Difficulty: Medium
Average Score: 68%
Practice
The nurse is assessing a client who is 2 days post-op following abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?
Correct answer
A
Rationale
The correct action for the nurse to take first in this scenario is to apply a sterile saline dressing to the wound (Choice A). This is crucial to prevent infection and maintain a clean environment for the exposed bowel. Applying a sterile saline dressing helps to keep the area moist, promote healing, and prevent further contamination. It is a priority to protect the exposed bowel and minimize the risk of complications.
Notifying the healthcare provider (Choice B) is important, but immediate intervention to protect the bowel is the priority. Administering pain medication (Choice C) can be done after the initial dressing is applied to address the client's discomfort. Covering the wound with an abdominal binder (Choice D) is not appropriate in this situation as it does not address the risk of infection or protect the exposed bowel.
Notifying the healthcare provider (Choice B) is important, but immediate intervention to protect the bowel is the priority. Administering pain medication (Choice C) can be done after the initial dressing is applied to address the client's discomfort. Covering the wound with an abdominal binder (Choice D) is not appropriate in this situation as it does not address the risk of infection or protect the exposed bowel.