# A client 2 hours after abdominal surgery has a heart rate of 122/min, blood pressure 86/50 mm Hg, cool clammy skin, and increasing abdominal dressing drainage. Which complication should the nurse suspect?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397167&lang=en  
> language: en  
> subject: Postsurgical Complications  
> category: ROR

## Question

A client 2 hours after abdominal surgery has a heart rate of 122/min, blood pressure 86/50 mm Hg, cool clammy skin, and increasing abdominal dressing drainage. Which complication should the nurse suspect?

## Option

1. Urinary retention.
2. Paralytic ileus.
3. Normal postoperative pain response.
4. Hemorrhage. **✔ Correct answer**

**Correct answer: 4**

## Explanation

Tachycardia, hypotension, cool clammy skin, and increasing drainage after surgery are cues of possible hemorrhage and shock. Urinary retention and ileus do not explain the bleeding and perfusion cues. Pain alone does not account for the full pattern.

## In-depth explanation

Clinical Judgment
Use the client cues, timing, labs, and safety risks to select the response that best fits Postoperative hemorrhage cues.

Memory Tip
Match the strongest cue cluster to the safest nursing judgment.

KR vs US
NCLEX items reward cue-based priority thinking rather than isolated recall.

## Clinical scenario

Clinical Practice Guide
For Postoperative hemorrhage cues, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **Hemorrhage** — Excessive bleeding that can reduce circulating volume.
- **Shock** — Inadequate tissue perfusion that can lead to organ dysfunction.
- **Postoperative Drainage** — Fluid from a surgical site that may signal expected healing or complications.

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