# A nurse is caring for a postoperative patient who underwent major abdominal surgery 48 hours ago. Which assessment finding would be the MOST critical indicator requiring immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542729 > language: ko > subject: Fundamentals ## 문제 A nurse is caring for a postoperative patient who underwent major abdominal surgery 48 hours ago. Which assessment finding would be the MOST critical indicator requiring immediate intervention? The nurse notices the patient appears restless and reports feeling anxious. Vital signs show increasing heart rate and decreasing blood pressure compared to baseline measurements. ## 보기 1. Blood pressure 88/52 mmHg with heart rate 118 bpm, patient reports feeling dizzy and weak **✔ 정답** 2. Temperature 101.2°F (38.4°C) with mild incisional tenderness and slight erythema around the surgical site. 3. Urine output of 25 mL/hour for the past 4 hours with amber-colored urine 4. Oxygen saturation 94% on room air with patient reporting mild shortness of breath **정답: 1** ## 해설 Hypotension (88/52 mmHg) with tachycardia (118 bpm) and symptoms like dizziness/weakness indicates hypovolemic shock, a life-threatening emergency requiring immediate fluid resuscitation and hemorrhage control. Other findings (fever, low urine output, mild hypoxia) are concerning but less immediately critical. ## 심화 해설 Clinical Reasoning and Priority Setting The patient is exhibiting the classic compensatory and early decompensatory signs of hypovolemic shock. After major abdominal surgery, the most immediate life-threatening risk is internal or concealed hemorrhage. The restlessness and anxiety reported are early neurological manifestations of cerebral hypoperfusion. The combination of rising heart rate (tachycardia) and falling blood pressure (hypotension) indicates that the body’s compensatory mechanisms—sympathetic nervous system activation leading to tachycardia and vasoconstriction—are failing to maintain adequate cardiac output and tissue perfusion [1]. Analysis of the Correct Answer (Option 1) A blood pressure of 88/52 mmHg with a heart rate of 118 bpm represents a state of hemodynamic instability. The systolic blood pressure has dropped to a level where vital organ perfusion is critically compromised (typically 90 mmHg). The heart rate is significantly elevated as the heart attempts to compensate for decreased stroke volume. The patient’s subjective report of dizziness and weakness further confirms inadequate cerebral blood flow. This clinical picture is a sentinel sign of a potentially catastrophic postoperative bleed, such as a concealed hematoma, which can lead to rapid decompensation, organ failure, and death if not immediately addressed with fluid resuscitation and surgical evaluation [1,2]. This aligns directly with the evidence that severe, unrecognized postoperative bleeding can result in shock and is a finding that demands immediate intervention [2]. Analysis of Incorrect Options Option 2 A temperature of 101.2°F (38.4°C) with mild incisional tenderness and slight erythema suggests a possible surgical site infection. While this requires intervention, including wound assessment, cultures, and notification of the provider, it does not represent an immediate threat to the patient’s airway, breathing, or circulation. The patient’s hemodynamic stability is the priority over a localized infection that develops over days. Option 3 A urine output of 25 mL/hour for four hours (averaging less than 0.5 mL/kg/hr) is a significant finding indicating acute kidney injury, which can be a consequence of hypovolemia. However, in the hierarchy of assessment, this is a downstream effect of the primary problem. The profoundly low blood pressure and tachycardia are the direct, immediate causes of the decreased renal perfusion. The nurse’s priority is to intervene on the cause (shock) rather than the effect (oliguria). The hypotensive crisis identified in Option 1 is the driver of this finding. Option 4 An oxygen saturation of 94% on room air with mild shortness of breath is a finding that requires monitoring and potential intervention, such as deep breathing exercises, incentive spirometry, or repositioning. A saturation of 94% is not a critical value and does not indicate immediate respiratory failure. In the context of a patient with clear signs of hemorrhagic shock, the profound circulatory collapse takes absolute precedence over a mild respiratory symptom. The evidence underscores that the central role of the nurse in such scenarios is the early recognition of hypovolemia and the initiation of life-saving interventions, making the hemodynamic instability the most critical finding [1].References (research sources) - [1]Best evidence for fluid resuscitation