Question

A client's abdominal incision eviscerates. The nurse should first:

a. lower the client's head and elevate the feet.
b. take the client's vital signs and call the health care provider (HCP).
c. cover the incision with a dressing moistened with sterile normal saline solution.
d. start an emergency infusion of IV fluids.

Answer 1

In case of evisceration of an abdominal incision, the nurse should first cover the incision with sterile saline moistened dressing and then call the health care provider.

Step-by-step explanation:

A client's abdominal incision eviscerates, meaning the internal organs are protruding through the incision site. In such a medical emergency, the nurse should first cover the incision with a dressing moistened with sterile normal saline solution. This is to protect the organs and keep them moist until surgical intervention can be administered. Immediately after securing the organs with moistened dressing, the nurse should take the client's vital signs and call the health care provider (HCP). While waiting for the HCP, the nurse should keep the client calm and monitor for any signs of shock or further complications. It is also crucial for the medical team, including the surgeon, nurse, and anesthesia professional, to conduct a time out before any procedure to review aloud the key concerns for the recovery and care of the patient to minimize errors and ensure a cohesive plan is in place.