Question

A nurse is performing a dressing change for a client who is recovering from a hemicolectomy when removing the dressing with 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. Cover the protruding bowel with a sterile, saline-soaked dressing
B. Notify the surgeon immediately
C. Attempt to gently push the bowel back into the abdominal cavity
D. Document the finding in the client's chart

Answer 1

The nurse should notify the surgeon immediately and cover the protruding bowel with a sterile, saline-soaked dressing if necessary.

Step-by-step explanation:

In this situation, the nurse should take the action of B. Notify the surgeon immediately.

A protruding bowel is a serious complication that requires immediate medical attention. The nurse should notify the surgeon to ensure prompt intervention and prevent further injury or complications.

After notifying the surgeon, the nurse may cover the protruding bowel with a sterile, saline-soaked dressing to protect it from further injury while awaiting surgical intervention.

It is important for the nurse to document the finding in the client's chart (option D) after taking immediate action.