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Difficulty: MediumPhysiological Adaptation

A practical nurse is conducting a postoperative assessment on a 76-year-old client who underwent a total abdominal hysterectomy four hours ago. Which assessment findings should the nurse identify as expected physiological responses that can be managed with routine ongoing monitoring? Select all that apply.

  1. Hypoactive bowel sounds auscultated in all four abdominal quadrantsAnswer
  2. Scant amount of dark red drainage on the intact surgical dressingAnswer
  3. Client report of surgical site pain rated as a 4 on a 0 to 10 numeric scaleAnswer
  4. D
    New onset of mild disorientation to the current year and hospital location
  5. E
    Heart rate of 112 beats/minute with a blood pressure of 94/58 mm Hg
  6. F
    Oxygen saturation reading of 89% on room air with shallow respirations

Answer

The expected postoperative findings that require only routine monitoring are hypoactive bowel sounds, a scant amount of dark red surgical drainage, and mild to moderate localized surgical site pain.
Following a major abdominal surgery, hypoactive bowel sounds are an expected physiological adaptation due to the effects of anesthesia and bowel manipulation. A scant amount of dark red (sanguineous) drainage is typical in the first few hours postoperatively. Mild to moderate localized incisional pain is also anticipated and can be managed with prescribed analgesics without requiring emergency escalation.

Step-by-Step Solution

1
Analyze the clinical scenario and the specific question being asked.
The client is 4 hours post-op from a major abdominal surgery. The question asks to identify expected, stable findings.
Understanding the timeline and surgical type is necessary to differentiate normal physiological adaptation from acute complications.
2
Evaluate each assessment finding against normal postoperative parameters.
Hypoactive bowel sounds, scant sanguineous drainage, and moderate pain are normal. Confusion, tachycardia with hypotension, and hypoxia are abnormal.
Systematic evaluation ensures critical signs of deterioration are not overlooked.
3
Select the options that represent expected, non-emergent findings.
The correct selections are the bowel sounds, the scant drainage, and the expected pain level.
These findings reflect appropriate physiological adaptation to surgery and can be safely managed with routine nursing care.

Key Concept

Differentiating expected postoperative physiological adaptations from early signs of acute complications in the older adult client.
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Topics

Physiological Adaptation

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