An older adult client had a colon resection 8 days ago. The client experiences a gush of serosanguinous drainage from the wound, feels the abdominal incision "give," and calls the nurse. Viscera are protruding from the wound
Which of these actions must the nurse take FIRST? a. Cover the viscera with sterile saline dressings.
b. Notify the surgeon of the situation.
c. Place the client on NPO, and begin preparation for emergency surgery.
d. Place the client in the semi-Fowler's position.
A
Evisceration occurs when the wound edges separate completely and the viscera protrudes from the wound. The first nursing action is to protect the wound by covering the viscera with sterile saline dressings and notifying the surgeon immediately.
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