Question

The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:

Apply a clean dressing to protect the wound.
Cover the exposed viscera with a sterile saline gauze.
Gently replace the abdominal contents.
Cover the area with a petroleum gauze.

Answer 1

In case of a penetrating abdominal wound with exposed viscera, a nurse should cover the area with sterile saline gauze to protect the tissues and maintain a moist environment. Replacement of the viscera should be avoided to prevent further damage.

Step-by-step explanation:

When encountering a trauma client in the emergency room with a penetrating abdominal wound with exposed viscera, the nurse should cover the exposed viscera with a sterile saline gauze. This action protects the delicate visceral peritoneum and helps maintain a moist environment, which is crucial for the health of the exposed tissues. Gently replacing the abdominal contents is not recommended due to the risk of further injury and contamination. Applying petroleum gauze is not indicated as it may adhere to the tissues and not maintain the needed moisture for the viscera.

When assessing a trauma client with a penetrating abdominal wound and exposed viscera in the emergency room, the nurse should cover the exposed viscera with a sterile saline gauze. This helps to protect the exposed viscera from contamination and further injury. Gently replacing the abdominal contents or applying a clean dressing may not provide adequate protection or maintain sterility.