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Difficulty: MediumReduction of Risk Potential

A practical nurse (PN) is assessing a client who is 12 hours postoperative following an open cholecystectomy. Which of the following assessment findings should the PN recognize as expected at this stage of recovery? Select all that apply.

  1. A
    A heart rate of 115 bpm and a blood pressure of 92/58 mm Hg
  2. Hypoactive bowel sounds auscultated in all four abdominal quadrantsAnswer
  3. C
    A morning serum potassium laboratory result of 2.9 mEq/L (2.9 mmol/L)
  4. Serosanguineous drainage on the surgical dressing that has not increased in size since the previous shiftAnswer
  5. A temperature reading of 99.5°F (37.5°C)Answer
  6. F
    An oxygen saturation of 88% on room air accompanied by new-onset restlessness

Answer

The expected postoperative findings for this client include hypoactive bowel sounds, stable serosanguineous drainage on the surgical dressing, and a low-grade temperature of 99.5°F (37.5°C).
Expected findings at 12 hours post-abdominal surgery include hypoactive bowel sounds (due to anesthesia and bowel manipulation), stable serosanguineous drainage (normal early wound healing), and a low-grade fever up to 100.4°F (38°C) resulting from the body's inflammatory response to surgical trauma. These require routine monitoring but no immediate escalation.

Step-by-Step Solution

1
Evaluate the vital signs for indicators of shock or respiratory compromise.
The elevated heart rate with low blood pressure and the critically low oxygen saturation are identified as abnormal, emergent findings.
Early identification of ABC (Airway, Breathing, Circulation) compromise prevents life-threatening postoperative complications like hemorrhage or hypoxia.
2
Analyze the laboratory values against normal therapeutic ranges.
The potassium level of 2.9 mEq/L is identified as critically low.
Hypokalemia must be escalated immediately because it can precipitate fatal cardiac arrhythmias.
3
Identify the expected physiological responses to abdominal surgery and anesthesia.
Hypoactive bowel sounds, a mild temperature elevation, and stable serosanguineous wound drainage are recognized as normal recovery milestones.
Surgical trauma and anesthesia predictably cause temporary bowel sluggishness, mild systemic inflammation, and initial wound weeping.

Key Concept

Discriminating between expected postoperative recovery milestones and emergent clinical complications.
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Reduction of Risk Potential

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