The nurse answers a patient's call light and finds the patient sitting up in bed with a wound evisceration. What action should the nurse take first?
a. Place the patient in low Fowler's position.
b. Cover the wound with sterile saline-soaked towels.
c. Notify the physician immediately.
d. Apply gentle pressure over the wound.
ANS: A
For evisceration, first place the patient in low Fowler's position with flexed knees. Cover the wound with sterile dressings or towels moistened with warm sterile normal saline. Notify the physician immediately. Apply gentle pressure over the wound, and keep the patient still and calm.
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