# A nurse is caring for a patient scheduled for major abdominal surgery in 2 hours. During the preoperative assessment, the patient reports having eaten a full breakfast 4 hours ago and expresses anxiety about the procedure. The patient's vital signs are stable, and all preoperative laboratory results are within normal limits. What is the nurse's priority action? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542728 > language: ko > subject: Fundamentals ## 문제 A nurse is caring for a patient scheduled for major abdominal surgery in 2 hours. During the preoperative assessment, the patient reports having eaten a full breakfast 4 hours ago and expresses anxiety about the procedure. The patient's vital signs are stable, and all preoperative laboratory results are within normal limits. What is the nurse's priority action? ## 보기 1. Reassure the patient that 4 hours of fasting is adequate for solid food and proceed with routine preoperative preparations. 2. Document the food intake and continue with routine preoperative care since vital signs are stable 3. Administer prescribed preoperative anxiolytic medication to help the patient relax before surgery 4. Immediately notify the surgeon and anesthesiologist about the patient's recent food intake **✔ 정답** **정답: 4** ## 해설 Patient safety is the highest priority. Recent solid food intake within 4 hours violates NPO guidelines (6-8 hours for solids), increasing aspiration risk during anesthesia. Immediate notification of surgeon/anesthesiologist is required to decide on surgery delay or preventive measures, while other options (reassurance, documentation, anxiolytic) do not address this urgent safety concern. ## 심화 해설 Understanding the Priority: Patient Safety and Aspiration Risk The nurse's priority action is to immediately notify the surgeon and anesthesiologist about the patient's recent food intake. This decision is rooted in the fundamental principle of patient safety, specifically the prevention of pulmonary aspiration during general anesthesia. While the patient's vital signs and laboratory results are reassuring, they do not mitigate the physiological risk created by recent solid food consumption. Why 4 Hours of Fasting for Solids Is Inadequate Standard preoperative fasting guidelines have evolved, but a key distinction exists between clear liquids and solid food. The international consensus statement highlights that existing guidelines are often associated with prolonged fasting, and the push for liberalization applies mainly to clear liquids to improve perioperative well-being and metabolic response . However, a full breakfast containing fats and protein significantly delays gastric emptying. The standard recommended fasting time for a light meal or solid food is typically a minimum of 6 to 8 hours. A 4-hour window after a full breakfast is therefore insufficient to guarantee an empty stomach, placing the patient at high risk for regurgitation and aspiration of gastric contents upon induction of anesthesia. The Heightened Concern with Modern Pharmacology The risk assessment is further complicated by the widespread use of medications that delay gastric emptying. The systematic review and related study on glucagon-like peptide-1 receptor agonists (GLP-1 RAs) explicitly warn of an increased risk of aspiration in patients taking these drugs, even after standard fasting intervals . These medications, commonly prescribed for type 2 diabetes and weight loss, work in part by delaying gastric emptying. Consequently, a patient on a GLP-1 RA could retain significant solid gastric contents many hours after their last meal. Although the question does not state the patient is on these medications, the core physiological principle remains: the nurse cannot assume gastric emptying is complete based solely on a time interval that is already below the standard minimum. The anesthesiologist must be informed to perform a point-of-care risk assessment, which may include gastric ultrasound, and to modify the anesthetic plan, such as employing a rapid sequence induction, to protect the airway. Why the Other Options Are Incorrect - Option 1: Reassuring the patient and proceeding is dangerous. A 4-hour fast for a solid meal does not align with established safety standards for preventing aspiration, regardless of the patient's anxiety level. - Option 2: Documenting and continuing routine care ignores a critical patient safety threat. Stable vital signs and normal labs do not predict gastric content volume. The presence of undigested food in the stomach is a mechanical and chemical risk that lab tests cannot detect. - Option 3: Administering an anxiolytic before clarifying the fasting status with the anesthesia team is unsafe. Sedation can further relax the lower esophageal sphincter and depress protective airway reflexes, compounding the aspiration risk if the stomach is not empty. The physiological safety concern must be addressed before the psychological one. The nurse's role is to act as a patient advocate by communicating critical assessment findings that directly impact the safety of the planned procedure. The presence of food in the stomach fundamentally changes the risk profile of general anesthesia, making immediate communication with the anesthesia and surgical team the only safe and appropriate course of action . ## 임상 시나리오 Preoperative Aspiration Risk Management Clinical Scenario A patient scheduled for major abdominal surgery in 2 hours reports eating a full breakfast 4 hours ago. Standard fasting guidelines for solid food require a minimum of 6-8 hours, making this a critical safety concern. Immediate Nursing Actions - **Notify the Team:** Immediately inform the surgeon and anesthesiologist. The decision to proceed, delay, or modify the anesthetic plan is a medical judgment. - **Document Findings:** Record the exact time, type, and amount of food consumed in the patient's chart. - **Withhold Premedication:** Do not administer any oral medications or anxiolytics until the anesthesia provider gives clearance. - **Maintain NPO Status:** Ensure the patient continues to take nothing by mouth. Clinical Reasoning A full breakfast containing fat and protein significantly delays gastric emptying. Even with stable vital signs, the patient is at high risk for regurgitation and pulmonary aspiration upon induction of general anesthesia. The anesthesiologist may choose to delay the surgery, proceed with a rapid sequence induction, or cancel the case based on the urgency of the procedure. Key Safety Principle Patient safety is the priority. Never assume fasting time is adequate without verifying the type of intake. Clear communication of any deviation from preoperative instructions is a core nursing responsibility. ## 핵심 개념 - **Pulmonary Aspiration** — Inhalation of gastric contents into the lungs, a serious complication of general anesthesia that can cause pneumonitis or airway obstruction. - **Preoperative Fasting Guidelines** — Evidence-based recommendations requiring a minimum of 6-8 hours of fasting for solid foods to ensure gastric emptying before surgery. - **Gastric Emptying** — The process by which the stomach contents are moved into the duodenum; delayed by high-fat or high-protein meals. ## 같은 주제 문제 - [A nurse is assessing a patient 24 hours after abdominal surgery. Which assessment finding …](https://mymerci.kr/pages/nclex_q.php?qn_id=542720) - [A nurse is assessing a patient 2 hours after abdominal surgery. Which assessment finding w…](https://mymerci.kr/pages/nclex_q.php?qn_id=542721) - [A nurse is assessing a patient 6 hours after orthopedic surgery for a fractured femur. 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