# A nurse is caring for a client who underwent abdominal surgery 48 hours ago and is now experiencing signs of paralytic ileus. The client reports severe abdominal distension, nausea, and has not passed flatus or had a bowel movement since surgery. Which nursing intervention should the nurse implement first?

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> subject: Next Gen NCLEX

## 문제

A nurse is caring for a client who underwent abdominal surgery 48 hours ago and is now experiencing signs of paralytic ileus. The client reports severe abdominal distension, nausea, and has not passed flatus or had a bowel movement since surgery. Which nursing intervention should the nurse implement first?

## 보기

1. Insert a nasogastric tube to decompress the stomach and prevent aspiration **✔ 정답**
2. Administer the prescribed antiemetic medication for nausea relief
3. Encourage early ambulation to stimulate bowel motility
4. Increase oral fluid intake to prevent dehydration

**정답: 1**

## 해설

Nasogastric tube insertion is the priority for paralytic ileus to decompress the stomach and prevent aspiration. Other interventions are secondary or contraindicated until decompression is achieved.

## 심화 해설

Core Nursing Explanation
**Key Concept Analysis**: This question assesses the priority nursing intervention for a patient with Paralytic ileus, a common post-operative complication where bowel motility temporarily ceases. The core pathophysiology involves the absence of peristalsis, leading to gas and fluid accumulation, abdominal distension, and risk of vomiting/aspiration. The priority is always Airway, Breathing, Circulation (ABC). In this context, severe distension and nausea directly threaten the airway via aspiration.

**Answer Rationale**: Key Point! The first and most critical intervention is Inserting a nasogastric tube (NGT) for decompression. This directly addresses the immediate threat: it relieves pressure, prevents further distension, removes gastric contents to reduce nausea and vomiting risk, and safeguards the airway from aspiration. This aligns with the nursing process where safety (Airway) is the top priority.

**Distractor Analysis**:

Watch out for confusion! While administering an antiemetic (Option 2) may provide symptom relief, it does not treat the underlying cause (the ileus) and could mask worsening symptoms. It is a supportive, not a priority, intervention.

Watch out for confusion! Encouraging ambulation (Option 3) is a **preventive** measure and a goal for recovery, but it is **contraindicated** as a first action in an *established* paralytic ileus with severe distension. The patient likely feels too unwell, and ambulation will not resolve the current obstruction.

Watch out for confusion! Increasing oral fluids (Option 4) is absolutely **contraindicated** in paralytic ileus. The bowel cannot absorb fluids, so giving more orally will worsen distension, increase nausea, and elevate aspiration risk. Fluids should be administered intravenously (IV) to maintain hydration.

**Related Concepts**: This scenario tests the ability to differentiate between preventive measures (early ambulation, chewing gum) and acute management for a complication. It also reinforces the principle of NPO (Nothing by mouth) status for non-functioning bowels and the use of IV fluids for maintenance.

Concept Summary

| Concept | Key Takeaway |
| --- | --- |
| Paralytic Ileus | Post-op bowel paralysis. S/S: Distension, nausea/vomiting, absence of flatus/bowel sounds. |
| Priority (ABCs) | Airway protection from aspiration is paramount. NGT decompression achieves this. |
| Nursing Interventions | 1. NGT to suction (Priority). 2. Maintain NPO. 3. Administer IV fluids. 4. Monitor I&O, abdomen. |
| Contraindications | Do NOT give anything by mouth (food/fluids/meds). Do NOT use stimulant laxatives. |

Side-by-Side Comparison!

| Condition | Mechanical Bowel Obstruction | Paralytic Ileus (Adynamic Ileus) |
| --- | --- | --- |
| Pathophysiology | Physical blockage (e.g., adhesion, tumor). | Functional paralysis of bowel motility. |
| Bowel Sounds | Often high-pitched, hyperactive initially; may become absent late. | Absent or markedly diminished. |
| Pain | Colicky, severe, intermittent. | Constant, diffuse discomfort from distension. |
| Common Cause | Post-op adhesions, hernia. | Post-op, electrolyte imbalance (low K+), peritonitis. |
| Initial Management | Similar: NGT, NPO, IV fluids. Often requires surgery. | Similar: NGT, NPO, IV fluids. Usually resolves with supportive care. |

Anatomy, Physiology & Pharmacology Points

- **Physiology**: Normal peristalsis is coordinated by the enteric nervous system. Surgery, anesthesia, and electrolyte imbalances (especially Hypokalemia) can disrupt this, causing ileus.

- **Pharmacology**: Opioid analgesics are a major contributor to post-op ileus. Nursing must balance pain management with bowel stimulation strategies (e.g., multimodal analgesia).

- **Lab Values**: Monitor electrolytes! Potassium (K+) < 3.5 mEq/L impairs muscle contraction, including intestinal smooth muscle.

Memory Tips

- **ABC for Ileus**: **A**spiration risk → **B**owel decompress (NGT) → **C**irculation (IV fluids).

