A client recovering from abdominal surgery tells the nurse that "something popped" in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. The first nursing action should be to:
1. Notify the client's surgeon.
2. Cover the area with a large, saline-soaked dressing.
3. Position the client in bed with knees bent.
4. Pack the wound with nonadherent gauze.
2. Cover the area with a large, saline-soaked dressing.
Rationale:
Evisceration occurs when an abdominal wound opens and the internal viscera protrude through the incision. The nurse's first action should be to cover the area with a large, saline-soaked dressing to keep the viscera moist. While notifying the surgeon and positioning the client are important, covering the wound is the priority. Nothing should be packed into this wound.
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