nursing in hypovolemic shock patients in emergency care based on GRADE system.Research articleWang Y, Lin J, Lin Y. (2026) · DOI: 10.2478/abm-2026-0009 - [2]Rectus Sheath Hematoma Following Cesarean Section: A Concealed Extrauterine Cause of Postpartum Hemorrhage.Research articleKumre B, Vijay N, Jain S, Humaney N. (2026) · DOI: 10.7759/cureus.108664 ## 임상 시나리오 Clinical Practice Guide: Recognizing Postoperative Hemorrhagic Shock A postoperative patient exhibiting restlessness, anxiety, tachycardia, and hypotension is in a peri-arrest state until proven otherwise. The primary differential is occult surgical hemorrhage. Immediate action is required to prevent progression to irreversible shock and cardiac arrest. Rapid Bedside Assessment - **Primary Survey (ABCs):** Ensure airway patency, administer high-flow oxygen, and assess for external bleeding or abdominal distension. - **Vital Sign Trend Analysis:** A narrowing pulse pressure, rising heart rate, and dropping systolic BP below 90 mmHg are late signs of decompensation. - **Focused Abdominal Exam:** Inspect and palpate the surgical site for firmness, distension, or visible bruising. Measure abdominal girth if a baseline exists. Immediate Nursing Interventions - **Activate the Rapid Response Team** or facility emergency protocol immediately. - **Optimize Venous Access:** Ensure two large-bore intravenous lines are functional. Initiate rapid isotonic crystalloid fluid resuscitation as per protocol or provider order. - **Prepare for Transfusion:** Type and crossmatch blood, and be ready to initiate massive transfusion protocol if indicated. - **Continuous Monitoring:** Place the patient on continuous cardiac monitoring and pulse oximetry. Monitor level of consciousness every 5 minutes. - **Notify the Surgeon:** Provide a concise SBAR report including vital sign trends, physical assessment changes, and current interventions. Prepare the patient for potential emergency surgical re-exploration. Differentiating from Other Postoperative Complications - **Sepsis:** Presents with fever, widened pulse pressure, and warm skin in early stages, unlike the cold, clammy vasoconstriction of hemorrhagic shock. - **Pulmonary Embolism:** Characterized by sudden dyspnea and chest pain with possible oxygen desaturation, but hypotension occurs later in massive embolism. - **Medication Effect:** Review recent analgesic or antihypertensive administration, though this rarely causes the profound tachycardia seen in volume loss. Critical Reminder: A falling blood pressure is a late and ominous sign in a young or previously healthy adult. Tachycardia and anxiety are the earliest indicators of significant blood loss. Do not delay intervention while waiting for confirmatory labs like hemoglobin, which may not reflect acute loss. ## 핵심 개념 - **Hypovolemic Shock** — A life-threatening condition caused by a critical loss of intravascular volume, leading to inadequate tissue perfusion and oxygen delivery. - **Compensatory Mechanisms** — Physiological responses, such as increased heart rate and systemic vasoconstriction, that attempt to maintain cardiac output and blood pressure during volume loss. - **Occult Hemorrhage** — Internal bleeding that is not immediately visible, often occurring in body cavities or at surgical sites, which can rapidly lead to hemodynamic instability. - **Hemodynamic Instability** — A state of abnormal or unstable blood pressure and heart rate that results in compromised organ perfusion and requires urgent medical intervention. - **Oliguria** — Abnormally low urine output, often defined as less than 30 mL/hour, which can be a sign of renal hypoperfusion or acute kidney injury. ## 같은 주제 문제 - [A nurse is assessing a patient who underwent exploratory laparotomy for bowel obstruction …](https://mymerci.kr/pages/nclex_q.php?qn_id=542730) - [A nurse is caring for a 65-year-old postoperative patient who underwent major abdominal su…](https://mymerci.kr/pages/nclex_q.php?qn_id=542731) - [A nurse is caring for a 60-year-old postoperative patient who underwent hip replacement su…](https://mymerci.kr/pages/nclex_q.php?qn_id=542732) - [A nurse is caring for a 70-year-old postoperative patient with a history of COPD who under…](https://mymerci.kr/pages/nclex_q.php?qn_id=542733) - [A nurse is caring for a 30-year-old postoperative patient who underwent emergency appendec…](https://mymerci.kr/pages/nclex_q.php?qn_id=542734) - [A nurse is caring for a 60-year-old postoperative patient who underwent laparoscopic chole…](https://mymerci.kr/pages/nclex_q.php?qn_id=542735) - [A nurse is caring for a postoperative patient who suddenly becomes restless, with decrease…](https://mymerci.kr/pages/nclex_q.php?qn_id=542736) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._