A nurse is caring for a 62-year-old woman who underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy for ovarian cancer 2 days ago. The patient reports abdominal pain rated 7/10, has decreased bowel sounds, and has not passed flatus since surgery. Which nursing intervention should be the priority?

This patient is at risk for postoperative paralytic ileus (POI), a common complication following major abdominal surgery such as total abdominal hysterectomy with bilateral salpingo-oophorectomy. The clinical triad of abdominal pain, decreased bowel sounds, and absent flatus by postoperative day 2 signals delayed return of gastrointestinal motility. The priority nursing intervention must address the underlying problem—GI hypomotility—while aligning with the strongest evidence for preventing progression to prolonged ileus and its sequelae.

In NCLEX-RN priority-setting frameworks, interventions that are non-invasive, evidence-based, and address the root cause of a complication take precedence over more invasive or symptomatic measures. The systematic review and meta-analysis by Pongam et al. ^[1] confirms that early mobilization is a cornerstone nursing intervention that significantly improves postoperative recovery outcomes, including the return of bowel function. This aligns with the Enhanced Recovery After Surgery (ERAS) protocol principles, which emphasize early ambulation to counteract the multifactorial contributors to ileus: sympathetic nervous system activation, inflammatory mediators, and opioid-induced gut stasis ^[4].

Option 2: Encourage early ambulation and deep breathing exercises is the correct priority. Ambulation promotes gravity-assisted peristalsis and reduces abdominal distension, while deep breathing exercises improve diaphragmatic excursion, indirectly massaging the intestines and stimulating parasympathetic activity. The meta-analysis ^[1] explicitly identifies early mobilization as an effective nursing intervention for improving clinical outcomes in abdominal surgery patients. Furthermore, the RCT by Koryakina et al. ^[3] demonstrates that non-pharmacological methods targeting GI reactivation—such as the Paula method exercises, which share mechanistic similarities with deep breathing and core engagement—are effective in accelerating the return of bowel function after surgery. This option directly addresses the cause of the patient's symptoms without introducing risks.

Option 1: Administer prescribed antiemetic medication is not the priority. While nausea often accompanies ileus, the patient's report focuses on pain and the objective finding of absent flatus. Antiemetics do not stimulate peristalsis; some, like ondansetron, can actually worsen constipation and ileus by slowing GI transit. Symptom control is important but secondary to interventions that restore function.

Option 3: Insert a nasogastric tube for decompression is an invasive intervention reserved for established ileus with significant distension, vomiting, or risk of aspiration. The patient has not passed flatus but is not reported to have intractable vomiting or marked abdominal distension. Prophylactic NG tube placement is not supported by ERAS protocols and would delay mobilization, contradicting the evidence [1,4]. This is a secondary intervention if conservative measures fail.

Option 4: Provide clear liquid diet to stimulate bowel function is premature and potentially harmful. In the absence of bowel sounds and flatus, introducing oral intake can worsen distension, pain, and nausea. The risk prediction model by Liu et al. highlights that factors such as prior abdominal surgery and the extent of surgical manipulation influence POI development; in a patient already exhibiting signs of ileus, early feeding without evidence of GI reactivation is contraindicated. Diet advancement should follow, not precede, the return of bowel function markers.

Postoperative ileus results from a complex interplay of neurogenic, inflammatory, and pharmacologic mechanisms. Surgical manipulation triggers an inflammatory response that inhibits smooth muscle contractility in the bowel. Opioid analgesics, commonly used for a pain score of 7/10, bind to mu-receptors in the myenteric plexus, further suppressing peristalsis ^[4]. Ambulation directly counteracts these effects by reducing sympathetic tone, promoting the release of prokinetic hormones, and mechanically facilitating gas movement. The meta-analytic evidence ^[1] supports that a bundle of nursing interventions—early mobilization, structured education, and pain management—synergistically reduces complication rates. By prioritizing ambulation, the nurse implements the least restrictive, evidence-based intervention that targets the physiologic basis of the patient's problem.