A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?
A) Place a dry, sterile dressing over the protruding organs.
B) Place a pressure dressing over the opening and secure.
C) Have the client lay quietly on back and call the physician.
D) Moisten sterile gauze with normal saline and place on any organ.
D
Feedback:
A wound evisceration occurs when the wound completely separates, and the internal organs protrude. The first action by the nurse would be to cover the protruding organs with sterile dressings moistened with normal saline. Once the client is safe, the nurse can notify the physician. The client is positioned in a manner that places the least stress on the organs. Dry or pressure dressings are placed over the protruding organ.
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