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Difficulty: MediumReduction of Risk Potential

Two hours after a diagnostic colonoscopy with multiple polypectomies, a client begins to complain of severe, continuous abdominal pain that radiates to the right shoulder. The nurse observes that the client's abdomen is rigid and board-like upon inspection. Vital signs reveal a blood pressure of 88/54 mm Hg and a heart rate of 122 beats per minute. Which intervention is the most critical to implement first?

  1. Maintain strict nothing-by-mouth (NPO) status, ensure patent intravenous access, and urgently notify the healthcare provider.Answer
  2. B
    Place the client in a prone position and apply a warm abdominal compress to alleviate retained gas pains.
  3. C
    Perform deep palpation of all four abdominal quadrants to accurately localize the source of the rebound tenderness.
  4. D
    Request a prescription for an arterial blood gas analysis to determine if the client is developing uncompensated alkalosis.

Answer

The most critical intervention is to maintain a strict NPO status, establish patent intravenous access, and immediately notify the healthcare provider.
The clinical presentation of a rigid, board-like abdomen, severe pain radiating to the right shoulder (referred pain from diaphragmatic irritation), and signs of shock (hypotension, tachycardia) strongly indicate a bowel perforation. This is a severe, life-threatening complication of a colonoscopy and polypectomy. The priority action is to prepare the client for emergent surgery by maintaining an NPO status, establishing robust intravenous access for fluid resuscitation, and immediately alerting the healthcare provider.

Step-by-Step Solution

1
Analyze the client's post-procedure clinical presentation.
The client has severe pain radiating to the shoulder, a rigid/board-like abdomen, hypotension (88/54 mm Hg), and tachycardia (122 bpm).
Identifying abnormal assessment data is necessary to determine if the client is experiencing an expected side effect or a severe complication.
2
Correlate the clinical findings with potential colonoscopy complications.
These findings are classic indicators of a bowel perforation causing peritonitis, referred diaphragmatic pain, and impending hemorrhagic or septic shock.
Connecting the symptoms to a specific physiological compromise guides the prioritization of nursing interventions.
3
Determine the highest priority intervention to reduce risk and stabilize the client.
The client requires emergency surgery and fluid resuscitation; therefore, keeping the client NPO, securing IV access, and alerting the provider is the immediate priority.
Preparing the client for emergency surgical repair addresses the root cause of the life-threatening deterioration.

Key Concept

Bowel Perforation and Post-Procedure Complication Management
Estimated Time:1m 15s
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Topics

Reduction of Risk Potential

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