Question

The nurse is assessing a client who had a colon resection two days ago. The client states, "I feel like my stitches have burst loose." Upon further assessment, dehiscence of the wound is noted. Which action should the nurse take?

Immediately place the client in the prone position.
Apply a sterile, saline-moistened dressing to the wound.
Administer atropine to decrease abdominal secretions.
Wrap the abdomen with an ACE bandage.

Answer 1

When a client has wound dehiscence, the nurse should apply a sterile, saline-moistened dressing and notify the surgical team immediately.

Step-by-step explanation:

The correct action the nurse should take when assessing a client with dehiscence of a wound following a colon resection is to apply a sterile, saline-moistened dressing to the wound. This action will help to protect the wound and provide a moist environment that can facilitate healing. It is also critical to notify the surgical team immediately about the dehiscence for further intervention. Placing the client in the prone position or wrapping the abdomen with an ACE bandage is not appropriate for wound dehiscence. Administering atropine to decrease abdominal secretions is also not relevant in this situation.