Question

A nurse is caring for a client on a medical-surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which of the following actions by the nurse is appropriate in this situation?

a. Cover the wound with a sterile saline dressing.
b. Encourage the client to cough more to clear the airway.
c. Keep the client NPO (nothing by mouth).
d. Call the surgeon immediately.
e. Document the findings in the chart.

Answer 1

The appropriate action for the nurse in this situation is to cover the wound with a sterile saline dressing. It is also important to call the surgeon immediately and document the findings in the chart.

Step-by-step explanation:

The appropriate action for the nurse in this situation is to cover the wound with a sterile saline dressing. This is because an evisceration is a medical emergency that requires immediate intervention to protect the exposed organs and prevent infection. By covering the wound with a sterile dressing, the nurse can help maintain a clean and sterile environment. It is also important to call the surgeon immediately to inform them of the evisceration and follow any further instructions.

Additionally, the nurse may need to keep the client NPO (nothing by mouth) as surgery may be required to repair the evisceration. Keeping the client's stomach empty reduces the risk of complications during surgery. Finally, documenting the findings in the chart is important for maintaining accurate medical records and ensuring continuity of care.