The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurse's first response?
A) Return the patient to his previous position and call the physician.
B) Place saline-soaked sterile dressings on the wound.
C) Assess the patient's blood pressure and pulse.
D) Pull the dehiscence closed using gloved hands.
Ans: B
Feedback:
The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the patient's vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.
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