# A nurse is assessing a patient 24 hours after abdominal surgery. Which assessment finding would be the priority concern requiring immediate intervention?

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## 문제

A nurse is assessing a patient 24 hours after abdominal surgery. Which assessment finding would be the priority concern requiring immediate intervention?

## 보기

1. Absent bowel sounds in all four quadrants
2. Incisional pain rated 6/10 on a numeric scale
3. Urine output of 25 mL/hour for the past 4 hours
4. Temperature of 102.2°F (39°C) with increased heart rate **✔ 정답**

**정답: 4**

## 해설

Fever with tachycardia 24 hours postoperatively indicates potential infection or sepsis, requiring immediate intervention. Other findings are less urgent.

## 심화 해설

Understanding the Priority Concern

After abdominal surgery, a patient is at risk for multiple complications, and the nurse must differentiate between expected postoperative changes and findings that signal a life-threatening event. The NCLEX-RN frequently tests the ability to prioritize using frameworks such as the ABCs (Airway, Breathing, Circulation) and the concept of systemic versus localized complications. In this scenario, a temperature of 102.2°F (39°C) combined with an increased heart rate is the most critical finding because it suggests a systemic inflammatory response that can rapidly progress to sepsis, a leading cause of postoperative mortality [2].

Analysis of the Correct Answer (Option 4)

A fever of this magnitude, accompanied by tachycardia, is a hallmark of the systemic inflammatory response syndrome (SIRS), which in a postoperative patient is highly suspicious for an infectious complication. The narrative review on infectious complications after major abdominal surgery emphasizes that such complications remain clinically relevant and can lead to readmission, reoperation, prolonged antimicrobial therapy, and mortality [2]. The pathophysiological basis involves the release of pro-inflammatory cytokines in response to a pathogen, which resets the hypothalamic temperature set-point and directly stimulates the sympathetic nervous system, increasing heart rate to meet the heightened metabolic and oxygen demands of the tissues. This finding requires immediate intervention, including a full septic workup (blood cultures, wound inspection, and possibly imaging), notification of the surgeon, and prompt initiation of the sepsis protocol.

Why the Other Options Are Not the Priority

Option 1: Absent bowel sounds in all four quadrants.

A temporary absence of bowel sounds, known as a postoperative ileus, is an expected physiological response to surgical manipulation, anesthesia, and opioid use within the first 24 to 48 hours. It represents a localized, non-life-threatening alteration in gastrointestinal motility. While it requires ongoing monitoring, it does not demand the same level of immediate, life-saving intervention as a systemic infection.

Option 2: Incisional pain rated 6/10.

Pain is an anticipated consequence of tissue trauma from surgery. A rating of 6 out of 10 indicates moderate pain that requires effective management, but it is not an immediate threat to the patient's central circulation or airway. The priority is to address the source of a potential systemic infection before focusing on comfort measures, as uncontrolled pain alone is not acutely life-threatening.

Option 3: Urine output of 25 mL/hour for the past 4 hours.

This finding defines oliguria (urine output less than 30 mL/hour) and is a significant concern that can indicate hypovolemia or an early stage of acute kidney injury. However, in the context of a patient with a high fever and tachycardia, the oliguria is likely a secondary effect of a more profound primary problem: the systemic vasodilation and third-spacing of fluids that occur in early sepsis. The source of the systemic response (the infection) must be treated to reverse the hemodynamic instability causing the low urine output. Therefore, the combination of fever and tachycardia is the primary driver and the priority finding to address.

