Question

A client 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?

A)Obtain vital signs to assess for shock The nurse should obtain vital signs to assess the client's current status.
B)The scrub technologist is wearing a watch under his scrubs.
Finger and wrist jewelry are likely contaminated with micro-organisms and bacteria. Therefore, the scrub technologist should remove jewelry before handling sterile objects.

Answer 1

After covering an eviscerated wound with a sterile, saline-soaked dressing, the nurse should obtain vital signs to assess for shock. Maintaining a sterile environment and using aseptic techniques are essential to prevent complications, including infections.

Step-by-step explanation:

When a nurse encounters a patient with a wound that has eviscerated after a transverse colectomy, the immediate step after covering the wound with a sterile, saline-soaked dressing is to obtain vital signs to assess for shock. This is to monitor the patient’s hemodynamic status for any signs of deterioration. In addition to physiological monitoring, the medical team should ensure that the patient remains in a sterile environment to prevent sepsis and further complications. The principles of aseptic technique and proper surgical attire, such as scrubbing for surgery, are in place to reduce the risk of microbial contamination in surgical wounds. Healthcare workers need to uphold these standards rigorously, which includes the removal of jewelry that can harbor bacteria before handling sterile objects. In cases where there is any suspicion of infection, as highlighted when treating wounds with signs of pus or redness, medical practitioners should swiftly collect samples and instigate appropriate treatment to manage any potential infections like necrotizing fasciitis or localized infections around catheter sites.