes as indicated. Prepare to administer oxygen if needed. Patient Safety and Precautions: Never dismiss referred pain after abdominal surgery or trauma. Shoulder pain is not a typical muscular ache in this context. Restlessness is an early neuro sign of hypoxia or hypovolemia. Do not attribute it solely to pain or anxiety without ruling out physiological causes. Contraindication: Do not give the patient anything by mouth (NPO) until the cause is determined, as he may need emergency surgery. Nursing Procedure & Medication Flow In a suspected post-op hemorrhage scenario: Procedure: Assist with or prepare for insertion of additional large-bore IV lines (e.g., 16- or 18-gauge) for rapid fluid resuscitation. Medication: Anticipate administration of IV fluids (crystalloids like Normal Saline or Lactated Ringer's) and possibly blood products (packed red blood cells). Monitor for transfusion reactions. Monitoring: Strict intake and output (I&O). Weigh abdominal dressings if saturated to estimate blood loss. A Word from Your Senior Nurse "Nursing intuition is powerful, but it's built on a solid foundation of knowledge. When a post-op patient tells you something 'just doesn't feel right,' or has pain in a strange place like their shoulder, listen and investigate. That moment you connect Kehr's sign to internal bleeding could be the moment you save a life. On the NCLEX and in practice, your ability to spot these subtle, high-priority changes separates good nurses from great ones. Always think: 'What is the worst possible thing this could be?' and rule that out first. You've got this!" 핵심 개념 Splenectomy — Surgical removal of the spleen, often performed due to trauma, malignancy, or certain blood disorders. Patients are at increased risk for hemorrhage and infection. Kehr's Sign — Referred pain to the left shoulder caused by irritation of the diaphragm, often due to blood or fluid in the abdominal cavity (e.g., from splenic injury or hemorrhage). A critical sign of internal bleeding. Hypovolemic Shock — A life-threatening condition where severe blood or fluid loss makes the heart unable to pump enough blood to the body. Early signs include restlessness, tachycardia, and cool, clammy skin. Post-operative Ileus — A temporary paralysis of the intestines that commonly occurs after abdominal surgery, characterized by absent bowel sounds, abdominal distension, and lack of flatus or stool. Overwhelming Post-Splenectomy Infection — A rare but rapidly fatal infection occurring in individuals without a functional spleen, caused primarily by encapsulated bacteria. Prevention includes vaccinations and patient education. 마이메르시로 국가고시 완벽 대비 기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요. 무료로 시작하기 App Store Google Play 학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.