On the fourth postoperative day, the client has a sudden coughing epis

On the fourth postoperative day, the client has a sudden coughing episode and tells the nurse that “something popped” in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What nursing action should be taken

1. Notify the client’s surgeon.
2. Cover the area with a large saline-soaked dressing.
3. Position the client in bed with knees bent.
4. Pack the wound with nonadherent gauze.

ANSWER

Correct Answer: 2
Rationale 1: Although notifying the surgeon is important, it is not the nurse’s first action.
Rationale 2: Evisceration occurs when an abdominal wound opens and there is protrusion of the internal viscera through the incision. The nurse’s first action should be to cover the area with a large saline-soaked dressing to keep the viscera moist.
Rationale 3: Although positioning the client is important, it is not the nurse’s first action.
Rationale 4: Nothing should be packed into this wound.