Clinical Application and Deeper Pathophysiology

The link between a local surgical complication and a systemic crisis is critical to understand. While a case report on post-cesarean complications notes that small amounts of intraperitoneal air can be normal, persistence or progression can indicate a hollow-viscus injury leading to peritonitis and sepsis . If a patient develops a sealed cecal perforation or an anastomotic leak, bacteria and fecal content contaminate the sterile peritoneal cavity. This triggers a massive inflammatory cascade. The review on elastography supports this, explaining that postoperative complications are frequently associated with a systemic inflammatory response and hemodynamic alterations . The body's attempt to compensate for the distributive shock caused by vasodilation results in a compensatory tachycardia. The nurse's role is to recognize that a fever above 38°C (100.4°F) with tachycardia is not just a number; it is the earliest clinical manifestation of a potentially catastrophic cascade that requires immediate source identification and control to prevent progression to septic shock and multi-organ failure [2].References (research sources)

- [2]Infectious Complications in Metabolic and Bariatric Surgery: A Comprehensive Narrative Review of Pathophysiology, Prevention, and Management.Research articleAgosta M, Augello E, Bellanca CM, Marino A, Rossitto C, Nunnari G, Sofia M, Latteri S. (2026) · DOI: 10.3390/life16050862

## 임상 시나리오

Clinical Practice Guide: Postoperative Fever and Tachycardia

Assessment and Early Recognition

In the first 24-48 hours after major abdominal surgery, a temperature of 102.2°F (39°C) with tachycardia is a red flag for systemic inflammatory response syndrome (SIRS) or early sepsis. Conduct a full head-to-toe assessment focusing on potential infectious sources: surgical wound (erythema, drainage, dehiscence), respiratory system (crackles, diminished breath sounds suggesting atelectasis or pneumonia), urinary tract (dysuria, cloudy urine if catheterized), and intravenous access sites (phlebitis). Monitor vital signs every 1-2 hours, trending heart rate, blood pressure, respiratory rate, and oxygen saturation for signs of deterioration such as hypotension or tachypnea.

Immediate Nursing Interventions

- Notify the surgical team and rapid response team if sepsis criteria are met (suspected infection plus two or more SIRS criteria with evidence of organ dysfunction).

- Obtain blood cultures from two separate sites, wound culture if drainage is present, and urine culture before initiating antimicrobial therapy.

- Administer antipyretics as ordered and initiate cooling measures (tepid sponging, cooling blanket) if temperature exceeds 39°C.

- Start intravenous fluid resuscitation with crystalloids (e.g., Lactated Ringer's or 0.9% sodium chloride) at 30 mL/kg bolus as prescribed for suspected sepsis.

- Administer broad-spectrum antibiotics within one hour of sepsis recognition, per facility protocol and surgical team orders.

- Monitor urine output hourly; oliguria (less than 0.5 mL/kg/hour) may indicate acute kidney injury from sepsis.

Differential Diagnosis and Ongoing Monitoring

While infection is the primary concern, consider non-infectious causes of fever and tachycardia: pulmonary embolism (sudden onset dyspnea, pleuritic chest pain), atelectasis (common in first 48 hours, usually low-grade fever), drug reaction, or transfusion reaction. Serial lactate levels, complete blood count with differential, and C-reactive protein can help differentiate infectious from non-infectious etiologies. Reassess the patient every 15-30 minutes until stabilized, documenting response to interventions and any changes in mental status, which is an early sign of cerebral hypoperfusion in sepsis.

## 핵심 개념

- **Systemic Inflammatory Response Syndrome (SIRS)** — A clinical syndrome characterized by systemic inflammation, often triggered by infection, trauma, or surgery, with criteria including fever, tachycardia, tachypnea, and elevated white blood cell count.
- **Sepsis** — A life-threatening organ dysfunction caused by a dysregulated host response to infection, often presenting with fever, tachycardia, and altered mental status in postoperative patients.
- **Paralytic Ileus** — A temporary impairment of gastrointestinal motility commonly occurring after abdominal surgery, manifesting as absent bowel sounds, abdominal distension, and nausea.
- **Tachycardia** — An abnormally rapid heart rate, typically over 100 beats per minute, which in a postoperative patient with fever can indicate systemic infection or compensatory response to increased metabolic demand.
- **Postoperative Fever** — Elevated body temperature after surgery, which can be caused by atelectasis, wound infection, urinary tract infection, or deep vein thrombosis, with timing and associated symptoms guiding diagnosis.

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