A patient's abdominal wound has been leaking serosanguineous drainage in increasing amounts for the last 2 days. Today, when the nurse removed the dressing, the incision was open and a loop of bowel was visible
What should the nurse do prior to notifying the surgeon? 1. Replace the old dressing and tape it securely.
2. Have the patient cough to assess for protrusion of the bowel.
3. Cover the incision with a sterile saline-moistened dressing.
4. Ask the patient if the incision has felt different today.
3
Rationale 1: The old dressing should not be put back on the open incision.
Rationale 2: The nurse should not attempt this assessment.
Rationale 3: The bowel should be kept moist with a sterile saline-moistened dressing.
Rationale 4: This information would not be helpful to the situation.
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