- **NPO Rule**: "If it doesn't go out (flatus/BM), don't put it in (food/water)."

- **NGT Purpose**: Think "Decompress, Drain, Defend the airway."

High-Frequency NCLEX Topics
This is a classic High Yield post-operative complication question. The NCLEX loves to test: 1) Recognizing signs of paralytic ileus vs. normal post-op recovery. 2) Prioritizing interventions based on patient safety (ABCs). 3) Knowing contraindicated actions (giving oral fluids).

Watch Out for Question Variations!

- **Symptom Recognition**: "Which finding indicates the client is developing a paralytic ileus?" (Answer: Absence of flatus + abdominal distension).

- **Priority Assessment**: "After inserting the NGT, which assessment is most important?" (Answer: Monitor for respiratory distress/aspiration and NGT patency/drainage).

- **Patient Education**: "What should the nurse teach the client as a sign that the ileus is resolving?" (Answer: Return of bowel sounds and passage of flatus).

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario**: You are on a surgical floor. Mr. Johnson, 65, had a colectomy 2 days ago. He calls you, anxious, pointing to his markedly swollen abdomen. He says, "I feel like I'm going to vomit, and I haven't passed gas at all." His abdomen is tympanic to percussion, and bowel sounds are absent in all quadrants.

**Nursing Intervention Strategy**:

- **Immediate Assessment & Action**: Assess ABCs, vital signs, and abdomen. Notify the surgeon immediately of suspected paralytic ileus. **Prepare for NGT insertion** as the priority order is likely.

- **NGT Management**: Once inserted, connect to low intermittent suction. Secure the tube properly to the nose. Monitor color, consistency, and amount of drainage (greenish bilious is expected). Irrigate per protocol to maintain patency.

- **Supportive Care**: Maintain strict NPO status. Administer IV fluids (e.g., 0.9% NaCl or Lactated Ringer's) as ordered to prevent dehydration and electrolyte imbalance. Provide frequent oral care since the patient is NPO with an NGT.

- **Monitoring & Evaluation**: Monitor intake and output (I&O) meticulously. Auscultate for return of bowel sounds. Ask the patient to report the first sensation of flatus or bowel movement. Gradually advance diet (clear liquids → full liquids → soft) only after ileus resolves, as per protocol.

**Patient Safety and Precautions**:

- **Airway**: Keep suction equipment at the bedside. Position the patient in semi-Fowler's position to minimize aspiration risk.

- **NGT**: Ensure the tube is not kinked. Never clamp an NGT connected to suction for decompression without an order.

- **Medications**:

- **Hold** all oral medications.

- **Opioids**: Advocate for a pain management plan that minimizes opioids (e.g., use of NSAIDs, regional anesthesia) as they worsen ileus.

- **Antiemetics** (like ondansetron) can be given IV for nausea *after* the NGT is placed, but they are not the first treatment.

Nursing Procedure & Medication Flow
**NGT Insertion & Care Key Points**:

- **Measurement**: Measure from tip of nose to earlobe to xiphoid process (NEX measurement) for gastric placement.

- **Verification**: Confirm placement by X-ray **before** initiating feeds or medications. Aspirating gastric contents and checking pH (pH ≤5.5) are bedside checks but do not replace X-ray confirmation for initial placement.

- **Suction Settings**: Use **low intermittent suction** (e.g., 80-120 mmHg) for decompression to prevent mucosal damage.

**IV Fluid Management**: Calculate maintenance fluids (e.g., 30-40 mL/kg/day). Monitor for signs of fluid overload (crackles, edema, increased JVP) versus dehydration (poor skin turgor, tachycardia, decreased urine output).

A Word from Your Senior Nurse
"Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In this scenario, you are the one who first sees the distended abdomen and hears the patient's concern. Your rapid recognition of paralytic ileus and understanding that the immediate threat is aspiration (not just discomfort) drives you to prioritize NGT insertion. In clinical practice, you'll often be the one to suggest this intervention to the provider. When studying for your boards, don't just memorize 'NGT for ileus' — connect it to the real patient: their swollen belly, their fear of vomiting. Always ask 'what is the worst thing that could happen right now?' (Aspiration) and 'what stops that?' (Decompression). That clinical reasoning will make you a safe, proactive, and confident nurse!"

## 핵심 개념

- **Paralytic Ileus** — A temporary paralysis or severe slowing of intestinal peristalsis, often occurring after abdominal surgery, leading to functional obstruction.
- **Nasogastric Tube** — A flexible tube passed through the nose into the stomach, used for decompression (removing gas/fluid), drainage, or administration of feedings/medications.
- **NPO (Nil Per Os)** — Latin for "nothing by mouth"; a medical instruction meaning the patient is not to ingest any food or drink orally.
- **Aspiration** — The inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract, which can cause pneumonia or airway obstruction.
- **Decompression** — The therapeutic removal of pressure, in this context, from the gastrointestinal tract using an NGT to relieve distension and prevent complications.

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