QLexNursing

Oxygen saturation

🔷 The client’s oxygen saturation dropped from 95% to 90% on the same 1 L/min nasal cannula, indicating worsening oxygenation postoperatively.

🔷 A declining SpO₂ with increased respiratory rate (16 → 24/min) and increased depth of respirations suggests potential respiratory compromise or early hypoxia.

🔷 According to ABC (Airway, Breathing, Circulation) priorities, changes in oxygenation and breathing must be addressed before other concerns like pain or bowel sounds.

🔷 The client also had an estimated blood loss of 1200 mL and now has Hgb 8.3 g/dL, so reduced oxygen-carrying capacity makes oxygen saturation even more critical to monitor.

🔷 Because a falling oxygen saturation can rapidly progress to life-threatening hypoxemia, the nurse should first follow up on and intervene for the client’s oxygen status (e.g., increase O₂, reassess, notify provider).

Behavioral findings

🔷 The client’s behavior changed from being alert, talking, and stable at 0950 to agitated and stating, “I feel like something is wrong” at 1025, which is a significant subjective and behavioral change.

🔷 Sudden agitation, anxiety, or a sense of impending doom can be an early indicator of hypoxia, shock, pulmonary embolism, or other serious complications.

🔷 Even when other vital signs are not profoundly abnormal, a client’s report that something “feels wrong” must be treated as an early warning sign.

🔷 When combined with increased respiratory rate and decreasing oxygen saturation, the change in behavior and perception strongly signals that the client’s condition may be deteriorating.

🔷 Therefore, the nurse should prioritize following up on behavioral findings along with oxygen saturation, as they point to possible early instability that needs rapid assessment and intervention.

Pain

🔷 The client reports incisional pain of 5/10, which is moderate and expected in the immediate postoperative period after abdominal surgery.

🔷 While pain management is very important, it is not the highest priority when compared to potential respiratory compromise and change in behavior.

🔷 The pain score is not extreme (not 8–10/10) and there is no indication of sudden severe or unmanageable pain that would suggest a complication like hemorrhage or dehiscence.

🔷 In the context of ABC priorities, treating pain comes after ensuring that airway and breathing are stable, especially with an SpO₂ drop and increased respirations.

🔷 Thus, although the nurse should address pain, it is not what the nurse should first follow up on in this situation, making it an incorrect selection for initial priority.

WBC count

🔷 The client’s WBC count is 10,800/mm³, which is only slightly above the upper normal limit and can be expected postoperatively due to stress and inflammation.

🔷 This mild elevation does not necessarily indicate an acute infection needing immediate intervention and is less urgent than the observed changes in oxygen saturation and behavior.

🔷 Laboratory values are important, but they are not always the first priority when current clinical signs show potential respiratory compromise.

🔷 The client’s agitation, increased respiratory rate, and decreased O₂ saturation point to more immediate threats than a borderline-elevated WBC.

🔷 Therefore, while the WBC should be monitored and documented, it is not one of the findings the nurse should first follow up on, making it an incorrect choice for priority.

Bowel findings

🔷 The notes describe hypoactive bowel sounds, which are normal and expected in the early postoperative period, especially after abdominal surgery.

🔷 The client does not have signs of severe abdominal distention, vomiting, or absent bowel sounds, which would be more concerning for ileus or obstruction.

🔷 While bowel function is important to monitor, it is not immediately life-threatening compared with declining oxygen saturation and behavioral changes.

🔷 Addressing bowel status can safely occur after the nurse has assessed and intervened for breathing and potential early hypoxia.

🔷 Therefore, bowel findings are not the first priority to follow up on in this scenario and are an incorrect choice for initial focus.