Question

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?

A) Document the assessments and intervention.
B) Reinforce the dressing with additional layers.
C) Administer pain medications intramuscularly.
D) Notify the physician and prepare for surgery.

Answer 1

After a nurse covers a protruding intestine wound with sterile towels, the next step is to immediately notify the physician and prepare for surgery due to the emergency nature of an evisceration.

Step-by-step explanation:

When encountering a situation where the intestines protrude through an opened wound, this is considered a medical emergency, and the nurse's actions are critical in stabilizing the patient. After the nurse covers the wound with towels moistened with sterile 0.9% sodium chloride solution, the immediate next steps would include notifying the physician and preparing for potential surgery. This is because the condition described suggests an evisceration, which requires prompt surgical intervention to prevent further complications.

Additional steps that a nurse may take, such as documenting the finding and interventions, reinforcing the dressing, or administering pain medications, are also important but secondary to the urgent need to escalate care. The immediate focus is on preventing further injury or infection and ensuring that the patient receives the necessary surgical care as quickly as possible.