# The nurse reviews recovery findings after endoscopic retrograde cholangiopancreatography. Which findings require immediate follow-up? Highlight the findings associated with possible perforation.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=495004&lang=en  
> language: en  
> subject: Complications of Procedures  
> category: ROR

## Question

The nurse reviews recovery findings after endoscopic retrograde cholangiopancreatography. Which findings require immediate follow-up? Highlight the findings associated with possible perforation.

Nurses' Notes
1630: The client returned from ERCP 40 minutes ago. The client reports mild throat soreness that improves after an ice chip. At 1640, the client describes severe epigastric pain that radiates to the back and worsens. The client is sleepy after sedation but awakens to name and follows commands. Oxygen saturation is 97% on the prescribed nasal oxygen. The nurse records that sedation level is improving with repeated verbal stimulation. The abdomen initially has mild fullness that began after the endoscopy procedure. The client now has the abdomen is rigid with involuntary guarding. The earlier bloating was relieved slightly after passing flatus. The blood pressure remains within the documented preprocedure range. At 1650, temperature is 38.4 °C and heart rate is 122/min as fever developed with new tachycardia. The client denies nausea at this time. The intravenous site is soft and dry. The client has no new rash or facial swelling. The procedure note documents biliary sphincterotomy. The nurse keeps the client fasting while contacting the endoscopy clinician. Emergency imaging has not yet been performed. No discharge teaching has begun.

## Explanation

Severe worsening epigastric pain radiating to the back, a rigid guarded abdomen, and fever with tachycardia require immediate follow-up. This pattern can indicate perforation after ERCP.

## In-depth explanation

Quick answer
Highlight severe worsening epigastric pain radiating to the back, a rigid abdomen with involuntary guarding, and fever with new tachycardia. This combination is concerning for perforation after ERCP.

Why this is correct
A perforation allows air, digestive contents, or inflammation to irritate tissues outside the gastrointestinal tract. Pain becomes severe or progressive, the abdominal wall tightens to protect the inflamed area, and systemic signs such as fever and tachycardia can develop. Prompt imaging and provider evaluation are needed rather than routine recovery observation.[2][3]

Easy analogy or mental picture
Imagine a sealed tube developing a leak. Worsening pain marks local irritation, a boardlike abdomen is the body guarding the leak, and fever with tachycardia signals a wider response. The image cannot distinguish perforation from every other abdominal emergency.

Memory hook
After ERCP, worsening pain plus guarding or systemic change means possible leak.

NCLEX decision rule
When post-ERCP pain is severe or worsening and is paired with rigidity, guarding, fever, or tachycardia, think perforation and escalate immediately. Mild improving bloating alone does not carry the same pattern.

Why the other choices are wrong
Mild throat soreness, arousable post-sedation sleepiness, stable oxygenation, improving bloating, passing flatus, stable blood pressure, and absence of nausea can occur without the displayed perforation pattern.References

- [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing

- [2]ASGE: Adverse Events Associated With ERCP and Related ProceduresAmerican Society for Gastrointestinal Endoscopy

- [3]ASGE: Adverse Events Associated With ERCPAmerican Society for Gastrointestinal Endoscopy

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