A nurse is caring for a client who is 6 hours postoperative from abdominal surgery. Which findings require immediate intervention? (Select all that apply)

Question

This select-all-that-apply (SATA) question challenges the student's application and analysis skills. This question asks what "red flag" signs and symptoms need to be addressed immediately vs. later.

Answer 1

A. Absent bowel sounds

B. Heart rate of 120 bpm

C. Oxygen saturation of 89% on room air

D. Moderate serosanguinous drainage on dressing

E. Urine output of 15 mL over the past hour

F. Client reporting incisional pain of 7/10

Correct answers: B, C, E

Rationale:

B. HR 120 bpm → Tachycardia may indicate hypovolemia or early signs of shock.

C. O2 Sat 89% → Hypoxia indicates the patient needs oxygen or further respiratory assessment to prevent further respiratory decompensation.

E. Urine output 15 mL/hr → Oliguria indicates a possible kidney perfusion issue, which can lead to an AKI.

Incorrect answers:

A. Absent bowel sounds → This is common in the early postoperative period, not alarming. Ambulation is key to promoting peristalsis.

D. Moderate serosanguinous drainage → This is expected in the early hours postoperatively. Drainage should start to turn serous as healing occurs.

F. Pain 7/10 → Moderate to severe pain should be addressed, but it is not an immediate priority unless the pain is unrelieved.