Question

A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. when removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. which of the following actions should the nurse take first

a. call for help
b. place client in supine position
c. measure VS
d. cover wound with sterile, saline-moistened dressing

Answer 1

The nurse should cover the wound with a sterile, saline-moistened dressing as the first action when a large part of the bowel is protruding through the abdomen during a dressing change for a client recovering from a hemicolectomy.

Step-by-step explanation:

When a nurse notes that a large part of the bowel is protruding through the abdomen during a dressing change for a client recovering from a hemicolectomy, the priority action should be to cover the wound with a sterile, saline-moistened dressing (Answer choice D).

Placing the client in a supine position (Answer choice B) may be necessary for a variety of nursing interventions, but in this urgent situation, covering the exposed bowel takes precedence.

The nurse should apply gentle pressure with a sterile saline-moistened dressing to keep the organs moist, prevent infection, and minimize the risk of further trauma to the exposed tissue.