The nurse notes evisceration of the patient's abdominal incision. Which nursing intervention is the priority before collaborating with the surgeon?
a. Reinforce the wound with a dry sterile dressing.
b. Use Steri-Strips to approximate the wound edges.
c. Ask the patient whether coughing or ac-tivity is the cause.
d. Cover the area with saline solu-tion–moistened sterile towels.
D
Wound evisceration means that internal organs protrude from the incision; thus the risk of infec-tion is high if the area is exposed. The nurse obtains sterile towels, gloves, and saline solution; moistens the towels; and covers the area. If the patient is stable, the nurse instructs the patient to remain in place and wait for additional instructions. Dry dressings are avoided because the dressing absorbs moisture from the protruding tissue, increasing the risk of infection or tissue damage. Applying Steri-Strips to a wound evisceration is inadequate because excessive pressure pushed the organs through a weakness in the incision. The nurse's priority is to prevent infection and tissue damage; identifying the events leading up to the evisceration can wait.
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