Question

A nurse is caring for a client who had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline soaked dressing, which of the following actions should the nurse take?

Option 1:
Notify the provider immediately.

Option 2:
Document the finding in the client's chart.

Option 3:
Reposition the client to reduce tension on the wound.

Option 4:
Administer pain medication as prescribed.

Answer 1

The nurse should immediately notify the healthcare provider when encountering wound evisceration post-transverse colectomy, as it is a critical situation requiring prompt medical intervention.

Step-by-step explanation:

If a nurse caring for a client who had an open transverse colectomy 5 days ago finds that the wound has eviscerated, the first action after covering the wound with a sterile, saline-soaked dressing is to notify the provider immediately. This situation is a surgical emergency, and prompt medical intervention is required to prevent further complications. Documentation of the findings in the client's chart, repositioning the client to reduce tension on the wound, and administering pain medication as prescribed are necessary steps, but they follow urgent communication with the healthcare provider.