Difficulty: Medium
Average Score: 73%
Full-length
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?
Correct answer
B
Rationale
Applying a sterile, saline-moistened dressing protects the dehisced wound and prevents infection. Prone positioning (A) is inappropriate, atropine (C) doesnÔÇÖt address dehiscence, and an ACE bandage (D) may worsen the condition.