During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?
A) Document the assessments and intervention.
B) Reinforce the dressing with additional layers.
C) Administer pain medications intramuscularly.
D) Notify the physician and prepare for surgery.
Ans: D
Protrusion of the intestines through an opened wound indicates evisceration. After covering the wound with towels soaked in sterile normal saline, the nurse should immediately notify the physician. Immediate surgical repair is required.
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