The nurse is assisting a client to ambulate several hours after his surgery. The client coughs and says to the nurse, "I feel like something ripped in my incision
" A large amount of blood is sud-denly apparent on the client's gown near the incision. What action does the nurse take first? a. Ease the client to the floor and call for as-sistance.
b. Put immediate pressure over the incision with the hands.
c. Call the Rapid Response Team to assess the client.
d. Lift up the gown and take off the dressing.
A
The first action of the nurse should be to ease the client to the floor to reduce tension on the inci-sion. This will help keep organs within the abdominal cavity and will help prevent the client from fainting and falling to the floor. The nursing staff should return the client to bed, and the nurse needs to reinforce the dressing while leaving the original one intact. The surgeon or the Rapid Response Team should be notified.
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