# A client is 6 hours after an open cholecystectomy performed under general anesthesia. The client has become increasingly restless. Skin is cool and clammy, and capillary refill is 4 seconds. Blood pressure is 88/54 mm Hg (preoperative 132/80 mm Hg), heart rate 128/min, respiratory rate 24/min, temperature 36.4°C (97.5°F), and SpO2 95% on 2 L/min. Lungs are clear, and neck veins are flat. Urine output has been 20 mL over the last hour. The abdominal dressing is dry and intact, and the abdomen is increasingly distended. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617429&lang=en  
> language: en  
> subject: Complications of Procedures  
> category: ROR

## Question

A client is 6 hours after an open cholecystectomy performed under general anesthesia. The client has become increasingly restless. Skin is cool and clammy, and capillary refill is 4 seconds. Blood pressure is 88/54 mm Hg (preoperative 132/80 mm Hg), heart rate 128/min, respiratory rate 24/min, temperature 36.4°C (97.5°F), and SpO2 95% on 2 L/min. Lungs are clear, and neck veins are flat. Urine output has been 20 mL over the last hour. The abdominal dressing is dry and intact, and the abdomen is increasingly distended. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Septic shock from an intra-abdominal infection
Hypovolemic shock from internal hemorrhage
Neurogenic shock from anesthesia
Cardiogenic shock from a perioperative infarction

Actions to take

Select 2
Draw blood cultures before any further treatment
Recheck the dressing and vital signs in 1 hour
Increase the IV fluid rate as prescribed
Encourage oral fluids to improve urine output
Notify the surgeon of the findings immediately

Parameters to monitor

Select 2
Temperature and white blood cell count
Serial hemoglobin and hematocrit
Serum troponin level
Dermatome level of sensory block
Blood pressure and heart rate trend

## Explanation

Tachycardia, hypotension, cool clammy skin, delayed capillary refill, oliguria, and increasing distention 6 hours after surgery indicate hypovolemic shock from internal bleeding; a dry dressing does not exclude it. The nurse increases IV fluids as prescribed and notifies the surgeon immediately. Hemoglobin/hematocrit and blood pressure/heart rate trends show whether bleeding continues and resuscitation is working.

## In-depth explanation

Quick answer
Hypovolemic shock from internal hemorrhage; increase IV fluids as prescribed and notify the surgeon immediately; monitor serial hemoglobin/hematocrit and the blood pressure and heart rate trend.

Why this is correct
Blood can collect in the abdomen without soaking the dressing, which is why the increasing distention matters. The client is afebrile (against early septic shock), tachycardic with cool skin after general anesthesia (against neurogenic shock, which causes bradycardia and warm skin after neuraxial block), and has clear lungs with flat neck veins (against cardiogenic shock). Volume replacement buys time while the surgeon decides on transfusion and return to surgery.

Easy analogy or mental picture
Picture a bucket with a hidden leak at the bottom: the outside looks dry, but the water level keeps dropping. The fix is to pour more in and call the person who can patch the leak.

Memory hook
"Dry dressing, wet belly" — trust the vital signs, not the gauze.

NCLEX decision rule
When postoperative findings show shock, restore circulating volume and escalate to the surgeon now; monitor the markers that show ongoing blood loss and hemodynamic response.

Why the other choices are wrong
Blood cultures fit septic shock but delay treatment in an afebrile client who is bleeding. Rechecking in 1 hour lets shock progress, and oral fluids are too slow and inappropriate soon after abdominal surgery. Temperature and WBC track infection, troponin tracks myocardial injury, and the dermatome level tracks a neuraxial block — none measures ongoing hemorrhage or the response to volume.

References
1MedlinePlus — Hypovolemic shockBlood or fluid loss causes hypovolemic shock with rapid pulse, cool clammy skin, low blood pressure, and decreased urine output; treatment restores volume and stops bleeding.

## Clinical scenario

Scenario
Six hours after open cholecystectomy the client shows falling blood pressure, tachycardia, poor perfusion, low urine output, and increasing abdominal distention despite a dry dressing.

## Key concepts

- **Hypovolemic shock** — Inadequate tissue perfusion caused by loss of circulating volume, such as bleeding.
- **Capillary refill** — Time for color to return to a nail bed after pressure; more than 3 seconds suggests poor peripheral perfusion.
- **Concealed hemorrhage** — Bleeding into a body cavity that is not visible on the dressing or drains.

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