# Two hours after abdominal surgery, a client has a saturated dressing, heart rate 126/min, and blood pressure 88/50 mm Hg. Which action should the nurse take first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393732&lang=en  
> language: en  
> subject: Postsurgical Complications  
> category: ROR

## Question

Two hours after abdominal surgery, a client has a saturated dressing, heart rate 126/min, and blood pressure 88/50 mm Hg. Which action should the nurse take first?

## Option

1. Apply firm pressure to the incision and notify the surgical team. **✔ Correct answer**
2. Document the drainage amount and recheck in 1 hour.
3. Remove the dressing to leave the incision open to air.
4. Encourage the client to ambulate to improve circulation.

**Correct answer: 1**

## Explanation

A saturated postoperative dressing with tachycardia and hypotension suggests active bleeding and possible shock. The nurse should apply pressure according to policy, maintain safety, and notify the surgical team immediately. Delayed reassessment, exposing the incision, or ambulation can worsen hemorrhage and instability.

## In-depth explanation

Clinical Judgment
Connect drainage plus vital sign changes to hemorrhage risk and act immediately.

Memory Tip
Bleeding plus low BP: pressure and call now.

KR vs US
NCLEX postoperative questions often combine visible drainage with subtle shock cues.

## Clinical scenario

Clinical Practice Guide
Postoperative bleeding assessment includes dressing saturation, vital signs, level of consciousness, urine output, and laboratory trends such as hemoglobin and hematocrit.

Caution
Normal early postoperative pain should not distract from signs of hemorrhage.

## Key concepts

- **Postoperative Bleeding** — Bleeding after surgery that may appear as saturated dressings, tachycardia, hypotension, pallor, or declining hemoglobin.
- **Hypovolemic Shock** — Shock caused by reduced circulating volume, often from bleeding or fluid loss.
- **CBC** — Complete blood count, a lab test that includes hemoglobin and hematocrit for bleeding assessment.

## Related questions

- [A 24-year-old patient is brought to the ED with a generalized tonic-clonic seizure that ha…](https://mymerci.kr/pages/nclex_q.php?qn_id=372718&lang=en)
- [A 28-year-old patient with a T4 spinal cord injury 3 months ago is admitted with sudden se…](https://mymerci.kr/pages/nclex_q.php?qn_id=372742&lang=en)
- [A patient who sustained blunt chest trauma 30 minutes ago is now in extreme respiratory di…](https://mymerci.kr/pages/nclex_q.php?qn_id=372743&lang=en)
- [Two hours after abdominal surgery, a client has a saturated dressing, heart rate 126/min, …](https://mymerci.kr/pages/nclex_q.php?qn_id=393731&lang=en)
- [A client scheduled for surgery tomorrow says, "I took my warfarin this morning like usual.…](https://mymerci.kr/pages/nclex_q.php?qn_id=394154&lang=en)
- [A client scheduled for surgery tomorrow says, "I took my warfarin this morning like usual.…](https://mymerci.kr/pages/nclex_q.php?qn_id=394155&lang=en)
- [A client is 6 hours postoperative after a thyroidectomy and develops stridor with increasi…](https://mymerci.kr/pages/nclex_q.php?qn_id=396607&lang=en)
- [A client is 6 hours postoperative after a thyroidectomy and develops stridor with increasi…](https://mymerci.kr/pages/nclex_q.php?qn_id=396608&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=393732&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=393732&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=393732&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=393732&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=393732&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._