A client at a health care facility who underwent an open appendectomy describes to the nurse that he feels like something has "given way"
On inspecting the surgical wound, the nurse notes a pinkish drainage on the dressing and a visible separation between the two sides of the incision. What intervention should the nurse perform in this case? A) Position the client to put the least strain on the operated area.
B) Place sterile dressings moistened with normal saline over the area.
C) Inform the head nurse immediately about the client's condition.
D) Inspect and palpate the wound to determine the extent of the secretion.
A
Feedback:
If wound disruption is suspected, the nurse should position the client to put the least strain on the operated area. The nurse should inform the physician immediately rather than informing the head nurse first. If evisceration occurs, the nurse places sterile dressings moistened with normal saline over the protruding organs and tissues. The nurse must be alert for signs and symptoms of impaired blood flow such as swelling, localized pallor or a mottled appearance, and coolness of the tissue in the area around the wound. Palpation of the wound would be an inappropriate action in this case.
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