A nurse is caring for a client on the first postoperative day following abdominal surgery. The client reports severe incisional pain rated 9 out of 10 on the pain scale despite receiving medication. The nurse assesses the client and notes a temperature of 101°F (38.3°C), a firm, distended abdomen, and absent bowel sounds. What is the nurse's best action?
Administer additional analgesics to address the client's pain.
Reassess the client's symptoms in one hour for changes.
Assist the client in ambulating to promote bowel movement.
Notify the healthcare provider about the client's symptoms.
The correct action is to notify the healthcare provider. The combination of severe, unrelieved pain, fever, abdominal distention, and absent bowel sounds can indicate a serious postoperative complication such as peritonitis or paralytic ileus. Prompt medical evaluation is necessary for diagnostic testing (e.g., imaging, labs) and interventions (e.g., nasogastric decompression, antibiotics, surgery). Administering additional analgesics may mask symptoms and worsen an ileus, ambulating could exacerbate an undiagnosed complication, and waiting an hour delays potentially urgent care.
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NCLEX RN
Physiological Integrity
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