# A nurse is caring for a 55-year-old patient who underwent major abdominal surgery 18 hours ago. Which assessment finding would be the most concerning indicator of potential rapid deterioration requiring immediate intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543596  
> language: ko  
> subject: Next Gen NCLEX

## 문제

A nurse is caring for a 55-year-old patient who underwent major abdominal surgery 18 hours ago. Which assessment finding would be the most concerning indicator of potential rapid deterioration requiring immediate intervention?

## 보기

1. Blood pressure 138/82 mmHg (baseline 125/78 mmHg)
2. Heart rate 98 bpm with occasional premature ventricular contractions
3. Urine output of 35 mL/hour for the past 2 hours
4. New onset confusion with restlessness and agitation **✔ 정답**

**정답: 4**

## 해설

New onset confusion with restlessness and agitation is a critical early warning sign of hypoxia, sepsis, or other life-threatening complications in post-operative patients, requiring immediate intervention. Other options represent less urgent findings manageable with routine monitoring.

## 심화 해설

Clinical Judgment
This question assesses the ability to identify early warning signs in a postoperative patient. The key is to find the 'most concerning' indicator, meaning a sign of rapid deterioration requiring immediate intervention. 18 hours post-surgery is a critical time when complications can begin to emerge.

Option 1 (elevated blood pressure) and Option 2 (heart rate 98 and occasional PVCs) are minor abnormalities or can be explained by postoperative stress response, not rising to the level of Notify HCP!. Option 3 (urine output 35mL per hour) falls within the normal range (30mL/hr or more). In contrast, Option 4's "new onset confusion, agitation, and anxiety" is a very dangerous signal. This indicates brain dysfunction and could be an early sign of hypoxia, sepsis, electrolyte imbalance, or shock from hidden bleeding. It is an early and sensitive indicator that can appear even when other vital signs are normal.

Memory Tip
Neurological changes are a **R**ed **F**lag! Remember "**C**onfusion is a **C**ritical **C**ue." Any change in mental status in a postoperative patient must always be taken seriously.

KR vs US
In Korea, there tends to be a higher sensitivity to vital sign numbers, but in NGN and US-style nursing, greater emphasis is placed on Clinical Judgment, which comprehensively evaluates the change from the patient's baseline and neurological status. 'New onset' confusion is a key clue showing a clear difference from the baseline.

## 임상 시나리오

Clinical Practice Guide
When caring for postoperative patients, it is essential to regularly assess the level of consciousness (LOC) along with vital sign monitoring. Consider using a confusion assessment tool (e.g., CAM-ICU).
Caution
In SATA (Select All That Apply) questions, choosing the "most concerning" single option is a common pitfall. While all options may be somewhat abnormal, you must identify the single indicator that can directly threaten life and requires immediate action. Focusing solely on objective values like urine output can cause you to miss critical subjective/behavioral clues such as neurological changes.

## 핵심 개념

- **Delirium** — A state of acute consciousness disturbance occurring after surgery, characterized by fluctuations in attention and cognitive function. Symptoms include confusion, agitation, and disorientation, and causes may include infection, medication, or metabolic abnormalities.
- **Early Warning Signs** — Clinical signs that may appear before a patient's condition rapidly deteriorates. These include neurological changes (confusion), vital sign changes, respiratory distress, etc., and are scored using systematic assessment tools (MEWS, NEWS).
- **Hypoxia** — A condition where body tissues, especially the brain, do not receive enough oxygen. After surgery, it can occur due to pneumonia, atelectasis, or excessive painkiller administration, and is one of the main causes of confusion and anxiety.
- **Sepsis** — A life-threatening organ dysfunction caused by a systemic inflammatory response to infection. Postoperative patients are vulnerable to infection, and altered mental status (confusion) can be an early sign of sepsis.
- **Clinical Judgment** — The process by which a nurse collects, analyzes, and integrates patient data to draw conclusions and determine actions. In this question, the key is to identify the "most concerning" cue among multiple assessment findings.

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