# A nurse is caring for a 45-year-old client who underwent a sigmoid colectomy for diverticulitis 2 days ago. The client reports severe abdominal pain and nausea. Which nursing intervention should the nurse implement first? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540731 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a 45-year-old client who underwent a sigmoid colectomy for diverticulitis 2 days ago. The client reports severe abdominal pain and nausea. Which nursing intervention should the nurse implement first? ## 보기 1. Administer the prescribed antiemetic medication 2. Encourage the client to ambulate in the hallway 3. Insert a nasogastric tube for decompression 4. Assess bowel sounds and abdominal distension **✔ 정답** **정답: 4** ## 해설 Assessment (bowel sounds and distension) is the first nursing priority to evaluate for complications like ileus or obstruction before implementing interventions. Other actions (antiemetic, ambulation, NG tube) should follow assessment findings. ## 심화 해설 This question requires you to prioritize nursing interventions for a client who is 2 days post-sigmoid colectomy and now reporting severe abdominal pain and nausea. The correct answer is to assess bowel sounds and abdominal distension first. Understanding the Clinical Priority The client’s symptoms of severe abdominal pain and nausea following a bowel resection are classic red flags for a serious postoperative complication, most notably a paralytic ileus or a mechanical bowel obstruction. In this scenario, the nurse must follow the nursing process, which dictates that assessment comes before intervention. You cannot know which intervention is appropriate or safe until you have gathered more focused data. Administering an antiemetic, encouraging ambulation, or inserting a nasogastric tube are all interventions that would follow a thorough clinical assessment. Why Assessment is the First Step The nursing process is the foundational framework for clinical decision-making on the NCLEX-RN. The first step is always assessment—collecting and analyzing data about the client’s condition. The systematic review and meta-analysis on nursing interventions for abdominal surgery patients supports this principle, emphasizing that effective nursing interventions, such as managing pain or promoting mobilization, are crucial but must be part of a structured, evidence-based approach that begins with evaluating the patient’s current status [2]. Jumping to an intervention without a focused assessment could mask symptoms, lead to an incorrect intervention, or even cause harm. For instance, encouraging a client with a developing obstruction to ambulate will not resolve the mechanical issue and may increase pain. Similarly, inserting a nasogastric tube for decompression is a dependent nursing action that requires a healthcare provider’s order, which is obtained based on the nurse’s assessment findings. Analyzing the Incorrect Options - Administering the prescribed antiemetic medication: While the client is nauseated, this is a comfort measure that treats a symptom, not the underlying cause. In a postoperative abdominal surgery patient, nausea can be a sign of a serious complication like an ileus. Giving an antiemetic before assessing the abdomen could mask a deteriorating condition and delay essential treatment. - Encouraging the client to ambulate in the hallway: Early mobilization is a cornerstone of enhanced recovery after surgery (ERAS) protocols. A randomized controlled trial on a targeted mobilization program after cesarean section found that structured mobilization improved recovery outcomes . However, this intervention is contraindicated in a patient who is acutely deteriorating with severe pain and potential obstruction. The priority is to first determine the cause of the acute symptoms. - Inserting a nasogastric tube for decompression: This is a critical intervention for a confirmed ileus or bowel obstruction to relieve distension and prevent vomiting. However, it is not the nurse’s first action. A nasogastric tube insertion requires a provider’s order, which is given based on the nurse’s clinical assessment. The nurse must first auscultate bowel sounds and palpate the abdomen to provide the data needed for the provider to make this decision. Applying the Postoperative Assessment The correct first action is a focused abdominal assessment. By auscultating for bowel sounds in all four quadrants and inspecting and palpating for distension and tenderness, the nurse gathers critical data. The absence of bowel sounds, coupled with a distended, tympanic abdomen, strongly suggests a paralytic ileus, a common complication after bowel surgery. This assessment data is the foundation for all subsequent clinical decisions, including notifying the healthcare provider and preparing for interventions like nasogastric tube insertion, keeping the client NPO, and administering IV fluids. This principle of thorough assessment before action is a universal standard in nursing care, as highlighted in studies focused on improving postoperative outcomes through structured nursing guidelines .References (research sources) - [2]Effects of nursing interventions on clinical outcomes in patients undergoing abdominal surgery: A systematic review and meta-analysis.Meta-analysis/systematic reviewPongam S, Chusak T, Banchonhattakit P, Chatchumni M. (2026) · DOI: 10.4103/jehp.jehp_602_25 ## 임상 시나리오 Post-Bowel Resection Assessment PriorityDifferentiating Ileus from Obstruction Severe pain and nausea 2 days post-colectomy are red flags for paralytic ileus or mechanical obstruction. The nurse must follow the nursing process and assess first before intervening. Perform a focused abdominal assessment: auscultate for bowel sounds (absent in ileus, high-pitched in early obstruction), inspect for distension, and palpate for firmness or guarding. CautionDo not administer antiemetics or encourage ambulation before assessment, as this can mask a worsening obstruction or perforation. An NG tube is an intervention requiring a provider order based on assessment findings. ## 핵심 개념 - **Paralytic Ileus** — A temporary cessation of bowel peristalsis often occurring after abdominal surgery, leading to abdominal distension, pain, and nausea. - **Nursing Process** — A systematic framework (Assessment, Diagnosis, Planning, Implementation, Evaluation) guiding clinical decision-making; assessment is always the first step. - **Sigmoid Colectomy** — Surgical removal of the sigmoid colon, commonly performed for conditions like diverticulitis, requiring close postoperative monitoring for complications. ## 같은 주제 문제 - [A nurse is assessing a 58-year-old client who was recently diagnosed with colorectal cance…](https://mymerci.kr/pages/nclex_q.php?qn_id=540726) - [A nurse is assessing a 58-year-old client who has been diagnosed with colorectal cancer. 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