The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.)
a. Place moist sterile gauze over the site.
b. Gently place the organs back.
c. Contact the surgical team.
d. Offer a glass of water.
e. Monitor for shock.
ANS: A, C, E
The presence of an evisceration (protrusion of visceral organs through a wound opening) is a surgical emergency. Immediately place damp sterile gauze over the site, contact the surgical team, do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for emergency surgery.
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