# A nurse is caring for a 72-year-old patient who underwent major abdominal surgery 18 hours ago. Which assessment finding would be the MOST concerning and require immediate intervention?

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> subject: Next Gen NCLEX

## 문제

A nurse is caring for a 72-year-old patient who underwent major abdominal surgery 18 hours ago. Which assessment finding would be the MOST concerning and require immediate intervention?

## 보기

1. Blood pressure decreased from 130/80 mmHg to 110/70 mmHg over 4 hours
2. Urine output of 25 mL in the past hour with dark amber color
3. Temperature increase from 98.6°F to 100.2°F with mild chills
4. New onset confusion and restlessness with decreased oxygen saturation **✔ 정답**

**정답: 4**

## 해설

New confusion and restlessness with decreased SpO2 indicate hypoxemia and altered mental status, requiring immediate intervention. Other findings (mild BP drop, low urine output, low-grade fever) are less urgent.

## 심화 해설

Clinical Reasoning & Priority Setting

The most concerning assessment finding requiring immediate intervention is new onset confusion and restlessness with decreased oxygen saturation. In a 72-year-old patient who is 18 hours post-major abdominal surgery, this clinical picture is the classic, acute presentation of postoperative delirium (POD), a medical emergency that signals a significant underlying physiological derangement or complication.

Pathophysiological Rationale for Priority

Postoperative delirium is the most common neurologic complication after surgery, affecting 15-50% of adults aged 65 and older, with onset typically occurring within 72 hours of anesthesia [1]. The acute change in mental status—characterized by an acute, fluctuating disturbance in attention, awareness, and cognition—is a cardinal sign [1]. When coupled with a drop in oxygen saturation, it demands an immediate search for life-threatening causes such as hypoxemia, pulmonary embolism, or sepsis. The brain’s heightened sensitivity to oxygen deprivation makes an acute confusional state a critical early warning sign. The urgency is underscored by evidence that POD is associated with a threefold increase in 30-day mortality, prolonged mechanical ventilation, and long-term cognitive decline [1].

Analysis of Other Options

| Option | Assessment Finding | Why It Is Less Immediate |
| --- | --- | --- |
| 1 | Blood pressure decreased from 130/80 mmHg to 110/70 mmHg over 4 hours. | This represents a downward trend but the current value remains within normotensive limits. While it requires close monitoring for ongoing fluid shifts or bleeding, it does not constitute an immediate crisis like an acute neurological change. The patient is not yet hypotensive. |
| 2 | Urine output of 25 mL in the past hour with dark amber color. | This is oliguria (< 30 mL/hour), indicating possible hypovolemia or acute kidney injury. It is a significant concern that warrants fluid status assessment and provider notification, but it is a more slowly evolving problem compared to an acute, hypoxic confusional state. |
| 3 | Temperature increase from 98.6°F to 100.2°F with mild chills. | A low-grade fever 18 hours post-surgery could indicate atelectasis or an early infectious process. It requires investigation but is a lower priority than a neurological change with hypoxia, which signals an immediate threat to cerebral oxygenation. |

Connecting to the Underlying Mechanisms

The development of POD is multifactorial, arising from a complex interplay of neuroinflammation, neurotransmitter imbalances, and metabolic stress [1,2]. Major abdominal surgery triggers a systemic inflammatory response, releasing cytokines that can disrupt the blood-brain barrier and alter neuronal function. When you observe new-onset confusion and restlessness, you are seeing the clinical manifestation of this cerebral dysfunction. The concept analysis on agitation in the ICU reinforces that such a behavioral change is a phenomenon of widespread concern linked to negative outcomes for patients, staff, and family, and it demands immediate, tailored management . The nurse’s priority is to assess oxygenation and perfusion to the brain, as the agitated state may be the only early indicator of a catastrophic event.References (research sources)

- [1]Evolving Clinical Management of Postoperative Delirium: A Narrative Review.Research articleAhmadzadeh S, Duplechin DP, Haynes AT, Hollander AV, Rieger R, Jean Baptiste C, Varrassi G, Shekoohi S, Kaye AD. (2025) · DOI: 10.7759/cureus.92927

## 임상 시나리오

Postoperative Delirium: Emergency AssessmentAcute Confusion + Hypoxia is a Code Situation
New onset confusion and restlessness with decreased oxygen saturation in an older adult post-surgery is a classic presentation of postoperative delirium (POD). This is a medical emergency, not an expected outcome, often signaling hypoxemia, sepsis, or pulmonary embolism.

Immediate nursing actions include assessing airway, breathing, circulation (ABCs), applying oxygen to maintain SpO2 above 92%, notifying the Rapid Response Team, and checking a blood glucose level. A focused neurological exam and review of recent medications are also critical.

CautionNever assume confusion is dementia or solely due to age. Postoperative delirium has a 3-fold increase in 30-day mortality and requires immediate identification and treatment of the underlying cause.

## 핵심 개념

- **Postoperative Delirium (POD)** — An acute, fluctuating disturbance in attention, awareness, and cognition occurring typically within 72 hours of surgery, most common in older adults, and a medical emergency signaling underlying physiological derangement.
- **Hypoxemia** — An abnormally low concentration of oxygen in the blood, which can lead to tissue hypoxia and is a common cause of acute confusion in postoperative patients.
- **Oliguria** — Urine output less than 30 mL per hour, often indicating acute kidney injury, hypovolemia, or decreased renal perfusion.

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