Difficulty: Medium
Average Score: 84%
Simulated
A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the clientÔÇÖs wound has eviscerated. After calling for help, which of the following actions should the nurse take first?
Correct answer
D
Rationale
The correct action is D: Cover the area with a sterile dressing moistened with 0.9% sodium chloride irrigation. This is the priority because evisceration is a medical emergency where abdominal contents protrude through the wound. Applying a sterile dressing moistened with saline helps prevent infection and dehydration. A: Placing the client supine with knees bent can be uncomfortable and delay appropriate intervention. B: Raising the head of the bed is not the first priority in this emergency situation. C: While assessing for shock is important, it should come after covering the evisceration to prevent further complications.