A client recovering from abdominal surgery tells the nurse that "something popped" in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What actions by the nurse are appropriate?
Select all that apply.
A) Notify the client's surgeon.
B) Pack the wound with nonadherent gauze.
C) Turn the client onto the abdomen.
D) Position the client in bed with knees bent.
E) Cover the area with a large, saline-soaked dressing.
Answer: A, D, E
Evisceration occurs when an abdominal wound opens and the internal viscera protrude through the incision. The nurse should cover the area with a large, saline-soaked dressing to keep the viscera moist. The nurse should also position the client with the knees bent and notify the surgeon. Nothing should be packed into this wound. The client should not be turned onto the abdomen.
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