Difficulty: Medium
Average Score: 79%
Simulated
A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile,saline-soaked dressing which of the following actions should the nurse take?
Correct answer
C
Rationale
Correct Answer: C - Prepare the client for emergency surgery.
Rationale: Evisceration, the protrusion of abdominal organs through the wound, is a surgical emergency that requires immediate intervention. Preparing the client for emergency surgery is crucial to address this life-threatening complication promptly. Prompt surgical repair is necessary to prevent further complications such as infection, organ damage, and potential mortality.
Incorrect Choices:
A: Positioning the client lying flat may worsen the evisceration and should be avoided.
B: Increasing oral fluid intake is not the priority when facing evisceration; immediate surgical intervention is necessary.
D: Applying pressure to the dressed wound may cause further harm and is not the appropriate action for evisceration.
Rationale: Evisceration, the protrusion of abdominal organs through the wound, is a surgical emergency that requires immediate intervention. Preparing the client for emergency surgery is crucial to address this life-threatening complication promptly. Prompt surgical repair is necessary to prevent further complications such as infection, organ damage, and potential mortality.
Incorrect Choices:
A: Positioning the client lying flat may worsen the evisceration and should be avoided.
B: Increasing oral fluid intake is not the priority when facing evisceration; immediate surgical intervention is necessary.
D: Applying pressure to the dressed wound may cause further harm and is not the appropriate action for evisceration.