# A nurse is assessing a patient 2 hours after abdominal surgery. Which assessment finding would be the most concerning and require immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542721 > language: ko > subject: Fundamentals ## 문제 A nurse is assessing a patient 2 hours after abdominal surgery. Which assessment finding would be the most concerning and require immediate intervention? ## 보기 1. Blood pressure 110/70 mmHg, pulse 88 bpm, and temperature 99.1°F 2. Small amount of serosanguineous drainage on surgical dressing with intact edges 3. Patient reports incisional pain rated 6/10 with slight tenderness on palpation 4. Absence of bowel sounds in all four quadrants with abdominal distention and firmness **✔ 정답** **정답: 4** ## 해설 Absence of bowel sounds with abdominal distention 2 hours postoperatively indicates paralytic ileus or obstruction requiring immediate intervention. Other findings are expected or less urgent. ## 심화 해설 Correct Answer: 4 Clinical Reasoning and Analysis The most concerning finding is the absence of bowel sounds in all four quadrants with abdominal distention and firmness. This clinical picture is highly suggestive of a paralytic ileus, a functional obstruction of the bowel, which is a common but serious complication following abdominal surgery. The handling of the intestines during surgery can cause a temporary cessation of peristalsis. While some degree of reduced bowel activity is expected, a completely silent abdomen with distention and a firm, board-like feel 2 hours postoperatively is an abnormal and alarming sign that requires immediate intervention. This presentation can indicate the progression from a normal postoperative ileus to a more severe, prolonged ileus or even an early sign of a mechanical obstruction or intra-abdominal complication. The distention and firmness suggest the accumulation of gas and fluid, which, if left unaddressed, can lead to increased intra-abdominal pressure, compromised respiratory function, splinting of the diaphragm, and potential fluid and electrolyte imbalances. A systematic review and meta-analysis on nursing interventions for abdominal surgery patients emphasizes that effective postoperative monitoring and management are crucial for improving recovery and mitigating complications [1]. The assessment finding in option 4 directly contradicts the expected trajectory of recovery and falls outside the scope of standard postoperative care, demanding a proactive nursing response such as continued NPO status, nasogastric tube insertion if ordered, and immediate notification of the surgical team. While a case report on a massive hemorrhage from a pancreatic pseudocyst highlights the life-threatening nature of certain postoperative complications, it underscores the principle that vigilant assessment for signs of internal catastrophe, such as the acute abdomen presentation here, is paramount [2]. Analysis of Other Options - Option 1: Blood pressure 110/70 mmHg, pulse 88 bpm, and temperature 99.1°F. These vital signs are within normal limits or show only a very slight elevation in temperature, which is a common physiological response to the stress of surgery and the inflammatory process. This would not be the priority concern. - Option 2: Small amount of serosanguineous drainage on surgical dressing with intact edges. A small amount of serosanguineous (blood-tinged, serum-like) drainage is a normal and expected finding on a surgical dressing in the early postoperative period. The fact that the dressing edges are intact is a positive finding, indicating the wound is properly approximated and the drainage is not excessive or suggestive of an active bleed or dehiscence. - Option 3: Patient reports incisional pain rated 6/10 with slight tenderness on palpation. Incisional pain is an expected outcome after abdominal surgery. A pain score of 6/10 indicates the need for pain reassessment and pharmacological or non-pharmacological intervention, but it is not the most immediately life-threatening finding. Effective pain management is a key nursing intervention for promoting recovery, as highlighted in the systematic review, but it is a lower priority than a potential ileus [1].References (research sources) - [1]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 - [2]Hemorrhage from a pancreatic pseudocyst eroding the stomach, diaphragm, and splenic artery: a case report on integrated surgical and nursing management.Case reportZhang L, Chen Y, Ding Y, Lao X. (2026) · DOI: 10.21037/acr-2025-194 ## 임상 시나리오 Clinical Practice Guide Two hours after abdominal surgery, the most critical assessment is for signs of paralytic ileus, a functional obstruction caused by the cessation of peristalsis. While some reduction in bowel sounds is expected, the combination of absent bowel sounds in all four quadrants, progressive abdominal distention, and a firm, rigid abdomen is a sentinel finding. This presentation indicates trapped gas and fluid, which can rapidly increase intra-abdominal pressure, splint the diaphragm, and compromise ventilation. Immediate nursing actions include keeping the patient NPO, notifying the surgical team, and preparing for interventions such as nasogastric tube insertion for decompression. This assessment takes priority over managing expected incisional pain or monitoring stable vital signs and normal wound drainage. Expected Findings - Hypoactive bowel sounds in early recovery - Mild, gradual return of peristalsis over 24-72 hours - Soft, non-distended abdomen Concerning Findings (Paralytic Ileus) - Absent bowel sounds in all quadrants - Firm, board-like abdominal distention - Nausea, vomiting, or increasing girth - Respiratory distress from diaphragmatic pressure Immediate Nursing Actions - Maintain strict NPO status - Notify the surgeon or rapid response team immediately - Prepare for nasogastric (NG) tube insertion and low-intermittent suction - Monitor vital signs, O2 saturation, and fluid/electrolyte balance - Elevate head of bed to ease respiratory effort ## 핵심 개념 - **Paralytic Ileus** — A functional obstruction of the bowel caused by cessation of peristalsis, often following abdominal surgery due to bowel manipulation. - **Serosanguineous Drainage** — A thin, watery wound drainage that is blood-tinged, composed of serum and red blood cells; a normal finding in early wound healing. - **Peristalsis** — The involuntary, wave-like muscle contractions that move food and fluid through the gastrointestinal tract. - **Abdominal Distention** — Swelling or enlargement of the abdomen, often caused by the accumulation of gas, fluid, or intestinal contents. - **Postoperative Ileus** — A temporary impairment of gastrointestinal motility after surgery, with an expected duration that varies by procedure; a prolonged or severe presentation is a complication. ## 같은 주제 문제 - [A nurse is assessing a patient 24 hours after abdominal surgery. 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